Staff at CSL Plasma, an industry leader, raised alarms about faulty masks as donors flooded in, but the FDA and OSHA were slow to act.

This article was published on Monday, September 21, 2020 in ProPublica

By J. David McSwane

Heather Steadman, a nurse at a CSL Plasma donation center near Pittsburgh, was about to enter a tiny closed-door room to administer an exam when the doctor handed her a mask in a translucent wrapper labeled KN95. The folded white mask, visible behind Chinese characters, was all her employer was providing to protect her from COVID-19.

Over a nearly 20-year career, she'd worn certified respirators in intensive care units and cared for patients dying from respiratory disease. That night in late June, she was about to lean into the face of a stranger, checking his throat and peering into his eyes, guarded only by a mask of questionable origin.

"There were just red flags all over it," she said of the mask, which corporate records show was advertised to employees as just as good as the vaunted American-made N95 respirator at stopping the spread of the coronavirus.

She stared at the doctor incredulously, then marched to a nearby storage hutch. She plunged her hand into a blue box of 50 or so masks, then two more boxes, like a kid frantically scrounging through cereal boxes for a magic ring.

From each, she pulled out a sheet of paper, hoping for evidence that the masks had been cleared as effective by the U.S. government — from the federal Food and Drug Administration, maybe, or the National Institute for Occupational Safety and Health, NIOSH, which certifies N95s that can filter out 95% of particles.

Instead, she read aloud the first line of English: "NOT for medical purpose."

Steadman, 41, had been in a standoff with her employer for months over inadequate personal protective equipment. She'd gone on leave in April, pressing CSL to provide decent masks. She'd complained, without success, to the federal Occupational Safety and Health Administration, which is supposed to ensure safe workplaces. Other CSL employees across the country had made similar complaints. Ten weeks later, though her complaints had been dismissed, she returned because the company said workers now had access to medical-grade masks.

CSL, a leader in the global plasma industry, says it was adhering to federal guidelines to protect front-line workers as it geared up a major national push — endorsed by President Donald Trump — to secure blood plasma donations from recovered COVID-19 patients. The FDA had authorized emergency use of convalescent plasma therapy as a treatment for the severely ill, despite a lack of scientific proof that it saves lives.

Steadman and other blood plasma workers feared a new level of risk as donors came in from the street and attested that they had been symptom-free for 14 days. The workers knew what the studies said: People looking to be paid in exchange for being stuck with a needle are more likely to conceal illness than those without financial incentive.

"These are not people that are going to tell me that they're sick," Steadman told me.

This, on top of the routine flow of non-COVID-19 donors coming in for $40 a draw, mostly poor people in high-risk groups, such as those working "essential" jobs where infections can spread wildly. A plasma donation involves repeated and prolonged contact with staff — in the reception area, in waiting rooms, during physical exams in closed spaces and when blood is drawn.

The company said it was following all federal guidelines, although no agency had quantified the dangers posed to workers like Steadman due to stepped-up plasma donations. Steadman had seen the many reports of counterfeit masks making their way to hospitals, endangering nurses and doctors. Rather than face what she saw as "imminent danger," Steadman told CSL she wouldn't return until she had assurances the company was providing safe masks. She also filed another OSHA complaint.

After weeks of waiting for regulators to act, she contacted ProPublica. She sent correspondence, CSL training materials, internal social media posts and samples of three masks from CSL's stockpile. She'd spent hours trying to track the masks' origins, to see if her colleagues were adequately protected, and none of the Chinese KN95s provided were at the time on the FDA's authorized list of masks that are roughly comparable to U.S.-approved N95s.

"They literally bought some off Amazon," she said, referring to records the company gave to OSHA.

Her story offers a glimpse into the confusion, anxiety and fear wrought by lax government oversight of the coronavirus mask market, where intense demand and low supply bred graft and fraud and left some front-line healthcare workers reliant on face coverings that might or might not work.

I'd spent the last six months delving into the murky world of PPE, tracking foreign vendors and middlemen, and documenting price gouging and questionable contracts. All of it unfolded against a backdrop of confusing and evolving guidance from the federal government.

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When Steadman and some other CSL workers agreed to talk, I got in my car and made the windy four-hour drive to the strip mall in McKeesport, Pennsylvania, where they worked.

The parking lot of the Olympia Shopping Center could be artfully rendered in pencil and pastel and slapped on a postcard labeled "Poverty, U.S.A." There's a payday loan store, a Dollar Tree, a Rent-A-Center, a shuttered Payless ShoeSource and in the corner, the glowing red sign of CSL Plasma.

With unemployment at near-record highs, CSL had made donating plasma an attractive option and mobilized workers nationwide to recruit new donors. In McKeesport, it offered a $100 cash bonus to donors who could prove they'd once tested positive for COVID-19 and advertised that regular donors could make about $700 monthly.

As FDA Hypes, OSHA Chills

CSL has more than 260 U.S. plasma donation centers with plans to open dozens more next year. Based in Australia, the company is proud of a history that spans from its early use of plasma to beat diphtheria a century ago to helping develop the swine flu vaccine a decade ago. With $2.2 billion in profits last year, CSL gave out a record dividend to U.S. shareholders.

