At least 80 Georgia healthcare workers have died from COVID-19, including after the state reopened its economy.

This article was published on Wednesday, August 19, 2020 in Kaiser Health News.

By Rachana Pradhan and Victoria Knight.

As the coronavirus crisis deepened in April, Georgia officials circulated documents showing that to get through the next month, the state would need millions more masks, gowns and other supplies than it had on hand.

The projections, obtained by KHN and other organizations in response to public records requests, provide one of the clearest pictures of the severe PPE deficits states confronted while thousands fell ill from rising COVID-19 cases, putting health workers at risk.

Georgia on April 19 had 932,620 N95 respirator masks — one of the best protections for health workers against infection — and expected to burn through nearly 7 million within a month. It urgently needed to buy 1.4 million more, according to documents obtained by the Brown Institute for Media Innovation and shared with KHN. For gowns, officials expected to go through 16.1 million in 30 days, a staggering amount compared with the 21,810 the state had at the time.

"Making progress with PPE needs. Biggest challenge now is gowns and we are working it," Georgia Emergency Management and Homeland Security Agency Director Homer Bryson wrote on April 19 to two of Gov. Brian Kemp's senior-most aides.

Even so, one day later, the first-term Republican governor announced he would begin to reopen the state's economy, including gyms, restaurants, hair salons, theaters and a host of other businesses.

"We have relied on data, science and the advice of healthcare professionals to guide our approach and decision-making," he said at a news conference, "putting the health and well-being of our citizens first and doing our best to protect lives and livelihoods."

"Our state agencies and the governor felt confident in the state's ability to meet daily PPE requests from our local emergency preparedness partners and medical facilities when Georgia began implementing its measured reopening plan," Cody Hall, the governor's spokesperson, said in response to questions. "We have continued to meet those needs since April." He noted the state is now building a PPE stockpile.

A Matter of Life or Death

After Georgia eased its lockdown, COVID cases spiked. Requests for PPE from health workers in the Atlanta area escalated through April and May, according to numbers provided by the nonprofit Atlanta Beats COVID-19, which makes face shields for health workers and other residents.

According to public data on the Georgia Department of Public Health's website, at least 80 Georgia healthcare workers have died from COVID-19, including after the state reopened its economy.

One was John "Derrick" Couch, a nurse practitioner who worked in Fort Oglethorpe, Georgia. Shortly after graduating with his master's degree in nursing on May 10, the worker at Med First Immediate Care Medical Center grew sick with COVID-19. His wife, Karol, cared for him at home for a time before he was hospitalized. He died after 36 days on a ventilator, according to a GoFundMe page set up to help his family cover his healthcare expenses.

"Karol wants everyone to know that Covid-19 doesn't care or discriminate. She says John would want all of his colleagues and friends in healthcare and community to demand proper equipment and protection," it said. Med First Immediate Care did not respond to a request for comment.

Between March 16 and Aug. 9, 48 COVID-19-related complaints regarding inadequate PPE in Georgia healthcare facilities were closed by the Occupational Safety and Health Administration, the federal agency responsible for workplace safety. The PPE complaints accounted for the majority — roughly 6 in 10 — of Georgia's COVID-19 complaints submitted to OSHA during the four-month period.

In April and May, "we received thousands of requests for N95 masks, but we couldn't get our hands on the right materials to even make an N95 mask," said Caroline Dunn, Atlanta Beats COVID-19's communications coordinator.

Nationally, health workers continue to express alarm about protective equipment supplies as COVID-19 hot spots reemerge across the country. A National Nurses United survey in July found 87% of nurses working in hospitals reported reusing at least one piece of single-use PPE. Only a quarter of nurses surveyed felt their employers were providing a safe workplace.

"There's really been this normalization and this acceptance that some people are going to be expendable. And that's completely unacceptable," said Dabney Evans, director of the Center for Humanitarian Emergencies at Emory University in Atlanta.

Another document projecting PPE supplies, dated April 10 and developed by Georgia health and emergency management officials, relied on a calculator from the U.S. Centers for Disease Control and Prevention to estimate how quickly Georgia would burn through supplies across hospitals, nursing homes, dialysis clinics, jails and prisons. The state had 527,424 N95 respirators but needed a total of nearly 1.1 million to get through the ensuing seven days. The projected need grew to 4.8 million masks when estimating supplies for the following 31 days.

