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."
Clinicians' struggles in coronavirus hotspots may well preview what medical providers in other states could face amid a national shortage of personal protective equipment.
This article was first published on Saturday, March 28, 2020 in ProPublica.
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.
Nurses at one hospital in southeastern Washington state have alleged that, amid the COVID-19 pandemic, they were ordered by supervisors to use one protective mask per shift, potentially exposing themselves to the novel coronavirus.
At another hospital, just east of Seattle, nurses had to use face shields indefinitely.
At a third hospital, on Washington's border with Oregon, nurses reported that respirators were expired. The hospital responded, the nurses said, by ordering staff to remove stickers showing that the respirators might be as much as three years out of date.
The accounts these nurses provided are drawn from nine complaints filed by the Washington State Nurses Association with the state Department of Labor & Industries since March 11. They paint a picture of how the first state hit by COVID-19 continues to struggle to provide adequate safety measures for medical workers.
Their struggle may well preview what medical providers in other states could face amid a national shortage of personal protective equipment, or PPE. The complaints from Washington also show the increasing sense of fear, frustration and powerlessness many nurses and other medical workers feel as COVID-19 pummels the healthcare system.
As of this weekend, the Washington Department of Health has reported 3,700 known COVID-19 cases in the state and 175 deaths.
ProPublica contacted all nine hospitals that were the subject of a nursing association complaint. Four responded. They said they were taking measures to protect their employees, but emphasized the unprecedented crisis in which their hospital staffs are now working. In a press briefing Thursday, Washington Gov. Jay Inslee said the federal government had supplied the state with "significant shipments of personal protective equipment" but added that he had "profound long-term concerns about being able to procure these necessities." Inslee, a vocal critic of the Trump administration, reportedly clashed with the president in a conference call with governors Thursday, according to The Washington Post, pleading with him to take more action.Bottom of Form
Some nurses in Washington state told ProPublica that they feel caught between their responsibility to care for patients and their own safety. They believe they have no choice but to keep working, at great personal risk and with limited means to raise concerns within their chains of command. They could be disciplined for talking to the media, and some said they had been explicitly warned about that in emails sent by hospital administrators. To refuse an assignment on safety grounds, they said, could find them ostracized by colleagues or, worse, fired for insubordination.
"It's a healthcare war zone," said a critical care nurse who works at one of the nine hospitals named in the complaints and, like all nurses interviewed for this story, asked to remain anonymous.
She told ProPublica that she has had to reuse masks and other PPE, if she can obtain it at all. She uses a simple surgical mask — a paper cover with ear loops, no eye cover — even when working with patients waiting for COVID-19 tests, because that's all that's available. Community members have been asked to donate handmade masks. She wears one over her surgical mask; it doesn't protect from viruses but at least is one more layer. Every night when she comes home, she strips down in the garage and throws her dirty hospital scrubs in the washer before rushing in to take a shower.
Workers at a VA hospital in New Mexico have been told not to wear face masks in certain cases, even though earlier CDC guidance said masks can protect against spread of the coronavirus.
"Never in a million years did we think when we were in nursing school that our employer would not provide us with the PPE they are legally obligated to provide us with, to care for those patients," she said.
Her supervisors acknowledge the shortage, she said, but have told staff members that unless they make do, they could run out of all protective gear, making their situation even more precarious.
"We take an oath of 'do no harm,'" the nurse said. "Would we be willing to take care of these patients with nothing?" She has a family, some of whom would be especially susceptible to the disease.
"I don't know what I would do," she said. "We are continuing to reuse this equipment so hopefully we don't have to make that choice."
'This is what you signed up for'
Nurses in Washington, where the virus first surfaced in the U.S., believe their early experience can help prepare healthcare workers elsewhere. The Washington State Nurses Association has even produced a list of recommendations for other states, called "Lessons learned from the front lines." Those lessons include, "Know your employer's plan for PPE (personal protective equipment)," and "Know the testing and treatment protocols now."