Its business seems poised to get even better.

An alliance of research institutions, plasma banks and drug companies promotes donations through "The Fight Is In Us" campaign, pitched online and on TV by stars such as Dwayne "The Rock" Johnson and Helen Mirren who urge COVID-19 survivors to visit plasma centers including CSL's. The Trump administration has praised the initiative and refers donors to the alliance.

Since the pandemic's early days, the administration has been pushing plasma donations and cleared the way for a limited study to see if treatments of concentrated antibodies, derived from the serum surrounding the blood cells of COVID-19 survivors, could help others recover.

In late August, the FDA opened the door for widespread use of convalescent plasma therapy, citing a study that kinda sorta showed the potential upsides of the treatment outweighed the risks. In doing so, FDA Commissioner Stephen Hahn claimed that the treatment could have saved 35 out of 100 patients, a statement he later recanted after scientists called it a gross exaggeration. Still, Alex Azar, secretary of the U.S. Department of Health and Human Services, called the approval of convalescent plasma therapy a "milestone achievement in President Trump's efforts to save lives from COVID-19."

This pushed CSL into high gear.

Weeks earlier, CSL Limited CEO Paul Perreault had made the case for the industry-led race to get antibody-laden plasma in a roundtable appearance with Trump and other federal officials at the American Red Cross headquarters in Washington.

"We need plasma. We need plasma donors. We need them wherever they are," Perreault told Trump.

Aside from the president's support, the company had also enlisted top pharmaceutical lobbyists to press the value of plasma therapy in Washington.

But many unknowns remained. Trump's administration skipped the tedious — and, scientists say, important — step of a randomized controlled study, comparing outcomes of patients who got plasma therapy with those who didn't. And while federal agencies stressed that plasma donation centers should remain open during the pandemic to keep the nation's blood supply flowing, worker safety went largely unmentioned.

Tom Inglesby, a director at Johns Hopkins' Center for Health Security, said the risk to workers in plasma donation centers depends on the spread in each community. The bigger risk, he said, might not be the people who have recovered from COVID-19 but all the other donors who are being let in without prior screening to a place where infections can spread easily.

"If I were working in this type of facility, I would like to have an N95 mask," Inglesby said.

"You'd have to call these people healthcare professionals, for sure. They're drawing blood."

Since March, OSHA has received about a dozen COVID-19-related workplace safety complaints from CSL workers in Pennsylvania, Indiana, Michigan, Minnesota and Texas. Half were about inadequate PPE such as masks, the rest about fear the company wasn't enforcing public health guidelines.

In late May, for instance, a Houston employee reported that a staff member tested positive and "six people working near the infected person were quarantined," according to OSHA data.

"Other staff members are being sent out to work at other locations," that complaint stated, "exacerbating the spread."

Contracts, emails and spreadsheets that Juanita and Dawn Ramos shared with ProPublica detail how domestic and foreign investors, many with marijuana industry ties, seized upon the nation's public health disaster.

Anthony Farina, CSL's spokesman, said OSHA has assessed no penalties based on these complaints.

"CSL Plasma has cooperated promptly with all requests for information, and has routinely shared documentation of our safety practices in place to prevent exposure. The company also investigated the allegations and reviewed our applicable requirements to confirm compliance with appropriate OSHA COVID-19 guidance," his statement said.

All but three of those cases were closed.

Debbie Berkowitz, a former top OSHA official in the Obama administration, said Steadman's journey is part of a larger trend. "OSHA has decided not to enforce the law and has abandoned its mission," she said. "Workers are on their own."

The agency has received more than 33,000 COVID-19-related complaints, according to OSHA data. More than two-thirds of those are closed. Nearly 9,000 complaints were about PPE at work.

She was particularly concerned about a company presentation that told CSL workers that KN95s, approved under Chinese standards, were just as good as N95s, approved by U.S. scientists.

Providing questionable Chinese masks "and sort of implying to workers that this is like an N95 — that is completely deceiving and dangerous because it gives these workers a false sense of security," Berkowitz said.

Afraid at Work

The angst among CSL workers began in March, when corporate guidance stated that "a mask does not adequately protect healthy people from an infection of coronavirus." In fairness, this was around the time U.S. Surgeon General Jerome Adams sent out a tweet he'd later recant:

"Seriously people- STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus"

CSL employees, including managers, described an internal tracker on the company's network showing hundreds of employees took leave from March through September because they were either exposed to COVID-19, sick or afraid. None of those workers were able to share raw data. CSL did not directly respond.

Steadman shared emails that hint at concern sweeping through CSL as employee absences shuttered entire centers.

March 17: "Due to staff illness, the Hillsboro [Florida] 126 center will delay opening …"

March 27: "Little Rock [Arkansas] 234 is closed due to staffing issues."

March 30: "... Peoria [Arizona] closed for the day due to staffing issues."

