Injured and Uninsured, Protesters Get Medical Aid From LA Doctor

KFF Health News, June 19, 2020

Hundreds of people have contacted Amir Moarefi for medical help since the Long Beach, California, ophthalmologist posted his offer on Instagram.

This article was first published on Friday, June 19, 2020 in Kaiser Health News.

By Jackie Fortiér, KPCC

It wasn't Deon Jones' fractured cheekbone or even his concussion that most worried Dr. Amir Moarefi. He was most concerned that Jones could go blind.

"He sustained a rubber bullet direct injury to the cheek, which broke his zygomatic bone, which is your cheekbone, literally about an inch and a half from his eye and about another inch and a half from his temple," Moarefi said.

The death of George Floyd led to a national wave of protests against police brutality and racism. Law enforcement's attempts to control impassioned, mostly peaceful crowds has included tactics often deemed "less than lethal," such as tear gas, pepper spray and rubber bullets. But depending on where a person is hit, Moarefi said, those tactics can cause serious long-term injuries. And, they can kill people.

Jones was hit with a rubber bullet during a protest at Pan Pacific Park in Los Angeles on May 30. He managed to get to the emergency room at Cedars-Sinai with the help of a health care worker who was also protesting. The X-rays confirmed he had facial fractures and doctors recommended he follow up with an ophthalmologist to make sure his optic nerve hadn't been damaged by the impact.

"I had bruising under my eye and it was puffy as well, and I don't currently have health insurance," Jones said.

He wasn't sure how he'd get the care he needed from a specialist until a friend told him about a local doctor who offered to treat injured protesters, especially those without health insurance.

"I called him, then went in and I filled out some paperwork," Jones said. "I remember the girl saying, 'Your visit today will be free,' and I thought about how many people need to hear that."

In a June 4 statement, the American Academy of Ophthalmology called on domestic law enforcement officials "… to immediately end the use of rubber bullets to control or disperse crowds of protesters."

Instagram Medicine

Jones is one of hundreds of people who have contacted Moarefi for medical help since the Long Beach, California, ophthalmologist posted his offer on Instagram.

"I started to get the messages coming in and first it started off with a lot of virtual consults, a lot of messages, pictures, FaceTime chats," Moarefi said.

The requests for help quickly snowballed. His Instagram post was shared among protest groups all over the country.

"I've seen broken ankles, broken hands, broken fingers, welts all over the body. I've seen people who have sustained really bad tear gas injuries, where their entire face broke out into these nasty hives, including their eyes. Pepper spray, I've seen really bad cases. You could just see visible swelling of their eyeball," Moarefi said.

In between regularly scheduled surgeries, Moarefi checks his phone for new requests. To treat protesters in other states, he has formed a loose network of doctors he knows from medical school and conferences. Mostly he gives people medical advice via text.

Even though clashes with the police have largely died down, some protesters have festering wounds from days-old injuries.

"You get that adrenalin where you feel like you're OK. But then later when you go home, you may be doing more harm than good [by not having an injury evaluated immediately]," Moarefi said.

Health Care As A Form Of Protest

Treating protesters is the ophthalmologist's mode of protest against racial injustice and a health care system that he said doesn't treat people of color equitably.

"The feeling of injustice is what this is all about. And this is just more little bits of injustice that people are feeling if they're peacefully protesting, and they're getting hurt," Moarefi said.

The large number of reported injuries during the protests, including among KPCC/LAist reporters, has led to demands for law enforcement to stop using less-than-lethal weapons at mass gatherings.

A coalition of community activists and civil rights lawyers called on the L.A. Police Commission to ban their use against protesters. A spokesperson for LAPD declined to comment on the demands.

In a statement, the LAPD said the department is looking into allegations of misconduct and use of excessive force against protesters. The department said it has assigned 40 investigators to the task, and reported a total of 56 complaint investigations, 28 of which involve alleged uses of force.

If the demonstrations continue, Moarefi and a group of 11 doctors, nurses and EMTs plan to take medical kits and treat people right on the street.

"When I put my head down and I got my pillow at night, I want to know that I've done everything that I can to help support a cause that I believe in," he said.

This story is part of a partnership that includes KPCC, NPR and Kaiser Health News.

Trump's Take On COVID Testing Misses Public Health Realities

KFF Health News, June 17, 2020

Essentially, the president is arguing that the United States is finding more cases of COVID-19 because we are testing more — and that our increased testing makes it appear the pandemic is worse in the U.S. than in other countries.

This article was first published on Wednesday, June 17, 2020 in Kaiser Health News.

By Shefali Luthra

President Donald Trump sought to downplay the numbers associated with COVID-19 in the United States — which have passed 2 million confirmed cases and are nearing 120,000 lives lost — by arguing that the soaring national count was simply the result of superior testing.“If you don’t test, you don’t have any cases,” Trump said at a June 15 roundtable discussion at the White House. “If we stopped testing right now, we’d have very few cases, if any.”

It’s a talking point the administration is emphasizing. Vice President Mike Pence reiterated it during a phone call to Republican governors that evening, recommending they use the argument as a strategy to quiet public concern about surging case tallies in some states. It’s also a variation on a tweet the president sent earlier in the day.

With that in mind, we wanted to dig deeper. We reached out to the White House for comment or clarification, but we never heard back. Independent researchers told us, though, that the president’s remarks are not only misleading — they’re also counterproductive in terms of thinking through what’s needed to combat the coronavirus pandemic.

The Big Picture

Essentially, the president is arguing that the United States is finding more cases of COVID-19 because we are testing more — and that our increased testing makes it appear the pandemic is worse in the U.S. than in other countries.

“We will show more — more cases when other countries have far more cases than we do; they just don’t talk about it,” he added.

But that isn’t true.

The numbers paint a stark picture. The United States has recorded 2.1 million cases of the novel virus so far, about a quarter of the global total and more than any other country. To Trump’s point, the country is testing more now than it did at the start of the outbreak — per capita, the U.S. is in the top 20% of countries when it comes to cumulative tests run.

This beefed-up testing still likely reflects an undercount in cases, though. The problem is that the U.S. outbreak is worse than that of many other countries — so we need to be testing a higher percentage of our population than do others.

To best understand this, consider the number of tests necessary to identify a positive case. If it’s easier to find a positive case, that suggests the virus has spread further and more testing is necessary to track the spread of COVID-19.

For instance, statistics from the United States and the United Kingdom are fairly similar in terms of how many coronavirus tests are done daily per million people. But those tests yield far more positive cases in the United States. That suggests the outbreak here requires more per capita testing than does the U.K.’s.

“We have a much bigger epidemic, so you have to test more proportionately,” said Jennifer Kates, a senior vice president at KFF.

Put another way, a larger health crisis means — even after controlling for population size — the United States will have to test more people to find out where and how the virus has spread. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation.)

And while the U.S. has ramped up its testing since March, many parts of the country still don’t have sufficient systems in place — from facilities to staff to medical supplies — for diagnosing COVID-19, researchers told us.

What If We Stopped Testing?

And what about the president’s assertion that “if we stopped testing right now, we’d have very few cases” or none at all?

On its literal phrasing, it’s absurd, experts said.

“The implication that not testing makes the problem go away is completely false. It could not be more false,” said Dr. Joshua Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health in Baltimore. That’s because testing doesn’t create instances of the virus — it is just a way of showing and tracking them. (The president made a similar point during the same White House roundtable event.)

But even if you take it figuratively — the idea that our expanded testing resources have inflated our sense of the epidemic — it’s still misleading.

