Newsom has until Sept. 30 to sign the bills into law or veto them.

This article was published on Friday, September 4, 2020 in Kaiser Health News.

By Rachel Bluth and Angela Hart and Samantha Young

SACRAMENTO, Calif. — California lawmakers convened this year with big plans to tackle soaring health care costs, expand health insurance coverage and improve treatment for mental health and addiction.

But the pandemic abruptly reoriented their priorities, forcing them to grasp for legislative solutions to the virus ripping through the state.

Legislative deliberations this year were defined by quarantined lawmakers, emergency recesses and chaotic video voting — plus a late-night partisan dust-up that led to the death of dozens of bills by the time lawmakers gaveled out early Tuesday morning. Nonetheless, legislators managed to send Gov. Gavin Newsom nearly 430 bills, roughly 40% of the number they’d send in a typical year, according to Sacramento lobbyist Chris Micheli.

Among them were about two dozen COVID-related bills that addressed a range of challenges, including dire shortages of protective gear, sick leave for workers and the administration of a hoped-for COVID-19 vaccine. The measures broadly fit into three categories: dealing with the current crisis, protecting workers and consumers, and preparing for future pandemics.

Newsom has until Sept. 30 to sign the bills into law or veto them.

“In a year that couldn’t be business as usual, this session we were still able to get important business done for the people of California who are facing so many challenges,” said Senate President Pro Tem Toni Atkins. “This year’s session may be over, but this pandemic is not, and neither is our work.”

Just as important as the measures that made it to Newsom’s desk were the ones that didn’t. For instance, bills that would have limited the use of sensitive personal information in contact tracing investigations died, as did a proposal to help rebuild and fund public health infrastructure across California.

“It leaves us with the status quo,” said Michelle Gibbons, executive director of the County Health Executives Association of California, which lobbies on behalf of the state’s county health directors. “If we had sufficient staffing of public health all along, and stronger resources, it would have helped.”

Immediate Action

Narrowly focused bills that targeted real-time COVID-related problems — and avoided big price tags — were among those easily winning approval.

AB-685, by Assembly member Eloise Gómez Reyes (D-San Bernardino), would require employers to notify their workers of COVID-19 infections at work — and would mandate the reporting of infection data to state and local public health authorities.

A different measure, AB-2164, would require Medi-Cal, California’s Medicaid program, to cover more telehealth visits in underserved areas by eliminating an existing requirement for patients and providers to establish an in-person relationship first.

But this wouldn’t be a permanent change: If signed, the law would sunset 180 days after the official COVID-19 state of emergency is over. Rivas said he had to scale back the cost of the measure by applying it only to the pandemic to get it passed.

“Had we not done that, it was very likely this bill would have been held in the Senate Appropriations Committee,” said Assembly member Robert Rivas (D-Hollister), who introduced the bill.

Another bill written with near missile-guided precision is AB-1710, which would allow pharmacists to administer a COVID vaccine once one is approved by the Food and Drug Administration.

“We want to make sure we can gear up as quickly as possible,” said Assembly member Jim Wood (D-Santa Rosa), who authored the bill.

Wood also authored AB-2644, which would require nursing homes to have a full-time “infection preventionist,” and to report deaths from communicable diseases to the state during an emergency. Wood said the bill was written after he “watched with horror” as COVID-19 killed thousands of nursing home residents in the spring.

Consumer and Worker Protections

Lawmakers took on powerful business interests to boost protections for essential workers.

A bill introduced by Sen. Jerry Hill (D-San Mateo) would make it easier for some employees infected with COVID-19 to file a workers’ compensation insurance claim until January 2023.

Should Newsom sign SB-1159, for instance, state law would presume that certain front-line workers — from health care workers in hospitals to firefighters who go into people’s homes — were infected on the job unless their employers prove otherwise.

The California Chamber of Commerce, which opposed the measure, questioned whether an employee’s illness could be traced to their job when the virus is so widespread. By varying degrees, at least 14 states have extended workers’ compensation to include COVID-related scenarios, according to the National Conference of State Legislatures.