The company shared online presentations outlining evolving pandemic guidelines. On April 10, it told workers that N95 respirators effectively filtered out airborne contaminants. But the company wasn't supplying them and mask use was voluntary.

Later correspondence indicates masks were not required because the company had no OSHA-approved respiratory program, which involves training on how to wear them and fit testing to ensure proper use.

That week, Steadman lodged her first complaint to management, took leave and complained to OSHA.

"I continued to work in good faith, despite genuinely believing that imminent danger exists," she wrote in a lengthy letter to CSL management. "However, the policy for 'recovered donors' is a risk I am not willing to take."

The drumbeat of staff absences indicated she was not alone in her fear.

April 17: "Taylor 240 [Pennsylvania] temporarily closed due to staffing issues."

On May 4, soon after the FDA gave emergency use authorization to import masks from 80 little-known Chinese manufacturers, the company announced it wasn't distributing those gold-standard N95s. It was instead providing Chinese KN95s. And 10 days later, a presentation told employees there was "very little difference in certification requirements between a N95 and KN95."

But company records show the three brands of KN95s CSL purchased and distributed were not on the FDA's list of Chinese masks that are roughly comparable to N95s and suitable for healthcare workers. And all three used earloops, which can be less snug than those that wrap around the head.

The move to distribute Chinese KN95s didn't halt the ongoing staff issues.

June 21: "... Homestead [Pennsylvania] unable to open due to staffing."

Meanwhile, CSL continued to aggressively recruit donors who had recovered from COVID-19, with workers posting flyers and hanging signs across the country, according to internal social media posts, some of which show workers improperly wearing KN95s.

Weeks passed, so Steadman called OSHA. She was told to file a new complaint. Too much time had passed. So she did.

In early July, OSHA told the company that regulators wouldn't investigate Steadman's updated complaint, deferring to CSL to look into it.

CSL reported to OSHA that its investigation had found no problem. A July 15 follow-up from corporate headquarters in Boca Raton, Florida, gave details about CSL's masks, including pictures and a snapshot of thousands apparently purchased through Amazon. According to CSL, the masks were sourced by the Utah-based medical equipment company HemaSource. Executives at HemaSource did not respond to messages from ProPublica.

In a letter the next day, an OSHA broke the news to Steadman.

"CSL Plasma has advised me that the hazards you complained about have been investigated. The employer states that the hazards have been corrected," Area Director Christopher Robinson wrote. "With this information, OSHA feels the case can be closed."

Steadman believed the mask details provided to OSHA demanded further inquiry.

"Who's going to make sure people have safe masks if not OSHA?" she said.

She rebutted her employer's response in a document that reads like a prosecutor's exhibit.

"Every certificate provided in this document is easily identifiable as plagiarized, and fits each criterion from the [Centers for Disease Control and Prevention] and NIOSH on identifying counterfeit masks and falsified documents," she wrote on July 19.

Here's where Steadman descended into the maddening vortex that's subsumed my reporting these last six months. After the FDA opened the gates for masks from China, later reversing course as junk masks ended up in healthcare settings, it became pretty dang hard to tell what was what. This is especially true of brands of masks the CDC or a private lab hasn't tested and published findings about, which is the case here.

Steadman went down a Google hole, cross-referencing images, technical data, model numbers and more. All of CSL's KN95s were labeled as not for medical use.

One type of mask connected back to a Chinese diaper company.

Another shipment, apparently from Amazon, came in packages of four (sterile masks typically come individually wrapped). Plus, the "CE" markings claiming they'd passed muster with European regulators were skewed and placed in different spots mask to mask, as if applied by hand with an ink stamp rather than precise machinery.

The third type, the KN95 Steadman was handed that stressful June night, links to a company registered with the FDA as ZK-Best, which sells masks approved by Chinese regulators for working around dust or filtering polluted air. The Chinese manufacturer did not respond to email requests for comment.

But CSL included a technical data sheet for these masks in its submission to OSHA that raises questions. The document purports to show that SGS, a global firm that deploys inspectors to factories to test goods for far-flung buyers, had found the ZK-Best respirator highly effective.

The document looked odd. The date format was month, day, year: "July 1st, 2015." That's an American convention I hadn't seen on other SGS documents. The inspection also appeared to be for a completely different mask model, a so-called PM2.5 mask designed for industrial use.

I reached out to experts who had imported and sold legitimate masks. I also reached out to SGS.

Richie Hecker, director of the medical supply company Traction and Scale, sold PPE to New York City and others. With his help, ProPublica asked a researcher in China to investigate. When the results came back, Hecker said he wouldn't buy these masks because SGS said the report provided to OSHA was fake, a "cut and paste job."

"This is not an original SGS document," SGS also wrote to me. "This document is thus of no value whatsoever and we advise you not to rely on it for any purpose."

Hecker said phony documents are common fare in the PPE market and "the KNs are the dirtiest item on the market." That's why reliable chain-of-custody documents connecting the mask in Steadman's hand to a specific factory are crucial.

When I asked CSL about the fake SGS document, a spokesperson said that the company would investigate and that it takes its responsibility to provide accurate information to federal regulators with "utmost seriousness."