“We’re seeing a lot of cases because we’re testing? It just doesn’t ring true,” Kates said. “The U.S. has made a lot of progress for sure. But that job is not finished.”

The president’s claim is part of a larger reelection strategy, argued Robert Blendon, a health care pollster at the Harvard T.H. Chan School of Public Health. The idea is to suggest that the health crisis is mostly exaggerated — and that things are getting better, and Americans should feel comfortable going back to work. “If the economy takes off, the president has a chance of reelection,” Blendon said. “If it contracts as a result of expansion of cases, and the only way we know how to respond is restriction of economic activity, he’s gone.”

But the problem, Blendon added, is that COVID-19 counts are still climbing in multiple states. And people are still dying of the virus.

That gets at another point: Diagnostic testing isn’t the only data source to reveal the pandemic’s existence. Let’s not forget about hospitalization rates and death counts. The number of deaths continues to rise, and hospitalizations are higher than they would be in the virus’s absence.

Our Ruling

Trump argued that the nation’s high count of COVID-19 cases is simply a result of our expanded testing capacity. His point is entirely incorrect.

The most relevant data suggests that the U.S. isn’t testing enough to match the severity of the pandemic. Even with our higher testing ratio, we’re probably still undercounting compared with other countries.

Testing doesn’t create the virus. Even without diagnostics, COVID-19 would still pose a problem. We just would know less about it.

And, in fact, eliminating testing may alter the public’s perception of the pandemic but it wouldn’t conceal it. If anything, it would likely worsen the crisis, since the public health system wouldn’t know how to accurately track and prevent the spread of the coronavirus.

The president’s claim has no merit and seriously misrepresents the severity of the public health crisis. We rate it Pants on Fire.

Citing COVID, Sutter Pushes to Revisit Landmark Antitrust Settlement

KFF Health News, June 17, 2020

Sutter reported an operating loss of $404 million through April, citing declining patient revenue and expenses resulting from the pandemic.

This article was first published on Wednesday, June 17, 2020 in Kaiser Health News.

By Jenny Gold

Six months after agreeing to a $575 million settlement in a closely watched antitrust case filed by California Attorney General Xavier Becerra, Sutter Health has yet to pay a single dollar, and no operational changes have gone into effect. The nonprofit health care giant was accused of using its market dominance in Northern California to illegally drive up prices.

Late last week, lawyers for Sutter filed a motion requesting that San Francisco Superior Court Judge Anne-Christine Massullo delay approval of the settlement for an additional 90 days, due to "catastrophic" losses stemming from the COVID-19 pandemic. Massullo originally was scheduled to rule on the agreement in February, but in April granted an earlier request from Sutter for a 60-day delay in the proceedings.

In court documents supporting its request, Sutter argues the pandemic has upended the financial landscape for hospitals and made numerous aspects of the agreement untenable. Last month, Sutter reported an operating loss of $404 million through April, citing declining patient revenue and expenses resulting from the pandemic. System officials said that loss took into account the more than $200 million the system received in COVID-19 relief funds from the federal government via the CARES Act.

"We're in a crisis situation," David C. Kiernan, a lawyer representing Sutter, told Massullo during a settlement conference earlier this month. "There are certain provisions that, if they went into effect today, would interfere with Sutter's ability to provide coordinated and integrated care to patients in California."

The settlement, announced in December, marked a dramatic turn in a long-running legal battle initiated in 2014 as a class-action lawsuit filed by the United Food and Commercial Workers International Union & Employers Benefit Trust, representing employers, unions and local governments whose workers use Sutter services. Becerra's office joined the case in 2018.

Sutter has 24 hospitals, 34 surgery centers and 5,500 physicians across Northern California, with $13 billion in operating revenue in 2019. Among other allegations, the state's lawsuit argued Sutter has aggressively bought up hospitals and physician practices throughout the Bay Area and Northern California, and exploited that market dominance for profit.

Health care costs in Northern California, where Sutter is dominant, are 20% to 30% higher than in Southern California, even after adjusting for cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley that was cited in the complaint.

In agreeing to the settlement, Sutter did not admit wrongdoing. Throughout the proceedings, it has maintained that its integrated health system offers tangible benefits for patients, including affordable rates and consistent high-quality care.

Still, under terms of the settlement, Sutter agreed to end a host of practices that Becerra alleged unfairly stifled competition. Among other conditions, the settlement requires Sutter to limit what it charges patients for out-of-network services and increase transparency by allowing insurers and employers to give patients pricing information.

Sutter Health spokesperson Amy Thoma Tan, in a statement to KHN, said the health care system "has not objected to any aspect of the settlement" but is asking whether the settlement approval process should be deferred, "given the extreme disruption to the health care industry caused by COVID-19 and the potential for COVID-19 to materially impact certain settlement terms."

In the court papers filed last week, Sutter's attorneys went further, arguing that the settlement "may no longer make sense in its current form and could jeopardize Sutter's ability to continue providing care.

"In this regard, Plaintiffs' statement that they will not reassess even a single provision of a proposed injunction negotiated prior to COVID-19 is troublesome because it ignores the potentially harmful consequences of railroading the settlement through to approval in such an uncertain time," they continued.

The court filing notes some specific settlement terms Sutter now considers problematic. Among them is a provision that calls for Sutter to end its all-or-nothing contracting deals with payers, which demanded that an insurer that wanted to include any one of the Sutter hospitals or clinics in its network must include all of them. Also cited is a provision that would limit the size of rate increases. Sutter says in the filing that it now may need to increase prices more than expected to pay for personal protective equipment and other unanticipated costs resulting from the pandemic.

In its filing, Sutter does not specifically object to the $575 million settlement amount. But Jaime King, an associate dean at UC Hastings College of the Law who has followed the case, said the request for a delay could be a tactical strategy to support such a move.

"The longer they can delay, the more they can show they have significant losses from COVID-19, which allows them to plead for a lower settlement," King said.

While Becerra's office has acknowledged the difficult circumstances that the pandemic has created for California hospitals, state lawyers said the settlement is binding and should not be delayed further.

"The plaintiffs are not going to renegotiate the settlement," Emilio Varanini, a lawyer from Becerra's office, told Massullo last month. "It's even more in the public interest in an era of COVID-19 that COVID-19 not be an excuse to allow anticompetitive acts that will hurt consumers."

Richard Grossman, lead counsel for the plaintiffs in the class-action lawsuit, echoed that sentiment. "Every hospital system in California is required to abide by California's antitrust statutes, and they are all required to abide by the rules of competition that are prescribed by our legislature," Grossman told KHN. "Sutter does not get an exception to that because there is a pandemic."

Sutter has earned an average 43% annual profit margin over the past decade from medical treatments paid for by commercial insurers, like that provided by the plaintiff companies, according to a recent analysis by Glenn Melnick, a health care economist at the University of Southern California. "Google and Apple would be jealous of those profit margins!" Melnick said.

Without a settlement in place, critics said, Sutter can continue to employ the negotiating tactics that the attorney general called anticompetitive. Some noted, with irony, that the more than $200 million in relief funds Sutter received from the federal CARES Act was based on a formula that awarded funds according to a hospital's prior-year revenues — meaning Sutter was compensated for a pricing system the attorney general argued was artificially inflated.

"I'd be curious if they're trying to get in their last licks on using these types of tactics to inflate prices in one last round of negotiations with insurers and other payers," said Anthony Wright, executive director of the advocacy group Health Access California.

Jenny Gold: jgold@kff.org, @JennyAGold

Health Experts Link Rise in Arizona COVID Cases to End of Stay-at-Home Order

KFF Health News, June 16, 2020

Arizona has emerged as one of the country's newest coronavirus hot spots, with the weekly average of daily cases more than doubling from two weeks ago.