Frustrated with outbreaks at meatpacking plants, lawmakers also advanced legislation calling on food-processing companies with at least 500 workers to provide two weeks of paid sick leave to those exposed to COVID-19 or advised to quarantine.

The measure, AB-1867, spearheaded by Assembly member Phil Ting (D-San Francisco), also would close a loophole in the federal emergency paid sick leave benefit that Congress authorized this spring, which excluded health care workers and emergency responders. If Newsom signs the bill, they too would qualify for two weeks of paid sick time.

And in what would be the biggest expansion to the state’s family leave program since it began in 2004, lawmakers voted to extend job protections to more workers who wish to take time off to care for a new baby or a sick relative.

California’s family leave program currently exempts small-business workers from the job protections, leaving millions of workers without the benefit. For example, an employee who works for a company with 20 or fewer employees does not qualify for job protection to bond with an infant. Employers with 50 or fewer workers aren’t required to guarantee someone’s job if they leave to care for a sick parent or other family member.

In both cases, that would change to employers with five or more workers if the governor signs SB-1383, introduced by Sen. Hannah-Beth Jackson (D-Santa Barbara).

“In the time of COVID, we are relying on families, grandparents, children to take care of each other when they get sick,” Jackson said. “We should be able to protect ourselves, to take responsibility for ourselves, to be able to protect ourselves without fear of losing our jobs.”

Lessons Learned

Inadequate personal protective gear emerged early on as one of the biggest impediments to California’s coronavirus response — and measures advanced by the legislature could prepare the state for future threats.

“We can be more prepared to protect our state in the next health crisis,” said Assembly Speaker Anthony Rendon.

California lawmakers approved a pair of high-profile bills to address protective equipment shortages. The more ambitious proposal, authored by Assembly member Freddie Rodriguez (D-Pomona), would require hospitals to stockpile a three-month supply by April 2021.

“We’ve already lost far too many members to COVID-19,” said Stephanie Roberson, lead lobbyist for the California Nurses Association, which sponsored AB-2537.

“It’s something that could have been prevented,” Roberson said, adding that “it’s the responsibility of employers to protect their workers.”

Newsom also must decide whether the state government should maintain a supply of protective gear for essential workers. SB-275, from Sen. Richard Pan (D-Sacramento) and sponsored by the Service Employees International Union California, would mandate the California Department of Public Health within one year to establish a PPE stockpile for health and other essential workers to last 90 days during a pandemic.

It also would require major employers of health care workers — such as dialysis clinics, nursing homes and hospitals — to establish by 2023 or later an additional 45-day stockpile of PPE.

An August report from the University of California-Berkeley found that at least 20,860 California cases of COVID-19 among essential workers could have been avoided, as well as dozens of deaths, if the state had had a sufficient supply of protective gear.

The powerful California Hospital Association fought both measures, saying the goals are laudable yet unworkable. “We agree that bolstering the supply and reliability of PPE for health care and other essential workers is a top priority,” said spokesperson Jan Emerson-Shea.

“It is critically important to remember, however, that we are still in the midst of a pandemic and there are still significant challenges with the global supply chain of PPE.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

As many as 45 hospitals from coast to coast have expressed interest in collaborating on a randomized, controlled clinical trial sponsored by Vanderbilt University Medical Center.

This article was published on Thursday, September 3, 2020 in Kaiser Health News.

By JoNel Aleccia

Dozens of major hospitals across the U.S. are grappling with whether to ignore a federal decision allowing broader emergency use of blood plasma from recovered COVID patients to treat the disease in favor of dedicating their resources to a gold-standard clinical trial that could help settle the science for good.

As many as 45 hospitals from coast to coast have expressed interest in collaborating on a randomized, controlled clinical trial sponsored by Vanderbilt University Medical Center, said principal investigator Dr. Todd Rice.

Officials at some hospitals said they are considering committing only to the clinical trial — and either avoiding or minimizing use of convalescent plasma through an emergency use authorization issued Aug. 23 by the federal Food and Drug Administration.

