If there is a silver lining to the flawed U.S. response to the coronavirus pandemic, it is this: The relatively high number of new cases being diagnosed daily — upward of 20,000 — will make it easier to test new vaccines.
To determine whether a vaccine prevents disease, the study's subjects need to be exposed to the pathogen as it circulates in the population. Reopening the economy will likely result in the faster spread of the coronavirus and therefore more opportunities to test a vaccine's efficacy in trial subjects.
Under a proposal under discussion by a committee set up by the National Institutes of Health, each of four or five experimental vaccines would be tested on about 20,000 trial participants with a placebo group of 10,000 for each vaccine. Some 50 U.S. medical centers — and perhaps an equal number overseas — would participate in these trials.
On Monday, Moderna, the biotech company, reported promising results in the first eight of 45 people enrolled in an initial test of the safety and immune responses to its vaccine. Analysts attributed a 900-point jump in the Dow that day at least partly to this very preliminary data, so eager are investors for any signs of progress in efforts to control the pandemic.
Moderna is running animal and human studies simultaneously and plans to invest hundreds of millions of dollars to build laboratories where the vaccine will be produced even before it's approved. The Food and Drug Administration on May 12 promised an accelerated review of Moderna's vaccine, which works by injecting pieces of synthetic viral RNA into the body to stimulate an immune response to the virus.
The speed in developing vaccines for widespread testing this summer is impressive, certainly compared with the nation's inadequate, delayed response to providing coronavirus testing and personal protective equipment to health care providers.
Still, many scientists have expressed skepticism at the breakneck timetable put forward by some Trump administration officials, who say that 100 million doses of a vaccine could be available by November. Even the normally sober Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, tolda Senate committee on May 12 that a vaccine could have proven safety and efficacy by then.
Running a trial of the size and speed contemplated by the NIH will be an immense undertaking. Just setting up trial locations and getting common consent and data-entry forms into shape usually take months. Enrolling 30,000 people for a single vaccine trial is a big challenge.
In addition, defining success in a vaccine against COVID-19 will be no simple matter. As scientists design vaccine trials, they first have to set the "endpoints" that determine success or failure. Death? Length of illness? Hospitalization? Number of days in which a subject is infectious?
If there is little virus circulating where a trial is being run, even a vast study won't prove anything. On the other hand, if a vaccine trial had started in early April in New York City, where roughly 10,000 cases a day were reported for weeks, 30,000 participants would have been plenty to show whether the vaccine protected against the disease.
In all likelihood, the big NIH trials will focus on rates of infection as well as clinical symptoms such as fever and cough. To discover whether the vaccine prevents severe disease, which is relatively rare, is harder. COVID-19, according to one account, kills about 0.6% of those it infects, while perhaps six times that many require hospitalization.
People who take part in a trial will be given clear instructions to protect themselves against infection through social distancing, face masks, frequent hand-washing and so on. That will lower the number of people infected during the study.
"You'd have to ask all the people enrolled in a trial to practice good hygiene," said Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia. "You don't want them to get infected — but you do."
When Jonas Salk announced the successful trial of his polio vaccine in 1955, the nation celebrated a vaccine that could virtually eliminate a deadly infectious disease overnight. A new coronavirus vaccine may not provide that kind of overnight success. Instead, it may be more akin to the flu vaccine, which reduces the risk or severity of the illness but requires a new shot each year.
Vaccinating 20,000 people in a trial can reveal whether a vaccine is clearly dangerous to a general population. But when 200 million receive the same vaccine, less common side effects could still affect thousands. Botched batches of polio vaccines released after Salk's trial permanently paralyzed 200 people and killed 10. Early vaccines against measles caused tens of thousands of cases of grave illness in the 1960s.
Maurice Hilleman, the vaccine pioneer who developed successful vaccines against measles, mumps, hepatitis A and B and other diseases, once said he never breathed a sigh of relief "until the first 3 million doses" had been delivered.
Unexpected problems naturally bedevil quick rollouts, as this one will almost certainly be as the nation searches for a way to check a pandemic that is killing tens of thousands of Americans and paralyzing the economy. But as Gregory Poland, the leader of Mayo Clinic's vaccine research, told me, "There is an irresolvable tension of speed versus safety."
Allen is the San Francisco editor for California Healthline, produced by Kaiser Health News, and the author of "Vaccine: The Controversial Story of Medicine's Greatest Lifesaver."
To reopen businesses and public spaces safely, experts say, states need to be testing and contact tracing on a massive scale. But only a handful of states are doing enough testing to stay on top of potential outbreaks, according to a state-by-state analysis published by NPR.
Among those, Tennessee stands out for its aggressive approach to testing. In Tennessee, anyone who wants a test can get one, and the state will pick up the tab. The guidance has evolved to "when in doubt, get a test," and the state started paying for it in April.
It's still rare for a community to encourage such broad symptom-free testing.
"In most places, you still need to show you have the signs and symptoms of COVID-19 to get a test," research professor Sabrina Corlette of Georgetown University said. "It's really patchwork."
Ample testing, preferably including people who are not symptomatic, can help contain future outbreaks of COVID-19 by giving health officials the knowledge to act quickly to suppress any new cluster of cases.
Because of testing shortages, many states still have limitations on who can get a test. Some states, such as Alabama, are inviting people without symptoms to be tested, but only if they qualify as high-risk. A few counties in Nevada have started asymptomatic testing, and Rite Aid in a dozen states has opened up its walk-in testing, but it's still for people who preregister.
Tennessee's commitment to testing so broadly has helped it pull ahead of most other states in its rate of testing. According to NPR's analysis, Tennessee is doing more than double the minimum number of tests needed to control its outbreak.
Tennessee Department of Health Commissioner Lisa Piercey gave credit for much of the state's testing success to private, commercial labs.
"We've called on almost all of them to say, 'We need you to ramp up, because you're about to get a flood of tests,' and that's exactly what we've given them," Piercey said at a daily briefing in late April.
In one weekend, it was more than 11,000 tests.
But private labs are shouldering the testing load in most states. What's novel in Tennessee is that the state guaranteed payment to those companies upfront.
So, rather than making them bill various health insurance plans — which are required to cover coronavirus testing but still create paperwork — the state is picking up the tab. And the typical rate set by the federal government just doubled to $100 a swab.
Memphis-based American Esoteric Laboratories has been processing the bulk of the state-collected swabs. The company declined to comment for this story.
Nashville-based Aegis Sciences Corp. jumped in more recently and is already doubling its capacity to 7,000 tests a day. CEO Frank Basile said the guaranteed payment was a big motivator.
"Clearly, it's beneficial for the lab companies like us to receive the assurance of payment," Basile said. "That's definitely a positive. And it gives us the confidence to put the effort and the capital in to make this happen."
And coronavirus testing requires more investment right now because the swabs and chemicals necessary to do it are in such high demand.
The tax dollars are well spent, said Dr. Ashish Jha, faculty director of the Harvard Global Health Institute, which has been tracking testing capacity by state. He said Tennessee's investment could more than pay for itself since ample capacity is seen as a necessity to reopen businesses. Jha said he's been recommending this approach to government officials across the country.