It had 196,500 gloves on hand but would need more than 12.1 million to get through a week, and 54 million for 31 days. The state had about 122,000 face shields but required more than 458,000 for the coming seven days. For a month, the projected need ballooned to over 2 million.

The April 10 estimates — a day when Georgia's new COVID-19 case count rose by about 1,000 people — were sent to the U.S. Department of Health and Human Services and Federal Emergency Management Agency as part of a broad effort to assess what states needed across healthcare settings to operate for at least seven days and up to a month. Federal officials asked state public health and emergency management officials to submit PPE projections daily, according to emails among state personnel, HHS and FEMA.

PPE estimates would be used "to determine projections for our region and the next hot spots within each state," Jeanne Eckes, an HHS official working with FEMA on the federal government's COVID-19 response, wrote in an April 3 email to officials in multiple states throughout the South, according to correspondence obtained by KHN.

Calculations Matter

Georgia officials contend the state's estimated PPE deficits were larger early in the pandemic because projections accounted for all COVID-positive cases. Once the state had more information on how many of these positives were asymptomatic cases and how many led to hospitalizations, it could better gauge what was needed, they argued. Multiple changes were made to its burn-rate calculations, including a May 8 adjustment that replaced the total case count with hospital-based COVID cases, which reduced the projected demand for PPE.

However, multiple experts disputed the idea that knowing the number of asymptomatic patients would be relevant for PPE projections. In facilities like nursing homes and jails — both of which were accounted for in the Georgia estimates — asymptomatic individuals could spread the virus if not quarantined immediately.

"Because there's not on-the-spot, point-of-care testing available for the most part, you have to use PPE throughout the hospital all the time," said Dr. Eric Toner, a senior scholar with the Johns Hopkins Center for Health Security. "In this day and age, you just have to presume that everyone has COVID."

When the state's case count began surging in March, many COVID-19 patients treated at Tift Regional Medical Center in Tifton, Georgia, needed ICU-level care and were from nearby Dougherty County, a Georgia hot spot where hospitals were quickly overwhelmed.

"There were times to which we were down to only having a few days of PPE left," said Dr. Kaine Brown, a physician and medical director at Tift, adding that the hospital was partly saved by donations of N95 and cloth masks. Gowns were the biggest problem. PPE supplies have since improved — as of early July, the hospital had stockpiled more than eight months' worth of surgical masks and enough N95s and gowns to last six months and about three months, respectively.

Georgia's stay-at-home order for most residents expired April 30; it remains in place for individuals at higher risk of severe illness.

"We were very apprehensive about [easing restrictions]," Brown said. "Those of us who had been working on the front lines knew how infectious this was."

Since May, Georgia has reopened a broad swath of businesses. In early July, more than 1,000 healthcare workers signed a letter to Kemp urging him to institute a statewide mandate requiring face coverings, to close bars and nightclubs, and prohibit indoor gatherings of more than 25 people. Georgia currently bans gatherings of more than 50 people if social distancing cannot be observed.

State officials say PPE supplies have "greatly improved" since the start of the public health emergency. As of Aug. 14, the state had distributed 3.9 million N95s, 13.1 million surgical masks, 36.6 million gloves, 4.6 million gowns and 1.6 million face shields, among other items, according to the Georgia Department of Public Health. Early on, Georgia also relied on donations to bolster PPE supplies when many items were unattainable through normal supply channels, which have since become more reliable.

However, even with the increased stocks, workers still reuse protective equipment and many fret over the uncertainty about how long they can do so safely. Another community-based organization, the Atlanta chapter of Sewing Masks for Area Hospitals, said that from April to June the organization gave out over 59,000 cloth masks to 152 healthcare facilities in the Atlanta area, including large hospitals, such as Children's Healthcare of Atlanta and Emory St. Joseph's Hospital. Kayla Hittig, a co-founder of the sewing group, said that healthcare workers were using the cloth masks to cover their N95 or surgical masks to make them last longer.

"That's the thing we hear the most — how often do we have to use these and how protective are they, for how long?" said Richard Lamphier, president of the Georgia Nurses Association.

Lamphier wasn't critical of the state officials' efforts to ensure health workers are protected.

"I think they've done the best they could with the situation they had," he said.

It wasn't enough to protect John Couch, whose family is reeling from his death.