When the novel coronavirus spread across Washington in February and March, the lack of supplies in hospitals, coupled with uncertainty over what protective measures were needed, presented many nurses with a difficult choice. Nurses given a dangerous job could accept the assignment and its attendant risks, or refuse and face possible discipline. The WSNA, a union that represents more than 17,000 nurses, advised members who refused an assignment to stay and do other jobs. For those nurses who accepted an "abnormally dangerous" assignment, the union advised filling out what is called an ADO form. ADO stands for Assignment Despite Objection.
When ProPublica mentioned ADO forms to some nurses in Washington, they did not react with enthusiasm. "It's the stuff of fairytales," said one nurse in the Seattle area who specializes in mental health. "Nurses, administratively, are strongly discouraged to use the forms or outright shamed for documenting what they are uncomfortable with in a caregiving situation."
Wearing swim goggles for face protection and trash bags for surgical gowns, frontline healthcare workers have been forced to fend for themselves amid federal stockpile shortages.
Under collective bargaining agreements, nurses disciplined for refusing an assignment can push back, arguing that the discipline lacked "just cause." But the WSNA has warned its members that given the current national and state emergency declarations, the resolution of any such objection "would likely be delayed and the outcome may be uncertain."
Ruth Schubert, the association's communications director, said the WSNA has received about 70 Assignment Despite Objection forms related to the coronavirus. She declined to provide copies, citing confidentiality, but did share excerpts, including one that said: "Continue to be asked to reuse single use masks for COVID-19 modified droplet patients and wear ill-fitting gowns that fall off shoulders. Goggles not available." Some nurses are unlikely to fill out an ADO for fear "that management will see them as complainers," Schubert wrote in an email.
The WSNA said nurses fear being disciplined for talking with the media. A doctor from PeaceHealth St. Joseph Medical Center in Bellingham, close to the Canadian border, told The Seattle Times on Friday that he was fired after he raised multiple concerns about the hospital's lack of protective measures against COVID-19. A spokesperson for PeaceHealth St. Joseph confirmed the doctor was fired but had no comment because the physician was employed by another company, called TeamHealth.
PeaceHealth St. Joseph is one of the nine hospitals the state nursing association has filed a complaint against, for allegedly asking nurses to reuse and share their protective equipment without proper cleaning. As of Saturday morning, PeaceHealth had not responded to ProPublica's inquiries about this incident or the complaints. TeamHealth, the doctor's primary employer, told ProPublica that the physician has "not been terminated," and that TeamHealth is "committed to engaging with him to try to find a path forward. Now more than ever, we need every available doctor, and we will work with [him] to find the right location for him."
A Seattle nurse who specializes in oncology said her hospital's administration initially downplayed the risks: "I had a manager come in and tell me, 'This is just like the common cold.'" The nurse added, "We're being told, business as usual, this is what you signed up for."
Some nurses in Washington have turned to Facebook to express their frustrations. (ProPublica isn't identifying the nurses in these threads, but did confirm their nursing credentials through state licensing records.)
Commenting on a Facebook post that warned against using cloth masks, one registered nurse wrote, "We need to be able to wear something!!!"
A different post linked to a Bloomberg story about hospital workers making masks from supplies bought at craft stores and Home Depot, including industrial tape and foam. "No offense but I'm not wearing someone's arts and crafts project with this thing," wrote one registered nurse.
Facebook posts linking to a Tacoma News Tribune story about nurses reusing disposable masks generated multiple me-too threads. "We are doing this," wrote a nurse in Everett. "Our hospital ... also," wrote a nursing assistant southeast of Seattle. "It's everywhere," one RN wrote, followed by a second RN, "This is everywhere," followed by a third RN, "Yep."
One nurse told ProPublica that she wrote on Facebook that she had decided to take a break from her job because she could no longer deal with what she considered an unsafe environment.
She was met with criticism by another nurse, who commented that they didn't get into this field to "cut and run." That devastated the nurse who spoke to ProPublica, who responded she didn't "sign up to die."