"If the state says they'll just pay everybody 100 bucks every time you do a test, that strikes me as very smart policy," he said.
Tennessee officials said they're banking on being reimbursed by the federal government at some point.
The Tennessee Department of Health doesn't yet know exactly how much it's on the hook for. But the tab grows by millions of dollars a week. Aside from weekend drive-thru events, the state is also paying to process the weekday testing being done by local health departments in 95 counties.
On a recent Sunday, more than 800 people were tested at a site in Hendersonville. Christine Garner was willing to wait in her minivan as she slowly moved through the parking lot of a local high school. "I said, 'I know there will be a long line, but we'll just sit and wait.' We charged our tablets, and I'm doing sight words with the kids," she said.
Garner closes refinanced mortgages for a living, which puts her in close contact with multiple families a day — often in their homes. Still, she had no symptoms. And her closest contact to someone with COVID-19 was secondhand.
"I'm just hypersensitive to any change in my body at all. I think a lot of people are," she said.
All this testing access is generally a good thing, said Dr. Kelly Moore, a pandemic consultant, formerly of the state health department. She refers to the test takers as primarily "the worried well" since nearly 99% of them have tested negative at some testing events.
"If these highly motivated, worried well people coming out for free tests are not taking up scarce resources we need for someone else, then it's definitely not a problem to test them," Moore said.
But there's a potential downside. All those negative test results improve a state's closely watched positivity rate — that is the percentage of cases coming back positive. A low rate of positives is seen as a sign that a community is doing enough testing. But it's possible to miss pockets of infection among people who might not have the awareness or resources to get tested.
"We can't draw conclusions about what's going on in the whole community based on this self-selected group of people who are so motivated they come out to get tested," Moore said.
From March 8 to April 11, the number of organ donors who died in traffic collisions was down 23% nationwide, while donors who died in all other types of accidents were down 21%.
This article was first published on Tuesday, May 19, 2020 in Kaiser Health News.
On Day Two of the San Francisco Bay Area's stay-at-home orders in March, Nohemi Jimenez got into her car in San Pablo, California, waved goodbye to her 3-year-old son and drove to her regular Wednesday dialysis appointment.
The roads were deserted. No traffic. Jimenez, 30, said it is hard to admit what she thought next: No traffic meant no car accidents. And that meant she'd be on the waiting list for a kidney transplant even longer.
"I don't want to be mean, but I was like, 'Oh, my God. Nobody's going to die,'" she said. "I'm not going to get my transplant."
Jimenez was 20 and pregnant with her first child when doctors discovered she had been born with only one kidney, and that lone kidney was failing. By age 29, doctors told her she needed a new one. It was strange and scary, she said, waiting for someone to die so she could live.
"You're just thinking about it," she said. "It's sitting in your mind. It just can never leave you alone."
Deaths from accidents are the biggest source of organs for transplant, accounting for 33% of donations, according to the United Network for Organ Sharing, UNOS, which manages the nation's organ transplant system.
But since the coronavirus forced Californians indoors, accidents have declined. Traffic collisions and fatalities in the state dropped by half in the first three weeks of sheltering in place, according to a study by the University of California-Davis. Drowning deaths dropped 80% in California, according to data compiled by the nonprofit Stop Drowning Now.
In April organ procurement organizations typically see a surge in donations related to outdoor, spring break-related activities and travel, but not this year.
From March 8 to April 11, the number of organ donors who died in traffic collisions was down 23% nationwide compared with the same period last year, while donors who died in all other types of accidents were down 21%, according to data from UNOS.
"Spring break accidents are almost nonexistent because there's no spring break — beach accidents, motorcycle accidents, hunting accidents," said Janice Whaley, CEO of Donor Network West, which manages organ donations for Northern California and Nevada.
Doctors said they've also noticed a decline in emergency room visits overall, not just for accidents, and this may also be limiting the supply of donor organs.
"Where are all the people with heart attacks? Where are all the people with strokes?" said George Rutherford, a professor and infectious disease physician at the University of California-San Francisco. "Are those patients staying away from the ERs for fear of COVID? Clearly, the census is way down in ERs."
Strokes and heart attacks are the second and third most common sources of organ donations, accounting for 27% and 20% of organs, respectively, according to UNOS.
When people die from a stroke or heart attack at home instead of a hospital, their organs cannot be used for transplant because of lost blood flow. Most organ donations occur after a person suffers a near-fatal event and lifesaving measures do not work. For organs to be viable, people must die or be declared brain-dead while on a ventilator, so blood keeps pumping to the heart, lungs, liver and kidneys.
COVID Preparations Slow Transplant Pipeline
A range of other logistical complications have made transplants difficult during the coronavirus pandemic. Hospitals have had to scale back surgeries of all kinds to preserve scarce supplies of personal protective equipment and ventilators. And many haven't had the bandwidth to manage the delicate timing and complexity of organ donation, recovery, transportation and transplantation.
Transplant surgeries across the country plummeted 52% from March 8 to April 11, according to UNOS data.
"There's a lot of things that have to happen perfectly, and now we're in an imperfect situation where we're trying to deal with so many other things," Whaley said.
As medical centers braced for a wave of COVID-19 patients, they wanted to free up as many ventilators as possible. In addition to donors needing to die on ventilators to keep their organs viable, doctors often keep them on ventilators for two or three days while transplant teams and recipients are lined up. Then the recipients need to be on ventilators during surgery.
"People were very antsy about having non-COVID-19 patients on ventilators, taking up space," Whaley said. "They wanted to make sure they were ready for that next patient."
Many COVID patients who died offered their organs for donation, but those were declined out of concern that recipients could become infected, she said.
And a shortage of coronavirus testing supplies made it difficult for transplant centers to test potential donors who later died of other causes to make sure they were not infected with the virus.
"So there may have been some organ turndowns that we normally wouldn't have seen," said Dr. Chris Freise, a professor and transplant surgeon at UCSF.
As a matter of policy, hospitals canceled virtually all organ transplants from living donors, where a family member or someone else donates a kidney or section of their liver.
"That involves bringing two patients into the hospital — the donor and the recipient — and we certainly didn't want to put donors at any significant extra risk," Freise said. "Living-donor kidney transplant ground down to almost a complete halt in most programs across the country."
Some hospitals began doing living donations again in early May, while donations from deceased donors started to increase slowly in mid-April.
That's when Jimenez got her call from Freise's team at UCSF. A condition related to Jimenez's three pregnancies made finding a donor match for her very difficult, Freise said, "like a needle in a haystack." That also put her at the top of the waiting list in case a match was found.
Jimenez's phone rang at 2 a.m. on April 17. A transplant staffer told her to get to the hospital right away.
"I was excited," Jimenez said. "But then my mind hit me: Somebody died."
All she knows is that the donor was 19 and died in an accident in Los Angeles. Jimenez wrote a letter to the donor's family.
"I told them that I will forever be thinking of them," she said. "I will have him or her in my body for the rest of my life, and I will live for both of us."