On Sept. 2, just two days after I first asked CSL about the ZK-Best masks, its ZKG 9501 KN95 mask appeared on the FDA's list as allowed under the emergency use authorization. This wasn't the case earlier in my research or during the months Steadman refreshed and refreshed the same website and sent questions to several government agencies.

An FDA official told me that brand of mask was authorized based on testing and approvals from the FDA's European Union counterpart, though the masks CSL distributed and their packaging lack the CE mark. NIOSH has seen multiple instances of counterfeit masks sold using the branding of manufacturers on the list. U.S. regulators have not tested the ZK-Best masks themselves, but anyone worried about masks at their workplace is encouraged to send them to NIOSH for testing, officials said.

A few days later, on Sept. 13, CSL provided new documents it said proved the masks were legitimate, including a new testing document and a letter apparently from a ZK-Best manager named "Chensu," who said the masks had been approved by SGS after all. There was a mixup with the mask models, the letter said, but the masks were good.

I tried to authenticate those documents with the factory but didn't hear back.

I asked a CSL spokesperson for proof the documents came from the factory, perhaps an email thread showing a chain of custody. The company declined but said, "We assure you that we did not alter any of the documentation."

I shared all of this with Steadman, who remains skeptical.

"That Put Me at Risk"

Workers in McKeesport remain on edge because of the masks but also CSL policies they say are conflicting and dangerous.

CSL says workers are safe because the centers don't treat patients who are currently sick with COVID-19.

Donors receive a blood pressure, temperature and pulse check, said Farina, the company spokesman, and COVID-19 survivors "must provide a doctor's note confirming their diagnosis and confirmation that they have recovered from COVID-19."

Yet late last month, two workers were potentially exposed to a donor who later tested positive, according to internal emails and interviews with CSL employees. That donor wasn't properly wearing her mask, employees told me.

Samantha Kelly, 30, was told she had contact with this person. She worked the reception desk and spent several minutes pricking the fingers and taking the blood pressure of walk-in donors. She said the company refused to tell her when that contact occurred, making it impossible to retrace her steps and warn those close to her.

Kelly is the primary caregiver for her mother, who has diabetes and a chronic inflammatory lung disease.

"That put me at risk," she told me. "That put my family at risk, everyone we had come in contact with."

She's technically still a CSL employee, on unpaid leave since Aug. 20, but she said she's not going back.

A CSL spokesperson said the company follows CDC and local guidelines on contact tracing but said patient privacy laws limit what they can tell employees.

Company records show CSL stopped doing temperature readings at the door in June.

CSL employees say the checks detailed by CSL's spokesman happen long after patients enter the centers, sometimes after they've signed in, talked with staff and sat in a waiting room before screening.

Ultimately, CSL staff don't have much but donors' word that they're not sick, employees say and records show.

This month, a woman who said she'd recovered from COVID-19 came into the McKeesport office to sell her plasma, according to CSL staff. Well after she arrived, a staffer found she was running a fever. She was sent home. Employees are still rattled.

CSL employees told me their need for good PPE was heightened by a recent policy change. Employees were told they cannot ask donors who refuse to wear masks to leave, according to corporate instructions sent out in late June.

Responding to Steadman's persistence, OSHA reopened its investigation. That inquiry is ongoing, and the agency won't say more until it's complete, a spokeswoman said in an email.

On Sept. 1, the company launched a COVID-19 antibody testing program in about 30 cities to help identify more potential donors who have recovered from the disease. That same day, the National Institutes of Health said there's no evidence to support convalescent plasma therapy as a standard treatment for COVID-19.

In the end, I found only some answers for Steadman, who remains on leave from CSL. She said she and her co-workers could have avoided heartache if the company had simply addressed her questions and found FDA-authorized masks back in May.

"Why would the company let me flail over here and let me freak out and contact several different agencies if everything is just fine?" she said. "Nothing that you've just told me convinces me that anybody is sure those masks would protect me from COVID — at all."

On a recent warm afternoon, as we talked in front of her parent's long log cabin home, Steadman was wearing scrubs even though she hadn't been to work in weeks. I asked why.

She was going to a job fair.

Yeganeh Torbati and Mollie Simon contributed reporting.

More than 70,000 residents and staff members in nursing homes and assisted living facilities had died of COVID-19 by mid-August, according to the latest count from Kaiser Family Foundation.

This article was published on Friday, September 18, 2020 in Kaiser Health News.

By Judith Graham

Where do we want to live in the years ahead?

Older adults are asking this question anew in light of the ongoing toll of the coronavirus pandemic — disrupted lives, social isolation, mounting deaths. Many are changing their minds.

Some people who planned to move to senior housing are now choosing to live independently rather than communally. Others wonder whether transferring to a setting where they can get more assistance might be the right call.

These decisions, hard enough during ordinary times, are now fraught with uncertainty as the economy falters and COVID-19 deaths climb, including tens of thousands in nursing homes and assisted living centers.

