When Gwendolyn Davis received her husband's death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Melissa Bailey and Eli Cahan

On Sundays, Bishop Bruce Davis preached love. Through his Pentecostal ministry, he organized youth parades and gave computers, bicycles and food to families in need.

During the week, Bruce practiced what he preached, caring for prisoners at a Georgia hospital. On March 27 he began coughing, and on April 1 he was hospitalized. He’d tested positive for covid-19. The virus swept through his household, infecting his wife and daughter and hospitalizing their disabled son. Ten days after landing in the hospital, Bruce died.

But when Gwendolyn Davis received her husband’s death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.

“He wouldn’t have had kidney failure if he didn’t have covid,” Gwendolyn said.

After Bruce died, his wife applied to two pandemic relief programs seeking help with $1,500 in missed payments on a truck and an electricity bill. But, she said, she was denied because his death certificate didn’t mention covid-19.

“I think it’s wrong,” Gwendolyn said. “It’s almost like we didn’t count.”

The count has profound implications for families and the country. Omitting covid-19 on death certificates threatens to undercount the toll of the pandemic nationwide. For Davis’ family and others, it can pile financial hardship onto emotional despair, as death benefits and other covid-19 relief programs are withheld. Interviews with families across the U.S. shed light on reasons covid deaths are being undercounted — and the consequences loved ones have endured.

When covid patients die, the “immediate” cause of death is always something else, such as respiratory failure or cardiac arrest. Residents, doctors, medical examiners and coroners make the call on whether covid was an underlying factor, or “contributory cause.” If so, the diagnosis should be included on the death certificate, according to the Centers for Disease Control and Prevention.

Even beyond the pandemic, there is wide variation in how certifiers describe causes of death: “There’s just no such thing as an objective measure of cause of death,” said Lee Anne Flagg, a statistician at the CDC’s National Center for Health Statistics.

Partly because of a lack of training in how to fill them out, “the quality of the death certificates is not good,” said Dr. James Gill, vice president of the National Association of Medical Examiners. And in cases in which people had other chronic conditions, it can be difficult to determine whether covid was a contributing cause of death, he said. That was especially true early on, when reliable testing was not widely available.

Since early in the pandemic, the CDC has encouraged certifiers who suspect covid as a cause of death to list it on the death certificate as “probable” or “likely.”

Still, some clinicians are “reluctant to certify a death as a covid death without a test in hand,” Gill said.

It’s not clear how Bruce Davis’ case slipped under the radar. His death was certified by William Ken Garland, deputy coroner in Baldwin County. Reached by phone, Garland said the causes of death were provided by Dr. Joseph Coppiano, a medical resident who pronounced Davis dead at Augusta University Medical Center, about 90 miles away. No autopsy was done.

“I did certify the record, but that’s about all I did,” Garland said.

Hospital spokesperson Danielle Harris declined to comment on the case, citing patient privacy. She said the hospital follows Georgia Department of Public Health guidelines.

In the absence of certainty, the CDC has encouraged coroners to document the virus. “We’re not worried that we’re overcounting the number of [covid-19] deaths,” Farida Ahmad, epidemiologist and mortality surveillance team leader at NCHS, said in April.

Missed cases are one reason that experts agree covid deaths are being undercounted nationwide. As evidence for that, they point to the vast number of excess deaths — additional deaths compared to what would be expected based on prior-year numbers and demographic trends.

Over the past year, the U.S. had endured up to 431,792 excess deaths as of Jan. 6, with 68% directly attributed to covid, according to the CDC.

These excess deaths “tend to track pretty closely with covid cases, trailing by a couple of weeks,” said Daniel Weinberger, an epidemiologist at Yale School of Public Health who has published on this topic. “This strongly suggests that a large proportion of these uncounted deaths are due to covid but not recorded as such.”

We may never know how many covid deaths went uncounted: Postmortem tests can detect the virus, but it’s “unlikely that this type of testing will be performed at a [sufficient] scale,” Weinberger said. Early in the pandemic, especially in the Northeast, many of those who were treated clinically for covid and then died were not tested for the virus — so they never made it into the statistics.

Testing Troubles Affect Lawsuits, Hospital Bills

Inaccurate death certificates can make it harder to pursue a lawsuit or win a workers’ compensation case when a loved one dies after contracting covid on the job. Gwendolyn Davis did win workers’ compensation death benefits from Bruce’s employer, a state psychiatric facility in Milledgeville, by providing medical records. But problems with covid testing can complicate the process.