Jimenez has six months of recovery ahead of her. She said she's looking forward to going back to work and having more energy to play with her kids.
This story is part of a reporting partnership that includes KQED, NPR and Kaiser Health News.
Children have largely escaped the ravages of COVID-19, but children's hospitals have not eluded the financial pain the pandemic has wrought on health care providers.
Pediatric hospitals offered themselves as backups to their adult counterparts in case of a surge of coronavirus patients. They suspended nonemergency surgeries and stockpiled protective gear and virus test kits, according to hospital executives and financial analysts.
But, in many regions, the surge was smaller than anticipated – or hasn't materialized. And children's hospitals that have offered to take sick kids off the hands of adult hospitals, or extend the age of people they admit, have not seen an influx of patients to fill the beds they emptied. As a result, numerous pediatric facilities, like many of the adult ones, face sharply declining revenues and extra expenses.
"We turned off a significant volume of our activity for a surge that isn't going to occur. And since we've had continuing expenses, it's been pretty devastating," said Paul A. King, CEO of Stanford Children's Health, which runs Lucile Packard Children's Hospital in Palo Alto, California.
King said he expected annual net revenue for the hospital and its affiliated clinics to drop about 10%. Lucile Packard's net revenue in 2019 was about $1.7 billion, according to data from California's Office of Statewide Health Planning and Development.
Other children's hospitals have given similarly downbeat assessments.
Many of them — including Lucile Packard and UCSF Benioff Children's Hospital — have furloughed staff members, required them to use paid vacation time, or cut hours or pay.
Robin Leffert, a registered nurse at UCSF Benioff's hospital in Oakland, California, said she's seen a "huge drop-off" in patients. Many staffers have been temporarily cut, requiring the nurses who are still working to perform extra tasks. "The physical environment feels different," she said. "There's an eerie, empty quality to it. But that doesn't decrease the tension we are feeling."
Stay-at-home orders have reduced car accidents, injuries and illnesses that would normally bring kids to the ERs of children's hospitals, while parents' fear of exposing their families to the COVID-19 virus has exacerbated the trend.
In early February, Jennifer Griffin, a 44-year-old mother of two boys, decided against taking her 9-year-old for adenoid removal surgery at Renown Children's Hospital in Reno, Nevada, where they live.
"We were not comfortable with what was going on with COVID and didn't know what the exposure was going to be like," Griffin said.
Renown, like many other children's hospitals, has begun to resume some of the nonemergency surgeries it halted as the COVID pandemic spread. Griffin is still not convinced it's safe to bring in her son, however.
"If people continue to not abide by the distancing guidelines and isolation guidelines, I might wait," she said.
Nicholas Holmes, chief operating officer of Rady Children's Hospital in San Diego, said his facility faces similar parent concerns and is making a push — via social media and in collaboration with local pediatricians — to "make sure families know it is safe to come to the campus."
For all their current problems, however, pediatric hospitals were generally in a stronger financial position than adult facilities before the pandemic, so many of them "are absolutely well positioned to weather the storm," said Kevin Holloran, a senior director at Fitch Ratings.
A 2019 Fitch report based on 2018 hospital audits showed the aggregate operating profit margin of a representative sample of not-for-profit children's hospitals was nearly triple that of nonprofit adult hospitals. The pediatric facilities had enough cash on hand to last 1.6 times longer than the adult hospitals.
In California, the average operating profit margin of children's hospitals was almost three times that of non-children's facilities last year — though individual results ranged widely, from an extremely profitable 25.38% for Rady to operating losses for UCSF Benioff's Oakland hospital (-0.78%) and Lucile Packard (-2.53%), according to the Office of Statewide Health Planning and Development.
Holloran and others say children's hospitals typically benefit from strong philanthropic and public support, and their specialization in complex acute cases results in higher prices while often affording them a commanding pediatric market share.
In 2018, California voters approved $1.5 billion in state bonds to help children's hospitals with capital expenses including equipment, construction and seismic retrofitting. That means they can save some of the dollars they would have spent on such projects.
So far, however, just 9% of that money — $142.1 million — has been distributed, and to only three hospitals, according to Frank Moore, executive director of the California Health Facilities Financing Authority.
Children's hospitals across the U.S. have reported declines in surgery and outpatient procedures of 60% to 80%, with inpatient admissions cut by nearly half as of the end of April, said Amy Knight, chief operating officer of the Children's Hospital Association in Washington, D.C.
At Children's Hospital New Orleans, ER visits plummeted from 4,000 in February to 1,700 in April, said Matt Schaefer, the chief operating officer. Outpatient visits dropped from 1,100 to about 400 over the same period. The hospital, like others around the country, has managed to offset some of the loss in outpatient volume with telehealth.
When COVID-19 was wreaking havoc in southeastern Louisiana, the children's hospital offered to take pediatric patients from adult hospitals and admit patients up to age 30, said George Bisset, the chief medical officer. "But we didn't get a lot of takers."
Children's facilities received virtually none of the first $30 billion in federal relief money intended for hospitals and other providers, though they have received some of a subsequent $20 billion tranche.
Children's hospitals that are part of larger health systems may also benefit from the aid received by affiliated adult hospitals. And belonging to a hospital chain can allow for greater operational flexibility, industry executives say.
Cohen Children's Medical Center in Queens, New York, part of the $13.5 billion, 23-hospital Northwell Health system, redeployed numerous staff members to the adult hospitals that were struggling to cope with an onslaught of COVID-19 cases, said Dr. Charles Schleien, Cohen's vice president for pediatric services.
Cohen also turned over more than half its beds to Long Island Jewish Medical Center, an adult hospital connected to Cohen by a hallway, and converted virtually every available space to more adult beds, Schleien said.
But filling beds with COVID patients doesn't offset the lost revenue from suspending profitable elective surgeries anyway, Schleien said. "The economics of it are brutal, because when you lose elective surgeries, that's where your margin is."
Even though children's hospitals have begun to resume nonemergency surgeries, they will likely continue to face financial challenges.
"If we enter into a recession, and particularly if it is prolonged, that will have an effect on hospitals, including children's hospitals, because people won't have jobs and may be uninsured, or more may be on Medicaid, which doesn't pay as well," said Lisa Martin, a senior vice president on the not-for-profit health care ratings team at Moody's Investors Service.
In California, nearly 60% of children's hospital charges are tied to Medicaid, more than double the proportion for adult hospitals, according to OSHPD data. At some pediatric facilities in the U.S., that figure is well above 70%.
After spending staggering sums to mitigate the consequences of the pandemic, Congress will be looking for programs to prune, said Knight, of the Children's Hospital Association. "One with a target on its back is Medicaid."
Jordan Rau, a senior correspondent for Kaiser Health News, contributed to this report.
Casa de Salud, a nonprofit clinic in Albuquerque, New Mexico, provides primary medical care, opioid addiction services and non-Western therapies, including acupuncture and reiki, to a largely low-income population.
And, like so many other health care providers that serve as a safety net, its revenue — and its future — are threatened by the COVID-19 epidemic.