Teresa Ignacio Gonzalvo and her husband, Jaime, both 68, chose to build a house rather than move into a continuing care retirement community when they relocate from Virginia Beach, Virginia, to Indianapolis later this year to be closer to their daughters.

Having heard about lockdowns around the country because of the coronavirus, Gonzalvo said, “We’ve realized we’re not ready to lose our independence.”

Alissa Ballot, 64, is planning to leave her 750-square-foot apartment in downtown Chicago and put down roots in a multigenerational cohousing community where neighbors typically share dining and recreation areas and often help one another.

“What I’ve learned during this pandemic is that personal relationships matter most to me, not place,” she said.

Kim Beckman, 64, and her husband, Mike, were ready to give up being homeowners in Victoria, Texas, and join a 55-plus community or rent in an independent living apartment building in northern Texas before COVID-19 hit.

Now, they’re considering buying an even bigger home because “if you’re going to be in the house all the time, you might as well be comfortable,” Beckman said.

“Everyone I know is talking about this,” said Wendl Kornfeld, 71, who lives on the Upper West Side of Manhattan. She has temporarily tabled the prospect of moving into a continuing care retirement community being built in the Bronx.

“My husband and I are going to play it by ear; we want to see how things play out” with the pandemic, she said.

In Kornfeld’s circles, people are more committed than ever to staying in their homes or apartments as long as possible — at least at the moment. Their fear: If they move to a senior living community, they might be more likely to encounter a COVID outbreak.

“All of us have heard about the huge number of deaths in senior facilities,” Kornfeld said. But people who stay in their own homes may have trouble finding affordable help there when needed, she acknowledged.

More than 70,000 residents and staff members in nursing homes and assisted living facilities had died of COVID-19 by mid-August, according to the latest count from KFF (Kaiser Family Foundation). This is an undercount because less than half of states are reporting data for COVID-19 in assisted living. Nor is data reported for people living independently in senior housing. (KHN is an editorially independent program of KFF.)

Nervousness about senior living has spread as a result, and in July, the National Investment Center for Seniors Housing & Care reported the lowest occupancy rates since the research organization started tracking data 14 years ago. Occupancy dropped more in assisted living (a 3.2% decline from April through June, compared with January through March) than in independent living (a 2.4% decline). The organization doesn’t compile data on nursing homes.

In a separate NIC survey of senior housing executives in August, 74% said families had voiced concerns about moving in as COVID cases spiked in many parts of the country.

Overcoming Possible Isolation

The potential for social isolation is especially worrisome, as facilities retain restrictions on family visits and on group dining and activities. (While states have started to allow visits outside at nursing homes and assisted living centers, most facilities don’t yet allow visits inside — a situation that will increase frustration when the weather turns cold.)

Beth Burnham Mace, NIC’s chief economist and director of outreach, emphasized that operators have responded aggressively by instituting new safety and sanitation protocols, moving programming online, helping residents procure groceries and other essential supplies, and communicating regularly about COVID-19, both on-site and in the community at large, much more regularly.

Mary Kazlusky, 76, resides in independent living at Heron’s Key, a continuing care retirement community in Gig Harbor, Washington, which is doing all this and more with a sister facility, Emerald Heights in Redmond, Washington.

“We all feel safe here,” she said. “Even though we’re strongly advised not to go into each other’s apartments, at least we can see each other in the hall and down in the lobby and down on the decks outside. As far as isolation, you’re isolating here with over 200 people: There’s somebody always around.”

One staff member at Heron’s Key tested positive for COVID-19 in August but has recovered. Twenty residents and staff members tested positive at Emerald Heights. Two residents and one staff member died.

Colin Milner, chief executive officer of the International Council on Active Aging, stresses that some communities are doing a better job than others. His organization recently published a report on the future of senior living in light of the pandemic.

It calls on operators to institute a host of changes, including establishing safe visiting areas for families both inside and outside; providing high-speed internet services throughout communities; and ensuring adequate supplies of masks and other forms of personal protective equipment for residents and staff, among other recommendations.

Some families now wish they’d arranged for older relatives to receive care in a more structured environment before the pandemic started. They’re finding that older relatives living independently, especially those who are frail or have mild cognitive impairments, are having difficulty managing on their own.

“I’m hearing from a lot of people — mostly older daughters — that we waited too long to move Mom or Dad, we had our head in the sand, can you help us find a place for them,” said Allie Mazza, who owns Brandywine Concierge Senior Services in Kennett Square, Pennsylvania.

While many operators instituted move-in moratoriums early in the pandemic, most now allow new residents as long as they test negative for COVID-19. Quarantines of up to two weeks are also required before people can circulate in the community.

Many older adults, however, simply don’t have the financial means to make a move. More than half of middle-income seniors — nearly 8 million older adults — can’t afford independent living or assisted living communities, according to a study published last year. And more than 7 million seniors are poor, according to the federal Supplemental Poverty Measure, which includes out-of-pocket medical expenses and other drains on cash reserves.