The nurse, who works in an eastern Washington hospital, started to get concerned when, on March 10, her hospital loosened some of its PPE guidelines. She is now using up all her vacation and sick leave because she's nervous to return to work. If she isn't approved for an extended leave of absence, she said, she is "100 percent prepared to resign."
'These are not normal times'
The most recent complaint filed by the state nurses association was on March 23 against Overlake Medical Center. Based in Bellevue, just east of Seattle, Overlake has had dozens of patients with COVID-19 on any given day. On Friday, the number was 40, said Morgan Brice, a hospital spokeswoman. At least 11 patients have died at Overlake from COVID-19, according to Brice. A number of them arrived at the hospital under "comfort care," meaning their death was imminent and the hospital made efforts to keep them comfortable in their final days.
The complaint filed with the Department of Labor & Industries said nurses were being required to reuse face shields "indefinitely." "They must clean them themselves and ... store in their own locker for reuse day after day, until the chinstrap is loose," the complaint says, adding: "RNs report the chinstrap is loose after one 12-hr shift." The complaint also said the hospital was failing to make sure that notification of exposure was reaching nurses on their days off, "thus prompting additional community and family exposure."
Brice, in an email, told ProPublica that Overlake had yet to receive a copy of the complaint and would not respond to the specific allegations until it has. But the hospital, she wrote, is "committed to investigating the facts related to any complaint and acting appropriately." She outlined some steps Overlake has taken during the outbreak, including having a team of nurses "committed to the health of our employees."
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"We have dedicated extensive resources to training staff on how to use and maintain their PPE," Brice wrote. "We have posted videos, daily FAQs for staff, formed a PPE float team to help guide employees, along with our managers rounding the floors on a consistent basis. We know we have taken extraordinary and proper measures to protect the health and safety of our staff, while we respond to the medical challenges being presented on a daily basis."
The complaints filed with Labor & Industries use a fill-in-the-blank form, with a narrative section to describe alleged hazards.
On March 11, the nurses association filed a complaint against St. Joseph Medical Center in Tacoma, saying nurses were being directed to reuse and share protective equipment. The complaint also alleged that nurses weren't being fit-tested for N95 masks, a protective respiratory device worn over the face. Masks that aren't properly fitted to a person's face can admit contaminated air.
CHI Franciscan, the medical system that includes Tacoma's St. Joseph, said it is cooperating with the investigation but was told by the Department of Labor & Industries that no action is required at this time. The system denied that nurses "have been or will be asked to use PPE in a manner not in compliance with CDC, FDA and DOH guidelines," according to an emailed statement from Cary Evans, the company's vice president for communications and government affairs.
The hospital is operating with "7-12 days of PPE" and said it has not had a situation where demand for PPE exceeded supply. Administrators have expanded fit testing for N95 masks. They are also accepting donations of PPE gear from the community. Normally, a 30-day PPE supply is preferred, according to the Washington State Hospital Association.
"These are not normal times," Evans' statement said, "and we are doing everything we can to keep our staff and patients safe, while also conserving masks under the latest local CDC guidelines."
The same day it filed the St. Joseph complaint, the nurses association submitted seven others, two against hospitals within the same medical system: Multicare Tacoma General Hospital and Multicare Good Samaritan Hospital in Puyallup, a community southeast of Tacoma. A spokesperson for the system wrote that all employees "have the appropriate personal protective equipment (PPE) they need today to do their jobs safely" and noted that hospital staff are allowed "to preserve PPE resources needed to care for our most critical patients."
"Due to supply chain disruptions, health systems worldwide are dealing with shortages of PPE," the statement read.
Another complaint, filed against PeaceHealth Southwest Medical Center, a hospital in Vancouver, across the Columbia River from Portland, Oregon, said nurses were reporting lack of access to masks and respirators. When the nurses reported that respirators were outdated, the hospital "directed staff to remove outdated 2017 and 2019 'service by' stickers on equipment," the complaint said.
As meatpackers rush to meet demand, their employees are starting to get COVID-19. But some workers say they're going to work ill because they don't have paid sick days and can be penalized for staying home.
