Low on essential supplies and fearing they'll get sick, doctors and nurses told ProPublica in-person care for coronavirus patients has been scaled back. In some cases, it's causing serious harm.
This article was first published on Thursday, April 10, 2020 in ProPublica.
Every morning, between 7 and 8, at Long Island Jewish Medical Center in Queens, several coronavirus patients are pronounced dead.
It's not that more people die at the beginning of the day, according to two medical providers at the hospital. But as a new shift arrives, doctors and nurses find patients who have died in the hours before and went undetected by a thin overnight staff.
Health care workers at several New York hospitals say they aren't entering patient rooms as often as usual. They say they are worried for their safety and are trying to conserve scarce personal protective equipment. And they say there are simply too many critically ill patients to provide the sort of continuous monitoring that should be standard.
"People haven't been seen in several hours overnight," a medical provider at Long Island Jewish said. "And when the morning team comes on, the person is sicker, or dead."
Across the city in Brooklyn, a similar ritual plays out each morning at Maimonides Medical Center, according to two doctors at the hospital. As the day shift begins, so does the blare of alarms: a patient's heart has stopped and they need to be resuscitated. "We hear the overhead speakers say, 'Code 3, Tower 7, Patient Room 732, Bed 1.' Then there will be another one. And another one," a doctor at Maimonides said.
"Normally there are so many steps we would take to keep a close eye on them," the doctor said. "But we're so swamped with patients coming in that we can't keep up."
In New York City, the epicenter of the virus, the surge in COVID-19 patients has overwhelmed many hospitals, forcing some health care workers to rethink and at times forgo certain essential safeguards.
In interviews, doctors and nurses at nine hospitals told ProPublica that to ensure they have enough PPE, like sterile gowns and masks, and to keep themselves from contracting the virus, hospital staff are not consistently providing the level of attention needed, and that lapses in care are imperiling COVID-19 patients, whose health can deteriorate very quickly.
The hospitals themselves insisted this wasn't so, saying their staff members have enough PPE and asserting that efforts to conserve equipment and protect staff weren't affecting patient care.
The pressures that front-line staff are reporting reveal what appears to be a disconnect between official policy and the decisions being made each day in beleaguered hospital wards. From hospital to hospital, the concerns raised and accounts provided were remarkably similar.
Some of the hospital workers interviewed by ProPublica said that in scaling back the level of care, they have missed important changes in patients' conditions they would ordinarily catch. One Brooklyn nurse said she and her colleagues have accidentally let patients' medicine bags run empty. And at another hospital in Brooklyn, a doctor said that last weekend, a 46-year-old patient took off his oxygen mask to go to the bathroom. No one noticed. They later found the man dead on the bathroom floor.
At many hospitals, when a patient "codes" — meaning their hearts or breathing have stopped — the response has slowed, too. In normal times, a team would rush into the room, scrambling to assess the patient and perform CPR. Now just a couple people go in, and often only after they stop to put on protective gear.
Hospital staff said they've had to adapt standards and come up with stopgaps. A doctor in Manhattan said he has taken to instructing patients, from outside their rooms, on how to change their own oxygen settings: The doctor stands outside the glass window, calls the patients over the phone, tells them how to turn on the oximeter, hook it up to their finger, read the knob on the machine, dial down the rate of oxygen and turn the monitor to face the window. "But you're talking to someone who is sick and who doesn't know how these machines work," the doctor said.
In New York City, more than 21,000 people have been hospitalized with COVID-19. Staff are stretched thin caring for so many critically ill patients, and some nurses are being asked to monitor up to 16 people at a time. The strain is exacerbated by a shortage of PPE.
Without sufficient equipment to feel safe, staff say they need to limit their exposure to the virus. They also want to limit how many supplies they go through. On Sunday, the president of SUNY Downstate Medical Center announced that the hospital was running out of gowns and would turn to garbage bags and rain ponchos.
One nurse at a Manhattan hospital said nurses are using N95 masks for up to 11 days, and getting a new one is always a struggle. In typical times, they wouldn't even go from one patient's room to another without changing masks. Now, they're scolded if they ask for more before their current mask is visibly dirty. Some of their colleagues have started deliberately ripping the mask's cord so their bosses have to give them a new one.
This week, a nurse employed by Maimonides started a GoFundMe campaign to raise money to buy her colleagues PPE. "We are in dire need of constant PPE to help us do our job safely & diligently," she wrote. (After she was contacted by ProPublica for comment, she took down the fundraiser. Last weekend, a nurse in Newark was suspended after using GoFundMe to buy PPE.)
A spokeswoman for Maimonides said the availability of PPE should not be a factor in patient care there. "We have had sufficient inventory of PPE to protect our staff and patients from the beginning of the pandemic. This is evident by our decision to mask our staff in our emergency room in the very early stages of the pandemic, followed by masking our entire hospital workforce soon thereafter. We did institute preservation-of-PPE guidelines for staff to reduce waste."
In response to the idea that patients code especially often during morning shift change, she said, "It is our experience that codes take place around the clock and are not clustered around any specific time."
A spokesperson for Northwell Health, the health care network overseeing Long Island Jewish, told ProPublica: "The claim that there has been a surge of deaths between 7 and 8 a.m. as a result of staffing shortages is blatantly false and disputed by our critical care specialists who have been on the front lines of this pandemic. ...The e-ICU staff remotely monitor patients' vital signs and alert on-site staff to any changes in patients' conditions. ... About 80% of COVID-positive patients within LIJ are not in intensive care but their pulse oximeters (the device that monitors oxygen saturation of a patient's blood) are checked regularly throughout the day and night."
"I strongly disagree with the assessment that we are lacking PPE," the spokesperson also said.
Hospital staff describe being put in an excruciating position. They are risking their lives and working tirelessly for their patients, and they've told reporters they're pained by not being able to give the quality of care they're used to. But they've seen their colleagues get sick and they don't want to bring the virus home to their families. And they know that if they fall ill, they wouldn't be able to care for patients at all. "Everyone has seen some otherwise healthy, young person die," said the provider at Long Island Jewish. "And they don't want that to be them."
Dr. Leigh Vinocur, spokesperson for the American College of Emergency Physicians, told ProPublica that coupled with PPE shortages, the highly contagious virus can force hospitals into a difficult calculus. "Of course, we want to do what's best for the patient, and in this situation we have to cut corners that we wouldn't usually," she said. "But the alternatives are losing half your workforce. Using all your resources on one patient, doing everything, everything, using all your PPE."
A Vital Loss of Precision
Critical care demands vigilance and precision. "It is the most meticulous part of medicine," Vinocur said. "You're managing every little vital sign. ... You're literally managing the physiology of the patient."
For the sickest coronavirus patients, hospital staff control everything from the patient's breathing to their kidney function. In normal times, providers say, patients this sick would have continuous, one-on-one monitoring, so that every change is noticed and acted upon. But now, providers say that sort of attention is impossible.
In a standard ICU, patient monitors are hooked up to a central system, so it's easy to track everyone's vital signs from afar. But in hospitals overwhelmed by COVID-19 patients, non-ICU floors have been converted into intensive care units, and they don't always have enough continuous oxygen monitors to check patient levels remotely. Instead, staff members check levels the old-school way. "Someone walks around the floor with an oxygen monitor, checks your oxygen in that moment in time and then walks away," the Long Island Jewish provider said. "And then no one checks it until the next person comes by — which is usually every four to six hours."
In order to contain infection, many hospitals keep the doors to patients' rooms closed, and doctors at Maimonides said that for some rooms, it's impossible to see inside. "And that's so scary," a second doctor at the hospital said, "because you'll walk in and a patient will be half on the bed and half on the floor."
A man with COVID-19 was recently admitted to a third hospital in Brooklyn and asked a doctor how long it was before he could leave. Before her shift ended, the doctor told him that he required oxygen, and he'd need a few days to recover. When she returned to work the next morning, she learned that the patient had taken a turn for the worse. He was on a high-concentration oxygen mask, at 15 liters per minute, the last step before intubation for COVID-19 patients.
Before the virus, doctors would check on patients on such a high oxygen setting every hour. But no doctor had evaluated this patient overnight and nurses had only checked his vital signs every four hours, the resident said.
That morning, the doctor found that he was taking 37 breaths per minute, a dangerously rapid rate. He was drowsy and sweating and gasping. "His breathing was going to stop at any moment," she said. The resident raced to the ICU to arrange an intubation. "I didn't want him to code and have a brain injury," she said. The patient needed a ventilator, but it would be another four hours before one became available.
Even in units where it's easy to check patients' vitals without entering their room, infrequent contact can mean other important changes fall through the cracks. For patients on ventilators, nurses must manage several crucial medications, and without frequent contact, it can take too long to realize that an IV bag needs to be replaced. The IV pumps have alarms to alert staff when the bags are running low, but since patients' doors are closed, nurses can't always hear them.
"That's happened to me, where it's like, 'Oh my fentanyl's out.' And I didn't notice," a nurse at Brooklyn Hospital Center said. "We're seeing that quite a bit. ... No one's letting their IV bags go completely dry for an extended period, I don't think. But you'll look at the monitors and say, 'Dude, do you see that your patient's blood pressure is super low?'"
Brooklyn Hospital Center did not respond to requests for comment.
"Patient Care Is Suffering"
Many of the medical staff interviewed said routine standards of care have also been neglected as hospitals switch into crisis mode. "If someone has a leaking stool bag, are you going to go in and change it every hour?" the Manhattan nurse asked. "No. You're not going to expose yourself."
It's unclear how, exactly, hospitals' legal obligations to patients have changed during this crisis. On March 23, New York Gov. Andrew Cuomo issued an executive order, as part of broader disaster emergency efforts, that temporarily limits liability for health care workers. The order modifies existing law to provide that many medical professionals are immune from civil liability for injury or death as a direct result from their actions or omissions, unless gross negligence can be proved. The wording, though, is vague. Inside the hospital, there's still uncertainty about the changes, according to a clinical administrative staff member at a hospital in Queens. And though some legal experts believe the order applies to hospitals, they are not explicitly written into the order. "There's still a lot up in the air, regulatory-wise," the clinical administrator said.
Front-line heath care workers have been sending incident notes to the clinical administrator, who has flagged fatal cases in the state's online tracking system, though there has been little time for follow-up.
Several doctors said that efforts to conserve PPE can affect a patient's care most when they are rapidly deteriorating. The Manhattan doctor explained that before COVID-19, if someone called a rapid response — meaning that a patient was at risk of losing a pulse within minutes — "all of us would rush into the room and there would be multiple moving parts to maximize the care and assess the situation quickly." Now, the policy is that the first person to get into the room makes the assessment. No one else from the medical team can enter, only a COVID-19 hospitalist and intensivist, when they arrive.
Recently, the doctor said, he was summoned for a rapid response for one of his patients, and when he got to the room, he found that a nurse was already inside. He had to stand outside and talk to her through the window: "Does this patient have a pulse?" he asked. The nurse said no. Before the coronavirus, the team likely would have started CPR. Instead, the doctor waited in the hall for the COVID-19 intensivist and hospitalist. They came within two minutes and decided to forgo CPR, as the patient, who was on dialysis, had a bad prognosis and CPR increases everyone's exposure. Still, if a doctor had been the first in the room, the doctor might have decided to start compressions immediately. "A nurse is not going to make that decision on their own."