Questions to Ask

For those able to consider senior housing, experts suggest you ask several questions:

• How is the facility communicating with residents and families? Has it had a COVID outbreak? Is it disclosing COVID cases and deaths? Is it sharing the latest guidance from federal, state and local public health authorities?
• What protocols have been instituted to ensure safety? “I’d want to know: Do they have a plan in place for disasters — not just the pandemic but also floods, fires, hurricanes, blizzards?” Milner said. “And beyond a plan, do they have supplies in place?”
• How does the community engage residents? Is online programming — exercise classes, lectures, interest group meetings — available? Are one-on-one interactions with staffers possible? Are staffers arranging online interactions via FaceTime or Zoom with family? Are family visits allowed? “Social engagement and stimulation are more important than ever,” said David Schless, president of the American Seniors Housing Association.
• What’s the company’s financial status and occupancy rate? “Properties with occupancy rates of 90% or higher are going to be able to withstand the pressures of COVID-19 significantly more than properties with occupancy below 80%, in my opinion,” said Mace of the National Investment Center for Seniors Housing & Care. Higher occupancy means more revenues, which allows institutions to better afford extra expenses associated with the pandemic.

“Transparency is very important,” Schless said.

While it's long been known that smoke can be dangerous when in the thick of it — triggering asthma attacks, cardiac arrests, hospitalizations and more — the Seeley Lake research confirmed what public health experts feared: Wildfire haze can have consequences long after it's gone.

This article was published on Friday, September 18, 2020 in Kaiser Health News.

By Katheryn Houghton

SEELEY LAKE, Mont. — When researchers arrived in this town tucked in the Northern Rockies three years ago, they could still smell the smoke a day after it cleared from devastating wildfires. Their plan was to chart how long it took for people to recover from living for seven weeks surrounded by relentless smoke.

They still don’t know, because most residents haven’t recovered. In fact, they’ve gotten worse.

Forest fires had funneled hazardous air into Seeley Lake, a town of fewer than 2,000 people, for 49 days. The air quality was so bad that on some days the monitoring stations couldn’t measure the extent of the pollution. The intensity of the smoke and the length of time residents had been trapped in it were unprecedented, prompting county officials to issue their first evacuation orders due to smoke, not fire risk.

Many people stayed. That made Seeley Lake an ideal place to track the long-term health of people inundated by wildfire pollution.

So far, researchers have found that people’s lung capacity declined in the first two years after the smoke cleared. Chris Migliaccio, an immunologist with the University of Montana, and his team found the percentage of residents whose lung function sank below normal thresholds more than doubled in the first year after the fire and remained low a year after that.

“There’s something wrong there,” Migliaccio said.

While it’s long been known that smoke can be dangerous when in the thick of it — triggering asthma attacks, cardiac arrests, hospitalizations and more — the Seeley Lake research confirmed what public health experts feared: Wildfire haze can have consequences long after it’s gone.

That doesn’t bode well for the 78 million people in the western United States now confronting historic wildfires.

Toxic air from fires has blanketed California and the Pacific Northwest for weeks now, causing some of the world’s worst air quality. California fires have burned roughly 2.3 million acres so far this year, and the wildfire season isn’t over yet. Oregon estimates 500,000 people in the state have been under a notice to either prepare to evacuate or leave. Smoke from the West Coast blazes has drifted as far away as Europe.

Extreme wildfires are predicted to become a regular occurrence due to climate change. And, as more people increasingly settle in fire-prone places, the risks increase. That’s shifted wildfires from being a perennial reality for rural mountain towns to becoming an annual threat for areas across the West.

Dr. Perry Hystad, an associate professor in the College of Health and Human Sciences at Oregon State University, said the Seeley Lake research offers unique insights into wildfire smoke’s impact, which until recently had largely been unexplored. He said similar studies are likely to follow because of this fire season.

“This is the question that everybody is asking,” Hystad said. “‘I’ve been sitting in smoke for two weeks, how concerned should I be?’”

Migliaccio wants to know whether the lung damage he saw in Seeley Lake is reversible — or even treatable. (Think of an inhaler for asthma or other medication that prevents swollen airways.)

But those discoveries will have to wait. The team hasn’t been able to return to Seeley Lake this year because of the coronavirus pandemic.

Migliaccio said more research is needed on whether wildfire smoke damages organs besides the lungs, and whether routine exposure makes people more susceptible to diseases.

The combination of the fire season and the pandemic has spurred other questions as well, like whether heavy smoke exposure could lead to more COVID-19 deaths. A recent study showed a spike in influenza cases following major fire seasons.

“Now you have the combination of flu season and COVID and the wildfires,” Migliaccio said. “How are all these things going to interact come late fall or winter?”

A Case Study

Seeley Lake has long known smoke. It sits in a narrow valley between vast stretches of thick forests.

On a recent September day, Boyd Gossard stood on his back porch and pointed toward the mountains that were ablaze in 2017.

Gossard, 80, expects to have some summer days veiled in haze. But that year, he said, he could hardly see his neighbor’s house a few hundred feet away.

“I’ve seen a lot of smoke in my career,” said Gossard, who worked in timber management and served as a wildland firefighter. “But having to just live in it like this was very different. It got to you after a while.”