Bruce’s supervisor at work, Mark DeLong, also died after contracting covid, but it did not appear on his death certificate with the other causes: cardiopulmonary arrest, respiratory failure and diabetes.

The omission on DeLong’s certificate seemed to stem from a delay in test results: His covid-positive results didn’t arrive until three days after he died, according to his widow, Jan DeLong. She has asked the local coroner to correct the record.

In New Jersey, attorney Paul da Costa represents 75 family members who lost loved ones at veterans homes in Menlo Park and Paramus in April and May. He said he knows of at least five patients whose death certificates did not list covid-19 despite evidence suggesting it killed them.

The root problem, he said, was a “complete dearth of testing.” Patients were transferred to hospitals, or dying in the veterans facilities, without ever being tested, he said.

The gap between excess deaths and confirmed covid deaths has “narrowed over time as testing has increased,” Weinberger said.

Early testing inaccuracy may also have led to undercounting, which creates a different burden: hospital bills. Without a diagnosis, families can be on the hook for thousands of dollars in charges that otherwise would have been covered under the CARES Act.

Correcting the Record

In some cases, families have sought to have death certificates changed to reflect covid. Dorothy Payton, 95, who lived in the ManorCare nursing home in Denver, first showed covid symptoms April 5. Five days later, Payton — known as “Nana Dee” — tested positive for it. And on April 13, her husband, Edward Benjamin, received a call that she had died.

The death certificate offered a litany of causes: vascular dementia, atrial fibrillation, congestive heart failure, gait instability, difficulty swallowing and “failure to thrive.”

But not covid-19. So it “seemed logical to fight for listing her cause of death under her cause of death,” Benjamin said.

After a few calls, her husband was able to get the certificate amended. ManorCare could not be reached for comment.

For Benjamin, it wasn’t about public health statistics or financial considerations. It simply offers a sense of closure.

“I want her life and death remembered the way it was, and I’m glad we set the record straight,” he said. “It’s the first step towards moving on.”

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Although covid vaccines are highly effective, health experts say there are good reasons to continue to mask up.

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Liz Szabo

As an emergency physician, Dr. Eugenia South was in the first group of people to receive a covid vaccine. She received her second dose last week  — even before President-elect Joe Biden.

Yet South said she’s in no rush to throw away her face mask.

“I honestly don’t think I’ll ever go without a mask at work again,” said South, faculty director of the Urban Health Lab at the University of Pennsylvania in Philadelphia. “I don’t think I’ll ever feel safe doing that.”

And although covid vaccines are highly effective, South plans to continue wearing her mask outside the hospital as well.

Health experts say there are good reasons to follow her example.

“Masks and social distancing will need to continue into the foreseeable future — until we have some level of herd immunity,” said Dr. Preeti Malani, chief health officer at the University of Michigan. “Masks and distancing are here to stay.”

Malani and other health experts explained five reasons Americans should hold on to their masks:

1. No vaccine is 100% effective.

Large clinical trials found that two doses of the Moderna and Pfizer-BioNTech vaccines prevented 95% of illnesses caused by the coronavirus. While those results are impressive, 1 in 20 people are left unprotected, said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention.

Malani notes that vaccines were tested in controlled clinical trials at top medical centers, under optimal conditions.

In the real world, vaccines are usually slightly less effective. Scientists use specific terms to describe the phenomenon. They refer to the protection offered by vaccines in clinical trials as “efficacy,” while the actual immunity seen in a vaccinated population is “effectiveness.”

The effectiveness of covid vaccines could be affected by the way they’re handled, Malani said. The genetic material used in mRNA vaccines — made with messenger RNA from the coronavirus — is so fragile that it has to be carefully stored and transported.

Any variation from the CDC’s strict guidance could influence how well vaccines work, Malani said.

2. Vaccines don’t provide immediate protection.

No vaccine is effective right away, Malani said. It takes about two weeks for the immune system to make the antibodies that block viral infections.

Covid vaccines will take a little longer than other inoculations, such as the flu shot, because both the Moderna and Pfizer products require two doses. The Pfizer shots are given three weeks apart; the  Moderna shots, four weeks apart.

In other words, full protection won’t arrive until five or six weeks after the first shot. So, a person vaccinated on New Year’s Day won’t be fully protected until Valentine’s Day.