As they do their best to take care of their patients, doctors and nurses feel that their hands are tied. "We're trying really hard to do our jobs and help people, but it's a really fine line. We're not being protected. We don't have the right equipment. Nurses are getting sick," the Brooklyn Hospital Center nurse said. "What do you expect? Patient care is suffering."
Many states report coronavirus cases and COVID-19 hospitalizations differently, and the federal government is way behind on data tracking. Without consistent information, the U.S. won't be able to properly respond as new coronavirus hot spots emerge.
This article was first published on Thursday, April 9, 2020 in ProPublica.
Late last month, Vice President Mike Pence sent a letter to administrators of the nation's 6,000 hospitals requesting a favor.
He asked them to complete a form each day with data on the patients they are treating with COVID-19, the disease caused by the novel coronavirus, and submit it to the Centers for Disease Control and Prevention.
"The data will help us better understand disease patterns and develop policies for prevention and control of health problems related to COVID-19," Pence wrote.
Now, as COVID-19 nears an apex in some parts of the country, it's unclear how many hospitals have submitted the requested information. For its part, the CDC has not released the data publicly, saying only that it plans to do so soon.
The U.S. health care system's response to the coronavirus has exposed many blind spots: the inability to quickly create a test that could be deployed widely, the lack of personal protective equipment for front-line doctors and nurses, and a lack of basic data on hospitalizations to help make informed decisions.
"We're in a fog because we have so little reliable data," said Dr. Ashish Jha, director of the Harvard Global Health Institute, which has been studying hospital capacity.
Having real-time data on hospitalizations across the country would do two things. First, it would provide a window into the spread of the coronavirus, albeit a week or so old because of the time it takes for infected patients to get sick enough to be hospitalized. Second, it would enable federal and state officials to identify hot spots that need more equipment and staffing and to shift resources from one region to another.
"You want to avoid what happened in Italy and Spain, where you first find out you have a COVID epidemic when ICUs are filling up," said Dr. Peter Hotez, co-director of the Center for Vaccine Development at Texas Children's Hospital and dean of the National School of Tropical Medicine at the Baylor College of Medicine in Houston. "It sounds like in some parts of the [United States], that's happening because the testing never got up to speed.
"The whole reason you're doing testing is to get ahead of that."
As of Wednesday, most states were releasing some information about the patients hospitalized for COVID-19, according to The COVID Tracking Project, which runs a website that tallies key metrics of the national response to the virus. But two states with a high number of cases — Michigan and Texas — were not doing so every day. Among those that are releasing data, the information is not consistent. Some report information on current hospitalizations, which offers a window into whether hospitals can handle the load, while others report information on cumulative hospitalizations, which gives a sense of the disease's ongoing toll.
What We Know About the Toll of COVID-19
What we are learning, experts say, is that COVID-19 appears to be hitting parts of the United States, particularly New York, in a similar way as it did Wuhan, China. Data from China indicated that approximately one in five patients hospitalized with COVID-19 died. Early data in the United States suggested that far fewer infected people who were hospitalized would die, but that has not held up as more data is reported. In part that's because seriously ill patients with COVID-19 often spend many days in intensive care before dying.
As of Wednesday night, 80,204 people had confirmed cases of COVID-19 in New York City. Of those, 20,474, or nearly 26%, required hospitalization at some point. All told, 4,260 died, more than 5% of those who have tested positive.
Other cities and regions have not reported data in the same way, so it's hard to draw comparisons. In California, for instance, 2,714 patients with COVID-19 were hospitalized as of Wednesday, of which 1,154 were in the ICU, more than 42%. Another 3,078 people who were suspected to have COVID-19 were also hospitalized, and 522 of those were in intensive care.
Bottom of FormSome states' data includes many unknowns. Massachusetts, for example, reported that 1,583 of its 16,790 COVID-19 patients required hospitalization, as of Wednesday. Another 4,717 did not. But the state listed the bulk of its cases, 10,490, as being under investigation.
The lack of available data raises questions about the federal government's $35 billion investment in electronic health records a decade ago, Jha and others say. The shift from paper to digital records was supposed to allow the health care system to be more nimble and provide information more quickly.
"If that's not happening, that's a huge failure of the system," he said.
In Harris County, Texas, which includes Houston, testing had not caught up with the reality in hospital wards.NBC News reported last week that as of March 30, the region around Houston had reported fewer than 950 confirmed coronavirus cases. "But on that same day, there were 996 people hospitalized in the region with confirmed or suspected cases of COVID-19."
A team at the University of Minnesota's Carlson School of Management has set out to gather hospitalization information directly from state health departments. In a post Tuesday in the journal Health Affairs, the team noted that there was wide variation between states in the percent of the adult population hospitalized.
In the states that released data on those currently hospitalized, the average hospitalization rate was 11.5 admissions per 100,000 adults, the report said. In Louisiana, the rate was far higher, 49.5 per 100,000 adults.
The report also noted that the average doubling time for cumulative hospitalizations was 4.21 days among the 14 states that reported data daily for at least the last 10 days. The doubling time in Massachusetts was 2.79 days while in Georgia it was 6.08 days. A faster doubling time could mean that there is more community transmission, and therefore, the health care system should be on a higher state of alert.
"While this could in part reflect differences in the timing of the pandemic reaching different states, it could also reflect differences in strategy across states and thus provide a learning opportunity" to understand what regions have done to keep their rates low, the authors wrote.
For its part, the CDC on Friday began releasing a weekly snapshot of hospitalizations, based on data from hospitals that serve about 10% of the U.S. population. It shows that hospitalization rates for COVID-19 in the first few weeks were similar to what is seen at the beginning of the yearly flu season. But given that the impact of COVID-19 has been felt most acutely since the cutoff period for the posted data, it seems certain hospitalization rates have gone up since then.
In a data brief released Wednesday, the CDC provided additional information on COVID-19-confirmed hospitalizations in 14 states from March 1 to 30, based on sites it studies in each state. The per-capita rates were highest in Connecticut, Michigan and New York and much lower in Oregon, Colorado and Ohio, showing the virus has affected different parts of the country differently. (Looking at raw case counts alone doesn't adjust for differences in state populations.) Older adults had higher hospitalization rates, and most of those hospitalized had underlying health conditions.
As for the initiative announced by Pence, the CDC said it is collecting the daily hospital data through its National Healthcare Safety Network. "The goal of this new module — once up and running — will be to help provide a better picture of what's happening inside U.S. hospitals during this outbreak. We hope to make this public soon," a spokeswoman said.
An Ongoing Blind Spot
Even when it comes to cruder forms of data, such as death data, the U.S. system has not proved particularly nimble. During the peak of the opioid epidemic a few years back, it took months and sometimes more than a year to gather accurate information about locations and causes of death, wasting precious time to put in place responses in hotspots, said Dr. Christopher J.L. Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington, whose COVID-19 models have informed the White House response.
"When it comes to hospital data, it's even less refined" than death data, Murray said. "If we had national daily reporting, inpatient admissions and ICU admissions, that would be a great boost for understanding where the next big wave is coming or where we're really seeing progress."
How soon regions run out of hospital beds depends on how fast the novel coronavirus spreads and how many open beds they had to begin with. Here's a look at the whole country. You can also search for your region.
This gap in data is causing problems with efforts to model the disease's toll. "We're starting to see this pattern where death reporting goes down on Sunday going into Monday and then they do catch up," Murray said. "This wreaks havoc on our models."
State health officials and hospital systems aren't waiting for good data to increase the number of hospital beds, ICU beds and ventilators available to treat COVID-19 patients.
In Indiana, for example, hospitals had 1,132 ICU beds as of March 1, Indiana Health Commissioner Dr. Kristina Boxin said at a briefing this week. By April 1, that had increased to 2,188 and by April 4, 2,964. "Our hospitals had done such an incredible job of converting every possible room into an ICU room," she said.
It's a good thing that happened. As of Sunday, about 58% of the currently available ICU beds across the state were occupied — more than the total available on March 1. Some 924 of the 1,721 occupied ICU beds were taken up by COVID-19 patients.
Dr. Nirav Shah, a senior scholar at Stanford University and the former health commissioner of New York state, said the health care system needs to learn from this crisis to better prepare for the next one, and having accurate, real-time data on hospitalizations is part of that.
"We don't have the early warning systems we need for this epidemic up and running," Shah said. "I think everyone understands and this epidemic has made abundantly clear that we need to create systems that are of the 21st century for a 21st-century disease, that we can't rely on the technology from the '80s and '90s that are what power our current survey systems."
Olga Matievskaya raised more than $12,000 to buy and distribute protective gear for her colleagues, who say they felt inadequately protected against COVID-19.
This article was first published on Tuesday, April 7, 2020 in ProPublica.
Olga Matievskaya and her fellow intensive care nurses at Newark Beth Israel Medical Center in New Jersey were so desperate for gowns and masks to protect themselves from the coronavirus that they turned to the online fundraising site GoFundMe to raise money.
The donations flowed in — more than $12,000 — and Matievskaya used some of them to buy about 500 masks, 4,000 shoe covers and 150 jumpsuits. She and her colleagues at the hospital celebrated protecting themselves and their patients from the spread of the virus.
But rather than thanking the staff, hospital administrators on Saturday suspended Matievskaya for distributing "unauthorized" protective gear.
Across the country, front-line medical providers and hospital administrators are butting heads about precautions against the coronavirus pandemic. Clinicians are being told to reuse or go without necessary supplies even when treating patients infected with COVID-19. That goes against the way they've been trained. Some doctors and nurses now say they are being instructed not to speak to journalists and disciplined for doing so or taking action to protect themselves.
Matievskaya spoke to ProPublica last week about the fundraising campaign. She said she had been able to purchase most of what the nurses needed on eBay. She did not criticize her administrators, and after her suspension she declined to comment. But four other Newark Beth Israel nurses spoke to ProPublica on the condition of anonymity about the dire shortage of gear.
All four said their administration has failed to provide the supplies they need to protect themselves and patients. Two of them work in the intensive care unit, which houses the sickest patients. The other two work in other areas of the hospital. They said Matievskaya showed leadership to keep people safe where their hospital administration has not. "There was no information distributed" about not being allowed to purchase supplies for others on staff, one of the nurses told ProPublica.
The hospital told ProPublica in a statement that Matievskaya's suspension ended Monday. "No employee is allowed to distribute unauthorized medical supplies within the hospital," the statement said. "The nurse in question was temporarily suspended for inappropriately distributing unauthorized medical supplies, against this policy."
The hospital said it ensures clinicians have the supplies they need by following guidance from the U.S. Centers for Disease Control and Prevention for reusing gear. "We are working 24-hours a day, 7-days a week to ensure that the appropriate PPE gets to the right staff, at the right time," the hospital said in its statement.
It did not answer questions about what would become of the supplies purchased through the campaign or whether other nurses who participated in the fundraising might be subject to discipline.
The confrontation at Newark Beth Israel may foretell what's coming in other cities. Northern New Jersey, just outside New York City, is one of the nation's hotspots, with more than 41,000 confirmed COVID-19 cases as of Monday. As of Thursday, the 665-bed hospital had housed 196 COVID-19 patients, according to an internal communication to hospital staff. Hospitals across the country have shortages of protective equipment, according to a report published Monday by the Office of Inspector General for the U.S. Department of Health and Human Services.