When Missoula County health officials urged people to leave town and flee the hazardous smoke, many residents stayed close to home. Some said their jobs wouldn’t let them leave. Others didn’t have a place to go — or the money to get there.

Health officials warned those who stayed to avoid exercising and breathing too hard, to remain inside and to follow steps to make their homes as smoke-free as possible. The health department also worked to get air filters to those who needed them most.

But when flames got too close, some people had to sleep outside in campsites on the other side of town.

Understanding the Science of Smoke

One of the known dangers of smoke is particulate matter. Smaller than the width of a human hair, it can bypass a body’s defenses, lodging deep into lungs. Lu Hu, an atmospheric chemist with the University of Montana, said air quality reports are based on how much of that pollution is in the air.

“It’s like lead; there’s no safe level, but still we have a safety measure for what’s allowable,” Hu said. “Some things kill you fast and some things kill you slowly.”

While air quality measurements can gauge the overall amount of pollution, they can’t assess which specific toxins people are inhaling. Hu is collaborating with other scientists to better predict how smoke travels and what pollutants people actually breathe.

He said smoke’s chemistry changes based on how far it travels and what’s burning, among other factors.

Over the past few years, teams of researchers drove trucks along fire lines to collect smoke samples. Other scientists boarded cargo planes and flew into smoke plumes to take samples right from a fire’s source. Still others stationed at a mountain lookout captured smoke drifting in from nearby fires. And ground-level machines at a Missoula site logged data over two summers.

Bob Yokelson, a longtime smoke researcher with the University of Montana, said scientists are getting closer to understanding its contents. And, he said, “it’s not all bad news.”

Temperature and sunlight can change some pollutants over time. Some dangerous particles seem to disappear. But others, such as ozone, can increase as smoke ages.

Yokelson said scientists are still a long way from determining a safe level of exposure to the 100-odd pollutants in smoke.

“We can complete the circle by measuring not only what’s in smoke, but measuring what’s happening to the people who breathe it,” Yokelson said. “That’s where the future of health research on smoke is going to go.”

Coping With Nowhere to Flee

In the meantime, those studying wildland smoke hope what they’ve learned so far can better prepare people to live in the haze when evacuation isn’t an option.

Joan Wollan, 82, was one of the Seeley Lake study participants. She stayed put during the 2017 fire because her house at the time sat on a border of the evacuation zone.

The air made her eyes burn and her husband cough. She ordered air filters to create cleaner air inside her home, which helped.

On a recent day, the air in Wollan’s new neighborhood in Missoula turned that familiar gray-orange as traces of fires from elsewhere appeared. Local health officials warned that western Montana could get hit by some of the worst air quality the state had seen since those 2017 fires.

If it got bad enough, Wollan said, she’d get the filters out of storage or look for a way to get to cleaner air — “if there is someplace in Montana that isn’t smoky.”

As the COVID-19 pandemic has laid bare healthcare inequities, more Black women are looking to home birth.

This article was published on Thursday, September 17, 2020 in Kaiser Health News.

By Rachel Scheier

From the moment she learned she was pregnant late last year, TaNefer Camara knew she didn't want to have her baby in a hospital bed.

Already a mother of three and a part-time lactation consultant at Highland Hospital in Oakland, Camara knew a bit about childbirth. She wanted to deliver at home, surrounded by her family, into the hands of an experienced female birth worker, as her female ancestors once did. And she wanted a Black midwife.

It took the COVID-19 pandemic to get her husband on board. "Up until then, he was like, 'You're crazy. We're going to the hospital,'" she said.

As the COVID-19 pandemic has laid bare healthcare inequities, more Black women are looking to home birth as a way not only to avoid the coronavirus but also to shun a health system that has contributed to African American women being three to four times more likely to die of childbirth-related causes than white women, regardless of income or education. Researchers argue that the roots of this disparity — one of the widest in women's healthcare — lie in long-standing social inequities, from lack of safe housing and healthy food to inferior care provided at the hospitals where Black women tend to give birth.

"It feels like we are needed," said midwife Kiki Jordan, who co-owns Birthland, a prenatal practice that opened early this year in a 400-square-foot storefront in Oakland's Temescal neighborhood targeting low-income women of color.

Since the COVID-19 pandemic hit in March, she said, the practice's clientele has more than tripled.

Images of hospitals inundated with coronavirus patients have sparked a flurry of new interest among women of all races in home births, which account for just over 1% of deliveries in the United States. Birth centers and midwives who attend home births say they've been swamped by new clients since the pandemic.

"Every midwife I'm talking to has seen their practice double or sometimes triple in the wake of COVID," said Jamarah Amani, a Florida midwife and co-founder of the National Black Midwives Alliance.

Many Americans think of giving birth at home as backward and scary, or as a quixotic practice of privileged white women, akin to cloth diaper services and home-cooked baby food.

But the growing interest in home births in recent years has fueled a growing Black midwifery movement that harks back to a venerable, if long-forgotten, tradition in the United States.