"He was my whole life," Karol Couch said. "My life is shattered."

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

Victoria Knight: vknight@kff.org, @victoriaregisk

Clinical Research Institute of Southern Oregon hopes to enroll 700 participants for its two-year study. 

This article was published on Monday, August 17, 2020 in Kaiser Health News.

By JoNel Aleccia

MEDFORD, Ore. — From the outside, it appears to be just another suburban allergy clinic, a tidy, tan brick-and-cinder-block building set back from a busy highway and across the road from an auto parts store.

But inside the offices of the Clinical Research Institute of Southern Oregon, Dr. Edward Kerwin and his staff are part of the race to save the world.

Kerwin, 63, was tapped this spring to lead one of the nearly 90 U.S. clinical trial sites taking part in the large-scale, phase 3 test of a vaccine produced by biotech startup Moderna to fight the virus that causes COVID-19.

Starting in late July, Kerwin's clinic, set in a working-class region roughly halfway between Seattle and San Francisco, began enrolling up to 40 participants a day for the two-year study. He hopes to recruit as many as 700 volunteers by the end of August.

They'll join the 30,000 test subjects needed nationwide to determine whether the Moderna vaccine can tame a disease that has infected 5.4 million Americans and claimed the lives of more than 170,000. Another vaccine, produced by Pfizer and BioNTech, a German company, is being tested in nearly 30,000 more recruits.

"It's a perfect opportunity for science to come to the rescue," said Kerwin, a lanky figure in a bright-blue shirt and khaki pants. He led visitors to a conference room, took a chair well outside social-distancing range and doffed his mask, the better to explain the magnitude of this moment.

He acknowledged "it may seem like a surprise" that Medford is the site of a clinical trial to halt the world's biggest medical challenge in a century. But Kerwin, who worked as a NASA scientist before heading to medical school and a career in allergy, asthma and immunology, has led more than 750 clinical trials over the past quarter-century, mostly focused on asthma, lung disease and skin disorders.

He moved to southern Oregon in 1993, choosing the rural Rogue Valley because of its beauty and cultural opportunities, such as the Oregon Shakespeare Festival in Ashland. As his medical expertise grew, he built a top-enrolling clinical trial site that coexists with a clinic that treats asthma and allergy patients. Along the way, he established deep roots in the valley, where he founded Bel Fiore, a $10 million winery and vineyard that features a 19,000-square-foot chateau.

Even with his experience, however, testing a vaccine to halt a global pandemic is a challenge like no other, Kerwin said. When the call came from Velocity Clinical Research — the North Carolina-based company that operates Kerwin's clinic, known as CRISOR, and more than a dozen other COVID trial sites across the U.S. — he paused for a moment.

"You take a big gasp and say, 'Do we have the resources to do this?'" Kerwin said. "You definitely do it, but you want to do your homework."

So far, the testing is going well, he said. Unlike most clinical trials, for which it's difficult to recruit enough volunteers, the COVID effort has attracted intense interest. All of Velocity's sites are paying participants $1,962 for the two-year trial, but Kerwin's staff of two dozen didn't advertise widely at first.

"We would worry our phone would ring off the hook," Kerwin said.

The Medford clinic is the only COVID vaccine clinical trial site in Oregon, so participants have come from as far as Portland, nearly 300 miles north.

It's a prime example of the gamble drugmakers and federal trial sponsors take when deciding where to host large-scale COVID clinical trials. To gauge whether the vaccine works, you need to know there's a good chance participants will be exposed to the virus in the environment. Ethically, in traditional phase 3 trials, you can't deliberately infect people with COVID, a disease with no treatment or cure, though some propose doing just that in controversial human challenge trials.

Southern Oregon has not been a hot spot for COVID, with fewer than 500 confirmed cases and two deaths in Jackson County, which includes Medford. But, Kerwin said, it's at risk of becoming one, offering the opportunity to vaccinate trial participants before the virus becomes widespread.

"It's almost too late in New York and Arizona," he said.

In the meantime, he's trying to shift the odds that trial volunteers will be exposed to COVID-19 by reaching out to people at greater risk of infection.

So Kerwin's team has contacted businesses in industries such as agriculture and food production, where the disease has been known to spread with particular virulence. Locally, that includes employers such as Harry & David, the food retailer famous for its fruit-of-the-month shipments, and Amy's Kitchen, the maker of vegetarian frozen meals, which operates a production plant in the area.