Aline Holmes, a clinical associate professor at the Rutgers School of Nursing, said she didn't know the details of the case but was "very surprised" to hear of Matievskaya's suspension. Hospital administrators are telling clinicians to reuse supplies, she said, which violates typical infection control standards. Suspending a nurse for obtaining protective equipment "doesn't make any sense," Holmes said.
"That just seems counterintuitive and really not a good message to send to your staff," Holmes said. "The staff have a right to protect themselves. If the hospital can't provide the necessary supplies, they have a right to do what they need to do. They're caring for the sickest patients in the hospital right now."
The situation is changing by the day as Newark Beth Israel acquires and runs through its supplies. But the four nurses told ProPublica that they have often not been given the N95 respirator masks the CDC has recommended to protect themselves from the virus. One of the ICU nurses said for at least one shift she received a regular surgical mask, which in her opinion is "like putting a paper towel over your face."
Some nurses outside the intensive care unit have been given a single surgical mask in a brown paper bag that they're expected to use for an entire week, one nurse said. Nurses at other hospitals around the country have made similar statements.
The shortage of gowns has also been a big problem, the nurses said. There should be enough to discard a gown after each interaction with an infected patient. But the shortage of gowns has required staff to leave the same gown hanging by the door of an infected patient's room and reuse it throughout a shift. In at least one case no gowns were available, one nurse said, so the staffer had to use a combination of a patient gown and bedsheet to treat an infected patient.
Some nurses in the intensive care unit have been caring for COVID-19 and non-COVID-19 patients on the same shift, the nurses said. So if they're not properly protected, the nurses said, they could pick the infection up on their masks or clothing in one room and carry it to the other. The nurses said they have heard of hospital staff testing positive for COVID-19, but they don't know where they picked it up and the facility's administration doesn't make any total numbers known. "We are spreading it, and we are getting it," one of the nurses said of the coronavirus.
The nurses said the situation is especially desperate because the hospital performs organ transplant operations, and those patients have compromised immune systems. A ProPublica report about the quality problems in the heart transplant program last year led to action by regulators. The hospital made the corrections required by the federal and state regulators, it said in a statement. The FBI also investigated the hospital as a result of the story, but the agency declined to comment Monday.
The nurses said some of the non-COVID-19 patients are heart and lung transplant recipients.
"We understand this is what we signed up for," one ICU nurse told ProPublica. "Just provide us with sufficient (protective equipment) so we can give these patients the optimal care that they need, and so we aren't contaminating others or ourselves."Bottom of Form
In some cases, nurses and administrators have disagreed about what is needed to keep them safe. The intensive care nurses said they have asked for jumpsuits, the overalls that cover their entire outfit. But administrators have told them such equipment isn't required, they said.
The intensive care nurses said they are directed to call a "command center" when they need more supplies. But when they reach out, "You get yelled at sometimes," one of the nurses said.
The hospital did not respond when ProPublica asked for an explanation of the various conditions described by the nurses.
But Dr. Matthew Schreiber, the hospital's chief operating officer, said in a brief phone conversation that the hospital has the personal protective equipment "that the staff require, which is at times not the same as the (protective equipment) that people want to have. There's lots of items people may bring from somewhere else."
Francis Giantomasi, an attorney who serves as the chairman of the hospital's board of trustees, said the problem isn't a lack of money. Newark Beth Israel had $186 million in net assets, according to its 2017 tax forms. It paid its chief executive officer Darrell Terry more than $1.4 million in salary and compensation, the documents show.
Gowns and masks and other critical gear "are in short supply everywhere and needed by everyone," Giantomasi said. "That's a serious, troubling, undeniable reality."
Darryl Young suffered brain damage during a heart transplant at Newark Beth Israel and never woke up. But, hardly consulting his family, doctors kept him alive for a year to avoid federal scrutiny.
One of the nurses said that if the hospital can afford to pay its CEO so well, then it should be able to go on eBay itself and purchase supplies for the staff.
In its statement the hospital blamed the problem on the way supplies are distributed. "No one person, institution, or hospital can independently correct this global supply shortage," it said.
Chris Neuwirth, assistant commissioner of the New Jersey Department of Health, said he feels that New Jersey is as prepared as it could have been. The 9/11 terrorist attacks, Superstorm Sandy and other events gave the emergency infrastructure a head start, he said. Meetings with hospital leaders began in early February. But the scope and magnitude of the coronavirus pandemic is beyond what emergency managers and public health officials could have anticipated, he said. When the crisis subsides, he predicted, there will be a reassessment of the stockpiles and what hospitals and health departments need to do in order to be prepared.
Holmes, the Rutgers professor, said hospital administrators need to step up and lead the providers on the front lines by communicating and building trust. If the staff members don't trust the administration, they might refuse to risk their lives and the health of their families, she said. They might stay home, she said.
Medical providers will not forget how administrators treated them when the COVID-19 pandemic is over, said Dr. Zubin Damania, a Stanford-trained physician who is now a popular social media personality known as ZDoggMD. Damania has more than 1.6 million Facebook followers and is pushing for clinicians to reform American health care. He said he is getting more than 250 private messages a week from doctors, nurses and other health care providers, lamenting the lack of protective equipment and unclear communication and intimidation they're getting from their administrators. In Mississippi, two doctors were reportedly fired for speaking out about coronavirus safety. A similar casewas reported in Washington state.
"There's so much distrust, and it's all borne out of poor coordination of leadership that should know better," Damania said.
Multiple private-equity-backed staffing companies have cut hours for thousands of emergency room doctors, physician assistants and nurse practitioners. That means there are fewer medical workers at a time in hospitals and they are receiving less pay.
This article was first published on Friday, April 3, 2020 in ProPublica.
The country's top employers of emergency room doctors are cutting their hours — leaving clinicians with lower earnings and hospitals with less staff in the middle of a pandemic.
TeamHealth, a major medical staffing company owned by the private-equity giant Blackstone, is reducing hours for ER staff in some places and asking for voluntary furloughs from anesthesiologists, the company confirmed to ProPublica. Multiple ER providers working for a main competitor, KKR-owned Envision Healthcare, said their hours also are being cut.
Even as some hospitals risk running out of room to care for COVID-19 patients, demand for other kinds of health care is collapsing. This irony is straining the business models of hospitals and the companies that staff them with doctors and other medical professionals.
Most ER doctors aren't direct employees of the hospitals where they work. Historically, the doctors belonged to practice groups that contracted with the hospitals. In recent years, private-equity investors started buying up and consolidating those practice groups into massive staffing companies.
Reduced hours are also hitting doctors employed by SCP Health, another medical staffing company backed by the investment firm Onex Corporation, according to internal memos obtained by ProPublica. US Acute Care Solutions, backed by the private-equity firm Welsh, Carson, Anderson & Stowe, said it's cutting hours in some places while increasing staffing elsewhere.
The staffing companies said they're responding to dropping revenue as non-coronavirus patients avoid the ER and hospitals cancel elective procedures. The companies also emphasize that they"re not cutting physicians' hourly rates.
But by assigning fewer hours to doctors and other providers such as physician's assistants and nurse practitioners, the companies are effectively paying them less. It also means that some hospitals have fewer clinicians working in the ER at a time.
"These actions are unacceptable and unnecessary," Scott Hickey, president of the Virginia College of Emergency Physicians, said in a statement. "This is very likely the 'calm before the storm' of critically ill patients entering hospitals with COVID-19 symptoms. Who will be there waiting to save those lives?"
The steepest cuts so far have occurred at Alteon Health, whose private-equity backers are New Mountain Capital and Frazier Healthcare Partners. The company says ER visits are down as much as 40% nationwide. In addition to the benefits cuts that ProPublica first reported on Tuesday, Alteon is furloughing some clinicians for 30 days to six months and won"t guarantee any hours for part-time employees, according to company memos obtained by ProPublica.
"Anyone not willing or unable to share the burden will need to be terminated to preserve employment for those who really feel part of our team and care about their coworkers," one manager wrote.
Alteon said its ER doctors and clinicians in places that are inundated with COVID-19 patients are working longer hours and being paid more. "We are doing all we can to provide the support to the people who are on the front lines of this fight right now and ensure we have resources for those who may be called on to do even more when surges come to their areas in the future," the company said in a statement to ProPublica.
In an earlier statement posted on Alteon's website, CEO Steve Holtzclaw said ProPublica's earlier article "mischaracterized" Alteon's actions, saying, "We have not cut clinical rates for providers in the field." In fact, ProPublica reported that Alteon wasn't cutting rates but was cutting hours, and fewer hours at the same rate amounts to lower earnings.
"It was worded in a way to make it sound like we weren't affected by this, but by cutting our hours we are," said an ER clinician who works for Alteon and has had hours reduced in a hospital with coronavirus patients. (The clinician, like others interviewed by ProPublica, spoke on the condition of anonymity because company policy prohibits their speaking publicly.) "When they're saying clinician pay is not affected, it certainly is. That was a straight lie."
The clinician added: "Health care workers are being applauded in the streets, and we are being stepped on by them."
TeamHealth initially told ProPublica that it was "not instituting any reduction in pay or benefits." However, the company is in fact paying some clinicians less in the form of reducing their hours. The company provided a new statement saying "we are not instituting any reduction in rate of pay or benefits as our emergency physicians face current challenges."
An ER clinician who works for TeamHealth said, "I probably wouldn't have complained as this situation is unprecedented, but to see TeamHealth blatantly lying is infuriating."
TeamHealth said it has reduced hours in some markets but is maintaining staffing above current demand in anticipation of a future surge of COVID-19 patients. While the company is asking anesthesiologists to take furloughs that may be mandatory if there aren't enough volunteers, TeamHealth said it's also looking for ways for anesthesiologists to use their skills to help out in emergency rooms or intensive care units. Blackstone declined to comment.
While some ERs in New York are overflowing with coronavirus patients, in many places people are staying home instead of going to the hospital. Studies have repeatedly shown that much of the care provided in the emergency room is for non-life-threatening issues.
"We always try to match our clinician coverage to our patient flow and we have done our best to do the same in this unpredictable time," Amer Aldeen, US Acute Care Solutions' chief medical officer, said in a statement. The company has not laid off, furloughed, reduced pay rates or cut benefits for any employees, Aldeen said.
Two clinicians working for Envision Healthcare said they were experiencing reduced hours. The company and its owner KKR did not respond to repeated requests for comment.
At SCP, salaries for nurse practitioners and physician's assistants will decrease in line with reduced hours, the company said in a memo on Thursday. Employees who don't accept the change will be terminated, the memo said.
"We know that this time is also difficult and uncertain for each of you, and we want all employees to be able to focus on getting through this time with as little worry as possible about their pay and benefits while avoiding unnecessary exposure to COVID-19," SCP executives said in the memo. "SCP Health is using its reasonable best efforts to retain all team members at this time in light of this unforeseeable pandemic."
SCP spokeswoman Maura Nelson said the company is dealing with a 30% drop in patients nationwide while the patients its providers are treating are more seriously ill. "We are calibrating our clinical coverage accordingly, so that we can address more flexibly the needs of our client hospitals," Nelson said. "This was a necessary adjustment as we weather this crisis, together."
Hickey of the Virginia physicians group called on staffing companies to take advantage of relief in the recent stimulus packages such as the Paycheck Protection Program and Medicare Accelerated and Advance Payment Program. But Alteon said it had already taken into account those relief measures before cutting compensation and benefits. "We have factored these actions into our plan," Holtzclaw said in his message to employees on Monday.