"I've been working for the past six weeks to figure out how to keep the doors open," said the clinic's executive director, Dr. Anjali Taneja. "We've seen probably an 80% drop in patient care, which has completely impacted our bottom line."
In March, Congress authorized $100 billion for health care providers, both to compensate them for the extra costs associated with caring for patients with COVID-19 and for the revenue that's not coming in from regular care. They have been required to stop providing most nonemergency services, and many patients are afraid to visit health care facilities.
But more than half that money has been allocated by the Department of Health and Human Services, and the majority of it so far has gone to hospitals, doctors and other facilities that serve Medicare patients. Officials said at the time that was an efficient way to get the money beginning to move to many providers. That, however, leaves out a large swath of the health system infrastructure that serves the low-income Medicaid population and children. Casa de Salud, for example, accepts Medicaid but not Medicare.
State Medicaid directors say that without immediate funding, many of the health facilities that serve Medicaid patients could close permanently. More than a month ago, bipartisan Medicaid chiefs wrote the federal government asking for immediate authority to make "retainer" payments — not related to specific care for patients — to keep their health providers in business.
"If we wait, core components of the Medicaid delivery system could fail during, or soon after, this pandemic," wrote the National Association of Medicaid Directors.
So far, the Trump administration has not responded, although in early April it said it was "working rapidly on additional targeted distributions" for other providers, including those who predominately serve Medicaid patients.
In an email, the Centers for Medicare & Medicaid Services said officials there will "continue to work with states as they seek to ensure continued access to care for Medicaid beneficiaries through and beyond the public health emergency."
CMS noted that states have several ways of boosting payments for Medicaid providers, but did not directly answer the question about the retainer payments that states are seeking the authority to make. Nor did it say when the funds would start to flow to Medicaid providers who do not also get funding from Medicare.
The delay is frustrating Medicaid advocates.
"This needs to be addressed urgently," said Joan Alker, executive director of Georgetown University's Center for Children and Families in Washington, D.C. "We are concerned about the infrastructure and how quickly it could evaporate."
In the administration's explanation of how it is distributing the relief funds, Medicaid providers are included in a catchall category at the very bottom of the list, under the heading "additional allocations."
"To not see anything substantive coming from the federal level just adds insult to injury," said Todd Goodwin.
He runs the John F. Murphy Homes in Auburn, Maine, which provides residential and day services to hundreds of children and adults with developmental and intellectual disabilities. He said his organization — which has already furloughed almost 300 workers and spent more than $200,000 on COVID-related expenses including purchases of essential equipment such as masks and protective equipment that will not be reimbursable — has not been eligible for any of the various aid programs passed by Congress. It gets most of its funding from Medicaid and public school systems.
The organization has tapped a line of credit to stay afloat. "But if we're not here providing these services, there's no Plan B," he said.
Even providers who largely serve privately insured patients are facing financial distress. Dr. Sandy Chung is CEO of Trusted Doctors, which has about 50 physicians in 13 offices in the Northern Virginia suburbs around Washington, D.C. She said about 15% of its funding comes from Medicaid, but the drop off in private and Medicaid patients has left the group "really struggling."
"We've had to furlough staff, had to curtail hours, and we may have to close some locations," she said.
Of special concern are children because Medicaid covers nearly 40% of them across the county. Chung, who also heads the Virginia chapter of the American Academy of Pediatrics, said that vaccination rates are off 30% for infants and 75% for adolescents, putting them and others at risk for preventable illnesses.
The biggest rub, she added, is that with the economy in free fall, more people will qualify for Medicaid coverage in the coming weeks and months.
"But if you don't have providers around anymore, then you will have a significant mismatch," she said.
Back in Albuquerque, Taneja is working to find whatever sources of funding she can to keep the clinic open. She secured a federal loan to help cover her payroll for a couple of months, but worries what will happen after that. "It would kill me if we've survived 15 years in this health care system, just to not make it through COVID," she said.
KHN senior correspondent Phil Galewitz contributed to this story.
Coronavirus patients and their families who believe a doctor, nurse, hospital or other provider made serious mistakes during their care may face a new hurdle if they try to file medical malpractice lawsuits.
This story was first published on Friday, May 15, 2020 in Kaiser Health News.
Coronavirus patients and their families who believe a doctor, nurse, hospital or other provider made serious mistakes during their care may face a new hurdle if they try to file medical malpractice lawsuits.
Under pressure from health provider organizations, governors in Connecticut, Maryland, Illinois and several other states have ordered that most providers be shielded from civil ― and, in some cases, criminal — lawsuits over medical treatment during the COVID-19 health emergency. In New York and New Jersey, immunity is now part of state law. In California, six hospital, physician and long-term care provider groups are pressing Gov. Gavin Newsom to also issue an order assuring immunity.
The efforts are attracting congressional attention as well and threatening to derail the next federal coronavirus stimulus package on Capitol Hill. Senate Majority Leader Mitch McConnell is demanding that Congress include liability protections against COVID-related suits for businesses and health care providers. The contentious issue of legal liability claims in health care has divided congressional Republicans and Democrats for years.
“We are not going to let health care heroes emerge from this crisis facing a tidal wave of medical malpractice lawsuits so that trial lawyers can line their pockets,” the Kentucky Republican said in the Senate on Tuesday. “This will give our doctors, nurses and other health care providers a lot more security as they clock in every day and risk themselves to care for strangers.”
Some legal experts and seniors’ advocates worry that the state immunity guarantees go too far, leaving patients with no way to hold providers accountable. Supporters argue that health care providers and facilities deserve protection from lawsuits as they battle a deadly virus during an unprecedented public health emergency.
Pennsylvania Gov. Tom Wolf, a Democrat, joined the movement last week, acknowledging that the COVID-19 epidemic has “required our health care providers to broaden their professional responsibilities and experiences like never before.” Like other governors, Wolf included in his order exceptions for the most egregious lapses in care involving intentional misconduct or extreme negligence.
“When you are asking nurses to work around-the-clock and the ICU has 2½ times as many people than it was engineered for, well, my goodness, doesn’t this make common sense?” said Kenneth Raske, president and chief executive officer of the Greater New York Hospital Association, which represents more than 160 hospitals and health systems in New York, New Jersey, Connecticut and Rhode Island.
The group helped draft New York’s immunity measure, said Raske. Supporters also include the American Medical Association, which urged the National Governors Association to use the New York law as a model for other states.
Immunity for providers during the COVID-19 emergency “is good for patients” because it encourages providers to work in extraordinarily tough conditions, said James Hodge, an Arizona State University law professor and regional director at the Network for Public Health Law.
It is an extension of the usual protection for a “good Samaritan” — the doctor or nurse who sees a car accident, for example, and stops to help the injured. The well-intentioned doctor doesn’t have the equipment and support of a hospital and shouldn’t be held to the same standards.
Similarly, some well-intentioned medical providers treating COVID-19 patients work with scarce supplies and overburdened staff and face other conditions often beyond their control.
Since some states offer no virus-related liability protection for long-term care providers — such as skilled nursing facilities, assisted living communities and continuing care retirement communities — during the current crisis, their trade associations are looking to the federal government instead.