The Medford trial site is also emphasizing enrollment of elder volunteers, those age 65 and up, who are at higher risk of serious illness or death from the coronavirus.

One of the first volunteers was Trish Malone, a 68-year-old cultural anthropologist who lives in Ashland. Like many of the other participants, she has enlisted in Kerwin's previous clinical trials of devices to treat asthma. When clinic staffers reached out to ask whether she'd participate in the COVID trial, she didn't hesitate.

"I said, 'Wow, yes,'" Malone recalled. "It's because of [Kerwin] and his expertise. Little Medford gets to have this testing."

Participating is a way to "give back" to her community, said Malone, who sat, calm and still, on a recent Thursday as study coordinator Audrey Kuehl sank the injection into Malone's left shoulder.

"She was fast. It was no pain, and it was fine," Malone said.

Half of the patients in the trial will receive two doses, 28 days apart, of the Moderna vaccine, called mRNA-1273. It uses a snippet of the genetic code of the coronavirus, not the virus itself, to instruct cells to produce a protein that triggers an immune response to protect against infection. The other half will receive a placebo, or saline dummy shot.

Three study coordinators at the Medford clinic, Kuehl among them, know which patients receive which dose, but the information is kept from volunteers and other staff members — including Kerwin, the principal investigator.

Participants who receive the vaccine may experience some side effects, such as redness at the injection site, muscle soreness, fatigue or headache, Kerwin said. "It's a sign the vaccine is working with your immune system," he said.

Four days after her first injection, Malone was disappointed to report no reaction at all. "I am bummed, totally bummed," she said. "I have no symptoms. I think I got the placebo."

That may not be true, of course. Even if it is, Malone said, she's happy to participate in an effort that may help stop the deadly virus.

"This a global pandemic," she said. "What can I do to help?"

The study will run for two years so that investigators can track the longer-term effects of the vaccine. Malone will keep a diary of her temperature and symptoms, if any, and have regular blood tests to determine whether she has antibodies to the virus.

Kerwin is optimistic about the chances the Moderna vaccine will work, agreeing with Dr. Anthony Fauci, the nation's top infectious disease expert, who predicted the study could demonstrate efficacy by November or December. Kerwin estimates that the vaccine could prove 90% effective, though outside infectious disease experts said it's far too soon to tell.

Even if the trial shows the vaccine is successful, it would take months longer to produce and deliver enough injections for the U.S. and beyond.

As he enrolls patients and awaits data, Kerwin said, he's mindful of the real-world implications of his work. His mother, in her 90s, lives in a Denver nursing home where, so far, there have been no cases of COVID-19. But the threat looms.

The tragedy of the pandemic has underscored the promise of science — and the interconnectedness of people far beyond this small corner of Oregon.

"Immunology has never been more fascinating than it is today," he said. "This is a year that reminds us we cannot live in isolation and do not live in isolation from the world."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Pennsylvania lawmakers set up an insurance exchange (nicknamed "Pennie"), designed to pass on expected savings to policyholders.

This article was published on Monday, August 17, 2020 in Kaiser Health News.

By Phil Galewitz

Pennsylvania is rolling out its new "Pennie" this fall: a state-run insurance exchange that officials say will save residents collectively millions of dollars on next year's health plan premiums.

Since the Affordable Care Act's marketplaces opened for enrollment in fall 2013, Pennsylvania, like most states, has used the federal www.healthcare.gov website for people buying coverage on their own.

But in a move defying the usual political polarization, state lawmakers from both parties last year agreed the cost of using the federal marketplace had grown too high and the state could do it for much less. They set up the Pennsylvania insurance exchange (nicknamed "Pennie"), designed to pass on expected savings to policyholders. Although the final rates for 2021 are not yet set, insurers have requested about a 3% average drop in premiums.

Pennsylvania is one of six states shifting in the next several years from the federal insurance exchange to run their own online marketplaces, which determine eligibility, assist with enrollment and connect buyers with insurance companies. They will join 12 states and the District of Columbia with self-contained exchanges.

The transitions come amid mounting evidence that state marketplaces attract more consumers, especially young adults, and hold down prices better than the federal exchange. They've also been gaining appeal since the Trump administration has cut the enrollment period on healthcare.gov and slashed funds for advertising and helping consumers.