The response comes amid concerns that the Trump administration pressured the FDA into approving broader use of convalescent plasma, which already has been administered to more than 77,000 COVID patients in the U.S. President Donald Trump characterized the treatment as a "powerful therapy," even as government scientists called for more evidence that COVID plasma is beneficial.

A National Institutes of Health panel this week countered the FDA's decision, saying that the therapy "should not be considered the standard of care for the treatment of patients with COVID-19" and that well-designed trials are needed to determine whether the therapy is helpful. Data so far suggests the treatment could be beneficial, but it's not definitive.

"It's an important scientific question that we don't have the answer to yet," said Rice, an associate professor of medicine and director of VUMC's medical intensive care unit.

Convalescent plasma uses an antibody-rich blood product taken from people who have recovered from a viral infection and injects it into people still suffering in the hopes that the therapy will jump-start their immune systems, boosting their ability to fight the virus. The approach has been used on an experimental basis for more than a century to fight other virulent diseases, including the 1918 flu, measles, Ebola, SARS and H1N1 influenza.

Last month, NIH officials awarded $34 million to Rice's study, the Passive Immunity Trial of the Nation for COVID-19, dubbed PassItOnII, which has also received funding from country music superstar Dolly Parton. The trial, which aims to enroll 1,000 adult hospitalized patients, could meet its goals by the end of October. If it shows evidence of likely benefit to COVID patients, it could immediately change clinical practice, Rice said.

Half of the participants will receive convalescent plasma with high levels of disease-fighting antibodies from a stockpile of more than 150 units of the product already collected, Rice said. The other half will receive a placebo solution.

Though the trial launched in April, enrollment has been slow. The funding allows enlistment at more than 50 sites nationwide. That has spurred new conversations about joining the trial — and about not employing the controversial authorization issued by the FDA, said Dr. Claudia Cohn, director of the Blood Bank Laboratory at the University of Minnesota Medical School. She expected her institution to decide this week.

"I'd rather frame it as not rejecting the FDA, but simply taking the longer view," said Cohn, who is also medical director for the AABB, an international nonprofit focused on transfusion medicine and cellular therapies.

At the Ohio State University Wexner Medical Center, officials have opted to join the trial and are considering making it "the first option" for COVID patients who qualify, said Dr. Sonal Pannu, an assistant professor and pulmonologist.

"Many of the academic leaders believe we should do the trial, and we would be severely limiting" the emergency use authorization, or EUA, she said, noting that first patients could be enrolled soon. The plasma still could be used under the EUA to treat patients such as prisoners, who are unable to consent to join a clinical trial, she added.

That's the same stance adopted by the University of Washington, said Dr. Nicholas Johnson, an assistant professor of emergency medicine who's leading the trial at the Seattle site. "We're really interested in enrolling patients as the first option," he said.

The questions are similar to those raised with hydroxychloroquine, another treatment Trump touted for treating COVID-19. FDA officials issued an EUA for the drug in April, only to revoke it in June after data indicated the drug might be harmful.

"On a couple of occasions, we've allowed clinical practice to get ahead of the science," Johnson said. "We've learned that lesson a couple of times now."

FDA officials did not respond to requests for comment.

Top federal health leaders, including NIH Director Dr. Francis Collins and Dr. Anthony Fauci, the nation's leading infectious disease doctor, initially resisted the move to issue the EUA for convalescent plasma last month, telling The New York Times that the evidence for it was too weak.

Trump has criticized the FDA for moving too slowly to speed approval of treatments and vaccines for COVID-19. He announced the EUA on the eve of the Republican National Convention, calling it a "truly historic announcement."

Issuing the EUA puts the fate of clinical trials into "extreme jeopardy," said Arthur Caplan, a professor of bioethics at the New York University School of Medicine. With convalescent plasma in very short supply, it sets the stage for fights over access and makes sick patients less inclined to join a trial, where they might receive a placebo.

"If you have the EUA, it starts to damage the trials," Caplan said.

Still, given that the FDA has authorized convalescent plasma for patients ill with COVID-19, hospitals that hesitate or refuse to provide it outside a trial are sure to face questions from families.

That creates "a very interesting and delicate ethics problem," said Cohn.