3. Covid vaccines may not prevent you from spreading the virus.

Vaccines can provide two levels of protection. The measles vaccine prevents viruses from causing infection, so vaccinated people don’t spread the infection or develop symptoms.

Most other vaccines — including flu shots — prevent people from becoming sick but not from becoming infected or passing the virus to others, said Dr. Paul Offit, who advises the National Institutes of Health and Food and Drug Administration on covid vaccines.

While covid vaccines clearly prevent illness, researchers need more time to figure out whether they prevent transmission, too, said Phoenix-based epidemiologist Saskia Popescu, an assistant professor in the biodefense program at George Mason University’s Schar School of Policy and Government.

“We don’t yet know if the vaccine protects against infection, or only against illness,” said Frieden, now CEO of Resolve to Save Lives, a global public health initiative. “In other words, a vaccinated person might still be able to spread the virus, even if they don’t feel sick.”

Until researchers can answer that question, Frieden said, wearing masks is the safest way for vaccinated people to protect those around them.

4. Masks protect people with compromised immune systems.

People with cancer are at particular risk from covid. Studies show they’re more likely than others to become infected and die from the virus, but may not be protected by vaccines, said Dr. Gary Lyman, a professor at Fred Hutchinson Cancer Research Center.

Cancer patients are vulnerable in multiple ways. People with lung cancer are less able to fight off pneumonia, while those undergoing chemotherapy or radiation treatment have weakened immune systems. Leukemia and lymphoma attack immune cells directly, which makes it harder for patients to fight off the virus.

Doctors don’t know much about how people with cancer will respond to vaccines, because they were excluded from randomized trials, Lyman said. Only a handful of study participants were diagnosed with cancer after enrolling. Among those people, covid vaccines protected only 76%.

Although the vaccines appear safe, “prior studies with other vaccines raise concerns that immunosuppressed patients, including cancer patients, may not mount as great an immune response as healthy patients,” Lyman said. “For now, we should assume that patients with cancer may not experience the 95% efficacy.”

Some people aren’t able to be vaccinated.

While most people with allergies can receive covid vaccines safely, the CDC advises those who have had severe allergic reactions to vaccine ingredients, including polyethylene glycol, to avoid vaccination. The agency also warns people who have had dangerous allergic reactions to a first vaccine dose to skip the second.

Lyman encourages people to continue wearing masks to protect those with cancer and others who won’t be fully protected.

5. Masks protect against any strain of the coronavirus, in spite of genetic mutations.

Global health leaders are extremely concerned about new genetic variants of the coronavirus, which appear to be at least 50% more contagious than the original.

So far, studies suggest vaccines will still work against these new strains.

One thing is clear: Public health measures — such as avoiding crowds, physical distancing and masks — reduce the risk of contracting all strains of the coronavirus, as well as other respiratory diseases, Frieden said. For example, the number of flu cases worldwide has been dramatically lower since countries began asking citizens to stay home and wear masks.

“Masks will remain effective,” Malani said. “But careful and consistent use will be essential.”

The best hope for ending the pandemic isn’t to choose between masks, physical distancing and vaccines, Offit said, but to combine them. “The three approaches work best as a team,” he said.

Across the country, some nursing home directors and healthcare officials say the partnership is actually hampering the vaccination process.

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Rachel Bluth and Lauren Weber

The effort to vaccinate some of the country's most vulnerable residents against covid-19 has been slowed by a federal program that sends retail pharmacists into nursing homes — accompanied by layers of bureaucracy and logistical snafus.

As of Thursday, more than 4.7 million doses of the Pfizer-BioNTech and Moderna covid vaccines had been allocated to the federal pharmacy partnership, which has deputized pharmacy teams from Walgreens and CVS to vaccinate nursing home residents and workers. Since the program started in some states on Dec. 21, however, they have administered about one-quarter of the doses, according to the Centers for Disease Control and Prevention.

Across the country, some nursing home directors and healthcare officials say the partnership is actually hampering the vaccination process by imposing paperwork and cumbersome corporate policies on facilities that are thinly staffed and reeling from the devastating effects of the coronavirus. They argue that nursing homes are unique medical facilities that would be better served by medical workers who already understand how they operate.

Mississippi's state health officer, Dr. Thomas Dobbs, said the partnership "has been a fiasco."

The state has committed 90,000 vaccine doses to the effort, but the pharmacies had administered only 5% of those shots as of Thursday, Dobbs said. Pharmacy officials told him they're having trouble finding enough people to staff the program.