The pandemic's strain on the economics of the health care industry is not limited to private-equity-backed staffing companies. Hospital operators are also announcing layoffs and pay cuts. Dallas-based Tenet Healthcare said it would furlough 500 staff members and borrow money.
"We have this crisis going on where hospitals need as many people as possible, and at the same time hospitals have to cut their budgets," said Brandon Jones, a nurse anesthetist and part-owner of a practice group called Greater Anesthesia Solutions in the Phoenix area. "Doctors are being sidelined or they're being let go completely."
While Jones' colleagues are out of work for elective surgeries, he said they're redeploying their skills to help treat COVID-19 patients — in particular by intubating them for breathing machines, which puts providers at a high risk to catch the virus. They're wearing hazmat suits donated by a nearby nuclear power plant, Jones said, and they're helping out even when they can't bill for it or stand to make much less than normal.
"We're going to do it because it's right," he said.
Cardinal Health withdrew the gowns just before the pandemic because a Chinese supplier failed to sterilize them properly. The recall has created what a hospital association official called a "ripple effect."
The article was first published on Friday, April 3, 2020 in ProPublica.
There’s an overlooked reason why hospitals treating COVID-19 patients are so short of protective gear. In January, just before the pandemic hit the United States, a key distributor recalled more than 9 million gowns produced by a Chinese supplier because they had not been properly sterilized.
“At this time, we cannot provide sterility assurances with respect to the gowns or the packs containing the gowns because of the potential for cross-contamination,” Cardinal Health wrote to customers on Jan. 15. It added, “We recognize the criticality of our gowns and procedure packs to performing surgeries, and we apologize for the challenges this supply disruption will cause.”
The recall immediately forced the canceling of some elective surgeries. It also meant that supplies of medical gowns were already low when hospitals and state governments began desperately searching for protective gear to cope with the pandemic. Most gowns are supposed to be worn once and not reused. As some doctors and nurses have resorted to covering themselves with trash bags, raincoats and hazardous materials suits bought online, many health care workers have contracted the virus, further taxing already overwhelmed hospitals.
“Demand has gone up at a time when supply was already constrained,” said Bindiya Vakil, the chief executive of Resilinc, a Milpitas, California, firm that monitors supply chain disruptions worldwide. “Coronavirus made what was already a bad situation a lot worse.”
Colin Milligan, a spokesman for the American Hospital Association, said that the group’s members continue to experience shortages of medical gowns and that the Cardinal recall “has had a ripple effect.”
A Cardinal spokeswoman said that “the supply of surgical gowns should not impact the supply of PPE,” or personal protective equipment, for health care workers because they usually wear another type of outer garment, isolation gowns, when tending to coronavirus patients.
Cardinal received approval Tuesday from the federal government to donate the 2.2 million recalled gowns that remain in its inventory to the Strategic National Stockpile for distribution as isolation gowns. Each pallet must be “labeled in with a warning that the articles are for use for non-sterile apparel purposes only,” according to the approval letter.
The company is “working around the clock to meet the needs of healthcare providers so they can safely serve the patients who depend on them,” a Cardinal spokeswoman wrote in an email.
The shortage of gowns even before the coronavirus outbreak highlights the vulnerabilities of a U.S. health care system that depends on protective equipment largely made in other countries, led by China. The quality of gowns and other gear has been a recurring problem, including a dead insect in the packaging of a Cardinal gown, complaint records show. Replacing an overseas supplier can take months, and even if a new one is found quickly, it still has to ramp up production and arrange shipping.
“Unfortunately, like others, we are learning in this crisis that overdependence on other countries as a source of cheap medical products and supplies has created a strategic vulnerability to our economy,” U.S. Trade Representative Robert Lighthizer said at a meeting Monday. “For the United States, we are encouraging diversification of supply chains and seeking to promote more manufacturing at home.”
The recall also exposes flaws in how both companies and government regulators monitor the overseas manufacturers that produce much of the country’s inventory of protective medical gear. Because surgical gowns are considered a medical device, their quality is monitored by the U.S. Food and Drug Administration, which inspects manufacturing plants every two years.
A spokeswoman for Cardinal, which is based in Dublin, Ohio, said that it has a “broad and diverse manufacturing and supplier network” that includes the U.S. and is not dependent on any one locale. Cardinal is also one of the largest prescription drug distributors in the world. It had revenues in 2019 of more than $145 billion, making it the 16th largest company in the U.S., according to Fortune.
Cardinal chief executive Mike Kaufmann told Wall Street analysts in February that the company understood “the gravity” of the recall. He said it had hired outside experts to review Cardinal’s quality assurance procedures.
The company’s board has established a special committee to review management’s actions pertaining to the recall, according to Cardinal’s website. The outside experts continue to scrutinize the company’s practices, a spokeswoman said.
Of the recalled gowns, Cardinal had already distributed almost 8 million to health care facilities; the others had not reached customers. Some had been manufactured as early as the fall of 2018, the company has said. Cardinal does not have information on how many of the gowns were used but believes a majority of them were, a spokeswoman told ProPublica. Asked if any health workers or patients were infected as a result, she said that “we continue to track and analyze complaint data.”
The FDA last inspected the problematic Chinese plant in April 2018 and did not identify any violations, an agency spokeswoman said. Manufacturers are responsible for detecting problems and reporting them to the FDA, she said, adding that the Chinese company did not report any such issues during the period covered by the recall.
The January recall was not the first time Cardinal had a problem with the supplier, which it has identified as Siyang HolyMed Products Co. in Jiangsu province on China’s coast. Cardinal disclosed in a January press release that in the spring of 2018, around the same time the FDA was inspecting the Chinese company’s manufacturing facility, the company learned that Siyang outsourced some of its production to an unqualified facility. Cardinal tested products at the time and determined there was no reason to take further action such as a recall, it said.
Then, last Dec. 10, Cardinal received a tip that Siyang was making gowns at two sites that weren’t approved by the U.S. company or registered with the FDA, a Cardinal spokeswoman said. Ten days later, an on-site investigation confirmed the tip, she said.
In a Jan. 21 letter to customers, Cardinal said it couldn’t guarantee that the gowns were sterile because Siyang made some of them at locations that “did not maintain proper environmental conditions as required by law.” They were “commingled with properly manufactured gowns,” Cardinal said.
Phone and email attempts to contact Siyang were unsuccessful. The FDA said in January that it was investigating how the gowns may have been contaminated. An agency spokeswoman did not respond to questions about the status of that investigation.
Health care workers wear gowns to protect themselves from coming in contact with blood and other bodily fluids, microorganisms and particulate material. The gowns offering the highest level of protection are sterilized. A gown that is not properly sterilized increases the risk of infection, which can be transmitted to a patient during a procedure.
Health care workers use two kinds of medical gowns. Surgical gowns, like those sold by Cardinal, provide the highest level of protection and are more heavily regulated by the FDA. Isolation gowns, which are produced in larger amounts, are not sterilized but are appropriate for many interactions with COVID-19 patients. Both are in short supply right now as hospitals are quickly burning through any gowns they have and, in some cases, using already depleted supplies of surgical gowns when isolation gowns are unavailable.
The 9.1 million gowns recalled by Cardinal likely represent about 30% of the company’s global distribution, according to Premier, a Charlotte, North Carolina, company that negotiates prices on supplies bought by more than 4,000 hospitals and health care systems. The recall “absolutely contributed to the challenges that some of our hospitals are having treating their patients,” Chaun Powell, a group vice president at Premier, said. “That put burden on the supply chain prior to COVID outbreaks, and then the COVID outbreaks only exacerbated that issue.”
In the past two years, the FDA has received several complaints about the quality of Cardinal gowns. Adverse event reports filed with the agency include accounts of inadequate and improper protective wrapping on sterile gowns, holes in gowns, and blood soaking through the protective material. The reports disclosed to the public do not name the facilities or individuals reporting the product defects. Complaints have been filed about gowns purchased from distributors other than Cardinal as well.
In 2019, a hospital reported that a sterile gown arrived from Cardinal improperly wrapped, rendering it non-sterile. “This was noticed before it was opened to the surgical field; however, had it been opened it would have contaminated the entire field,” the report said. Ten days later, another report noted another packaging defect that could have caused contamination. “This is not the first time this has happened,” according to the report. “The gowns are coming from the manufacturer this way.”
In February, after the recall, a hospital found a dead insect in the packaging of a Cardinal sterile gown, according to a report filed with the FDA. The hospital said the gown was not part of the recall. The report noted there had been previous, unconfirmed reports of hair, gum and a cigarette butt found in Cardinal products labeled as sterile.
Cardinal did not respond to questions about the adverse event reports.
China is the source of 45% of all the protective medical garments imported to this country, according to an analysis last month by the Peterson Institute for International Economics. Other countries where gowns for U.S. health care workers are manufactured include Mexico, Thailand, Cambodia, Honduras and the Dominican Republic, according to the nonprofit ECRI Institute in Plymouth Meeting, Pennsylvania.
Another major distributor of surgical gowns, Medline Industries Inc., declined to answer questions about where its gowns are made. Attempts to contact another supplier, Halyard, were unsuccessful.
At a health care conference last month, Halyard’s parent company reported making surgical gowns at a plant in San Pedro Sula, Honduras.
For Cardinal, the recall has been a costly blow to its bottom line and reputation. The company’s operating earnings declined 34% in the second quarter ending Dec. 31, in part due to a $96 million charge related to the recall.
“We don’t know how this could affect our business going forward, and we’re hoping that it doesn’t,” Cardinal’s Kaufman said in a conference call with investment analysts in February. “But we know that we have created some pain.”
No, the coronavirus is not an "equalizer." Black people are being infected and dying at higher rates. Here's what Milwaukee is doing about it — and why governments need to start releasing data on the race of COVID-19 patients.
The article was first published on Friday, April 3, 2020 in ProPublica.
The coronavirus entered Milwaukee from a white, affluent suburb. Then it took root in the city’s black community and erupted.
As public health officials watched cases rise in March, too many in the community shrugged off warnings. Rumors and conspiracy theories proliferated on social media, pushing the bogus idea that black people are somehow immune to the disease. And much of the initial focus was on international travel, so those who knew no one returning from Asia or Europe were quick to dismiss the risk.
Then, when the shelter-in-place order came, there was a natural pushback among those who recalled other painful government restrictions — including segregation and mass incarceration — on where black people could walk and gather.
“We’re like, ‘We have to wake people up,’” said Milwaukee Health Commissioner Jeanette Kowalik.
As the disease spread at a higher rate in the black community, it made an even deeper cut. Environmental, economic and political factors have compounded for generations, putting black people at higher risk of chronic conditions that leave lungs weak and immune systems vulnerable: asthma, heart disease, hypertension and diabetes. In Milwaukee, simply being black means your life expectancy is 14 years shorter, on average, than someone white.
As of Friday morning, African Americans made up almost half of Milwaukee County’s 945 cases and 81% of its 27 deaths in a county whose population is 26% black. Milwaukee is one of the few places in the United States that is tracking the racial breakdown of people who have been infected by the novel coronavirus, offering a glimpse at the disproportionate destruction it is inflicting on black communities nationwide.
In Michigan, where the state’s population is 14% black, African Americans made up 35% of cases and 40% of deaths as of Friday morning. Detroit, where a majority of residents are black, has emerged as a hot spot with a high death toll. As has New Orleans. Louisiana has not published case breakdowns by race, but 40% of the state’s deaths have happened in Orleans Parish, where the majority of residents are black.