"If you commit to the randomized controlled trial only, you're committing to a long-term dedication to science," she said. "The question is, is it ethically inappropriate not to provide a therapy that has been shown to be possibly beneficial?"

Johnson, at the University of Washington, said most patients have been willing — even eager — to participate in clinical trials once they understand the need for rigorous scientific results.

And Caplan, the bioethicist, applauded the decision of hospitals to minimize the EUA and focus on the trial, calling it "a pretty feisty action."

"It's sensible," he said. "It's likely to really generate an answer to the question of 'Does COVID convalescent plasma do anything?'"

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Health departments that have been underfunded for decades say they currently lack the staff, money and tools to educate people about vaccines and then to distribute, administer and track hundreds of millions of doses.

This article was published on Wednesday, September 2, 2020 in Kaiser Health News.

By Liz Szabo

Millions of Americans are counting on a COVID-19 vaccine to curb the global pandemic and return life to normal.

While one or more options could be available toward the end of this year or early next, the path to delivering vaccines to 330 million people remains unclear for the local health officials expected to carry out the work.

"We haven't gotten a lot of information about how this is going to roll out," said Dr. Umair Shah, executive director of Texas' Harris County Public Health department, which includes Houston..

In a four-page memo this summer, the federal Centers for Disease Control and Prevention told health departments across the country to draft vaccination plans by Oct. 1 "to coincide with the earliest possible release of COVID-19 vaccine."

But health departments that have been underfunded for decades say they currently lack the staff, money and tools to educate people about vaccines and then to distribute, administer and track hundreds of millions of doses. Nor do they know when, or if, they'll get federal aid to do that.

Dozens of doctors, nurses and health officials interviewed by KHN and The Associated Press expressed concern about the country's readiness to conduct mass vaccinations, as well as frustration with months of inconsistent information from the federal government.

The gaps include figuring out how officials will keep track of who has gotten which doses and how they'll keep the workers who give the shots safe, with enough protective gear and syringes to do their jobs.

With only about half of Americans saying they would get vaccinated, according to a poll from AP-NORC Center for Public Affairs Research, it also will be crucial to educate people about the benefits of vaccination, said Molly Howell, who manages the North Dakota Department of Health's immunization program.

The unprecedented pace of vaccine development has left many Americans skeptical about the safety of COVID-19 immunizations; others simply don't trust the federal government.

"We're in a very deep-red state," said Ann Lewis, CEO of CareSouth Carolina, a group of community health centers that serve mostly low-income people in five rural counties in South Carolina. "The message that is coming out is not a message of trust and confidence in medical or scientific evidence."

Paying for the Rollout

The U.S. has committed more than $10 billion to develop new coronavirus vaccines but hasn't allocated money specifically for distributing and administering vaccines.

And while states, territories and 154 large cities and counties received billions in congressional emergency funding, that money can be used for a variety of purposes, including testing and overtime pay.

An ongoing investigation by KHN and the AP has detailed how state and local public health departments across the U.S. have been starved for decades, leaving them underfunded and without adequate resources to confront the coronavirus pandemic. The investigation further found that federal coronavirus funds have been slow to reach public health departments, forcing some communities to cancel non-coronavirus vaccine clinics and other essential services.

States are allowed to use some of the federal money they've already received to prepare for immunizations. But KHN and the AP found that many health departments are so overwhelmed with the current costs of the pandemic — such as testing and contact tracing — that they can't reserve money for the vaccine work to come. Health departments will need to hire people to administer the vaccines and systems to track them, and pay for supplies such as protective medical masks, gowns and gloves, as well as warehouses and refrigerator space.

CareSouth Carolina is collaborating with the state health department on testing and the pandemic response. They used federal funding to purchase $140,000 retrofitted vans for mobile testing that they plan to continue to use to keep vaccines cold and deliver them to residents when the time comes, said Lewis.

But most vaccine costs will be new.

Pima County, Arizona, for example, is already at least $30 million short of what health officials need to fight the pandemic, let alone plan for vaccines, said Dr. Francisco Garcia, deputy county administrator and chief medical officer.