Dobbs pointed to neighboring Alabama and Louisiana, which he says are vaccinating long-term care residents at four times the rate of Mississippi.

"We're getting a lot of angry people because it's going so slowly, and we're unhappy too," he said.

Many of the nursing homes that have successfully vaccinated willing residents and staff members are doing so without federal help.

For instance, Los Angeles Jewish Home, with roughly 1,650 staff members and 1,100 residents on four campuses, started vaccinating Dec. 30. By Jan. 11, the home's medical staff had administered its 1,640^th dose. Even the facility's chief medical director, Noah Marco, helped vaccinate.

The home is in Los Angeles County, which declined to participate in the CVS/Walgreens program. Instead, it has tasked nursing homes with administering vaccines themselves, and is using only Moderna's easier-to-handle product, which doesn't need to be stored at ultracold temperatures, like the Pfizer vaccine. (Both vaccines require two doses to offer full protection, spaced 21 to 28 days apart.)

By contrast, Mariner Health Central, which operates 20 nursing homes in California, is relying on the federal partnership for its homes outside of L.A. County. One of them won't be getting its first doses until next week.

"It's been so much worse than anybody expected," said the chain's chief medical officer, Dr. Karl Steinberg. "That light at the end of the tunnel is dim."

Nursing homes have experienced some of the worst outbreaks of the pandemic. Though they house less than 1% of the nation's population, nursing homes have accounted for 37% of deaths, according to the COVID Tracking Project.

Facilities participating in the federal partnership typically schedule three vaccine clinics over the course of nine to 12 weeks. Ideally, those who are eligible and want a vaccine will get the first dose at the first clinic and the second dose three to four weeks later. The third clinic is considered a makeup day for anyone who missed the others. Before administering the vaccines, the pharmacies require the nursing homes to obtain consent from residents and staffers.

Despite the complaints of a slow rollout, CVS and Walgreens said they're on track to finish giving the first doses by Jan. 25, as promised.

"Everything has gone as planned, save for a few instances where we've been challenged or had difficulties making contact with long-term care facilities to schedule clinics," said Joe Goode, a spokesperson for CVS Health.

Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, acknowledged some delays through the partnership, but said that's to be expected because this kind of effort has never before been attempted.

"There's a feeling they'll get up to speed with it and it will be helpful, as health departments are pretty overstretched," Plescia said.

But any delay puts lives at risk, said Dr. Michael Wasserman, the immediate past president of the California Association of Long Term Care Medicine.

"I'm about to go nuclear on this," he said. "There should never be an excuse about people not getting vaccinated. There's no excuse for delays."

Bringing in Vaccinators

Nursing homes are equipped with resources that could have helped the vaccination effort — but often aren't being used.

Most already work with specialized pharmacists who understand the needs of nursing homes and administer medications and yearly vaccinations. These pharmacists know the patients and their medical histories, and are familiar with the apparatus of nursing homes, said Linda Taetz, chief compliance officer for Mariner Health Central.

"It's not that they aren't capable," Taetz said of the retail pharmacists. "They just aren't embedded in our buildings."

If a facility participates in the federal program, it can't use these or any other pharmacists or staffers to vaccinate, said Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties.

But many nursing homes would like the flexibility to do so because they believe it would speed the process, help build trust and get more people to say yes to the vaccine, she said.

Howell pointed to West Virginia, which relied primarily on local, independent pharmacies instead of the federal program to vaccinate its nursing home residents.

The state opted against the partnership largely because CVS/Walgreens would have taken weeks to begin shots and Republican Gov. Jim Justice wanted them to start immediately, said Marty Wright, CEO of the West Virginia Healthcare Association, which represents the state's long-term care facilities.

The bulk of the work is being done by more than 60 pharmacies, giving the state greater control over how the doses were distributed, Wright said. The pharmacies were joined by Walgreens in the second week, he said, though not as part of the federal partnership.

"We had more interest from local pharmacies than facilities we could partner them up with," Wright said. Preliminary estimates show that more than 80% of residents and 60% of staffers in more than 200 homes got a first dose by the end of December, he said.

Goode from CVS said his company's participation in the program is being led by its long-term care division, which has deep experience with nursing homes. He noted that tens of thousands of nursing homes — about 85% nationally, according to the CDC — have found that reassuring enough to participate.