The hospital did not respond to requests for comment from ProPublica as of Saturday morning.
Beth Zborowski, senior vice president of membership engagement and communications for the Washington State Hospital Association, said a lack of PPE is probably the medical community's top problem in the state, in terms of its efforts to fight COVID-19. The association advises hospitals to follow Department of Health and CDC recommendations, though many nurses say the latter keeps changing.
"Prior to the pandemic, masks were available on carts outside of rooms," Zborowski said. "What started happening is those things started disappearing pretty quick. People had to put conservation measures in." It's one reason the state canceled elective procedures in recent weeks.
It's unclear how many healthcare workers in the state may have become ill as a result of COVID-19, though a doctor at EvergreenHealth near Seattle has been infected and Schubert, of the state nursing association, said she knows of nurses who have become sick. Zborowski said the state hospital association does not have a formal record but added she has not heard about many front-line medical workers becoming ill, as they have in New York and Italy. She hopes that means the conservation and safety measures hospitals are taking are working. The goal is to preserve the PPE; otherwise, "I think we will start to see healthcare workers getting sick."
Eileen Ravella, a physician assistant at an urgent care facility in Olympia, said her employer is doing well under the circumstances, trying to keep COVID-19 cases cordoned off from other patients and using a drive-through testing area they set up to meet the need. This is helping them preserve PPE, but she knows the system is breaking under the weight of the pandemic.
"I think we all have to step up and do our best despite the obstacles," Ravella said. "Those patients need us."
A nurse who works in a western Washington emergency room said that a few weeks into the pandemic, the crisis conditions had begun to feel normal, "which is kind of horrible, too."
Now she's advising nurses in other states about what she's experienced. Initially, many of them refused to take her seriously.
She admits that she downplayed COVID-19 at first. Then, in mid-March, she found out about the EvergreenHealth doctor who had contracted the virus.
"It became really real then that some of us may not make it out of here alive," she said.
A few days later, she and her colleagues received a message from their hospital administrator, advising them to complete their advanced directives — basically a living will.
"[N]ow with COVID-19 making who gets sick an unpredictable event," the message read, "it's an important time to get this done."
Leaders at the Department of Veterans Affairs say they are ready to answer the call to assist HHS or FEMA. But the call has not come.
This article was first published on Friday, March 27, 2020 in ProPublica.
The Trump administration is leaving untapped reinforcements and supplies from the U.S. Department of Veterans Affairs, even as many hospitals are struggling with a crush of coronavirus patients.
The VA serves 9 million veterans through 170 hospitals and more than 1,000 clinics, but it’s also legally designated as the country’s backup health system in an emergency. As part of the National Disaster Medical System, the VA has deployed doctors and equipment to disasters and emergencies in recent instances such as Hurricane Maria and the Pulse nightclub shooting in Orlando, Florida. The VA system has 13,000 acute care beds, including 1,800 intensive care unit beds.
But for the coronavirus pandemic, VA Secretary Robert Wilkie told lawmakers this week that the agency won’t spring into action on its own. Instead of responding to pleas for help from states and cities, Wilkie said he’s waiting for direction from the Department of Health and Human Services or the Federal Emergency Management Agency.
And those calls, for the most part, haven’t come. HHS hasn’t asked the VA for significant help with the coronavirus pandemic. FEMA did not take a leading role in the government’s response until last Friday, and it has yet to involve the VA either.
“VA stands ready to support civilian health care systems in the event those systems encounter capacity issues,” press secretary Christina Mandreucci said. “At this time, VA has not received specific requests from FEMA for assistance.”
The White House referred questions to the VA. The VA referred a question about taking directions from HHS and FEMA to those agencies. HHS referred questions to FEMA, and FEMA referred questions to the VA.