“Long-term care workers and centers are on the front line of this pandemic response,” said Cristina Crawford, a spokesperson for the American Health Care Association, “and it is critical that states and the federal government provide the necessary liability protection.”
But Mairead Painter, director of Connecticut’s State Long Term Care Ombudsman Program, said the immunity guarantee could discourage nursing home residents and their families from filing complaints about abuse or neglect, or challenging their transfer to other homes as administrators try to separate residents who have the coronavirus from those without it.
“So they might sort of just let it fall to the wayside, and we don’t want them to do that,” she said.
As infection rates slowly decrease, providers should be expected to follow the usual standard of care, said Barry Furrow, director of Drexel University law school’s health law program in Philadelphia, who has studied hospital corporate negligence.
“These immunity statutes do too much, because now we’re settling back to a more normalized health care situation where we have a new disease vector, which we’re beginning to understand,” he said.
The immunity guarantee covers the duration of the COVID-19 emergency, which could continue for several more months, if not longer, Furrow said, so states are letting providers “off the hook.”
Despite the state immunity guarantees, the Centers for Medicare & Medicaid Services ordered state health inspectors to crack down on nursing homes that don’t follow infection-control requirements, and, starting May 8, required facilities to inform residents or their families by 5 p.m. the day after a new case of COVID-19 is confirmed. And officials in some parts of the country have begun criminal investigations of nursing homes suspected of endangering residents.
The mixed messages are most evident in New York, the coronavirus epicenter in the U.S., which has one of the nation’s most comprehensive COVID-19 shields against medical liability. It protects individual medical professionals as well as health care facilities from both civil and criminal lawsuits involving any patients, regardless of whether they had the virus. There’s an exception for egregious conduct, which Furrow said is a high bar and up to a jury to define.
“This sends a message to the nursing home inspectors to step back,” said Richard Mollot, executive director of the Long Term Care Community Coalition in New York City. “This is an insidious quieting of accountability just when it is needed the most.”
But Dani Lever, a spokesperson for Gov. Andrew Cuomo, said the immunity law “imposes no limitations on the ability of the state to investigate nursing homes.”
About 20% of the 27,450 confirmed and presumed coronavirus deaths in the state by Wednesday have occurred in nursing homes, prompting an investigation by Cuomo and Attorney General Letitia James. When Cuomo described the investigation, he was both sympathetic and critical of nursing homes.
“This is a crisis situation for nursing homes … through no fault of their own,” he said. “Mother Nature brought a virus and the virus attacks old people.” Nonetheless, he added, they must “do their job by the rules and regulations.”
Although scientists and stock markets have celebrated the approval for emergency use of remdesivir to treat COVID-19, a cure for the disease that has killed nearly 260,000 people remains a long way off — and might never arrive.
Hundreds of drugs are being studied around the world, but "I don't see a lot of home runs right now," said Dr. Carlos del Rio, a professor of infectious diseases at the Emory University Rollins School of Public Health. "I see a lot of strikeouts."
Researchers have launched more than 1,250 studies of COVID-19. Pharmaceutical companies are investing billions to develop effective drugs and vaccinesto help end the pandemic.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, was cautious when announcing the results of a clinical trial of remdesivir last week, noting it isn't a "knockout." Although remdesivir helped hospitalized COVID-19 patients recover more quickly, it hasn't been proved to save lives.
"This [drug] is opening the door," Fauci said. "As more companies and investors get involved, it's going to get better and better."
Researchers have already announced that they will combine remdesivir with an anti-inflammatory drug, baricitinib — now used to treat rheumatoid arthritis — in the hope of improving results.
But COVID-19 is an elusive enemy.
Doctors treating COVID patients say they're fighting a war on multiple fronts, battling a virus that batters organs throughout the body, causes killer blood clots and prompts an immune system overreaction called a "cytokine storm."
With so many parts of the body under siege at once, scientists say, improving survival rates will require multiple routes of attack — and more than one drug. While some of the experimental medications target the virus, others aim to prevent the immune system from inflicting collateral damage.
"There are so many pieces of this, and they will all require different therapies," said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine, whose doctors provide intensive care.
Scientists are also taking a fresh look at existing medications that might be repurposed to fight COVID-19. These include antivirals for influenza, arthritis drugs, estrogen patches and even antacids. If repurposed drugs are successful, they could reach patients relatively quickly, because doctors are already familiar with their side effects and safety concerns.
Some doctors are skeptical that drugs for heartburn or hot flashes have any chance of treating a killer like COVID-19.
Dr. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic, said he fears that hype over unproven products will harm patients, even if it temporarily boosts company stock prices. Patients who demand antacids or antimalarial drugs being studied in COVID-19 could be harmed by side effects, for example. Those who hoard drugs — on the hope of protecting themselves from COVID-19 — could deprive other patients of medications they need to stay healthy. Some people may refuse to participate in clinical trials because they fear being given a placebo.
"This rush to get every imaginable treatment into a study, it's not prudent," Nissen said. "It's not good medicine. It's an act of desperation."
Other experts say scientists should cast a wide net.
"I don't think we want to rule anything out because it sounds out of the ordinary," said Dr. Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh.
Antivirals In The Spotlight
Antivirals such as remdesivir aim to prevent viruses from replicating, said Dr. Peter Hotez, a professor at Baylor College of Medicine in Houston.
That doesn't always work. A small Chinese study of remdesivir, published last month in The Lancet, found no benefit to severely ill COVID-19 patients. Remdesivir had previously failed when tested against Ebola.
Antivirals tend to be most helpful in the early stages of infection, when most of the harm to the patient is caused by the virus itself, rather than the immune system, Hotez said.
Remdesivir is just one of many antivirals being tested against COVID-19.
International researchers are studying the antiviral favipiravir, developed to fight the flu.
A study in the New England Journal of Medicine likewise found no benefit in giving two antivirals used to treat HIV ―a combination of lopinavir and ritonavir, sold as Kaletra— in adults hospitalized with severe COVID-19.
Harnessing The Immune System
One of the therapies generating excitement is also one of the oldest: antibody-rich blood from COVID survivors.
The immune system produces antibodies in response to invaders such as viruses and bacteria, allowing the body to recognize and neutralizethem. Antibodies also recognize and neutralize the virus the next time that person is exposed.
Doctors hope that patients who develop antibodies against the novel coronavirus will become immune, at least for a few years, although this hasn't been proved.
Scientists developing this "convalescent plasma" are studying whether COVID-19 survivors can share this immunity with others by donating their plasma, the liquid part of blood that contains antibodies, said Dr. Shmuel Shoham, an associate professor of medicine at the Johns Hopkins University School of Medicine.
In addition to treating people who are already sick, donated plasma could potentially prevent people exposed to the virus — such as health care workers — from developing symptoms.
Donated antibodies ― and any immunity they might provide — don't last forever, said Dr. William Schaffner, a professor at the Vanderbilt University Medical Center. The body destroys aging antibodies as part of its routine maintenance, he said. In general, half of donated antibodies are eliminated in about three weeks.