This article was first published on Tuesday, June 16, 2020 in Kaiser Health News.

By Will Stone

With new daily coronavirus cases rising in at least two dozen states, an explosion of new infections in Arizona is stretching some hospitals and alarming public health experts who link the surge in cases to the state’s lifting of a stay-at-home order a month ago.

Arizona has emerged as one of the country's newest coronavirus hot spots, with the weekly average of daily cases more than doubling from two weeks ago. The total number of people hospitalized is climbing, too.

Over the past week, Arizona has seen an average of more than 1,300 new COVID-19 cases each day.

After the state's largest hospital system warned about a shortage of ICU beds, Arizona Gov. Doug Ducey, a Republican, pushed back on claims that the health care system could soon be overwhelmed.

"The entire time we’ve been focused on a possible worst-case scenario with surge capacity for hospital beds, ICU beds and ventilators," Ducey told reporters. "Those are not needed or necessary right now."

While he acknowledged a spike in positive cases, Ducey said a second stay-at-home order was "not under discussion."

"We put the stay-at-home order there so we could prepare for what we are going through," he said.

Some states have reopened more slowly with a set of specific benchmarks for different regions, but Arizona took a more aggressive approach.

The state began easing restrictions on businesses in early May and lifted its statewide lockdown order after May 15. Under Arizona's reopening plan, businesses are advised to follow federal guidance on social distancing.

There is also no requirement for everyone to wear masks in public.

Public health experts agree: The timing of this spike reflects the state’s reopening.

"Perhaps, Arizona will be a warning sign to other areas," said Katherine Ellingson, an epidemiologist at the University of Arizona. "We never had that consistent downward trend that would signal it's time to reopen and we have everything in place to do it safely."

Before Arizona lifted its stay-at-home order, only about 5% of COVID-19 tests registered as positive. On Monday, that number was around 16%.

A slower reopening gives public health agencies time to identify whether cases are rising and then respond with contact tracing and isolating those who are infected.

"With a fast, rapid reopening, we don't have the time to mobilize those resources," said Ellingson.

Maricopa County, home to about 60% of the state’s population, has ramped up contact tracing in recent weeks, but it may not have enough capacity if the surge in cases continues.

Dr. Peter Hotez said the spike in Arizona, as well as in parts of Texas such as Houston, Dallas and Austin, is the consequence of removing restrictions too quickly and without a public health system that can keep pace.

"It was just 'open it up' and then more or less business as usual, with a little bit of window dressing," said Hotez, the dean for the National School of Tropical Medicine at Baylor College of Medicine in Houston. "This is not an abstract number of cases. We're seeing people pile into intensive care units."

Arizona's governor has also faced criticism from the mayors of Arizona's two biggest cities for not putting in place more stringent requirements.

"There is a pandemic and it's spreading uncontrollably," said Tucson Mayor Regina Romero, a Democrat. Ducey, she said, "is just putting up his hands and saying 'the spread is happening and we just have to go about our business.'"

And the governor's executive order forbids local governments from implementing their own extra measures, which adds to Romero's frustration. Texas has a similar measure.

"What he did was pretty much tie the hands of mayors and public health officials," Romero said.

Arizona's hospital industry has tried to tamp down fears that it's on the verge of a crisis. Hospitals are still performing elective surgeries.

"It's very unfortunate because hospitals right now in Arizona are quite busy with elective procedures," said Saskia Popescu, a Phoenix-based epidemiologist with George Mason University. "You throw in increasing cases of COVID, and that's going to very much stress your hospital systems."

Phoenix's triple-digit summer temperatures actually may fuel the spread of the virus. People forgo outdoor activities and retreat to air-conditioned indoor spaces, where the risk of transmitting the virus goes up significantly.

"My concern is we're going to see a lot more people in close quarters for prolonged periods of time," Popescu said.

Since the stay-at-home order was lifted, Popescu and others say they've seen people returning to a pre-pandemic mindset, neglecting to wear masks or maintain social distance. Videos of crowded bars have only propelled these fears.

On Thursday, however, Arizona's top doctor stressed there were also dangers to keeping the state on lockdown, including the mental health effects of loneliness and isolation.

"We know that it's in the community. We are not going to be able to stop the spread. And so we can't stop living as well," said Dr. Cara Christ, health director for the Arizona Department of Health Services.

But Dr. Quinn Snyder, an emergency medicine physician in Mesa, Arizona, said there needs to be more consistent messaging on public health measures like wearing masks.

"Frankly, I just think a wholesale reevaluation of where we're at is critical right now, but I can tell you that we're not doing nearly enough," said Snyder, who has seen the uptick in seriously ill COVID-19 patients firsthand.

"If we continue to head down this path, the virus will press our health care facilities beyond capacity, where we're going to have to be making tough decisions like who gets a ventilator and who doesn't."

This story is part of a reporting partnership between NPR and Kaiser Health News. 

Wealthy Hospital Taps Craft Breweries for Aid to Buy Masks, Gloves

KFF Health News, June 16, 2020

Beltway Brewing has donated more than $18,000 from its sales to Inova Health to help buy PPE.

This article was first published on Tuesday, June 16, 2020 in Kaiser Health News.

By Phil Galewitz

WOODBRIDGE, Va. — As Inova Health System sought donations in March to buy personal protective equipment for its staff to treat COVID-19, Zach Mote, a police officer turned brewer, came to their aid.

Even though his Water's End Brewery taproom in this Washington, D.C., suburb had been forced to close, he enlisted the help of nearby Beltway Brewing to make a new ale, PPE beer. They've donated the more than $18,000 from its sales to the hospital system to help buy masks, gloves and other personal protective equipment.

Inova, which serves some of Washington's wealthiest suburbs, told bondholders last year that it had $3.1 billion in investments it could liquidate in three days. It has received more than $144 million in advanced Medicare payments and $49 million in other federal coronavirus assistance.

As of early June, Inova has raised $4.3 million from more than 3,300 donors by appealing for donations to its Emergency Preparedness Fund.

"The optics of this aren't great," said Niall Brennan, president of the nonprofit Health Care Cost Institute, a research and policy organization, when asked about the fundraising effort at Inova. "This is one of the wealthier hospital systems in the area, and they should not be appealing for charitable donations for PPE."

Inova is one of several large hospital systems raising money to offset the cost of their vital role in combating the COVID pandemic. Yale New Haven Health, the largest hospital system in Connecticut, and UCLA Health in California are also soliciting donations to pay for PPE and other needs.

The pandemic upended hospitals' usual financing equations — forcing them to cancel lucrative nonemergency procedures and redirect much of their energy to treating a new disease that can keep patients in the hospital for weeks. But it has also engendered new fundraising efforts as it has raised hospitals' visibility.

"Some of this is tapping into the large reservoir of goodwill that the hospital has amassed because of their efforts over the course of the pandemic," Brennan said, "and many people want to help and are not sure how, beyond staying at home."

The efforts come even though the federal government has rushed out billions of dollars in relief funding to hospitals around the country, which hospitals say is not enough to defray their losses from the coronavirus outbreak.

The relief "will not fully cover our COVID-related losses, estimated at more than $200 million," UCLA Health, which received nearly $55 million in federal coronavirus grants and $276.5 million in advanced Medicare payments, said in a statement. "On the long road to recovery, we will continue to accept the generosity of those who support our mission."