The VA has fielded a handful of limited tasks. It asked 12 health technicians and nursing assistants to volunteer to help HHS and the Centers for Disease Control and Prevention with coronavirus screenings for two weeks in February. The agency sent 14 medical technicians to help HHS with screenings at an Air Force base in California where evacuees from the Diamond Princess cruise ship were being quarantined. And a spokeswoman for CalVet, the state’s veterans agency, told ProPublica that the VA emergency manager in the region has helped provide supplies such as N95 masks.
Lawmakers are frustrated to see the VA largely sitting on its hands as the crisis escalates.
“It is unconscionable that HHS has not utilized every tool it has to address the real suffering of individuals in this nation and called upon VA,” Sen. Jon Tester of Montana, the ranking Democrat on the Senate Veterans’ Affairs committee, said in a March 25 letterto HHS Secretary Alex Azar. “States, communities and patients are already suffering as a result of HHS’s inaction. Get them help now.”
According to the VA’s pandemic plan released on Friday, the agency’s role in the governmentwide response may include helping emergency responders with protective gear, screening and training; helping to staff FEMA’s operations teams; dispatching advisers to state and local public health authorities; supplying medicines and equipment; and helping with burials.
The stimulus deal that the Senate passed late Wednesday includes $27 billion for HHS to reimburse the VA for providing care to the general public. That’s on top of $20 billion to help the VA care for veterans.
Just a month ago, at a House budget hearing, Wilkie declined additional funding. “Right now I don’t see a need for us,” he said. “We are set.”
The VA held its first planning meeting on the coronavirus on Jan. 22, the day after the first case was confirmed in the U.S., according to the agency’s response to an inspector general report released Thursday. But the department did not implement measures until two days after the World Health Organization formally declared a pandemic, on March 11. The VA did not issue guidance on screening patients until March 16.
Wilkie abruptly fired his deputy last month and is under investigation by the VA’s inspector general for allegedly seeking damaging information about a congressional staffer who said she was sexually assaulted at a VA hospital. (He denies doing so.) Wilkie took time off in recent weeks and has taken a back seat at White House task force meetings. Since joining the White House’s Coronavirus Task Force on March 2, Wilkie has spoken publicly only once, on March 18. (Mandreucci said Wilkie has attended 20 task force meetings.) At that time, Wilkie said the VA was preparing to join the disaster response but had not yet engaged.
“We are the buttress force in case that FEMA or HHS calls upon us to deploy medical professionals across the country to meet crises,” Wilkie said. “We plan for that every day. We are gaming out emergency preparedness scenarios. And we stand ready, when the president needs us, to expand our mission.”
Wilkie told Politico the VA was preparing to deploy 3,000 doctors, nurses and other emergency workers but had no timeline.
The VA’s role as the country’s emergency medical backup was first established by Congress in 1982 and is known as the agency’s “Fourth Mission.” (The first three missions are sometimes identified as care, training and research, and other times as health, benefits and memorials.) This month, a description of this Fourth Mission was suddenly scrubbed from the website of the VA’s Office of Emergency Management. Mandreucci noted it appeared on a different page.
The VA’s ability to support FEMA could be limited by demands from its own patients, who are largely older and part of the demographic that’s most vulnerable to the coronavirus. As of Friday, the VA had 571 patients who tested positive and nine who have died.
The VA’s inspector general said in a report on Thursday that health center leaders reported concerns about running out of medicines and protective gear. Leaders at the VA hospitals in Durham, North Carolina, and Detroit said they needed more ventilators. The inspector general’s report said 43% of the facility leaders surveyed planned to share ICU beds or protective gear with local providers.
“That assistance is dependent upon the availability of resources and funding, and consistency with VA’s mission to provide priority services to veterans,” Wilkie said in a March 23 letter to lawmakers.
Demand for chloroquine and hydroxychloroquine surged over the past several days as President Donald Trump promoted them as possible treatments for the coronavirus.
This article was first published on Tuesday, March 24, 2020 in ProPublica.
Pharmacists told ProPublica that they are seeing unusual and fraudulent prescribing activity as doctors stockpile unproven coronavirus drugs endorsed by President Donald Trump.