The use of convalescent plasma goes back more than a century. It was used during the 1918 flu pandemic and was shown to improve survival during the 2009-10 H1N1 pandemic.
Doctors don't know yet whether convalescent plasma will benefit people with COVID-19.
In general, convalescent plasma is expected to be more effective in preventing illness than in treating it. It may be less likely to help someone in intensive care, Shoham said.
Researchers are also studying the use of prepackaged plasma, called intravenous immunoglobulin, in COVID patients. This product, known as IVIG, is taken from healthy donors in the general population and has long been used to help patients with weakened immune systems fight off infections. Hospitals keep it in stock and some are already using it to treat COVID patients.
Although the antibodies in prepackaged IVIG don't specifically target the coronavirus, researchers hope they will tamp down the immune response.
In a third form of immune therapy, researchers are trying to identify the specific antibodies that are most important for neutralizing the coronavirus, then reproduce them as drugs called monoclonal antibodies. Monoclonal antibodies are already used to treat a variety of conditions, from cancer to rheumatoid arthritis and migraines.
"When we give people an antibody, they are immediately at least partially immune to that specific virus," said Dr. James Crowe, director of the Vanderbilt Vaccine Center, who hopes to have antibodies ready for a clinical trial in a few months. "We're moving the immune system from one person to another."
Ideally, doctors would develop a very potent monoclonal antibody or a cocktail of antibodies for COVID-19 patients, to ensure the best chance of success, Crowe said. But manufacturing these drugs can be complicated, expensive and time-consuming.
"Making two antibodies would be at least twice as complicated as making one," Crowe said. "A cocktail might be preferred, but cocktails are harder to move quickly."
Calming The Immune System
In most cases of COVID-19, the immune system neutralizes the coronavirus and patients recover without going to the hospital.
For reasons that doctors don't totally understand, the immune system of some COVID-19 patients becomes hyperactive, attacking not just the virus but the patient's own cells. A "cytokine storm," in which the immune system floods the body with inflammatory chemicals, can do more damage than the virus itself.
In an effort to calm the immune system, researchers are testing immune-suppressing drugs, including monoclonal antibodies already used to treat autoimmune diseases such as rheumatoid arthritis, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.
Health care giant Roche is conducting large clinical trials of its drug, Actemra, in the hope of preventing cytokine storms, which can cause organ failure and a life-threatening condition called sepsis. Actemra is designed to lower levels of an inflammatory chemical, interleukin-6, which has been found to be elevated in some COVID-19 patients.
Another immune suppressant from Regeneron and Sanofi, called Kevzara, has had disappointing results in clinical trials. The manufacturers plan to continue studying the drug to see if it can help certain types of patients.
Dr. Anar Yukhayev, a New York OB-GYN who was hospitalized with COVID-19 on March 16, agreed to join a clinical trial of Kevzara.
"I was having so much trouble breathing that I was desperate for anything to help," said Yukhayev, 31, who was treated at Long Island Jewish Medical Center.
About 36 hours after receiving an infusion, as Yukhayev was being treated in intensive care, his symptoms began to improve. He was able to avoid being put on a ventilator. Doctors didn't tell him if he received Kevzara or a placebo, but his liver enzymes also began to rise, suggesting the organ was under stress. Elevated liver enzymes are a known side effect of Kevzara.
Yukhayev made a full recovery and went back to work full time April 13. He donated his plasma to researchers.
Until vaccines and other preventive medicines are developed, the best way to prevent coronavirus infections is to maintain social distancing, Adalja said.
"Social distancing is a blunt tool," he said, "but it's all that we have."
As the COVID-19 pandemic swept into Montana, it spread into the Marias Heritage Center assisted living facility, then flowed into the nearby 21-bed hospital.
Toole County quickly became the state's hot spot for COVID-19 deaths, with more than four times the infection rate of all other counties and the most recorded deaths in the state. Six of the state's 16 COVID deaths through Tuesday have occurred here.
But another danger loomed: What if it got into the prison, less than 4 miles away from the hospital and assisted living facility? The county was nearly overwhelmed as it was. Across rural America, prisons and jails sit in places like Toole County that have minimal intensive care unit beds and ventilators and few additional medical resources. Many hospitals there were strained before the pandemic.
This rural, 5,000-person county tucked under the Canadian border might not have seemed like a breeding ground for the contagion. It is a primarily agricultural community almost twice as large as Rhode Island situated in the Great Plains under a big Montana sky. Some areas of the county don't have cellphone coverage, much less internet, and winters are cold enough that people plug in their cars not because they are electric but because they must heat the engines to keep them from freezing.
"When you look at the per capita infection rate in the county and deaths, unfortunately, in our community, it's very, very staggering," said William Kiefer, CEO of the Marias Medical Center, which is affiliated with the assisted living facility. "And the impact is clearly similar to what's happening in some of the urban areas that have been hit really hard."
The two original cases of COVID-19 at the assisted living facility exposed 63 staffers at the center and the affiliated hospital. Thirteen tested positive, and one was hospitalized. All of them recovered. It took a monumental effort by the entire county to keep the hospital from shuttering.
At the worst point, Kiefer and his CFO were the only original staff members not quarantined and able to work. The Montana National Guard helped wash laundry, former employees came out of retirement to fill in, nurses worked as many as five different roles for weeks on end, and quarantined staff coordinated administrative work from sunup to sundown while isolating from their families.
But, through it all, the dreaded coronavirus hasn't yet crept into the site of one of the community's largest employers, the Crossroads Correctional Center prison. It holds almost 15% of the county's total population with a 712-bed facility for both federal and state inmates.
Almost 70% of the nation's more than 1,100 prisons are located outside of metropolitan areas, according to 2017 research by John M. Eason, an associate professor in sociology at the University of Wisconsin-Madison. A building boom occurred from 1980 through 1999 as struggling towns eyed prisons as economic salvations.
But in many of those same communities, rural hospitals that would be tasked to care for inmates during a pandemic have since struggled, with more than 120 rural hospitals closing nationwide in the past decade.
"It's going to be a nightmare because rural communities are so disadvantaged," Eason said. "We're going to see a lot of people in prison contract and die of COVID."
It is not just the inmates behind bars, but also the people in the surrounding community, many of whom work at the facilities, who would be at risk. The employees leaving prisons and jails daily could spread the virus to inmates on the inside and community members on the outside. Already such rural communities on average have sicker and older populations than the rest of the country, even before considering the added risk of close-quartered prisons and jails.
"What is at stake is, in some way, always what's been at stake," said Jessica Pishko, the senior legal adviser at the Justice Collaborative, a nonprofit focused on the justice system. "The most vulnerable are already the ones who are the most impacted."
The Justice Collaborative released a report last month finding that 12% of people held in jails are in counties without intensive care unit beds. In Montana, the report said, over a third of jail detainees are in counties without them. And Toole County has none. Jails, which hold people pretrial, often have a higher rate of turnover of inmates moving in and out of the facility than prisons, increasing the chance of spreading the disease. Still, prisons have similar difficulties with COVID-19 prevention inside facilities.
Of course, not all people infected with the coronavirus end up in need of intensive care, but even a small number of serious cases in a small jail or prison could overwhelm limited resources.