Inova's top fundraising official, Sage Bolte, said the federal funding did not come close to meeting Inova's needs. The hospital system's revenue is down more than $100 million from last year, she said, and the system spent tens of millions of dollars helping it gear up to handle COVID-19 patients. Inova laid off 427 employees in nonclinical positions, a spokesperson said.

Inova made a $1 billion profit in 2019, with the gain coming mostly from investments, according to its audited financial statement.

Still, the fundraising does raise concerns among some experts.

Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management in Baltimore, said hospitals don't usually raise money for everyday equipment. "It's a cost of doing business," he said.

"They are taking advantage of their goodwill here," he added.

Simone Singh, assistant professor of health management and policy at the University of Michigan, also questioned the need for PPE fundraising. "A health system like Inova that is doing so well financially certainly should have the resources to purchase necessary PPE for their employees without having to rely on community fundraisers," she said.

Water's End and Beltway Brewing are donating $6 of the $18 cost for six-packs of the PPE beer, a bitter West Coast-style India pale ale. The label shows "PPE" stands for "People Performing under Extreme conditions."

The first batch of PPE was so successful it sold out on the first weekend in April. When they sell out the second batch of beer, made in late May, Mote said, the total donations to Inova should be about $27,000.

Mote said that, when he reached out to Inova, he did wonder how giving thousands of dollars to a multibillion-dollar company would make a difference.

When Bolte showed up in April to watch the PPE beer being canned, Mote told her: "This is probably just a drop in the bucket for you."

But Mote said she explained how the price of masks, gloves and other PPE had risen dramatically and how supplies were tough to get in April. Since then, he's been reassured he made the right move. "I got the impression that these donations have made an impact," he said.

"A lot of people don't realize that while the number of COVID cases are improving, a lot of people are going to work and putting themselves at risk," Sten Sellier, Beltway's president, said about his reasons for helping to make PPE. "That's something we wanted to bring attention to."

"This was a way to recognize and give attention to people who do the hard jobs and handle the risks," said Mote, who employs 10 people. The brewery has survived by converting its taproom into a packaging line and selling PPE and its other beers in a drive-thru set up in its parking lot.

Inova's Bolte said the hospital is grateful for all the businesses and individuals who donated to the emergency fund. Local defense contractors General Dynamic and Northrop Grumman have made six-figure donations, she said.

"The donations have truly made a difference in our supply of PPE to help us go on," Bolte said.

In May, Inova began resuming elective procedures that were put on hold in March, she said. The hospital system, she added, has enough PPE for staffers now but is gearing up for another surge in COVID cases this fall.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

At a Time of Great Need, Public Health in California Lacks 'Lobbying Muscle'

KFF Health News, June 15, 2020

Persuading lawmakers to increase spending is difficult because public health doesn't carry the same political clout as other power players such as hospitals, doctors or public employee unions.

This article was first published on Monday, June 15, 2020 in Kaiser Health News.

By Angela Hart

SACRAMENTO — If there were ever a time for more public health funding, health experts say, it's now.

Yet California Gov. Gavin Newsom and the state's Democratic-controlled legislature are expected to reject a plea from local public health officials for an additional $150 million a year to battle the COVID-19 pandemic and protect against future public health threats.

"I'm not holding my breath," said Riverside County Public Health Director Kim Saruwatari. "Right now, more than ever, the gaps that we have in our public health infrastructure have been exposed."

Public health officials vow to continue making their case. But persuading lawmakers to increase spending in a time of cuts will be even more difficult because public health doesn't carry the same political clout in the Capitol as other power players such as hospitals, doctors or public employee unions, which plow millions of dollars into lobbying each year.

"I've not met anybody who is a lobbyist for public health," said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee. "The organizations that wear the whitest of hats have the least resources. Consequently, it's easier to say 'No.'"

The novel coronavirus has decimated California's economy and, like local and state governments around the country, the state faces unprecedented budget challenges. Newsom is projecting a $54 billion deficit for the 2020-21 fiscal year, and says the state must make painful decisions before his July 1 deadline to sign a balanced budget into law.

The budget lawmakers are poised to send to Newsom on Monday does not include the additional public health funding.

Similar funding battles are taking place elsewhere, such as in Wisconsin, where the state faces budget cuts and officials are asking for more public health money.

"We need to have a plan to build up public health," said Dr. Georges Benjamin, executive director of the American Public Health Association. "We have to figure out how to afford it, otherwise we're going to have the same kind of economic consequences the next time something like this happens."Bottom of Form

California's 61 local health departments are the backbone of the state's public health system, and the two leading public health organizations representing local health officials have spent pennies on the dollar to lobby the governor, lawmakers and state agencies compared with big-name groups.

The Health Officers Association of California spent almost $7,000 on lobbying from January 2019, the start of the current legislative session, through March 2020, according to lobbying disclosures from the California Secretary of State office. The County Health Executives Association of California spent $191,000 over the same period. And while other groups employ in-house lobbyists to influence Capitol decision-makers full time, the public health organizations' executive directors pull double duty, serving as head lobbyists when they can fit it in.

Among the top spenders on lobbying were the powerful California Teachers Association, at $7.4 million, and the Service Employees International Union California, at $5.3 million.

Deep-pocketed health industry groups have also outspent public health interests. DaVita Inc. and Fresenius Medical Care, the two dominant dialysis companies operating in the U.S., spent $5.3 million on lobbying during that period. The California Hospital Association spent $3.4 million and the California Medical Association, representing doctors, spent $2.7 million. The groups collectively employ at least 15 in-house lobbyists.

In addition to paying for lobbyists, the money is used to curry favor with the governor, lawmakers and agency officials. California lobbyists are allowed to give gifts, and to wine and dine officials.

In October, for example, the California Medical Association hosted a "legislative reception" and dinner that included lawmakers, with the tab at the Napa Rose restaurant at the Disneyland Resort totaling more than $22,500.

Although political spending doesn't always get big industry groups everything they want, it has gained them more access to the governor and other state leaders steering pandemic response plans. It has also enabled moneyed health industry groups to continue working on other legislative priorities, such as relaxing hospital seismic safety standards and opposing a proposal granting nurse practitioners the ability to work without doctor oversight.

By comparison, lobbying by public health groups consists primarily of visiting lawmakers' offices, often accompanied by health officials from the lawmakers' jurisdictions.

Public health leaders are regularly invited to testify at legislative hearings tackling issues like measles outbreaks, the opioid epidemic or teen vaping, but they don't have anywhere near the "lobbying muscle" that major health industry groups have cultivated, said Kat DeBurgh, executive director of the Health Officers Association of California.

"We have no money; we advocate with our ideas," DeBurgh said. "We don't have millions of dollars to spend on billboards, and we can't call in a hundred people to stand up at a hearing and say 'I didn't get sick because of public health measures.'"

State spending for state and county public health programs has declined over the past decade. The governor's budget proposal for 2020-21 would continue that trend, reducing the current $3.4 billion public health budget to $3.2 billion.

Counties also are confronting a $1.7 billion loss in public health dollars due to pandemic-related declines in sales tax revenue and vehicle license fees, county health officials said, and they have asked Newsom to provide $1 billion from the state's general fund to help make up for it.

Newsom has said the state may not be able to afford to do that given other financial demands.

Health officials say the additional $150 million they're requesting would help them hire public health nurses and disease investigators, fund public health labs and purchase protective gear. They say addressing the underfunding of public health is especially critical now because counties are primarily responsible for providing adequate testing and contact tracing before easing stay-at-home restrictions.

"That $150 million, that doesn't even get anywhere close to where we need to be because so much of our funding has eroded away," said Mimi Hall, president of the County Health Executives Association of California, who is also the director of the Santa Cruz County health department.

State Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee, is also a pediatrician. Pan has consistently pushed for public health funding during his time in the legislature, and Capitol insiders view him as a de facto lobbyist for public health.

Pan said he plans to continue to advocate for the additional public health funding — despite the economic turmoil.

"It's hard because what public health does is invisible and you have to move people's hearts," Pan said.

Other lawmakers acknowledged concerns about public health shortfalls but said it would be difficult to increase spending this year. However, organizations that can afford to hire high-priced lobbying firms "will probably do OK in this budget," said Wood, the Santa Rosa Assembly member.

He is among the lawmakers considered most friendly to public health and said he supports more money, but wants to understand how it would be spent before deciding.

"They have been underfunded for years," Wood said. "But some of that happens at the local level, too."

Last year, public health officials sought $50 million a year from state lawmakers to help rebuild public health infrastructure following years of recession-era budget cuts. Newsom denied their request.

County health directors say chronic underfunding has forced them to make difficult decisions to curtail spending and cut programs like public health labs — 11 of 40 have shuttered in the past two decades.

And for years, they have warned California leaders that the state would be quickly overwhelmed should a public health crisis strike. Their pleas have gone largely ignored.

The impact of the relentless cuts has been felt across the state, including in Riverside County, which has slashed its public health staff by about 60% over the past decade, leaving just 30 disease investigators, contact tracers and public health nurses to serve the sprawling region of 2.5 million people, said Saruwatari, its public health director.

"Had we had the ability to test earlier, I think we would have been able to get out in front of this a little bit more," she said.

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

Angela Hart: ahart@kff.org, @ahartreports

COVID-19 Batters A Beloved Bay Area Community Health Care Center

KFF Health News, June 13, 2020

Golden Gate Village, Marin City's aging public housing project, remains a pocket of poverty and unemployment in one of America's wealthiest counties.

This article was first published on Friday, June 12, 2020 in Kaiser Health News.

By Rachel Scheier

MARIN CITY, Calif. ― A small band of volunteers started the Marin City Health and Wellness Center nearly two decades ago with a doctor and a retired social worker making house calls in public housing high-rises. It grew into a beloved community resource and a grassroots experiment in African American health care.

“It was truly a one-stop shop,” said Ebony McKinley, a lifelong resident of this tightknit, historically black enclave several miles north of the Golden Gate Bridge. “And it was ours.”

By early 2020, the center had a multimillion-dollar annual operation with two clinics, in Marin City and Bayview-Hunters Point, a predominantly black community in an industrial section of southeastern San Francisco. The clinics offered primary care geared to low-income residents of color, as well as access to dentists, psychotherapists, a substance abuse clinic and chiropractor.

In Marin City, ladies shouldering empty tote bags lined up on Tuesday afternoons to score free fresh produce at the clinic’s weekly Food Pharmacy program ― a big hit in a neighborhood where for years grocery shopping meant stopping by the dollar store for a couple of pork chops and maybe a withered, overpriced apple from CVS.

But in the wake of the coronavirus shutdown, there are worries about the future of this neighborhood clinic and others like it. Community health centers ― which provide medical services for 1 in 6 Californians ― have been forced to cancel in-person patient visits, and more than 200 of the clinics have closed since March. Despite several tranches of emergency government aid, the losses have forced widespread layoffs, said Carmela Castellano-Garcia, president of the California Primary Care Association.

“When your patient numbers go down by 66%, and that’s your main source of revenue, it calls for some drastic measures, unfortunately,” said Brenda Crawford, interim CEO of the Marin City Health and Wellness Center (MCHWC).

In April, the clinic laid off 10 people ― almost a fifth of the staff ― just as an avalanche of data emerged showing the novel coronavirus wreaking a disproportionate burden of illness and death on black communities.

African Americans account for 13.4% of the population but nearly 60% of COVID-19 deaths, according to a national study released in May. Blacks in the U.S. have a relatively high prevalence of conditions such as asthma, obesity, heart disease and diabetes that put them at greater risk of COVID complications, and are more likely to live in communities with low-wage jobs and less access to decent medical care.

The residents of Marin City have a front-row seat to such inequities. Golden Gate Village, its aging public housing project, remains a pocket of poverty and unemployment in one of America’s wealthiest counties. Last year, its struggling public school was hit with California’s first desegregation order in half a century.

Marin City took shape during World War II, as some of the thousands of new arrivals who flooded the Bay Area to work in shipyards were housed on the swamplands north of Sausalito. In “On the Road,” his 1950s almanac of traversing the United States, Jack Kerouac described the dormitories as “the only community in America where whites and Negroes lived together voluntarily.”

Marin County today is known for its redwood trees and Tesla-driving tech executives. It is also one of the most segregated counties in California, stemming in part from discriminatory policies that barred blacks from relocating within the county after the war’s end.

A nonprofit in 2018 rated Marin home to the largest racial inequities of any county in the state. And while it was ranked the healthiest county in California for nine of the past 10 years, black residents here live on average only half as long as whites, according to the Robert Wood Johnson Foundation.

A half-dozen failed redevelopment plans between the 1950s and the late 1980s left Marin City without a supermarket, school or post office. For residents without a car, getting to the nearest clinic for a Pap smear or a blood pressure check required an hour-long trek involving two buses followed by a walk up a steep hill. “Or they just didn’t go anywhere,” said Terrie Green, a longtime Marin City resident who helped found the center.

Bad health was something she knew well. Two of Green’s brothers died of heart attacks, and a third of a stroke at age 57. Her father succumbed to diabetes complications after losing several toes and one leg below the knee to the disease.

“Folks was having funerals it looked like every other week,” said Green. “I was tired of that.”

In 2002, she quit her job as a county mental health worker to focus on bringing a clinic to Marin City. As a member of a community group called ISOJI, the Yoruba word for “resurrection,” Green organized health fairs in the bustling parking lots of Marin City’s peach-colored public housing towers, setting up a blood pressure machine alongside kids riding scooters and old men playing dominoes.

Accompanied by a family physician with a practice in neighboring Sausalito, she did home visits at the apartments of elder residents. “I knew everyone, so I’d ask questions, and they’d open the door, and then he’d do the medical piece,” said Green. “He could not believe what he was seeing in Marin City ― the asthma and high blood pressure, the levels of chronic disease.”

MCHWC opened its Marin City clinic in 2006 using $225,000 in cobbled-together seed money.

Dr. Carianne Blomquist joined the clinic a few years later, becoming the first doctor to set up an office in Marin City since the 1950s. Her personable approach brought a diverse clientele to the clinic’s cramped offices in a scruffy community center, one wall decorated by a mural of Barack Obama and Martin Luther King Jr. In the parking lot, moms in SUVs and gentlemen leaning on canes passed muscled young men on their way to the boxing gym next door.

MCHWC is one of about 1,400 community health centers across the country that function as a safety net for the poor and uninsured. Conceived by civil rights activists during the 1960s, such facilities have steadily expanded as studies showed they improved the health of communities. The passage of Obamacare in 2010 brought in millions of newly insured patients.

In 2016, MCHWC opened a clinic in San Francisco’s Bayview-Hunters Point, like Marin City a working-class island amid the world’s highest concentration of billionaires. In the 2000s, it had the highest rate of childhood asthma in the city and an incidence of infant mortality on par with Jamaica.

The clinic opened in an old medical building where the neighborhood’s last private family doctor, Arthur Coleman, had operated until his death at age 82 in 2002.