Some federal funds will expire soon. The $150 billion that states and local governments received from a fund in the CARES Act, for example, covers only expenses made through the end of the year, said Gretchen Musicant, health commissioner in Minneapolis. That’s a problem, given vaccine distribution may not have even begun.

Although public health officials say they need more money, Congress left Washington for its summer recess without passing a new pandemic relief bill that would include additional funding for vaccine distribution.

"States are anxious to receive those funds as soon as possible, so they can do what they need to be prepared," said Dr. Kelly Moore, associate director of immunization education at the Immunization Action Coalition, a national vaccine education and advocacy organization based in St. Paul, Minnesota. "We can't assume they can take existing funding and attempt the largest vaccination campaign in history."

What's the Plan?

Then there's the basic question of scale. The federally funded Vaccines for Children program immunizes 40 million children each year. In 2009 and 2010, the CDC scaled up to vaccinate 81 million people against pandemic H1N1 influenza. And last winter, the country distributed 175 million vaccines for seasonal influenza vaccine, according to the CDC.

But for the U.S. to reach herd immunity against the coronavirus, most experts say, the nation would likely need to vaccinate roughly 70% of Americans, which translates to 200 million people and — because the first vaccines will require two doses to be effective — 400 million shots.

Although the CDC has overseen immunization campaigns in the past, the Trump administration created a new program, Operation Warp Speed, to facilitate vaccine development and distribution. In August, the administration announced that McKesson Corp., which distributed H1N1 vaccines during that pandemic, will also distribute COVID-19 vaccines to doctors' offices and clinics.

"With few exceptions, our commercial distribution partners will be responsible for handling all the vaccines," Operation Warp Speed's Paul Mango said in an email.

"We're not going to have 300 million doses all at once," said Mango, deputy chief of staff for policy at the Health and Human Services Department, despite earlier government pledges to have that many doses ready by the new year. "We believe we are maximizing our probability of success of having tens of millions of doses of vaccines by January 2021, which is our goal."

Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, said it will take time for the vaccines to be widespread enough for life to return to what's considered normal. "We have to be prepared to deal with this virus in the absence of significant vaccine-induced immunity for a period of maybe a year or longer," Adalja said in August.

In preliminary guidance for state vaccine managers, the CDC said doses will be distributed free of charge from a central location. Health departments' local vaccination plans may be reviewed by both the CDC and Operation Warp Speed.

The CDC has vetted state and federal vaccination plans in five locations: North Dakota, Florida, California, Minnesota and Philadelphia. No actual vaccines were distributed during the "microplanning" sessions, which focused on how to get vaccines to people in places as different as urban Philadelphia, where pharmacies abound, and rural North Dakota, which has few chain drugstores but many clinics run by the federal Indian Health Service, said Kris Ehresmann, who directs infectious disease control at the Minnesota Department of Health.

Those planning sessions have made Ehresmann feel more confident about who's in charge of distributing vaccines. "We are getting more specific guidance from CDC on planning now," she said. "We feel better about the process, though there are still a lot of unknowns."

Outdated Technology Could Hamper Response

Still, many public health departments will struggle to adequately track who has been vaccinated and when, because a lack of funding in recent decades has left them in the technological dark ages, said Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials.

In Mississippi, for example, health officials still rely on faxes, said the state's health officer, Dr. Thomas Dobbs. "You can't manually handle 1,200 faxes a day and expect anything efficient to happen," he said.

When COVID-19 vaccines become available, health providers will need to track where and when patients receive their vaccines, said Moore, the medical director of Tennessee's immunization plan during the H1N1 influenza pandemic in 2009 and 2010. And with many different shots in the works, they will need to know exactly which one each patient got, she said.

People will need to receive their second COVID-19 dose 21 or 28 days after the first, so health providers will need to remind patients to receive their second shot, Moore said, and ensure that the second dose is the same brand as the first.

The CDC will require vaccinators to provide "dose-level accounting and reporting" for immunizations, so that the agency knows where every dose of COVID-19 vaccine is "at any point in time," Moore said. Although "the sophistication of these systems has improved dramatically" in the past decade, she said, "many states will still face major challenges meeting data tracking and reporting expectations."