"You can't just airlift 10 people to another hospital," Pishko said.
The Marias Medical Center has two ventilators and added a six-bed COVID-19 isolation tent behind the hospital. It has two regular staff nurses. But, like many rural hospitals, it is designed to stabilize patients and then transfer them to other, bigger hospitals, if needed. Those are some 80 and 160 miles away.
COVID-19 has only magnified the existing resource problems of the medical center.
"We almost got pushed to the limit where we didn't have sufficient staff to maintain our emergency room open, and that would be catastrophic to a community," Kiefer said.
In normal times, the facility saw about five of the prison's inmates a month in the emergency room. Now, amid the pandemic, officials from the medical center and county have been coordinating with the company that runs Crossroads to form plans in case a new wave of COVID-19 compromises the facility. Ryan Gustin, a spokesperson for CoreCivic, which runs Crossroads, said they are all sharing information to "strengthen our collective response."
The Montana Department of Corrections also helped the private prison distribute educational materials, such as newsletters detailing information about the virus and prevention. As of Monday, no inmates had tested positive in Montana state-run facilities and three staff had tested positive.
Even so, Toole County Health Department interim director Blair Tomsheck wrote in an email that "any outbreak has the potential to overwhelm our medical resources."
The number of patients seeking care for injuries caused by what's known as penetrating trauma — gunshot wounds or stabbings — appear to be holding steady, straining hospitals already busy fighting COVID-19.
This article was first published on Thursday, May 14, 2020 in Kaiser Health News.
CHICAGO — On an early March day at the beginning of the COVID-19 pandemic, the emergency room at the University of Chicago Medical Center teemed with patients.
But many weren't there because of the coronavirus. They were there because they'd been shot.
Gunshot victims account for most of the 2,600 adult trauma patients a year who come to this hospital on the city's sprawling South Side. And the pandemic hasn't dampened the flow.
"The visible virus of violence continues unabated," said trauma chief Dr. Selwyn Rogers Jr.
The Chicago hospital's experience mirrors what's happening at other metropolitan trauma units around the nation, where the number of patients seeking care for injuries caused by what's known as penetrating trauma — gunshot wounds or stabbings — appear to be holding steady, straining hospitals already busy fighting COVID-19.
The Hyde Park hospital's Level 1 trauma center has been bustling since it launched in May 2018. On that day in March, about a half-dozen gowned staffers in the unit — which is separated from the rest of the ER by a set of double doors — hurriedly worked on a patient who had just been brought in through the ambulance bay.
"We pretty much opened and became one of the busiest trauma centers in the city," Rogers said.
Much of that is because of its location, he said. The South Side of Chicago is home to busy expressways and vast manufacturing plants, but also some of the most violent neighborhoods in the city. About a third of the University of Chicago Medicine's adult trauma patients are gunshot victims, Rogers said.
The volume has remained steady despite the city and state issuing a stay-at-home order March 21 in response to the coronavirus pandemic. In fact, Rogers said, domestic violence incidents appear to be on the rise as people shelter in place.
"It's not surprising that penetrating trauma has kind of stayed stable," said Dr. Kenji Inaba, trauma chief for the Los Angeles County-USC Medical Center. "One could surmise there's a lot of potential for this: people being at home, in close contact with others. There's still potential for that human-on-human interaction to occur."
Trauma Care Affected Everywhere
Overall trauma statistics appear to be on the decline nationally, driven by a decrease in blunt trauma from fewer car crashes as people drive less during the pandemic, said Jennifer Ward, president of the Trauma Center Association of America.
"You would expect that to be down," she said. "Less people are going out. You would expect them to be doing less dangerous things than they're doing on other days, less traffic, things like that."
But injuries from gunshots and stab wounds are not dropping.
"As far as domestic violence, I think communities are in a heightened state of awareness," said Kathleen Martin, a board member for the American Trauma Society. Also "gun sales are up. People are looking at protecting themselves."
These trends are playing out across the nation.
At the Los Angeles trauma center, early spring is generally quieter than other times of year. Inaba, the trauma chief, said the unit usually has about 60 to 70 patients weekly with blunt injuries, such as those caused by car or construction accidents. That number has recently been down to as low as 10 to 25 cases as fewer people are driving and working.
But the number of gunshot and stabbing victims has effectively remained static — and maybe even ticked up a bit — hovering around 10 to 15 cases a week, Inaba said.
"Trauma is an interesting thing," he said. "Here at USC, we have for weeks now stopped all of our elective surgeries. This is one specialty you can't stop. We need to have surgeons available 24/7."
At Houston's Memorial Hermann-Texas Medical Center, which has been called the busiest trauma center in the country, blunt trauma cases dropped by about 5% while penetrating trauma incidents rose by roughly 3% in the three weeks after the city started its March 16 shutdown, according to trauma chief Dr. Michelle McNutt. Although she has anecdotally seen cases of intrafamily violence, she said, it's too early to have solid data showing whether domestic violence is up.
Metropolitan Family Services, a Chicago-area nonprofit with locations on the South Side, has had a steady number of domestic violence victims seeking services, according to spokesperson Bridget Hatch.
"There's just less mobility for victims," said Melanie MacBride, a legal aid attorney with the nonprofit. "People are down to one income or no income. Even when you're in a domestic violence situation, that might make you more reticent to upend your situation."
Renata Stiehl, who supervises domestic violence court advocacy for Metropolitan Family Services, said the stay-at-home orders and economic stress could exacerbate tensions and make it harder to report cases before they escalate.
"It's really like a forced hostage situation," Stiehl said. "When you have these ingredients and you have someone who has the propensity to commit this type of abuse, you're creating the perfect environment for it to thrive."
Stiehl noted that in Cook County, however, accusers are now able to file and have remote court hearings for orders of protection.
And neighbors may be more likely to call the police about a domestic disturbance because they're home to hear it.
Pandemic's Toll On Trauma Staff
As trauma center staffers continue to treat injuries inflicted by violence, they are also being pulled in other directions because of the pandemic.
Trauma surgeons are often certified in critical care, so they're helping pulmonologists with COVID-19 patients. Trauma nurses are assisting in now overwhelmed intensive care units. Trauma data collectors have instead been asked to help compile coronavirus statistics.
To soak up the overflow demand, pediatric trauma units are increasing the age limits of patients they treat from the usual 18 to 21. The pandemic has also forced other changes for trauma patients. Family members generally can't visit their traumatically injured loved ones because of the coronavirus. Violence-prevention activities have been limited by the outbreak.
Even though protective gear has been hard to come by, doctors and nurses in the trauma centers are having to outfit themselves with personal protective equipment for every patient. "We have to assume they're COVID-positive until proven otherwise," Martin said. Trauma staffers are so specialized that if any of them get infected, it can set the whole unit back.
Dr. Brian Williams, a University of Chicago trauma surgeon, said he and his colleagues also work to reduce their patients' infection risk, putting masks on them when they arrive and housing them in an ICU separate from the one used for treating COVID-19.