State policymakers say they can run their own exchanges more cheaply and efficiently, and can better respond to residents' and insurers' needs.

"It comes down to getting more bang for your buck," said Rachel Schwab, a researcher at Georgetown University's Center on Health Insurance Reforms in Washington, D.C.

The importance of state-run exchanges was highlighted this year as all but one of them held special enrollment periods to sign up hundreds of thousands of people hurt financially by COVID-caused economic turmoil. The federal exchange, run by the Trump administration, refused to do so, although anyone who has lost workplace insurance is able to buy coverage anytime on either the state or federal exchange.

Like Pennsylvania, New Jersey expects to have its state-run exchange operational for the start of open enrollment on Nov. 1.

In fall 2021, New Mexico plans to launch its own marketplace and Kentucky is scheduled to fully revive its state-run exchange, which was dismantled by its Republican governor in 2015. Maine has also announced it will move to set up its own exchange, possibly in fall 2021.

Virginia's legislature passed an exchange bill this year and hopes to start it in 2022 or 2023.

Nationwide, about 11 million people get coverage through the state and federal exchanges, with more than 80% receiving federal subsidies to lower their insurance costs.

"Almost across the board, states with their own exchanges have achieved higher enrollment rates than their federal peers, along with lower premiums and better consumer education and protection," according to a study published this month in the Journal of Health Politics, Policy and Law.

Controlling 'Their Own Destiny'

Since 2014, states using the federal marketplaces have had a rise in premiums of 87% while state exchanges saw 47% growth, the study found.

In one key metric, from 2016 to 2019 the number of young enrollees in state exchanges rose 11.5%, while states using the federal marketplace recorded an 11.3% drop, a study by the National Academy for State Health Policy found.

Attracting younger enrollees, who tend to be healthy, is vital to helping the marketplaces spread the insurance risk to help keep premiums down, experts say.

When the Affordable Care Act was debated, Republicans and some Democrats in Congress were cautious about a one-size-fits-all approach to insurance and accusations about a federal takeover of healthcare. So the law's advocates gave states more control over selling private health coverage. The law's framers included a provision that allowed states to use millions in federal dollars to launch their own insurance exchanges.

Initially, 49 states took the money. But in 2011, conservative groups convinced Republican-controlled states that forgoing state-run exchanges would help undermine Obamacare.

As a result, most GOP-controlled states defaulted to the federal marketplace.

In the ensuing years, several states that had started their own marketplaces, such as Oregon, Nevada and Hawaii, reverted to the federal exchange because of technological problems. Nevada relaunched its exchange last fall.

"States want to control their own destiny, and the instability of healthcare.gov in the Trump administration has frustrated states," said Joel Ario, managing director for the consulting firm Manatt Health Solutions and a former Obama administration official, who helped set up the exchanges. States running their own platform can use data to target enrollment efforts, he said.

An Effort to Hold Down Premium Increases

Marlene Caride, New Jersey commissioner of Banking and Insurance, said that "the beauty of [a state-based exchange] is we can tailor it to New Jersey residents and have the ability to help [them] when they are in dire need."

About 210,000 New Jersey residents enrolled in marketplace health plans for this year.

New Jersey has been spending $50 million a year in user fees for the federal exchange. After startup costs, the state estimates, it will cost about $7.6 million a year to run its own exchange enrollment platform and $7 million a year for a customer service center.

Open enrollment on the New Jersey exchange — called Get Covered NJ — will run from Nov. 1 to Jan. 31.

New Jersey plans to provide additional government subsidies for lower-income enrollees. Those would supplement federal subsidies.

Kentucky officials said insurers there were paying $15 million a year in user fees for healthcare.gov, a cost passed on to policyholders. When the state switches to its own operation, it plans to collect $5 million in its first year to cover the startup costs to revive its Kynect exchange and another $1 million to $2 million in annual administrative costs. So insurers will pay lower fees and those savings will help cut premium costs, said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services.

States using the federal marketplace this year paid either a 2.5% or 3% surcharge to the federal government on premiums collected.

In Pennsylvania, where about 330,000 residents buy coverage through an exchange plan, those fees accounted for $90 million a year. State officials estimate they can run their own exchange for about $40 million and will use the savings for a reinsurance program that pays insurers to help cover the cost of extremely expensive healthcare needed by some customers. Removing those costs from the insurers' responsibility allows them to drop premiums by 5% to 10%, the state projects.