The CDC is developing an app called the Vaccine Administration Monitoring System for health departments whose data systems don't meet standards for COVID-19 response, said Claire Hannan, executive director of the Association of Immunization Managers, a nonprofit based in Rockville, Maryland.

"Those standards haven't been released," Hannan said, "so health departments are waiting to invest in necessary IT enhancements." The CDC needs to release standards and data expectations as quickly as possible, she added.

Meanwhile, health departments are dealing with what Minnesota's Ehresmann described as "legacy" vaccine registries, sometimes dating to the late 1980s.

A Historic Task

Overwhelmed public health teams are already working long hours to test patients and trace their contacts, a time-consuming process that will need to continue even after vaccines become available.

When vaccines are ready, health departments will need more staffers to identify people at high risk for COVID-19, who should get the vaccine first, Moore said. Public health staff also will be needed to educate the public about the importance of vaccines and to administer shots, she said, as well as monitor patients and report serious side effects.

At an August meeting about vaccine distribution, Dr. Ngozi Ezike, director of Illinois' health department, said her state will need to recruit additional health professionals to administer the shots, including nursing students, medical students, dentists, dental hygienists and even veterinarians. Such vaccinators will need medical-grade masks, gowns and gloves to keep those workers safe as they handle needles amid the contagious coronavirus.

Many health officials say they feel burned by the country's struggle to provide hospitals with ventilators last spring, when states found themselves bidding against one another for a limited supply. Those concerns are amplified by the country's continuing difficulties providing enough testing kits; supplying health workers with personal protective equipment; allocating drugs such as remdesivir; and recruiting contact tracers — who track down everyone with whom people diagnosed with COVID-19 have been in contact.

Although Ehresmann said she's concerned Minnesota could run out of syringes, she said the CDC has assured her they will provide them.

Given that vaccines are far more complex than personal protective equipment and other medical supplies — one vaccine candidate must be stored at minus 94 degrees Fahrenheit — Plescia said people should be prepared for shortages, delays and mix-ups.

"It's probably going to be even worse than the problems with testing and PPE," Plescia said.

Associated Press writer Michelle R. Smith and KHN Midwest correspondent Lauren Weber contributed to this report.

This story is a collaboration between The Associated Press and KHN.

Liz Szabo: lszabo@kff.org, @LizSzabo

Instead of being celebrated for their difficult and dangerous work, public health officials face violent threats and political attacks from those who disagree with their tactics.

This article was published on Tuesday, September 1, 2020 in Kaiser Health News.

By Angela Hart

As a veteran who served back-to-back tours in Iraq, I initially cringed when commentators compared the COVID-19 crisis to wartime — no bullets, no blood and no one volunteered for this.

But after my months of reporting on the pandemic, it has become painfully clear this is like war. People are dying every day as a result of government decisions — and indecision — and the death toll is climbing with no end in sight.

Less than six months into the pandemic, COVID-19 has already killed at least 183,000 Americans, more than triple the number who died in the Vietnam War, and far more than the wars in Iraq and Afghanistan combined.

We are all being asked to make sacrifices for the good of our country. And we're experiencing, as a nation, a deeply traumatic event. Like war, the toll will be felt for a long time.

In California, local public health officials are leading the front lines in this battle against COVID-19, dictating strategy, issuing orders and developing tactics to carry out that strategy. Every day, they make gut-wrenching calls to protect our health and livelihoods, even if those decisions may inflict initial harm on the economy or contradict politicians and popular opinion.

But instead of being celebrated for their difficult and dangerous work, as I was, they are now facing violent threats and political attacks from those who disagree with their tactics — such as requiring masks in public and ordering businesses and parks closed to prevent the spread of infection.

I can't imagine being afraid of the people I signed up to protect.

When I interview them, often late at night, I hear in their voices that familiar mix of emotions that often come with war: exhaustion, anxiety and devotion to duty.

"We've become easy scapegoats for people's fear and anxiety during COVID-19," said Dr. Gail Newel, the health officer for Santa Cruz County, who continues to face threats for issuing public health orders.