A nationwide shortage of two drugs touted as possible treatments for the coronavirus is being driven in part by doctors inappropriately prescribing the medicines for family, friends and themselves, according to pharmacists and state regulators.
"It's disgraceful, is what it is," said Garth Reynolds, executive director of the Illinois Pharmacists Association, which started getting calls and emails Saturday from members saying they were receiving questionable prescriptions. "And completely selfish."
Demand for chloroquine and hydroxychloroquine surged over the past several days as President Donald Trump promoted them as possible treatments for the coronavirus and online forums buzzed with excitement over a small study suggesting the combination of hydroxychloroquine and a commonly used antibiotic could be effective in treating COVID-19.
Reynolds said the Illinois Pharmacists Association has started reaching out to pharmacists and medical groups throughout the state to urge doctors, nurses and physician assistants not to write prescriptions for themselves and those close to them.
"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."
In one case, Reynolds said, the prescriber initially tried to get the pills without an explanation and only offered up that the individual had rheumatoid arthritis after the pharmacist questioned the prescription.
In a bulletin to pharmacists on Sunday, the state association wrote that it was "disturbed by the current actions of prescribers" and instructed members on how to file a complaint against physicians and nurses who were doing it.
"People are losing their minds about this product," said Brian Brito, president of SMP Pharmacy Solutions in Miami. "We're selling so much of this stuff and people are just stockpiling it prophylactically if anybody in their family gets sick — they're just holding on to it.
The two drugs are only available through a prescription and cannot be purchased over the counter. Hydroxychloroquine, sold under the brand name Plaquenil, is approved to treat lupus and rheumatoid arthritis while chloroquine is an anti-malarial treatment.
There is little evidence that the drugs work to treat coronavirus, although clinical trials are underway to find out. But as coronavirus cases multiply and protective gear for medical workers vanishes from emergency rooms, many patients and physicians see the drugs as the only hope to reverse the course of serious disease.
Brito said his pharmacy had about 800 tablets on Monday and were nearly sold out in about an hour. One doctor called and asked for 200 tablets, but the company refused. "He was a little upset about it but he understood and he went quickly from 200 to 42 tablets, which is essentially treating two people," Brito said. "So yeah, they're stockpiling it."
A pharmacist in Houston, who asked to remain anonymous for fear of retaliation and violating patient privacy, said he was recently asked by a surgeon for an unusually large quantity with unlimited refills. "He said it was because his wife had lupus," the pharmacist said, "but when I asked him for her name and diagnosis, he told me just to put it in his."
Lupus patients are reporting difficulty in refilling their prescriptions for the drug. On Monday, the Lupus Foundation of America issued a joint statement asking the White House Coronavirus Task Force to "take action to ensure current supplies are allocated for patients taking them for indicated uses." Several states in the past few days have already moved to limit prescriptions of the drugs, neither of which is approved to treat the coronavirus. Trump, in press conferences and tweets over the past week, has promoted the use of the drugs as potentially blunting the impact of the COVID-19 outbreak.
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.
"It's unfortunate that a news conference, I think prematurely, made it sound like this was the answer, and that's led to this panic," Michelle Petri, director of Johns Hopkins University School of Medicine's Lupus Center, said Friday. "I have spent the last two days trying to help lupus patients who actually need their refills." She said some patients have refills on back order while others are being provided smaller amounts than usual.
The West Virginia Board of Pharmacy, in an alert Saturday, ordered pharmacists to limit new prescriptions to no more than 30 tablets and only to cases where the drugs were being used for approved indications.
"Currently, both nationally and in West Virginia, some prescribers have begun writing prescriptions for these drugs for family, friends, and coworkers in anticipation of Covid-19 related illness," the board wrote.
Texas and Ohio have also restricted prescribing of the drugs. Louisiana on Sunday also issued an emergency rule limiting when the drugs can be prescribed, citing "inappropriate use" and "hoarding." On Monday, the Louisiana Board of Pharmacy said it was rescinding that order because manufacturers had boosted distribution of the drugs.