Patient Gail Hampton, 64, came in the first time with such a debilitating fear of needles that she’d shake uncontrollably at the mere sight of a white coat. But Hampton soon began recommending the clinic to everyone from her grandkids to her church group. “They treated you like they wanted to help you,” she said. “Not just take your Medicare card and get your money.”

She was shocked to get a phone call in early April notifying her that her dentist and nine other employees were being let go. An earlier shake-up in leadership had led to the resignation of several providers including Blomquist, who quit in December and has not been replaced.

Under Crawford, a retired management consultant who took the helm in mid-2019, several services have been suspended, including an experimental high school for troubled teens and a birth center designed to address the staggering infant and maternal mortality rates among black women. Crawford said the birth center will reopen, but some are skeptical.

“It feels like a disservice to the community to allow the clinic to fall apart the way it is during this pandemic, which is killing black people,” said Dr. Joshwin Hall, a Bayview-Hunters Point native and a dentist at the clinic until he was laid off in April.

Green has been “beating the bushes” to open a drop-in coronavirus testing site at the clinic, so far without much luck. In the meantime, volunteers have been distributing “essential bags,” with supplies like thermometers and soap, and information on protecting against the virus.

The effort reminds Green of nearly 20 years ago, when she led the campaign to open the clinic.

“We’re still fighting,” she said.

Public Health Officials Face Wave Of Threats, Pressure Amid Coronavirus Response

KFF Health News, June 12, 2020

Emily Brown was director of the Rio Grande County Public Health Department in Colorado until May 22, when the county commissioners fired her after battling with her over coronavirus restrictions.

This article was first published on Friday, June 12, 2020 in Kaiser Health News.

By Lauren Weber and Anna Maria Barry-Jester and Michelle R. Smith, The Associated Press

Emily Brown was stretched thin.

As the director of the Rio Grande County Public Health Department in rural Colorado, she was working 12- and 14-hour days, struggling to respond to the pandemic with only five full-time employees for more than 11,000 residents. Case counts were rising.

She was already at odds with county commissioners, who were pushing to loosen public health restrictions in late May, against her advice. She had previously clashed with them over data releases and had haggled over a variance regarding reopening businesses.

But she reasoned that standing up for public health principles was worth it, even if she risked losing the job that allowed her to live close to her hometown and help her parents with their farm.

Then came the Facebook post: a photo of her and other health officials with comments about their weight and references to “armed citizens” and “bodies swinging from trees.”

The commissioners had asked her to meet with them the next day. She intended to ask them for more support. Instead, she was fired.

“They finally were tired of me not going along the line they wanted me to go along,” she said.

In the battle against COVID-19, public health workers spread across states, cities and small towns make up an invisible army on the front lines.  But that army, which has suffered neglect for decades, is under assault when it’s needed most.

Officials who usually work behind the scenes managing everything from immunizations to water quality inspections have found themselves center stage. Elected officials and members of the public who are frustrated with the lockdowns and safety restrictions have at times turned public health workers into politicized punching bags, battering them with countless angry calls and even physical threats.

On Thursday, Ohio’s state health director, who had armed protesters come to her house, resigned. The health officer for Orange County, California, quit Monday after weeks of criticism and personal threats from residents and other public officials over an order requiring face coverings in public.

As the pressure and scrutiny rise, many more health officials have chosen to leave or been pushed out of their jobs. A review by KHN and The Associated Press finds at least 27 state and local health leaders have resigned, retired or been fired since April across 13 states.

From North Carolina to California, they have left their posts due to a mix of backlash and stressful, nonstop working conditions, all while dealing with chronic staffing and funding shortages.

Some health officials have not been up to the job during the biggest health crisis in a century. Others previously had plans to leave or cited their own health issues.

But Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials, said the majority of what she calls an “alarming” exodus resulted from increasing pressure as states reopen. Three of those 27 were members of her board and well known in the public health community — Rio Grande County’s Brown; Detroit’s senior public health adviser, Dr. Kanzoni Asabigi; and the head of North Carolina’s Gaston County Department of Health and Human Services, Chris Dobbins.

Asabigi’s sudden retirement, considering his stature in the public health community, shocked Freeman. She also was upset to hear about the departure of Dobbins, who was chosen as health director of the year for North Carolina in 2017. Asabigi and Dobbins did not reply to requests for comment.

“They just don’t leave like that,” Freeman said.

Public health officials are “really getting tired of the ongoing pressures and the blame game,” Freeman said. She warned that more departures could be expected in the coming days and weeks as political pressure trickles down from the federal to the state to the local level.

From the beginning of the coronavirus pandemic, federal public health officials have complained of being sidelined or politicized. The Centers for Disease Control and Prevention has been marginalized; a government whistleblower said he faced retaliation because he opposed a White House directive to allow widespread access to the malaria drug hydroxychloroquine as a COVID-19 treatment.

In Hawaii, U.S. Rep. Tulsi Gabbard called on the governor to fire his top public health officials, saying she believed they were too slow on testing, contact tracing and travel restrictions. In Wisconsin, several Republican lawmakers have repeatedly demanded that the state’s health services secretary resign, and the state’s conservative Supreme Court ruled 4-3 that she had exceeded her authority by extending a stay-at-home order.

With the increased public scrutiny, security details — like those seen on a federal level for Dr. Anthony Fauci, the top infectious disease expert — have been assigned to state health leaders, including Georgia’s Dr. Kathleen Toomey after she was threatened. Ohio’s Dr. Amy Acton, who also had a security detail assigned after armed protesters showed up at her home, resigned Thursday.

In Orange County, in late May, nearly a hundred people attended a county supervisors meeting, waiting hours to speak against an order requiring face coverings. One person suggested that the order might make it necessary to invoke Second Amendment rights to bear arms, while another read aloud the home address of the order’s author — the county’s chief health officer, Dr. Nichole Quick — as well as the name of her boyfriend.

Quick, attending by phone, left the meeting. In a statement, the sheriff’s office later said Quick had expressed concern for her safety following “several threatening statements both in public comment and online.” She was given personal protection by the sheriff.

But Monday, after yet another public meeting that included criticism from members of the board of supervisors, Quick resigned. She could not be reached for comment. Earlier, the county’s deputy director of public health services, David Souleles, retired abruptly.

An official in another California county also has been given a security detail, said Kat DeBurgh, the executive director of the Health Officers Association of California, declining to name the county or official because the threats have not been made public.

Many local health leaders, accustomed to relative anonymity as they work to protect the public’s health, have been shocked by the growing threats, said Theresa Anselmo, the executive director of the Colorado Association of Local Public Health Officials.

After polling local health directors across the state at a meeting last month, Anselmo found about 80% said they or their personal property had been threatened since the pandemic began. About 80% also said they’d encountered threats to pull funding from their department or other forms of political pressure.

To Anselmo, the ugly politics and threats are a result of the politicization of the pandemic from the start. So far in Colorado, six top local health officials have retired, resigned or been fired. A handful of state and local health department staff members have left as well, she said.

“It’s just appalling that in this country that spends as much as we do on health care that we’re facing these really difficult ethical dilemmas: Do I stay in my job and risk threats, or do I leave because it’s not worth it?” Anselmo asked.

In California, senior health officials from seven counties, including Quick and Souleles, have resigned or retired since March 15. Dr. Charity Dean, the second in command at the state Department of Public Health, submitted her resignation June 4. Burnout seems to be contributing to many of those decisions, DeBurgh said.

In addition to the harm to current officers, DeBurgh is worried about the impact these events will have on recruiting people into public health leadership.