"That underscores the trust the long-term care community has in CVS and Walgreens," he said.

Vaccine recipients don't pay anything out-of-pocket for the shots. The costs of purchasing and administering them are covered by the federal government and health insurance, which means CVS and Walgreens stand to make a lot of money: Medicare is reimbursing $16.94 for the first shot and $28.39 for the second.

Bureaucratic Delays

Technically, federal law doesn't require nursing homes to obtain written consent for vaccinations.

But CVS and Walgreens require them to get verbal or written consent from residents or family members, which must be documented on forms supplied by the pharmacies.

Goode said consent hasn't been an impediment so far, but many people on the ground disagree. The requirements have slowed the process as nursing homes collect paper forms and Medicare numbers from residents, said Tracy Greene Mintz, a social worker who owns Senior Care Training, which trains and deploys social workers in more than 100 facilities around California.

In some cases, social workers have mailed paper consent forms to families and waited to get them back, she said.

"The facilities are busy trying to keep residents alive," Greene Mintz said. "If you want to get paid from Medicare, do your own paperwork," she suggested to CVS and Walgreens.

Scheduling has also been a challenge for some nursing homes, partly because people who are actively sick with covid shouldn't be vaccinated, the CDC advises.

"If something comes up — say, an entire building becomes covid-positive — you don't want the pharmacists coming because nobody is going to get the vaccine," said Taetz of Mariner Health.

Both pharmacy companies say they work with facilities to reschedule when necessary. That happened at Windsor Chico Creek Care and Rehabilitation in Chico, California, where a clinic was pushed back a day because the facility was awaiting covid test results for residents. Melissa Cabrera, who manages the facility's infection control, described the process as streamlined and professional.

In Illinois, about 12,000 of the state's roughly 55,000 nursing home residents had received their first dose by Sunday, mostly through the CVS/Walgreens partnership, said Matt Hartman, executive director of the Illinois Healthcare Association.

While Hartman hopes the pharmacies will finish administering the first round by the end of the month, he noted that there's a lot of "headache" around scheduling the clinics, especially when homes have outbreaks.

"Are we happy that we haven't gotten through round one and West Virginia is done?" he asked. "Absolutely not."

KHN correspondent Rachana Pradhan contributed to this report.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

My covid symptoms started Dec. 7, and we got our positive results back the next morning.

This article was published on Wednesday, January 14, 2021 in Kaiser Health News.

As a health care journalist in Los Angeles reporting on the pandemic, I knew exactly what I needed to do once I landed in the hospital with covid pneumonia: write my goodbye emails.

I’d seen coverage of some final covid messages during this terrible year. They were usually directed to spouses, but my No. 1 concern was how to explain my own death to my 3-year-old, Marigold, whom we call “Goldie.” How much of me would she remember, and how would she make peace with what happened to me, when I could barely believe it myself?

After the emergency room doctor confirmed pneumonia in both of my lungs on Dec. 17, I was whisked upstairs to the hospital’s covid unit, where I got a blood thinner injection, infusions of steroids and remdesivir, and continued on the supplemental oxygen they had started in the ER.

Immediately after the treatments, my mind was clearer and more focused than it had been in the nine days since my husband, daughter and I had all received positive covid results (and when my raging fevers began). As I lay in my hospital bed, my roommate’s TV blaring, I started thinking about my daughter’s understanding of death. A lapsed evangelical married to a Jewish man, I had adopted his family’s perspective on the afterlife — that discussing it wasn’t very important — but had also inadvertently abdicated the death discussion to Hollywood.

Goldie’s afterlife education began with the movie “Coco,” about the Mexican Day of the Dead, in which families put pictures of their ancestors on a home altar, or ofrenda. Then came “Over the Moon,” in 2020, about a little girl in China who loses her mom to illness and struggles to accept a new stepmother, all while her mom’s spirit visits her in the form of a crane.

That prompted her first question about my death.

“Are you going to die like Fei Fei’s mom did?” Goldie asked me in November, before I got sick. I told her at the time that no one knows when they’re going to die, but that I would love her with all of my heart for as long as I lived.

After that, Goldie would sometimes randomly declare, “I don’t think you’re going to die,” or she would ask if we could all die together, at the same time — to which I’d say, “Sure!”