Illinois and North Carolina are two of the few areas publishing statistics on COVID-19 cases by race, and their data shows a disproportionate number of African Americans were infected.
“It will be unimaginable pretty soon,” said Dr. Celia J. Maxwell, an infectious disease physician and associate dean at Howard University College of Medicine, a school and hospital in Washington dedicated to the education and care of the black community. “And anything that comes around is going to be worse in our patients. Period. Many of our patients have so many problems, but this is kind of like the nail in the coffin.”
The U.S. Centers for Disease Control and Prevention tracks virulent outbreaks and typically releases detailed data that includes information about the age, race and location of the people affected. For the coronavirus pandemic, the CDC has released location and age data, but it has been silent on race. The CDC did not respond to ProPublica’s request for race data related to the coronavirus or answer questions about whether they were collecting it at all.
Experts say that the nation’s unwillingness to publicly track the virus by race could obscure a crucial underlying reality: It’s quite likely that a disproportionate number of those who die of coronavirus will be black.
The reasons for this are the same reasons that African Americans have disproportionately high rates of maternal death, low levels of access to medical care and higher rates of asthma, said Dr. Camara Jones, a family physician, epidemiologist and visiting fellow at Harvard University.
“COVID is just unmasking the deep disinvestment in our communities, the historical injustices and the impact of residential segregation,” said Jones, who spent 13 years at the CDC, focused on identifying, measuring and addressing racial bias within the medical system. “This is the time to name racism as the cause of all of those things. The overrepresentation of people of color in poverty and white people in wealth is not just a happenstance. … It’s because we’re not valued.”
Five congressional Democrats wrote to Health and Human Services Secretary Alex Azar, whose department encompasses the CDC, last week demanding the federal government collect and release the breakdown of coronavirus cases by race and ethnicity.
Without demographic data, the members of Congress wrote, health officials and lawmakers won’t be able to address inequities in health outcomes and testing that may emerge: “We urge you not to delay collecting this vital information, and to take any additional necessary steps to ensure that all Americans have the access they need to COVID-19 testing and treatment.”
Milwaukee, one of the few places already tracking coronavirus cases and deaths by race, provides an early indication of what would surface nationally if the federal government actually did this, or locally if other cities and states took its lead.
Milwaukee, both the city and county, passed resolutions last summer that were seen as important steps in addressing decades of race-based inequality.
“We declared racism as a public health issue,” said Kowalik, the city’s health commissioner. “It frames not only how we do our work but how transparent we are about how things are going. It impacts how we manage an outbreak.”
Milwaukee is trying to be purposeful in how it communicates information about the best way to slow the pandemic. It is addressing economic and logistical roadblocks that stand in the way of safety. And it’s being transparent about who is infected, who is dying and how the virus spread in the first place.
Kowalik described watching the virus spread into the city, without enough information, because of limited testing, to be able to take early action to contain it.
At the beginning of March, Wisconsin had one case. State public health officials still considered the risk from the coronavirus “low.” Testing criteria was extremely strict, as it was in many places across the country: You had to have symptoms and have traveled to China, Iran, South Korea or Italy within 14 days or have had contact with someone who had a confirmed case of COVID-19.
So, she said, she waited, wondering: “When are we going to be able to test for this to see if it is in our community?”
About two weeks later, Milwaukee had its first case.
The city’s patient zero had been in contact with a person from a neighboring, predominately white and affluent suburb who had tested positive. Given how much commuting occurs in and out of Milwaukee, with some making a 180-mile round trip to Chicago, Kowalik said she knew it would only be a matter of time before the virus spread into the city.
A day later came the city’s second case, someone who contracted the virus while in Atlanta. Kowalik said she started questioning the rigidness of the testing guidelines. Why didn’t they include domestic travel?
By the fourth case, she said, “we determined community spread. … It happened so quickly.”
Within the span of a week, Milwaukee went from having one case to nearly 40. Most of the sick people were middle-aged, African American men. By week two, the city had over 350 cases. And now, there are more than 945 cases countywide, with the bulk in the city of Milwaukee, where the population is 39% black. People of all ages have contracted the virus and about half are African American.
The county’s online dashboard of coronavirus cases keeps up-to-date information on the racial breakdown of those who have tested positive. As of Thursday morning, 19 people had died of illness related to COVID-19 in Milwaukee County. All but four were black, according to the county medical examiner’s office. Records show that at least 11 of the deceased had diabetes, eight had hypertension and 15 had a mixture of chronic health conditions that included heart and lung disease.
Because of discrimination and generational income inequality, black households in the county earned only 50% as much as white ones in 2018, according to census statistics. Black people are far less likely to own homes than white people in Milwaukee and far more likely to rent, putting black renters at the mercy of landlords who can kick them out if they can’t pay during an economic crisis, at the same time as people are being told to stay home. And when it comes to health insurance, black people are more likely to be uninsured than their white counterparts.
African Americans have gravitated to jobs in sectors viewed as reliable paths to the middle class — health care, transportation, government, food supply — which are now deemed “essential,” rendering them unable to stay home. In places like New York City, the virus’ epicenter, black people are among the only ones still riding the subway.
“And let’s be clear, this is not because people want to live in those conditions,” said Gordon Francis Goodwin, who works for Government Alliance on Race and Equity, a national racial equity organization that worked with Milwaukee on its health and equity framework. “This is a matter of taking a look at how our history kept people from actually being fully included.”
Fred Royal, head of the Milwaukee branch of the NAACP, knows three people who have died from the virus, including 69-year-old Lenard Wells, a former Milwaukee police lieutenant and a mentor to others in the black community. Royal’s 38-year-old cousin died from the virus last week in Atlanta. His body was returned home Tuesday.
Royal is hearing that people aren’t necessarily being hospitalized but are being sent home instead and “told to self-medicate.”
“What is alarming about that,” he said, “is that a number of those individuals were sent home with symptoms and died before the confirmation of their test came back.”
Health Commissioner Kowalik said that there have been delays of up to two weeks in getting results back from some private labs, but nearly all of those who died have done so at hospitals or while in hospice. Still, Kowalik said she understood why some members in the black community distrusted the care they might receive in a hospital.
In January, a 25-year-old day care teacher named Tashonna Ward died after staff at Froedtert Hospital failed to check her vital signs. Federal officials examined 20 patient records and found seven patients, including Ward, didn’t receive proper care. The report didn’t reveal the race of those whose records it examined at the hospital, which predominantly serves black patients. Froedtert Hospital declined to speak to issues raised in the report, according to a February article from the Milwaukee Journal Sentinel, and it had not submitted any corrective actions to federal officials.
“What black folks are accustomed to in Milwaukee and anywhere in the country, really, is pain not being acknowledged and constant inequities that happen in health care delivery,” Kowalik said.
The health commissioner herself, a black woman who grew up in Milwaukee, said she’s all too familiar with the city’s enduring struggles with segregation and racism. Her mother is black and her father Polish, and she remembers the stories they shared about trying to buy a house as a young interracial couple in Sherman Park, a neighborhood once off-limits to blacks.
“My father couldn’t get a mortgage for the house. He had to go to the bank without my mom,” Kowalik said.
It is the same neighborhood where fury and frustration sparked protests that, at times, roiled into riots in 2016 when a Milwaukee police officer fatally shot Sylville Smith, a 23-year-old black man.
And it is the same neighborhood that has a concentration of poor health outcomes when you overlay a heat map of conditions, be it lead poisoning, infant mortality — and now, she said, COVID-19.
Knowing which communities are most impacted allows public health officials to tailor their messaging to overcome the distrust of black residents.
“We’ve been told so much misinformation over the years about the condition of our community,” Royal, of the NAACP, said. “I believe a lot of people don’t trust what the government says.”
Kowalik has met — virtually — with trusted and influential community leaders to discuss outreach efforts to ensure everyone is on the same page about the importance of staying home and keeping 6 feet away from others if they must go out.
Police and inspectors are responding to complaints received about “noncompliant” businesses forcing staff to come to work or not practicing social distancing in the workplace. Violators could face fines.
“Who are we getting these complaints from?” she asked. “Many people of color.”
Residents have been urged to call 211 if they need help with anything from finding something to eat or a place to stay. And the state has set up two voluntary isolation facilities for people with COVID-19 symptoms whose living situations are untenable, including a Super 8 motel in Milwaukee.
Despite the work being done in Milwaukee, experts like Linda Sprague Martinez, a community health researcher at Boston University’s School of Social Work, worry that the government is not paying close enough attention to race, and as the disease spreads, will do too little to blunt its toll.
“When COVID-19 passes and we see the losses … it will be deeply tied to the story of post-World War II policies that left communities marginalized,” Sprague said. “Its impact is going to be tied to our history and legacy of racial inequities. It’s going to be tied to the fact that we live in two very different worlds.”
Update, April 3, 2020: This story has been updated to reflect that Illinois and North Carolina are breaking coronavirus cases down by race.
State data shows that New York is paying enormous markups for vital supplies, including almost $250,000 for an X-ray machine. Laws against price gouging usually don't apply.
The article was first published on Thursday, April 2, 2020 in ProPublica.
With the coronavirus outbreak creating an unprecedented demand for medical supplies and equipment, New York state has paid 20 cents for gloves that normally cost less than a nickel and as much as $7.50 each for masks, about 15 times the usual price. It's paid up to $2,795 for infusion pumps, more than twice the regular rate. And $248,841 for a portable X-ray machine that typically sells for $30,000 to $80,000.
This payment data, provided by state officials, shows just how much the shortage of key medical equipment is driving up prices. Forced to venture outside their usual vendors and contracts, states and cities are paying exorbitant sums on a spot market ruled by supply and demand. Although New York's attorney general has denouncedexcessive prices, and ordered merchants to stop overcharging people for hand sanitizers and disinfectant sprays, state laws against price gouging generally don't apply to government purchases.
With little guidance from the Trump administration, competition among states, cities, hospitals and federal agencies is contributing to the staggering bill for fighting the pandemic, which New York has estimated will cost it $15 billion in spending and lost revenue. The bidding wars are also raising concerns that facilities with shallow pockets, like rural health clinics, won't be able to obtain vital supplies.
As the epicenter of the pandemic, with about 40% of the nation's coronavirus cases, New York state is especially desperate for medical equipment, no matter what the tab. "We know that New York and other states are in the market at the same time, along with the rest of the world, bidding on these same items, which is clearly driving the fluctuation in costs," budget office spokesman Freeman Klopott said in an email.
The Office of General Services, New York's main procurement agency, declined to say which sellers were inflating prices for essential medical gear. "At this moment in time the New York State team is focused on procuring goods and services based on current market conditions," OGS spokeswoman Heather Groll wrote in an email. "There will be time to look back and pull together info on all this, that time will be when the pandemic is over."
New York isn't the only government paying whatever it takes — and keeping quiet about who's overcharging. Houston Mayor Sylvester Turner told reporters last week that he authorized paying $4 per N95 mask and still lost the bid. Turner's spokeswom
"What Mayor Turner mentioned was not an isolated incident but rather the norm for today's extreme demand on masks," Benton told ProPublica. "Given the urgency of the city's COVID-19 response and the focus on doing the work, the need for masks and other supplies, at this time we see no value in publicly calling out other cities or companies by name."