“It’s disheartening to see people who disagree with the order go from attacking the order to attacking the officer to questioning their motivation, expertise and patriotism,” said DeBurgh. “That’s not something that should ever happen.”

Some of the online abuse has been going on for years, said Bill Snook, a spokesperson for the health department in Kansas City, Missouri. He has seen instances in which people took a health inspector’s name and made a meme out of it, or said a health worker should be strung up or killed. He said opponents of vaccinations, known as anti-vaxxers, have called staffers “baby killers.”

The pandemic, though, has brought such behavior to another level.

In Ohio, the Delaware General Health District has had two lockdowns since the pandemic began — one after an angry individual came to the health department. Fortunately, the doors were locked, said Dustin Kent, program manager for the department’s residential services unit.

Angry calls over contact tracing continue to pour in, Kent said.

In Colorado, the Tri-County Health Department, which serves Adams, Arapahoe and Douglas counties near Denver, has also been getting hundreds of calls and emails from frustrated citizens, deputy director Jennifer Ludwig said.

Some have been angry their businesses could not open and blamed the health department for depriving them of their livelihood. Others were furious with neighbors who were not wearing masks outside. It’s a constant wave of “confusion and angst and anxiety and anger,” she said.

Then in April and May, rocks were thrown at one of their office’s windows — three separate times. The office was tagged with obscene graffiti. The department also received an email calling members of the department “tyrants,” adding “you’re about to start a hot-shooting … civil war.”  Health department workers decamped to another office.

Although the police determined there was no imminent threat, Ludwig stressed how proud she was of her staff, who weathered the pressure while working round-the-clock.

“It does wear on you, but at the same time we know what we need to do to keep moving to keep our community safe,” she said. “Despite the complaints, the grievances, the threats, the vandalism — the staff have really excelled and stood up.”

The threats didn’t end there, however: Someone asked on the health department’s Facebook page how many people would like to know the home addresses of the Tri-County Health Department leadership. “You want to make this a war??? No problem,” the poster wrote.

Back in Colorado’s Rio Grande County, some members of the community have rallied in support of Brown with public comments and a letter to the editor of a local paper. Meanwhile, COVID-19 case counts have jumped from 14 to 49 as of Wednesday.

Brown is grappling with what she should do next: dive back into another strenuous public health job in a pandemic, or take a moment to recoup?

When she told her 6-year-old son she no longer had a job, he responded: “Good — now you can spend more time with us.”

This story is a collaboration between The Associated Press and Kaiser Health News.

AP writer Audrey McAvoy in Honolulu and KHN correspondent Angela Hart in Sacramento contributed to this report.

Health Workers Resort to Etsy, Learning Chinese, Shady Deals to Find Safety Gear

KFF Health News, June 12, 2020

The global pandemic has ordinary healthcare workers going to extremes in a desperate hunt for medical supplies.

This article was first published on Friday, June 12, 2020 in Kaiser Health News.

By Eli Cahan and Sarah Varney

A nursing home worker in New Jersey rendezvoused with "the parking lot guy" to cut a deal for gowns. A director of safety-net clinics in Florida learned basic Chinese and waited outside past midnight for a truck to arrive with tens of thousands of masks. A cardiologist in South Carolina tried his luck with "shady characters" to buy ingredients to blend his own hand sanitizer.

The global pandemic has ordinary health care workers going to extremes in a desperate hunt for medical supplies. Community clinics, nursing homes and independent doctors, in particular, find themselves on the fringe of the supply chain for masks, gowns, gloves and ventilators.

Their missions have the cinematic quality of the drug trade or a black-market arms deal: Desperate administrators wire money to mysterious offshore bank accounts, wary of the flimflam man.

Most medical supplies ― from isolation gowns to the filtration components of N95 masks ― originate in China, in vast factories that manufacture so-called spunbond polypropylene out of toxic chemicals. Decades of honing has turned the supply chain into an efficient, just-in-time wonder of globalization. But that system crumbled in the midst of the pandemic as countries, states, cities and health care providers all sought the same things at the same time.

"You had all these brokers entering the market looking for arbitrage," said Michael Alkire, president of Premier, a company that negotiates supply contracts for hospitals. "Unless you were a significant player, it was hard to get access."

That's how Carol Silver Elliott, president of the Jewish Home Family in Rockleigh, New Jersey, ended up here: "We wired 'the parking lot guy' half the money," she said. "I swear I don't know his name."

At the end of May, the "parking lot guy" remained her go-to source. The nursing home is spending "significant money," Silver Elliott said, but the risk is worth it if she can outfit her staff with adequate personal protective equipment, known as PPE.

As the crisis dissipates at major hospital systems in urban centers like New York, Seattle and Detroit, the collateral damage is becoming apparent elsewhere.

The burden of managing the disease long term is shifting to nursing homes, safety-net clinics and outpatient medical practices. As these facilities brace for rolling waves of new infections, they are hustling to stock up on essential medical supplies — masks, gowns, testing kits, even disinfectant wipes — needed for basic care.

Thus far, things are not going well.

The first time Andy Behrman pulled up to the warehouse in Ocala, it was empty.

Behrman, director of the Florida Association of Community Health Centers, had spent the beginning of April trying to get gowns, gloves and masks for community clinics across the state's 67 counties.

During that time, he ventured into dark corners of the internet to identify 15 distributors, spent hours on the phone vetting vendors, traveled to Tallahassee to obtain a six-figure bank draft, rented a warehouse and loading trucks, and then hired staff for the three-day distribution operation. Getting the goods was "a complete free-for-all, a feeding frenzy," Behrman said. Sourcing has "basically come down to a huge dose of 'God, I hope these guys are legit.'"

Despite his best efforts, the original order — placed the second week of April with a vendor from Tulsa, Oklahoma — was delayed for hours, then days. It had been diverted to Cincinnati — the opposite direction. One hundred thousand N95 masks were expected. Only 50,000 arrived and they were KN95s, which do not meet U.S. quality standards. The bill due was the same: $180,000. After the distributor phoned on a Saturday morning to report another delay and request credentials to access funds in the secure FedEx account, Behrman said, he had "so much angina that [he] couldn't practically breathe." He called it off.

Nearly a week later, on April 24, a different vendor drove masks overnight from Duluth, Georgia, and 600 clinics had more of what they needed to safely treat their patients.

Behrman is still hunting for gowns and gloves. Without bulk donations from organizations like Direct Relief, a provider of humanitarian aid, and the philanthropic arms of companies like Centene, a health insurer, "I don't know what the hell we'd do," he said. To get a leg up in negotiations, he's been teaching himself rudimentary Chinese.

International Community Health Services (ICHS), a nonprofit health center in Seattle, depends on LabCorp for nasal swabs needed for testing but recently has been receiving oral swabs instead. Over the past two months, to alleviate shortages of various supplies, the organization "had to get extremely creative," said Rachel Koh, chief operating officer. They tried to get equipment from Hungary, "but that didn't really work out," Koh said. In the end, an ICHS physician knew a local businessman who knew an international distributor in Hong Kong, who could coordinate the logistics and arrange to import the supplies they needed.

"We are always on the hunt for new suppliers," Koh said, "but you have to be brave, because you don't know [whom] you can trust anymore."

Likewise, throughout April and May, Dr. Ian Smith — a cardiologist in South Carolina — tried to find necessities for the two clinics he owns. "I stopped at every general store between them," he said, "but all their shelves were cleared out."

Then he turned to "shady characters" halfway across the world ― learning a bit of Lithuanian in the process ― to no avail. So he's taken on patient safety as a Sunday "do-it-yourself" project: ordering products like ethyl alcohol, aloe vera and storage vessels from Amazon and Etsy to mix his own hand sanitizer.