The latest — a menacing email sent to her in late July calling her a "communist bitch" — prompted local law enforcement to recommend she get a guard dog and firearm to protect herself. "That weighs very heavily," she said.

I can't imagine the burden. Although many of us serving in Iraq disagreed with the war, we remained dedicated to our mission and enjoyed broad support at home.

I joined the military as a U.S. Army reservist in 1999 and was deployed on active duty to Iraq in early 2003, when it truly was like the Wild West.

Serving first as logistics clerk and then the acting supply sergeant for a military police company out of San Jose, California, I helped ensure my military brothers and sisters had proper equipment. When the George W. Bush administration sent us to Iraq, for example, it did so without armoring our Humvees — a major failure that elevated our risk of being blown up by roadside explosives.

I returned home in July 2004 and spent years putting the battlefield behind me as I transitioned to a career in journalism. But living through COVID-19 has resurrected those feelings of being at war.

Now, just like then, there is an overall sense of fear and uncertainty because we don't know when the crisis will end. We aren't free to go about our lives as we once did and we yearn for the comforts we took for granted. We miss our loved ones we can't see.

We must remain hyper-vigilant to potential threats, and even make sure to don our "armor" when we leave our homes, except now it's masks and gloves instead of helmets and flak jackets.

There's something that happens when you're in a conflict zone — the air feels heavier. You can feel threats all around you, just waiting to strike. There's deep anxiety for what the future holds, and you wonder whether you'll be alive next week or next month.

Living through COVID-19 has resurrected those feelings of being at war.

Public health officers are shouldering the added anxiety that duty brings. For much of the pandemic, Gov. Gavin Newsom has pushed the responsibility — and blame — of reopening largely onto counties and the state's 61 local health officers, who have worked for months without days off, giving up time with their families to attack this crisis head-on.

I have interviewed dozens of them. Some have broken into tears while talking with me, and worry chokes their voices as they lament problems with testing or explain how they don't have enough supplies or contact tracers to safely reopen. They felt rushed into lifting stay-at-home restrictions in May and June, yet they had no choice in the face of pressure from politicians and suffering residents and businesses. After years of severe underfunding, public health agencies don't have the money or resources to deploy an adequate response.

They're also wrestling with the guilt and trauma that come with making decisions that affect people's lives and livelihoods.

"It has been hard on all of us," acknowledged Sacramento County's health officer, Dr. Olivia Kasirye. "We're getting phone calls daily from people saying they're going bankrupt and they can't pay their rent and they have loved ones who are dying that they can't see."

I know how that feels, having been conflicted about our long-term strategy in the Middle East and the harm we inadvertently inflicted on innocent civilians. But I can't imagine being afraid of the people I signed up to protect.

Public health officials have become targets of aggressive and personal attacks. Some have seen their photos smeared with Hitler mustaches, while others have had their personal phone numbers and home addresses circulated publicly, prompting the need for round-the-clock security.

"Imagine treating American soldiers and military families with the kind of hatred and disrespect that local health officers are facing," said Dr. Charity Dean, unprompted, a day after she left her job as one of the top public health officials in the Newsom administration. "They're the ones taking all the risk, and it makes me angry to see how they've been treated."

Since the start of the pandemic, at least eight career public health officials in California have resigned, and more are considering it. But most are soldiering on.

Mimi Hall, Newel's boss and Santa Cruz County's top public health official, told me law enforcement is investigating a threatening letter addressed to her that was allegedly signed by a far-right anti-government extremist group.

In response, Hall considered retiring early. But she didn't want to abandon her troops and wasn't going to let fear stop her from doing her job. So she had a perimeter fence and home security system installed over the weekend — and reported for work promptly Monday morning.

Yes, we are waging a life-or-death battle in which innocent people are hurt, but it's these battle-scarred public health officers who are making deeply personal sacrifices to steer us to safety.

We commemorate military leaders with medals and parades. Why not treat our public health officials with the same level of appreciation?

Angela Hart: ahart@kff.org, @ahartreports