"When we talk about bringing something back to state control, that is a real narrative that can appeal to both sides of the aisle," said Jessica Altman, the state's insurance commissioner. "There is nothing political about making health insurance more affordable." (Altman is the daughter of Drew Altman, CEO of KFF. KHN is an editorially independent program of KFF.)

Without the savings from running its own exchange, Pennsylvania would not have been able to come up with the more than $40 million needed for the reinsurance program, state officials said.

In addition, Pennsylvania has extended its enrollment period to run an extra month, until Jan. 15 (federal marketplace enrollment ends Dec. 15). Pennie also plans to spend three to four times the $400,000 that the federal government allocated to the state for navigators to help with enrollment, said Zachary Sherman, who heads Pennie.

"We think increased outreach and marketing will bring in a healthier population and broaden enrollment," he said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Mayra Ramirez received a double lung transplant after COVID-19 caused irreversible damage to her lungs. 

This article was published on Friday, August 14, 2020 in Kaiser Health News.

By Christine Herman, Side Effects Public Media

Mayra Ramirez remembers the nightmares.

During six weeks on life support at Northwestern Memorial Hospital in Chicago, Ramirez said, she had terrifying nightmares that she couldn’t distinguish from reality.

“Most of them involve me drowning,” she said. “I attribute that to me not being able to breathe, and struggling to breathe.”

On June 5, Ramirez, 28, became the first known COVID-19 patient in the U.S. to undergo a double lung transplant. She is strong enough now to begin sharing the story of her ordeal.

Mysterious Exposure

Before the pandemic, Ramirez worked as a paralegal for an immigration law firm in Chicago. She enjoyed walking her dogs and running 5K races.

Ramirez had been working from home since mid-March, hardly leaving the house, so she has no idea how she contracted the coronavirus. In late April, she started experiencing chronic spasms, diarrhea, loss of taste and smell, and a slight fever.

“I felt very fatigued,” Ramirez said. “I wasn’t able to walk long distances without falling over. And that’s when I decided to go into the emergency room.”

From the ER to a Ventilator

The staff at Northwestern checked her vitals and found her oxygen levels were extremely low. She was given 10 minutes to explain her situation over the phone to her mother in North Carolina and appoint her to make medical decisions on her behalf.

Ramirez knew she was about to be placed on a ventilator, but she didn’t understand exactly what that meant.

“In Spanish, the word ‘ventilator’ — ventilador — is ‘fan,’ so I thought, ‘Oh, they’re just gonna blow some air into me and I’ll be OK. Maybe have a three-day stay, and then I’ll be right out.’ So I wasn’t very worried,” Ramirez said.

In fact, she would spend the next six weeks heavily sedated on that ventilator and another machine — known as ECMO, or extracorporeal membrane oxygenation — pumping and oxygenating her blood outside of her body.

One theory about why Ramirez became so sick is that she has a neurological condition that is treated with steroids, drugs that can suppress the immune system.

By early June, Ramirez was at risk of further decline. She began showing signs that her kidneys and liver were starting to fail, with no improvement in her lung function. Her family was told she might not make it through the night, so her mother and sisters caught the first flight from North Carolina to Chicago to say goodbye.

When they arrived, the doctors told Ramirez’s mother, Nohemi Romero, that there was one last thing they could try.

Ramirez was a candidate for a double lung transplant, they said, although the procedure had never been done on a COVID patient in the U.S. Her mother agreed, and within 48 hours of being listed for transplant, a donor was found and the successful procedure was performed on June 5.

At a recent news conference held by Northwestern Memorial, Romero shared in Spanish that there were no words to describe the pain of not being by her daughter’s side as she struggled for her life.

She thanked God all went well, and for giving her the strength to make it through.

‘I Just Felt Like a Vegetable’

Dr. Ankit Bharat, Northwestern Medicine’s chief of thoracic surgery, performed the 10-hour procedure.

“Most patients are quite sick going into [a] lung transplant,” Bharat said in an interview in June. “But she was so sick. In fact, I can say without hesitation, the sickest patient I ever transplanted.”

Bharat said most COVID-19 patients will not be candidates for transplants because of their age and other health conditions that decrease the likelihood of success. And early research shows that up to half of COVID patients on ventilators survive the illness and are likely to recover on their own.