That same price was apparently too much for the U.S. Coast Guard. It ordered 1 million N95 face masks for $5 apiece on March 17, then downgraded the order to 200,000 masks, before canceling altogether, according to federal procurement databases and interviews with the contractor, Clean Harbors.
Chuck Geer, the company's senior vice president of field services, said Clean Harbors doesn't manufacture masks. It simply offered to pass along the supplies from a vendor with access to 200,000 masks, Geer said. The Coast Guard didn't return requests for comment.
In his daily press conferences, New York Gov. Andrew Cuomo has often complained about having to compete with states and the Federal Emergency Management Agency for personal protective equipment, and ventilators for patients in respiratory failure. "It's like being on eBay with 50 other states bidding on a ventilator," Cuomo told reporters on Tuesday. "And then, FEMA gets involved and FEMA starts bidding! And now FEMA is bidding on top of the 50! So FEMA is driving up the price. What sense does this make?"
A FEMA spokesperson said that "if a bidding conflict does arise, we will work closely with the state to resolve it in a way that best serves the needs of their citizens." FEMA has not disclosed the prices it has paid for supplies and equipment during the pandemic.
Typically, New York state buys a wide range of medical supplies from a list of approved distributors, which agree to provide those goods at a set price. Contracts are negotiated in bulk and over the long term, with public solicitations that generate multiple competitive bids.
Politicians have touted debt relief, but the various proposals are patchwork. Many homeowners and renters won't get much help; those struggling with credit card, car and other loan payments will get none.
That changed with the coronavirus outbreak. New York stateinvited anyone with needed supplies to sell them to the state, which means that prospective vendors can ask whatever prices the market will bear. Now, after running through their inventory, vendors are passing on higher costs from their own suppliers.
Hackensack, New Jersey-based Shield Line LLC, a recently approved New York state vendor, has a price list that includes 3.5 cents per glove and 3 cents for a simple surgical mask. But its CEO, Joe Kastner, says he has mostly sold out. If New York, which hasn't bought from him yet, was to order medical gear now, he might have to raise his prices, he said. He gets some of his products from Chinese companies, which reduced exports at the height of the epidemic there and are now resuming sending supplies to the U.S. — but at a higher price. "In some cases the cost is 15 to 20 times higher," Kastner said.
Neither federal nor state law accounts for a situation in which government agencies at all levels are vying with each other for the same goods. "The government has in normal times a lot of things to protect it, including lengthy contracts and oversight," said Justin Oberman, a former Transportation Security Administration official who now consults with businesses trying to navigate the federal procurement process. "In this case, raised voices may end up carrying the day."
Normally, there's no such crime as price gouging. In most states, it's only illegal during a declared state of emergency. During the current crisis, New York and other states have activated their price gouging statutes. However, most of these laws only apply to the sale of consumer goods and services, not to purchases by states or by private or nonprofit businesses, said Gretchen Jankowski, a commercial litigation attorney with Buchanan Ingersoll & Rooney. In order to go after a company for price gouging the state in Michigan, for instance, prosecutors would have to prove price fixing or fraud — a much higher bar.
Price gouging laws in New York state and New York City do not apply to state and city purchases, such as the $248,881 X-ray machine. While X-rays aren't recommended to diagnose COVID-19 patients, they are often used to assess how much damage the disease has done to a patient's lungs. Portable machines are more desirable than fixed machines because they help reduce the spread of infection. Caregivers don't have to bring patients to an X-ray room; the machine comes to them.
New York is paying bloated prices for another reason: Large national distributors are reluctant to steer more equipment to states with the most coronavirus cases. For fear of being accused of favoritism or even collusion, and in order to prevent stockpiling, they've put all of their customers on the same "allocation," or what a customer purchased in the past. Distributors say the federal government should step in to help them adjust those allocations based on need.
"Only the federal government has the data and the authority to provide this strategic direction to the supply chain and the healthcare system," Health Industry Distributors Association President Matthew Rowan wroteto FEMA administrator Peter Gaynor last weekend.
Dozens of cities have signed on to a letter coordinated by the nonprofit Public Interest Research Group asking the federal government to designate a "medical equipment czar" who would buy all the supply and fulfill requests from local jurisdictions. A bill sponsored by Sen. Chris Murphy, a Connecticut Democrat, would do the same.
WIthout federal intervention, states and hospitals may only become more vulnerable to the demands of brokers and speculators outside the normal supply chain, said Chaun Powell, vice president for strategic supplier engagement at the national health care consultant Premier Inc., which helps negotiate contracts for hospitals and health systems.
"The more COVID patients they get, the more masks they're going to burn," Powell said. "They're getting desperate because they're running out faster, so they're willing to pay."
ProPublica's health reporter Caroline Chen explains what the conversation around asymptomatic coronavirus carriers is missing, and what we need to understand if we're going to beat this nefarious virus together.
The article was first published on Thursday, April 2, 2020 in ProPublica.
In the early days of the coronavirus outbreak in the U.S., around the last week of February, I joked to a colleague that maybe now, finally, people would learn how to wash their hands properly. My remark revealed a naive assumption I had at the time, which was that all we needed to do to keep the novel coronavirus contained was follow a few simple guidelines: stay home when symptomatic and maintain good personal hygiene. The problem, I thought, was that nobody was following the rules.
In the past few weeks, however, more and more reports have emerged to challenge my neat assumptions. Seven out of 14 NBA players, coaches and staff who tested positive didn't have symptoms when they were diagnosed, The Wall Street Journal reported. The U.S. Centers for Disease Control and Prevention issued a case study on a nursing facility in King County, Washington, where 23 residents tested positive for COVID-19, and it found that 13 reported no symptoms initially. Sixty singers went to rehearsal and followed all the rules, according to the Los Angeles Times — nobody hugged, shook hands or appeared ill — yet three weeks later, 45 were diagnosed with COVID-19 or had symptoms of the disease, and two have died.
With articles about "silent spreaders" and "stealth transmission" flying across the internet, friends were starting to text me: Was it still OK to go for a walk with a friend, even 6 feet apart? Or should all interaction be avoided? Should we start wearing masks to the grocery store? At the same time, my colleagues were scrutinizing guidelines at various workplaces and agencies we cover: The New York City Fire Department told workers on March 19 they were to come to work, so long as they had no symptoms, even if they had had "close contact with someone who is a known positive COVID-19 patient," according to a document obtained by ProPublica. Was that policy wise?
I decided to dive into the available data. What I discovered is that not only can people be infected and experience no symptoms or very mild symptoms for the first few days, but this coincides with when the so-called viral load — the amount of virus being emitted from an infected person's cells — may be the highest. That makes the virus a truly formidable opponent in our densely packed, globally connected world. We're going to have to be smarter than this virus to stay on top of it.
What does asymptomatic really mean?
Let's start with the basics. Dr. Maria Van Kerkhove, head of the emerging diseases and zoonoses unit at the World Health Organization, told me that the WHO so far has found few truly asymptomatic cases, in which a patient tests positive and has zero symptoms for the entire course of the disease. However, there are many cases where people are "pre-symptomatic," where they have no symptoms at the time when they test positive but go on to develop symptoms later.
"Most of the people who were thought to be asymptomatic aren't truly asymptomatic," said Van Kerkhove. "When we went back and interviewed them, most of them said, actually I didn't feel well but I didn't think it was an important thing to mention. I had a low-grade temperature, or aches, but I didn't think that counted."
The WHO senta team to China and visited community centers, clinics and hospitals, and transportation hubs. Through their data collection, the team found that about 75% of people who were initially classified as "asymptomatic" went on to develop symptoms, she said. This matches up with the CDC's findings at the nursing facility in Washington. Of the 13 positive patients who initially reported no symptoms during testing,10 later developed symptoms.
But ultimately, the only way to really find out how many asymptomatic COVID-19 carriers are out there would be to conduct blood tests across large swaths of the population to look for antibodies, which are a type of protein that provide evidence that a person's immune system did battle with the coronavirus. Tests that can look for these antibodies are now being developed in several countries.
For the purposes of containing the outbreak right now, however, Jeffrey Shaman, a professor of environmental health sciences at Columbia University's Mailman School of Public Health, says the focus on asymptomatics is a bit of a red herring.
"In some sense, symptomatic versus asymptomatic isn't really the appropriate dividing line" for us to be focusing on, he said. "The appropriate dividing line is documented versus undocumented infection."
What Shaman means by "documented" is people who are identified as being infected, either because they were sick enough to go seek care or were tested through contact tracing, which is when public health officials track down all the contacts of someone who tested positive. The "undocumented" could be people who have symptoms but didn't get tested, because of lack of access to testing, dislike of doctors or sheer stoicism — or more concerningly, people who had no symptoms or such mild symptoms that they decided to just carry on with their daily lives.
"Maybe they pop some ibuprofen, but still go to work, still get on public transportation, still do all the things we normally do, and the consequence of that is those people with mild infections — as well as if they're truly asymptomatic — are taking the virus out into the community, and they're spreading it far and wide," Shaman said.
Shaman and colleagues published a studyin the journal Science on March 16 in which, using a statistical model, they estimated that 86% of all infections in China were "undocumented" prior to Jan. 23, when Chinese authorities cut off Wuhan, canceling all planes and trains leaving the city. This would help explain the rapid spread of the virus across the country, they said, concluding that their findings "indicate containment of this virus will be particularly challenging."
The disease IS spread by liquid "droplets." But the human body has lots of ways of creating these minuscule, virus-laden flecks.
If there are thousands of asymptomatic or pre-symptomatic people out in public, how are they transmitting the disease, if they're not coughing or sneezing? After all, as I'm sure many of us have heard, this disease spreads primarily via droplets.
The WHO's Van Kerkhove said research so far shows that liquid droplets are necessary to transmit the virus, and they need to go from the infected person's mouth or nose into someone else's eyes, nose or mouth. (People can also get infected if they touch a contaminated surface where a droplet has fallen onto and then touch their eyes, nose or mouth.)
But sneezing and coughing aren't the only ways droplets get transmitted.
"People clear their throat," Van Kerkhove pointed out. "Some people spit when they talk." I winced.
Angela Rasmussen, a virologist at Columbia's Mailman School, provided more vivid descriptions for my mental tableau. "Droplets are not necessarily huge, like globs. We release respiratory droplets when we speak."
"When you go outside and it's really cold out and you see your breath fog — that's respiratory droplets," she said.
This doesn't mean that the coronavirus is being transmitted as an "aerosol," which is the term that many researchers use when virus particles remain suspended in the air for long periods of time. That applies to the measles virus, for example, which is why that microbe is so incredibly contagious.
However, it does mean that if you're standing right next to someone who is infected and they're talking to you, or, say, if you're in a room full of singers who are projecting their voices in an enclosed space, there are going to be droplets in the air, and yes, you could inhale them.
What's still fuzzy is exactly how far one needs to stand in order to be ideally protected from coronavirus droplets. The WHO says 1 meter, or 3.2 feet. The CDC says 6 feet. Lydia Bourouiba, a fluid dynamics expert at the Massachusetts Institute of Technology, published a paperlast week that said that "peak exhalation speeds" can create "a cloud that can span approximately 23 to 27 feet." Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, later called the study "terribly misleading."
While the exact measurements are being debated, the experts I spoke to said that if you have to leave home, staying outdoors is the safest bet, since open air can help to "dilute" any potential microbes that reach you. While, of course, this isn't free of risk, one has to balance that risk against, for example, the mental and physical health benefits of going out for a run. So keep going out to exercise, the experts said. Maintain a 6 foot distance, at least.