Dr. Paula Muto, a general surgeon in Massachusetts, has struggled to find lidocaine and saline. Both are critical during surgery. "All the doctors are competing with each other to get this stuff," she said.

Muto anticipates that when routine procedures begin again, given the fragility of the health care supply chain, "all the supplies you can't buy at Staples" may go on back order. This includes almost everything except hand sanitizer and disinfectant wipes — assuming she can find those on shelves.

But she has "a backup plan." A distributor she knows in Alabama sources supplies from Spain and other European countries.

"We're already stocking up," she said. "We're trying to make sure we're at the top of every distributors' list."

Eli Cahan: emcahan@stanford.edu, @emcahan

Sarah Varney: svarney@kff.org, @SarahVarney4

Using Stories to Mentally Survive as a COVID-19 Clinician

KFF Health News, June 11, 2020

Learning to be storytellers also helps clinicians communicate better with non-professionals, said writer and geriatrician Dr. Louise Aronson.

This article was first published on Thursday, June 11, 2020 in Kaiser Health News.

By Stephanie Stephens

Dr. Christopher Travis, an intern in obstetrics-gynecology, has cared for patients with COVID-19 and performed surgery on women suspected of having the coronavirus. But the patient who arrived for a routine prenatal visit in two masks and gloves had a problem that wasn’t physiological.

“She told me, ‘I’m terrified I’m going to get this virus that’s spreading all over the world,'” and worried it would hurt her baby, he said of the March encounter.

Travis, who practices at the Los Angeles County + University of Southern California Medical Center, told the woman he knew she was scared and tried to assure her she was safe and could trust him.

Asking many questions and carefully listening to the answers, Travis was exercising the craft of narrative medicine, a discipline in which clinicians use the principles of art and literature to better understand and incorporate patients’ stories into their practices.

“How do we do that really difficult work during the pandemic without it consuming us so we can come out ‘whole’ on the other end?” Travis said. Narrative medicine, which he studied at Columbia University, has helped him be aware of his own feelings, reflect more before reacting, and view challenging situations calmly, he said.

The first graduate program in narrative medicine was created at Columbia University in 2009 by Dr. Rita Charon, and the practice has gained wide influence since, as evidenced by the dozens of narrative medicine essays published in the Journal of the American Medical Association and its sister journals.

Learning to be storytellers also helps clinicians communicate better with non-professionals, said writer and geriatrician Dr. Louise Aronson, who directs the medical humanities program at the University of California-San Francisco. It may be useful to reassure patients — or to motivate them to follow public health recommendations. “Tell them a story about having to intubate a previously healthy 22-year-old who’s going to die and leave behind his first child and new wife, and then you have their attention.”

“At the same time, telling that story can help the health professional process their own trauma and get the support they need to keep going,” she said.

Teaching Storytelling To Doctors

This fall, Keck School of Medicine of USC will offer the country’s second master’s program in narrative medicine, and the subject also will be part of the curriculum in the new Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, which opens its doors July 27 with its first class of 48 students. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Narrative medicine trains physicians to care about patients’ singular, lived experiences — how illness is really affecting them, said Dr. Deepthiman Gowda, assistant dean for medical education at the new Kaiser Permanente school. The training may entail a close group reading of creative works such as poetry or literature, or watching dance or a film, or listening to music.

He said there’s also “real, intrinsic value” for patients because a doctor isn’t only being trained to care about the body and medications.

“Literature in its nature is a dive into the experience of living — the triumphs, the joys, the suffering, the anxieties, the tragedies, the confusions, the guilt, the ecstasies of being human, of being alive,” Gowda said. “This is the training our students need if they wish to care for persons and not diseases.”

Dr. Andre Lijoi, a geriatrician at WellSpan York Hospital in Pennsylvania, recently led a virtual session for 20 front-line nurse practitioners who work in nursing homes. Two volunteers recited Mary Oliver’s 1986 poem “Wild Geese,” which reads, “Tell me about despair, yours, and I will tell you mine. Meanwhile the world goes on.”

Sharing the poet’s words helped the nurses relieve their pent-up tensions, enabling them to express their feelings about life and work under COVID-19, Lijoi said.

One participant wrote, “As the world goes on around me I mourn seeing my aging parents, planning my daughter’s wedding, and missing my great niece’s baptism. I wonder, when will life be ‘normal’ again?”

Processing Fear To Provide Better Care

Dr. Naomi Rosenberg, an emergency room physician at Temple University Hospital in Philadelphia, studied narrative medicine at Columbia and teaches it at Temple’s Lewis Katz School of Medicine. The discipline helps her “metabolize” what she takes in while caring for COVID-19 patients, including the fear that comes with having to enter patients’ rooms alone in protective gear, she said.

The training helped her counsel a worried woman who couldn’t visit her sister because the hospital, like others around the country, wasn’t allowing relatives to visit COVID-19-infected patients.

“I’d read stories of Baldwin, Hemingway and Steinbeck about what it feels like to be afraid for someone you love, and recalling those helped me communicate with her with more clarity and compassion,” Rosenberg said. (After a four-day crisis, the sister recovered.)

Close readings can also help students understand the various ways metaphor is used in the medical profession, for good or ill, said Dr. Pamela Schaff, who directs the Keck School’s new master’s program in narrative medicine.

Recently, Schaff led third-year medical students through a critical examination of a journal article that described medicine as a battlefield. The analysis helped student Andrew Tran understand that describing physicians as “warriors” could “promote unrealistic expectations and even depersonalization of us as human beings,” he said.

Something similar happens in the militarized language used to describe cancer, he added: “We say, ‘You’ve got to fight,’ which implies that if you die, you’re somehow a failure.”

In the real world, doctors are often focused narrowly, devoting most of their attention to a patient’s chief complaint. They listen to patients on average for only 11 seconds before interrupting them, according to a 2018 study in the Journal of General Internal Medicine. Narrative medicine seeks to change that.

While listening more carefully may add one more item to a physician’s lengthy “to-do” list, it could also save time in the end, Schaff said.

“If we train physicians to listen well, for metaphor, subtext and more, they can absorb and act on their patients’ stories even if they have limited time,” she said. “Also, we physicians must harness our narrative competence to demand changes in the health care system. Health systems should not mandate 10-minute encounters.”

Telling The Patient’s Whole Story

In practice, narrative medicine has diverse applications. Modern electronic health records, with their templates and prefilled sections, can hamper a doctor’s ability to create meaningful notes, Gowda said. But doctors can counter that by writing notes in language that makes the patient’s struggles come alive, he said.

The school’s curriculum will incorporate a different patient story each week to frame students’ learning. “Instead of, ‘This week, you will learn about stomach cancer,’ we say, ‘This week, we want you to meet Mr. Cardenas,'” Gowda said. “We learn about who he is, his family, his situation, his symptoms, his concerns. We want students to connect medical knowledge with the complexity and sometimes messiness of people’s stories and contexts.”

In preparation for the school’s opening, Gowda and a colleague have been running Friday lunchtime mindfulness and narrative medicine sessions for faculty and staff.

The meetings might include a collective, silent examination of a piece of art, followed by a discussion and shared feelings, said Dr. Marla Law Abrolat, a Permanente Medicine pediatrician in San Bernardino, California, and a faculty director at the new school.

“Young people come to medicine with bright eyes and want to help, then a traditional medical education beats that out of them,” Abrolat said. “We want them to remember patients’ stories that will always be a part of who they are when they leave here.”

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

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.

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