"It's as if nothing has changed as far as the volume and acuity of the traumatic injuries we are seeing," he said. "What has changed is how we approach our job in taking care of patients who come in and making sure patients and health care workers are mutually protected without diminishing the level of care we provide."
Some doctors fear the situation could get worse.
In Cleveland, Dr. Glen Tinkoff, who heads trauma for University Hospitals and sits on the board of the American Trauma Society, said that although his system's trauma volume has been down about 10% lately, he expects that number to go in the opposite direction once sheltering-in-place restrictions begin to be lifted.
"We'll see a spike as desperation, despair and hopelessness increase," he predicted. "There's a lot of people out of work. I fear that. You can sense the desperation around the city right now. People are wandering. You see individuals that are just kind of looking for trouble now on the streets."
A septuagenarian was recently brought to the hospital after being beaten with a baseball bat at an ATM, Tinkoff said.
He noted that while shooting injuries were down initially in Cleveland, he doesn't believe that will continue there or anywhere in America.
"You're going to see many of us be very busy as the spring and summer months start to come upon us," he said. "The aftermath is going to be tough. I hope I'm wrong."
In early March, Madalynn Rucker, then 69, agonized over whether to close her Sacramento consultancy office. On the 16th, she finally succumbed to a barrage of texts and calls from her daughter about the heightened risk of the coronavirus, and told her employees to begin working from home. That was three days before California Gov. Gavin Newsom's statewide stay-at-home order.
Her daughter was right in more ways than one. While Rucker's age alone raised her potential danger of being hospitalized or dying of COVID-19, she and many of her employees share another risk factor: They are black. Rucker wonders if more public health messages targeting African Americans could have helped millions like her better prepare for the disease's onslaught.
Officials and commentators said little about race early in the pandemic, recalled Rucker, now 70 and the executive director of OnTrack, a diversity consulting firm. "Could this have made a difference in some way? Not just in educating ourselves, but in how the pandemic was controlled and managed?"
By late February, doctors in China had published that, in addition to older patients, those with chronic health conditions, particularly hypertension and diabetes, were more likely to have severe cases of COVID-19 that ended in ICU admission, mechanical ventilation or death.
It wouldn't have been difficult, some community leaders say, for officials to make an explicit connection between the coronavirus risk factors and African Americans and Latinos, who are more likely to have chronic diseases, and at younger ages ― and then craft tailored, respectful messages for them.
"The messaging I got from the news was, is that if you're young, you're good, and if you're old, you've got to stay home," said Eddie Anderson, the 30-year-old pastor of McCarty Memorial Christian Church, an African American congregation in South Los Angeles.
When Anderson became ill with what turned out to be another viral infection in early March, he was alarmed by the lack of information about how to get tested for COVID-19. The experience motivated him to bring a physician friend to church the next week to explain the disease to his flock.
"I think targeted messaging to the African American community would have been helpful," he said.
But public health and infectious disease experts say the novelty of the virus, whose targets and mode of attack continue to confound scientists, meant that specific racial disparities weren't a foregone conclusion.
"I don't know that it's fair to say that it would have been something that could be 100% predicted," said California Surgeon General Nadine Burke Harris. She called the novel coronavirus "a little bit of a head-scratcher." For example, it doesn't appear to affect children under age 2 or pregnant women the same way similar viruses would, she noted.
"Sometimes when you predict too strongly, it can have the effect of assuming that's going to be the outcome, and it can come across pejoratively," Burke Harris said.
But the disease has disproportionately hurt blacks. In California, 10% of COVID-19 deaths occurred among African Americans, who make up 6% of the state population. A national Centers for Disease Control and Prevention survey showed that 33% of hospitalized COVID patients were non-Hispanic blacks, though that group represented only 18% of residents in the surveyed communities.
Officials are finding it's still difficult to talk about race and COVID-19. Fear of stigmatization remains high, said Burke Harris, who said she walks a fine line by letting certain groups know about the heightened risks without casting blame on them.
"One of the things I've been dealing with a lot in having conversations with black media and black health researchers, right, is this notion of, well, wait a minute, as this data is coming out, how are we not blaming black and brown communities?" said Burke Harris, who is black. "It's like, 'Oh, are you saying we're sicker?'"
Preexisting conditions aren't the only reason black people are dying at disproportionate rates of COVID-19, said Dr. Sonia Angell, director of the California Department of Public Health.
Despite states' orders to stay at home, entire sectors of "essential" jobs have disproportionately high rates of minority employees, which increases their exposure risk. These workers don't benefit as much from social distancing, Angell said.
"They're the ones that are keeping our care delivery system functioning so that when any of us get sick, we have a place to go," she said. "They're the ones that are keeping our grocery stores running and stocked."
The absence of coordinated, official public messaging in February and early March about the potential racial disparity of COVID-19's impact created a vacuum into which conspiracy theories rushed.
Initially came rumors that black people were somehow resistant to the coronavirus. At the same time, black media outlets like The Philadelphia Tribune (Feb. 4), Essence (March 2), the St. Louis American (March 11) and The Undefeated (March 13) made the connection between the virus and America's preexisting health inequalities, publishing forward-thinking pieces about the virus' potential threat to black Americans because of chronic medical conditions, working and commuting conditions, and a historical lack of access to health care and insurance due to institutionalized racism.
Their predictions soon proved true. Local officials began noting higher death rates for black COVID-19 patients in Milwaukee on March 23. In the first week of April, city officials in Chicago, Los Angeles and New Orleans made similar announcements. The CDC published its first national data on racial disparities on April 8. A recent CDC study, published April 29, found that black people made up 83% of COVID-19 hospitalizations in Georgia, a disproportionate level compared with overall hospitalizations.
Public health messages targeting specific populations should be voiced by trusted community leaders, or at least someone of the same race, on media platforms where they're most likely to be seen or heard, said Dr. Oliver Brooks, president of the National Medical Association, which represents black physicians.
Other targeted messages include Spanish-language public service announcements featuring Burke Harris and LA Galaxy soccer player Javier "Chicharito" Hernández. Those have run on Univision; Radio Bilingüe, a Spanish-language public radio network; and other Spanish-language stations, as well as Instagram and Facebook. In Hernández's clip, he encourages listeners in Spanish to seek medical attention if they have COVID-19 symptoms, no matter what their immigration status is.
Targeted messaging can sometimes offend or insult, even with the best of intentions, said Daniel Schober, assistant professor of public health and behavioral psychology at DePaul University in Chicago.
The city of Chicago offended some with a 2015 flu shot campaign that featured a black baby on a billboard next to the words, "I am an outbreak." It inspired graffiti artists to weigh in with their own message: "I am beautiful."
But the city's COVID-19 campaign, featuring Mayor Lori Lightfoot, who is black, has charmed residents, said Schober. The campaign played off social media memes depicting a no-nonsense Lightfootshutting down iconic Chicago landmarks under shelter-in-place directives. The city's official video showed the mayor baking, learning the guitar and sipping tea while exhorting people to "stay home, save lives."
"That's a great example of a message that isn't necessarily tailored toward specific racial or ethnic groups, but is really meant to be universal in its reach," Schober said.