Jordan's practice is now 98% Black, "something I've never seen before," she said. She provides pre- and postnatal care regardless of where women plan to deliver, though the majority of her clientele choose home births.

African American infants are more than twice as likely to die as white infants, and the risks extend across social class. Tennis superstar Serena Williams' harrowing 2018 account of her own near-death postpartum experience with a blood clot in her lungs and a cascade of life-threatening complications was a sobering reminder that even wealth and fame are no protection from being dismissed or mistreated during one of the most vulnerable moments of a woman's life.

At least three Black women have died in childbirth since March in New York City, which was hit hard early on by the coronavirus. One of the women, 26-year-old Amber Isaac, had reportedly tried to switch to a home or birth-center delivery after not getting an in-person appointment with her obstetrician as providers abruptly switched to telemedicine in the wake of the shutdown.

For Katrina Ayoola, 29, avoiding unnecessary medical interventions that researchers say can lead to dangerous maternal complications was a key reason for switching to a home birth. As the coronavirus hit last spring, when Ayoola was around five months pregnant with her first baby, she was already frustrated with her obstetricians in Martinez, California. She didn't like their system of rotating providers, to whom she felt she constantly had to reexplain herself. The last straw was being told to go shopping for a home blood pressure monitor. They were sold out everywhere. "I ended up canceling what would have been an online appointment, and I haven't heard from them since," said Ayoola.

"I did not feel cared for," she said.

On Aug. 1, Ayoola delivered her son, Oluwatayo, at home in Fairfield with her husband, Daré, and her mother at her side following a 29-hour labor supervised by Jordan and her partner, Anjali Sardeshmukh.

"At the hospital, I'd probably have had a C-section," said Ayoola, who said her home birth was "an amazing, empowering experience," worth every penny of the out-of-pocket $4,500 the couple paid for it — a discount, based on their insurance and income, from Birthland's typical $6,500 fee.

Cost is a major barrier for poor people to access out-of-hospital births. Medicaid, the federal-state health insurance program that covers many low-income pregnant women, pays for home births in only a handful of states. Since 2015 these have included California, but reimbursement is low and bureaucratic requirements make it difficult for most midwives to accept Medi-Cal, California's Medicaid program. A quarter of U.S. states do not even offer midwife licenses, making the practice of home birth effectively illegal.

Jordan led a free-standing birth center in San Rafael that was the first in the state to accept Medi-Cal when it opened in 2016. She and a handful of other Black midwives around the country are leading the effort to make out-of-hospital births more accessible to low-income women, a group that could particularly benefit from community-based midwifery, according to a 2018 study.

Many of these birth workers are struggling to break even, but that's nothing new.

In past generations, Black midwives sometimes walked miles and stayed days with laboring women, massaging their feet, cooking and babysitting, and reading from the Bible in exchange for a few dollars or a chicken, according to historical accounts. Immigrants and African Americans dominated midwifery during much of this country's history, and in the South, enslaved women passed from mother to daughter childbirth techniques and remedies brought from West Africa starting in the 1600s.

In certain rural pockets, Black midwives continued to deliver babies for poor Black and white families alike, even into the last century, as modern obstetrics regulated traditional birth attendants virtually out of existence. Midwives delivered half of the nation's babies in 1900 and just over 10% by the 1930s, as physicians launched a campaign to promote hospital birth as safe and hygienic, while dismissing midwives as "relics of barbarism."

But in recent years, with hospital birth as the norm, the United States has registered the poorest birth outcomes in the industrialized world. The numbers have worsened during the past 25 years even as they've improved in most of the world, largely because of the disproportionate toll on African Americans.

California has led the effort to reverse that trend, cutting its maternal death rate by 55% between 2006 and 2013, though the disparity for Black mothers has persisted.

Researchers have documented countless instances of pregnant African American women being ignored, drug-tested without permission, or sutured without pain medication.

There is a growing consensus among medical researchers and social scientists that discrimination can result in toxic stress that causes maternal complications or premature births. Respectful, holistic prenatal care can improve outcomes, said Jennie Joseph, a British-trained midwife. Her prenatal clinic in Florida serving mostly low-income women of color has had consistently low rates of maternal complications and premature and low-birth-weight babies.

Joseph believes it matters less where a woman gives birth than how she is treated during the previous nine months, and most of her clients deliver in hospitals.

Groups like Amani's are encouraging more midwives of color to penetrate what she calls the profession's "old girls' network." Just 2% of American midwives are Black, and research has shown that Black patients tend to do better with Black providers.

There is evidence that their numbers are growing with demand, however. California now has about half a dozen licensed Black midwifery practices, including three that have opened in the San Francisco Bay Area since 2017.

Camara said she wanted to support them: She's had supportive, competent white birth attendants in the past, "but it wasn't the same," she said. "This is returning to what we did before."

At around 6 on a Saturday morning in mid-August, as a heat wave gripped the Bay Area, she phoned Jordan to tell her she was having contractions. Barely two hours later, the midwives helped her give birth to her son, Esangu, 8 pounds, 6 ounces, on her hands and knees on her living room floor.

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

Rachel Scheier: @rachelscheier