But for some, like Ramirez, Bharat said, a transplant can be a lifesaving option of last resort.

When Ramirez woke up after the operation, she was disoriented, could barely move her body and couldn’t speak.

“I just felt like a vegetable. It was frustrating, but at the time I didn’t have the cognitive ability to process what was going on,” Ramirez said.

She recalled being sad that her mother wasn’t with her in the hospital, not understanding that visitors weren’t allowed because of the pandemic.

Her family had sent photos to post by her hospital bed, and Ramirez said she couldn’t recognize anyone in the pictures.

“I was actually sort of upset about it, [thinking,] ‘Who are these strangers and why are their pictures in my room?’” Ramirez said. “It was weeks later, actually, that I took a second look and realized, ‘Hey, that’s my grandmother. That’s my mom and my siblings. And that’s me.”

After a few weeks, Ramirez said, she finally understood what happened to her. When COVID-19 restrictions loosened at the hospital in mid-June, her mother was finally able to visit.

“The first thing I did was just tear up,” Ramirez said. “I was overjoyed to see her.”

The Long Road to Recovery

After weeks of inpatient rehabilitation, Ramirez was discharged home. She’s now receiving in-home nursing assistance as well as physical and occupational therapy, and she’s working on finding a psychologist.

Ramirez eagerly looks forward to being able to spend more time with her family, her boyfriend and her dogs and serving the immigrant community through her legal work.

But for now, her days are consumed by rehab. Her doctors say it will be at least a year before she can function independently and be as active as before.

Ramirez is slowly regaining strength and learning how to breathe with her new lungs.

She takes 17 prescription medicines, some of them several times a day, including medicines to prevent her body from rejecting the new lungs. She also takes anxiety meds and antidepressants to help her cope with daily nightmares and panic attacks.

The long-term physical and mental health tolls on Ramirez and other COVID-19 survivors remain largely unknown, since the virus is so new.

While most people who contract the virus are left seemingly unscathed, for some patients, like Ramirez, the road to recovery is full of uncertainty, said Dr. Mady Hornig, a physician-scientist at the Columbia University Mailman School of Public Health.

Some patients can experience post-intensive care syndrome, or PICS, which can consist of depression, memory issues and other cognitive and mental health problems, Hornig said. Under normal circumstances, ICU visits from loved ones are encouraged, she said, because the human interaction can be protective.

“That type of contact would normally keep people oriented … so that it doesn’t become as traumatic,” Hornig said.

Hopes for the Future

COVID-19 has disproportionately harmed Latino communities, as Latinos are overrepresented in jobs that expose them to the virus and have lower rates of health insurance and other social protections.

Ramirez has health insurance, although that hasn’t spared her from tens and thousands of dollars’ worth of medical bills.

And even though she still ended up getting COVID-19, she counts herself lucky for having a job that allowed her to work from home when the pandemic struck. Many Latino workers don’t have that luxury, she said, so they’re forced to risk their lives doing low-wage jobs deemed essential at this time.

Ramirez’s mother is a breast cancer survivor, making her particularly vulnerable to COVID-19. She had been working at a meatpacking plant in North Carolina, for a company that Ramirez said has had hundreds of COVID-19 cases among employees.

So Ramirez is relieved to have her mom in Chicago, helping take care of her.

“I’m glad this is taking her away from her position,” Ramirez said.

Friends and family in North Carolina have been fundraising to help pay her medical bills, selling raffle tickets and setting up a GoFundMe page on her behalf. Ramirez is also applying for financial assistance from the hospital.

Her experience with COVID-19 has not changed who she is as a person, she said, and she looks forward to living her life to the fullest.

If she ever gets the chance to speak with the family of the person whose lungs she now has, she said, she will thank them “for raising such a healthy child and a caring person [who] was kind enough to become an organ donor.”

Her life may never be the same, but that doesn’t mean she won’t try. She laughs as she explains how she asked her surgeon to take her skydiving someday.

“Dr. Bharat actually used to work at a skydiving company when he was younger,” Ramirez said. “And so he promised me that, hopefully within a year, he could get me there.”

And she has every intention of holding him to that promise.

This story is part of a reporting partnership that includes Illinois Public Media, Side Effects Public Media, NPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.