My covid symptoms started Dec. 7, and we got our positive results back the next morning. Thankfully, my husband and daughter had almost no symptoms except stuffy noses and a day of low fever. But I started off with a fever that would burn me up to 104 degrees, over and over again. Tylenol and Advil could bring it down only to 100 or 101. I would cry as the painful fevers reached their peak and wondered if God had been preparing Goldie all along this year for my eventual death.

My breathing problems began eight days later. The scariest moment during that time was when I was in the middle of a shower (much needed after days of sweaty fevers) and realized I was gasping for air. I punched the shower curtains out of my way and ran to my bed, where I could lie on my stomach and get my oxygen levels up again. As I lay there, hyperventilating, soaking wet, with shampoo still in my hair, the pulse oximeter monitor registered 67, before inching back up to 92. I began thinking of what I wanted to say to Goldie in my final letter to her, but I was too weak to type it out.

Two more uterine procedures led to a successful embryo transfer, but a miscarriage put me in the ER on Oct. 8. By then, Los Angeles County had seen 278,665 cases and 6,726 deaths — horrifying numbers that I monitored and reported on as a health journalist, but data points I couldn’t, or wouldn’t, use to alter the decision-making in my own life.

With four miscarriages now under my belt and no more viable embryos left to use, my husband, Simon, and I decided we’d give in vitro fertilization one final try. I started my injections for an egg retrieval in late November, and by the time the procedure rolled around on Dec. 3, L.A. was well into its scary, almost vertical holiday season ascent, posting 7,854 new cases that day — up fivefold from a month earlier.

A close friend was supposed to start her IVF injections at the same time, but she decided to postpone at the last minute because covid cases were so high in our area. By that point, we were so driven in our pursuing of pregnancy that I was startled to hear her say that, as the thought had never even crossed my mind.

I have no way of knowing for sure if I was exposed to the virus sometime during this last fertility treatment. The surgical center is located on a large medical campus that also hosts a covid-19 testing drive-thru in the garage where we parked. We waited, masks on, for almost an hour outside the building, which we thought was a safer choice than the fertility clinic waiting room, but that actually put us in proximity to a lot of sick people waiting for rides home.

I also had to remove my mask just before the actual egg retrieval, because I was under anesthesia and the doctors needed quick access to my mouth in case I needed a breathing tube.

Five days after the egg retrieval, we found out we were covid-positive. I called the clinic right away to warn them; the fertility doctor told me a few days later that none of her staffers had gotten sick. And also that none of the eggs they retrieved from me had developed properly. We had no embryos to use.

Of course, as anyone who has done fertility treatments knows, all the dangers and risks we undertook would have been “worth it” if it had worked. Because it didn’t work for us, I felt defeated and foolish.

In sum, we wanted to give Goldie a sibling, but attempting to do so may have been what threatened her mother’s life. This thought haunts me and will stay with me forever, even though I’ll never know how exactly the virus entered our home.

Our nanny, who also experienced covid symptoms and tested positive three days before us, could have picked it up at the supermarket. We could have gotten it from her or while walking around our neighborhood or playing in the park. But the act of choosing, over and over again, to engage in fertility treatments as the pandemic raged on, fills me with doubt and remorse.

This was all too much to put in my goodbye letter to Goldie. Instead, this is some of what I wrote:

Around Halloween, you and I were eating breakfast together and I asked you how your life was going, and if there were any improvements I could make for you. You said, with absolute seriousness, “I’m afraid of ghosts.”

Now that I’m a ghost, I hope there’s less reason to be afraid.

Please put my picture on the ofrenda once a year. I’ll always be in your heart and in your memories. I will try to visit you too. But not in a spooky way, just a gentle way.

I will always love you. Thank you so much for being born to us. You made everything better.

After finishing my goodbye letter, I went to sleep. In the morning, I woke up, got a second infusion of steroids and remdesivir, and then was released home with oxygen tanks and an oxygen concentrator. I stayed in bed, on oxygen, for another week before my lungs were strong enough for me to stand and walk on my own. We had a wonderful Christmas morning together opening presents during a Zoom call with my family. Other than fatigue, I am now almost back to normal.

After the holidays, I sat down with Goldie for breakfast as we usually do. Feeling morose about how the year had turned out, I asked, dreading her response, if she would like to have a baby brother or sister one day.

She put her hand on my neck and pressed her forehead into mine, a face-to-face embrace that we call a “pumpkin hug.”

“No, Mom,” she said. “I want it to be just you and me, forever.”

I took a deep breath, and then sighed with relief.