You're likely most infectious right after you contract the virus, possibly before you know you're sick.
So we have a virus that can transmit from one person to another, standing a few feet apart, in the course of conversation, perhaps helped along by a few errant throat clearings, while the infected person either didn't have any symptoms yet or had a few minor body aches they didn't think much of.
That's already a recipe for a bad outbreak, but this coronavirus has another aspect that's helping to amp up its contagion factor. Studies are now finding that people are shedding more virus during early stages of the disease rather than the later stages.
The term "shedding" may bring to mind my cats, whose fluff seems to evade even my most ardent of vacuuming attempts, but it doesn't actually mean that virus particles are being emitted off patients' skin in an infectious cloud. It's a term used by researchers measuring the amount of viral RNA from someone who is infected, from a sample gathered via a method like a throat swab.
When nurses at one Washington State hospital complained about having to use expired respirators, they allege that staff were ordered to remove stickers showing the equipment was years out of date.
A studyof 94 patients in Guangzhou, China, found "the highest viral load in throat swabs at the time of symptom onset" and concluded that meant that patients would be most infectious right before or at the time when symptoms started appearing. That study was published online as a pre-print and has not yet been peer-reviewed, but lead author Dr. Gabriel Leung, dean of medicine at the University of Hong Kong, said it has been accepted for publication in the journal Nature Medicine. Another study, also conducted by researchers in Hong Kong and published in the journal Lancet last week, found that viral load, this time in a saliva sample, was "highest during the first week after symptom onset and subsequently declined with time."
The authors of the Lancet paper noted that this profile contrasted with COVID-19's coronavirus cousins SARS, where the peak viral load was around 10 days, and MERS, at the second week after onset of symptoms. COVID-19's "viral load profile" actually appears to be more similar to the flu, the authors wrote, which also "peaks at around the time of symptom onset." Viral load is thought to correlate with a patient's ability to infect others, and when the peak comes later on during the course of disease, it's more likely that a patient will have already sought care, been tested and either started treatment or gotten instruction to stay isolated.
The high viral load early on in the course of disease for COVID-19 patients "suggests that [the virus] can be transmitted easily, even when symptoms are relatively mild," wrote the authors of the Lancet paper. This finding "could account for the fast-spreading nature of this epidemic."
All of this makes it extra hard to set workplace standards.
Against this wily virus, it's difficult to set comprehensive guidelines. "What we recommend is if you're feeling unwell, stay home," said the WHO's Van Kerkhove. That sounds simple, but after our conversation, I was doubtful as to how to carry this out. What counts as "unwell"? If I wake up with a scratchy throat, how can I tell if that's seasonal allergies or a potential early COVID-19 symptom? When's a headache just a headache?
I'm fortunate that I've been able to work from home for the past month and rarely need to leave my apartment. But many aren't that lucky. My colleague Michael Grabell recently wrote about workers in the meatpacking industry who often don't have paid sick days and work shoulder-to-shoulder. Even if on paper, their employers say they "don't want team members who feel sick to come to work," it's unclear what counts as "sick" enough that they won't get in trouble.
I asked the CDC, given what its own studies are finding on asymptomatic transmission, how workplaces are supposed to set policies, and the agency directed me to this page, which says: "Employees who have symptoms (i.e. fever, cough, or shortness of breath) should notify their supervisor and stay home."
Like the WHO instructions, that really doesn't seem to address the questions posed by a virus that can be spread by people before they experience symptoms. But it's also understandable why agencies are setting guidelines around black-and-white things like fevers (which are objectively measurable) and coughs (which is also a binary call). It's pretty much impossible for the CDC to weigh in all the possible symptoms that this coronavirus might cause, especially the more subjective ones like mild headaches or fatigue, even if they could turn out to be early COVID-19 symptoms for some.
Dr. Raphael Viscidi, a professor of pediatrics at Johns Hopkins School of Medicine who worked on a vaccine for the SARS coronavirus, notes that there are different standards being asked of the general population and of essential workers, for good reason.
"On a population basis, the message has to be strong, it has to be consistent, and it has to be repeated: We have to exercise maximum social distancing," he said. "But then you start saying, well, what about the people that have to go to work?"
Hospitals that are short-staffed don't have the luxury of having conservative policies and telling staff to stay home and quarantine themselves before they exhibit symptoms, even if they've been exposed to someone who has a confirmed infection.
"The problem is we need the health care responders, because we have to care for the critically ill, so there's probably going to need to be an exception," said Columbia's Shaman. "And they're going to have to rely on their PPE, the personal protective equipment, to prevent them from spreading it to other people."
Viscidi acknowledged: "You are giving one message to the people you're asking to work and another message to the general population. For sure, some people are forced to take slightly greater risks."
We've got to fight this virus with all we've got. Here's how we do that.
Since symptoms-based policies alone cannot be perfect, we need to turn to other strategies to catch the people who slip through the gaps presented by a broad "If you're feeling unwell, stay home"-type recommendation.
In recent days, there's been a new enthusiasm for masks, with many calling for widespread use among the general public. The idea there is that masks could help prevent droplets from traveling far, particularly from an asymptomatic person who doesn't yet realize they're infected.
Leung, from the University of Hong Kong, is a fan of this idea. "Wear a mask, preferably universally in public spaces," he said, when I asked him how to solve the problem of asymptomatic transmission. But he also pointed out that there's a practical hurdle to this plan — "Of course this is not possible for some places where there are mask shortages even for hospital workers," which would be most of the United States.
After months of saying that healthy individuals should not wear masks, administration officials are now considering guidance for much broader, communitywide use of masks, Fauci toldCNN on Tuesday.
In an absence of an abundant supply of masks — which, by the way, also need to be worn properly to provide protection — both the WHO and CDC stressed how important social distancing was. "COVID-19 spreads between people who are in close contact with one another," the CDC said in a statement. "That's why the CDC recommends staying at least 6 feet away from other people, so someone doesn't spread the disease if they are sick or are exposed through contact with someone who is sick."
Not only can social distancing protect you as an individual, but the better the general public is at adhering to these guidelines and staying at home, the less virus will be circulating in the public to potentially infect paramedics, grocery store workers and public works employees and other essential staff.
For workers who absolutely have to turn up in person, Columbia's Rasmussen explained to me that dose also matters. We understand this instinctively. If someone infected sneezes straight at you from a foot away, splattering your entire face with wet gunk, you're going to feel more nervous about your likelihood of getting sick than if a single virus landed in your mouth.
"It's not always as simple as you come into contact with a single infectious particle and you're going to be infected," Rasmussen said. "You usually have to have a certain number of those particles in order for them to evade the immune system, get past the mucus barrier that's in your nose and throat, come into contact with a cell that has the virus receptor on it, and then get into the cell and start replicating."
So increasing the chance that the virus will be "diluted" is important. That means workplaces like meatpacking factories and delivery warehouses should do whatever they can to space out their workers, and not have meetings en masse in indoor spaces, where droplets are likely to persist and don't have a chance to be carried away by wind. And of course, companies should have generous sick leave policies, so workers can err on the side of caution if they do feel unwell.
And let us not forget about testing. Testing is critical, because it can let people know if they're sick before symptoms emerge and prompt them to self isolate. At a big picture level, testing helps public health officials know the disease is spreading and better allow them to direct resources and responses efforts.
I was wrong to ever think that curbing the novel coronavirus could be simple. It is truly a dastardly bug. But I'm confident we can be smarter. Even if COVID-19 doesn't vanish and becomes a seasonal illness, if we give it all we've got, I think we stand a good chance of getting this stealthy virus under control.
Alteon Health, a staffing company backed by private-equity firm Frazier Healthcare Partners, will cut salaries, time off and retirement benefits for providers, citing lost revenue. Several hospital operators announced similar cuts.
The article was first published on Tuesday, March 31, 2020 in ProPublica.
Emergency room doctors and nurses many of whom are dealing with an onslaught of coronavirus patients and shortages of protective equipment — are now finding out that their compensation is getting cut.
Most ER providers in the U.S. work for staffing companies that have contracts with hospitals. Those staffing companies are losing revenue as hospitals postpone elective procedures and non-coronavirus patients avoid emergency rooms. Health insurers are processing claims more slowly as they adapt to a remote workforce.
"Despite the risks our providers are facing, and the great work being done by our teams, the economic challenges brought forth by COVID-19 have not spared our industry," Steve Holtzclaw, the CEO of Alteon Health, one of the largest staffing companies, wrote in a memo to employees on Monday.
The memo announced that the company would be reducing hours for clinicians, cutting pay for administrative employees by 20%, and suspending 401(k) matches, bonuses and paid time off. Holtzclaw indicated that the measures were temporary but didn't know how long they would last.
In a follow-up memo sent to salaried physicians on Tuesday night, Alteon said it would convert them to an hourly rate, implying that they would start earning less money since the company had already said it would reduce their hours. The memo asked employees to accept the change or else contact the human resources department within five days "to discuss alternatives," without saying what those might be. The memo said Alteon was trying to avoid laying anyone off.
"It's completely demoralizing," said an Alteon clinician who spoke on the condition of anonymity. "At this time, of all times, we're putting ourselves at risk but also putting our families at risk."
Some co-workers are already taking on extra burdens such as living apart from their families to avoid the risk of infecting them, the clinician said. "A lot of sacrifices are being made on the front line that the administration is not seeing because they're not stepping foot in a hospital," she said. "I've completely lost trust with this company."
Other employers will soon follow suit, Holtzclaw said, citing conversations with his counterparts across the industry. "You can be assured that similar measures are being contemplated within these organizations and will likely be implemented in the coming weeks," he wrote.
However, another major staffing company for emergency rooms, TeamHealth, said its employees would not be affected. "We are not instituting any reduction in pay or benefits," TeamHealth said in a statement to ProPublica. "This is despite incurring significant cost for staffing in anticipation of surging volumes, costs related to quarantined and sick physicians, and costs for PPE as we work hard to protect our clinicians from the virus."
Alteon and its private-equity backer, Frazier Healthcare Partners, didn't immediately respond to requests for comment.
Private equity investors have increasingly acquired doctors' practices in recent years, according to a study published in February in JAMA. TeamHealth was bought by Blackstone Group in 2016; another top staffing firm, Envision Healthcare, is owned by KKR. (The staffing companies have also been implicated in the controversy over "surprise billing.")
Hospital operators have also announced cuts. Tenet Healthcare, a Dallas-based publicly traded company that runs 65 hospitals, said it would postpone 401(k) matches and tighten spending on contractors and vendors. Emergency room doctors at Boston's Beth Israel Deaconess Medical Center have been told some of their accrued pay is being held back, according to The Boston Globe. More than 1,100 staffers at Atrius Health in Massachusetts are facing reduced paychecks or unpaid furloughs, and raises for medical staff at South Shore Health, another health system in Massachusetts, are being delayed. Several other hospitals have also announced furloughs.
"We all feel pretty crestfallen," another ER doctor employed by Alteon said in a text message. "I did expect support from our administrators, and this certainly doesn't feel like that."
At Alteon, Holtzclaw wrote that the measures were necessary despite relief available from the $2 trillion stimulus that Congress passed last week. Those provisions include deferring payroll taxes, suspending reimbursement cuts and receiving advance Medicare payments.
Alteon's pay cut doesn't affect hourly rates for clinicians, but some of the people characterized as administrative employees are practicing doctors such as medical directors, according to one who spoke on the condition of anonymity. In his case, he said the cut amounts to about $20,000 a year.
"Every day I'm in county and federal emergency meetings. This is besides seeing patients. I'm doing more hands-on work right now than ever before," he said. "I'm getting calls 24/7 from the hospital administration, the county management team. I have not had a day off in over two weeks. And I'm working all this for 20% less."
The medical director said he understood the company has to cope with lost income, but he wished the leadership had let employees choose among a range of sacrifices that would best suit their individual circumstances.
"This decision is being made not by physicians but by people who are not on the front lines, who do not have to worry about whether I'm infecting my family or myself," he said. "If a company cannot support physicians during the toughest times, to me there's a significant question of integrity."
Another Alteon physician said he had been planning to ask for time off to go help out in New York, where the coronavirus outbreak is the worst in the nation. Now he has no paid time off, and he thinks his employer won't support him if he gets sick. He said if his pay drops he'll have to look for a new job.
"I have a huge loan payment. I have rent. I have groceries. I'm not going to sacrifice my life for when I get sick and they're going to say, 'You were replaceable,'" the physician said. "I cannot believe they did that to us."
There isn’t enough evidence that decades-old anti-malarial drugs work for the treatment or prevention of coronavirus, but here’s what we do know so far.
This article was first published on Sunday, March 29, 2020 in ProPublica.
President Donald Trump's excitement about decades-old anti-malarial drugs to treat the coronavirus has touched off widespread interest in the medications, hoarding by some doctors, new clinical trials on the fly and desperation among patients who take them for other conditions.
Many experts say there isn't enough evidence that the drugs work for the coronavirus, but at least a few say there's little to lose in giving hydroxychloroquine to patients who are severely ill with coronavirus.
"It's unlikely to worsen COVID-19, and given that it might help ... we have literally nothing else to offer these patients other than supportive care," said Dr. David Juurlink, an internist and head of the division of clinical pharmacology and toxicology at the University of Toronto in Canada.
Here's what we know and don't know about the drugs, chloroquine and hydroxychloroquine, also known by the brand name Plaquenil.
What We Know
The drugs are approved by the U.S. Food and Drug Administration, but not for the treatment of the coronavirus.
The drugs have been around for decades and are approved by the FDA. Hydroxychloroquine has been approvedfor the prevention and treatment of acute attacks of malaria, as well as lupus and rheumatoid arthritis. Chloroquine is approved to prevent and treat malaria.
At a briefing on March 19, Trump suggested that the FDA had approved hydroxychloroquine for treatment of the coronavirus, which is not accurate. At the same briefing, Dr. Stephen Hahn, the FDA's commissioner said: "That's a drug that the president has directed us to take a closer look at, as to whether an expanded-use approach to that could be done to actually see if that benefits patients. And again, we want to do that in the setting of a clinical trial — a large, pragmatic clinical trial — to actually gather that information and answer the question that needs to be answered and — asked and answered."
That said, doctors are generally allowed to prescribe drugs for unapproved uses.
A number of hospitals are using the drug to treat patients with the coronavirus.
The University of Washington, the University of Michigan and other academic medical centers have added hydroxychloroquine to their treatment protocols. "Hydroxychloroquine is an inexpensive and generally safe drug for short term use, with few drug-drug interactions," the University of Washington protocol says. "While it is unknown if it is effective to treat COVID-19, there is a favorable risk:benefit and cost ratio. Multiple trials are ongoing, and this recommendation will be updated when further data is available."
While Trump has talked about the combination of hydroxychloroquine and the antibiotic azithromycin, also known as Zithromax, the University of Michigan recommends against the use of azithromycin for use in treatment of COVID-19, calling the evidence "weak."
Patients who rely on hydroxychloroquine for other conditions can't get it.
As we reported last week,patients with lupus have not been able to refill their prescriptions. Anna Valdez, a nurse in California, told us that without the drug, she will likely have a disease flare or have to switch to stronger immune suppressing medicines that could, paradoxically, put her at more risk of serious consequences should she contract the coronavirus.
"When I think about the other people out there with lupus and other autoimmune disorders, we're all really scared right now," Valdez said a week ago. "If I get coronavirus, unlike someone else my age, almost 50 years old, who is likely to recover and will be fine, I will likely end up in the ICU."
Trump's unproven claim that hydroxychloroquine could be used to treat COVID-19 has led to hoarding, putting Lupus patients and others at even greater risk. As of Saturday afternoon, Anna Valdez had 27 pills left. That number is now down to 25.
According to a report by BuzzFeed News, health insurer Kaiser Permanente seems to be prioritizing getting the drug to COVID-19 patients above patients with lupus. The insurer told a California patient that it would not refill her prescription for hydroxychloroquine. "Thank you for the sacrifice you will be making for the sake of those that are critically ill; your sacrifice may actually save lives," her doctor's office said in a message.
A Kaiser regional medical director told BuzzFeed that Kaiser, like other health care organizations, "has had to take steps to control the outflow of the medication to ensure access to severely sick patients, including both COVID-19 and those with acute lupus."
She said the decision wouldn't adversely affect lupus patients. "Extensive experience and research show that hydroxychloroquine builds up in the body and continues to work for an average of 40 days even after the last dose is taken. By then, we expect the drug manufacturers to have ramped up production to meet the increased demand."
Some doctors and their families are hoarding the drug.
We reported that pharmacies and state pharmacy boards are concerned about hoarding by doctors and their families.
"It's disgraceful, is what it is," said Garth Reynolds, executive director of the Illinois Pharmacists Association. "And completely selfish."
"We even had a couple of examples of prescribers trying to say that the individual they were calling in for had rheumatoid arthritis," he said, explaining that pharmacists suspected that wasn't true. "I mean, that's fraud."
Some state pharmacy boards have put in place restrictions on prescribing of the drug. And the American Medical Association called on doctors to stop hoarding the drug.
"The AMA is calling for a stop to any inappropriate prescribing and ordering of medications, including chloroquine or hydroxychloroquine, and appealing to physicians and all health care professionals to follow the highest standards of professionalism and ethics," said Patrice A. Harris, president of the American Medical Association.
In a memo to his staff on Thursday, Dr. Craig R. Smith, the chair of surgery at NewYork-Presbyterian/Columbia University Irving Medical Center, responded to the reports of hoarding. "Doesn't that make you proud?" he wrote sarcastically. Instead, he encouraged randomized double-blind clinical trials to assess whether the drugs work.
There are efforts to increase the supply of the drug, but other moves could tighten it.
Several drugmakers have said they plan to step in. Novartis said it would donate up to 130 million doses of generic hydroxychloroquine globally to support the response to COVID-19. Other companies have alsopledged millions of doses.
At the same time, the Indian government last week imposed a moratorium on the export of hydroxychloroquine, except under certain conditions including "humanitarian grounds on case to case basis." India is a major supplier of generic drugs used in the United States.
Conservative groups and television hosts are talking up the benefits of the drug.
As we reported last week, a conservative business group is pushing the Trump administration to use hydroxychloroquine, saying in an online petition that "red tape, regulation, and a dysfunctional healthcare supply chain" are impeding the ability of plants in the United States to produce the drug.
The Job Creators Network, founded by Republican political donor and Home Depot co-founder Bernard Marcus, has taken out Facebook ads and texted supporters to sign a petition urging the president to "CUT RED TAPE" and make the drug available.
A nonprofit started by the billionaire co-founder of Home Depot says plants are ready to produce the drug but for "red tape." Experts caution it's unproven and possibly dangerous.
Fox News likewise has been touting the drug. Tucker Carlson said: "Several days ago, the president expressed confidence in hydroxychloroquine as a treatment for the epidemic. That was it for the media. If Trump is for it, they're against it, even if it might save American lives." He added: "What reactive children they are. And they immediately began a sustained push to discredit the drug long before the clinical results were in."
Trump's personal lawyer Rudy Giuliani on Friday tweeted a quote from a conservative activist who falsely called hydroxychloroquine 100% effective at treating COVID-19 and said Michigan's governor was threatening doctors who prescribe it, Mediaite reported. (The drug has not been shown to be 100% effective and Michigan, like many states, has warned doctors against hoarding the drugs for themselves.) Twitter removed Giuliani's tweetbecause it violated the site's rules.
And cardiac surgeon Dr. Mehmet Oz enthusiastically spoke of the drug on Sean Hannity's Fox News program: "So we don't want people using this stuff willy nilly. You must talk to your physician. But a lot of doctors here in New York and around the country are getting comfortable with the idea of using this earlier in the course of the treatment of their patients."
Clinical trials are underway.
New York state, which has been the epicenter of the U.S. outbreak, has acquired 70,000 doses of hydroxychloroquine, 10,000 doses of azithromycin and 750,000 doses of chloroquine to be used in clinical trials.
"The president is optimistic about these drugs, and we are all optimistic that it could work," New York Gov. Andrew Cuomo said on March 22. "I've spoken with a number of health officials, and there is a good basis to believe that they could work. Some health officials point to Africa, which has a very low infection rate, and there's a theory that because they're taking these anti-malaria drugs in Africa, it may actually be one of the reasons why the infection rate is low in Africa. We don't know, but let's find out and let's find out quickly. And I agree with the president on that."
The University of Minnesota is also enrolling patients in a clinical trial. But it isn't getting enough volunteers, according to ABC News. In a story Wednesday, ABC reported that the lead investigator is seeking 1,500 volunteers for one clinical trial, "but in the week since he obtained FDA approval, he has managed to recruit only 411." Only 25 of 1,500 volunteers needed for a second trial had signed up.
Some people are self-medicating with harmful results.
Banner Health in Arizona reported last week that a man died and his wife was hospitalized after the couple, both in their 60s, took chloroquine phosphate, an additive commonly used at aquariums to clean fish tanks. "Within 30 minutes of ingestion, the couple experienced immediate effects requiring admittance to a nearby Banner Health hospital," the system said.
The man's wife told NBC News that she saw the president's briefings in which he promoted the value of chloroquine and hydroxychloroquine. "I saw it [chloroquine phosphate] sitting on the back shelf and thought, 'Hey, isn't that the stuff they're talking about on TV?'" she told the network. "We were afraid of getting sick."
On Saturday, the Centers for Disease Control and Prevention warned that "chloroquine phosphate, when used without a prescription and supervision of a healthcare provider, can cause serious health consequences, including death. Clinicians and public health officials should discourage the public from misusing non-pharmaceutical chloroquine phosphate (a chemical used in home aquariums)."
What We Don't Know
Whether the drugs are effective at treating the coronavirus.
One small study in France seemed to suggest that hydroxychloroquine, combined with azithromycin, could work as a treatment for COVID-19. A different small study out of China suggests that hydroxychloroquine was not effective in patients compared with those who did not get the medication.
"I think this is an example where the speed of the virus is moving faster than the speed of the evidence," Joel F. Farley, a professor at the University of Minnesota College of Pharmacy, wrote in an email to ProPublica.
Juurlink of the University of Toronto said he supports the use of the drugs in patients with serious illness but not those with mild symptoms or to try to keep people from getting infected.
"I might have a completely different answer a month or two from now once we have better data," he said. "I have no idea whether the advice I'm giving you is good or not, but it's the best I can come up with as of March 27."