Experts are warning that any use of the drugs outside of a hospital setting can be dangerous, and admonished doctors to stop prescribing the medicines inappropriately.
Daniel Brooks, the medical director of the Banner Poison and Drug Information Center in Phoenix, said it was "immoral" for physicians to hoard the medications.
"One should not be selfish and scared, especially medical providers," he said. "I find it incredibly embarrassing and unfortunate that physicians appear to be prescribing these medications inappropriately."
This weekend Brooks cared for a man in his 60s who died after ingesting a version of chloroquine commonly used to clean fish tanks. The man, who thought he might have COVID-19, took a small amount of the substance in a misguided effort to treat his symptoms. His wife was also hospitalized after taking the substance but survived.
Brooks said the amount the couple ingested was equivalent to a couple days' worth of prescription chloroquine.
Ken Thai, the owner of a chain of Los Angeles-area pharmacies, said his stores are witnessing a rash of inappropriate prescribing.
"A lot of physicians, unfortunately, are writing high amounts for more than the required number of tablets and calling in five, six, seven and eight prescriptions at a time," he said. "I don't want to insinuate what is going on, but it is very unusual."
He said his pharmacists are declining to fill suspicious orders and telling prescribers they don't have enough of the medication on hand to complete those requests. Among the prescriptions flagged are those for people who have not previously taken the drug as well as orders from doctors who do not typically treat lupus and rheumatoid arthritis patients.
"If a doctor is writing a prescription for himself or aunts and uncles, that is usually a red flag for us," he said. "Whatever we have in stock, we have to preserve for the patients we currently service."
On Twitter, pharmacy workers traded stories about dentistsand opthamologistsrequesting hydroxychloroquine under dubious pretenses. "A dentist just tried to call in scripts for hydroxychloroquine + azithromycin for himself, his wife, & another couple (friends)," tweeted a pharmacist in Eugene, Oregon. "I have patients with lupus that have been on HCQ [Hydroxychloroquine] for YEARS and now can't get it because it's on backorder."
Steve Moore, president of the Pharmacists Society of the State of New York, said medical providers hoarding the drugs is occuring in the state, which has the highest number of coronavirus cases in the country.
"That's a double whammy," he said. "We're potentially taking that medication away from patients with autoimmune conditions and patients with the actual virus that may need treatment."
Administering coronavirus tests requires time and supplies that are already running out. But aggressive testing has proven to be the best way to track and isolate the disease, stopping its spread. The best path forward depends on where you are.
This article was first published on Monday, March 23, 2020 in ProPublica.
There's a seeming paradox in experts' advice on testing people for COVID-19. A growing number of epidemiologists are calling for a nationwide regimen of tests to identify hot spots and allow public health workers to isolate the close contacts of anyone who's infected.
Yet New York City, the epicenter of the outbreak in the U.S., has ordered doctors not to test anyone who is "mild to moderately ill" with COVID-like symptoms, a position also taken by Los Angeles. As New York's Health Department succinctly put it: "Outpatient testing must not be encouraged, promoted or advertised."
Dr. Tom Frieden, former health commissioner of New York City and former head of the Centers for Disease Control and Prevention, said both viewpoints make sense.
"Where you stand depends on where you sit," Frieden said. "Local context is all important. In New York City, today, you should not get tested if you have mild symptoms."
The reason, he said, is that the health care systems in places like New York, Los Angeles and Seattle are about to be overwhelmed by a wave of people seriously ill from COVID-19. They know it's coming. Administering each test takes up protective gear, swabs and health care workers' time, all of which should be reserved for patients with life-threatening conditions. On Monday, for instance, NewYork-Presbyterian Hospital reported that it had more than 600 patients with COVID-19.
Conversely, Frieden and other experts pointed out, the United States will need to pursue a policy of very broad testing if it hopes to slow the spread of the disease and restart parts of the economy anytime soon. Frieden noted that one of the countries most effective in lowering its infection rate, Singapore, had great success in tracing and isolating the contacts of each infected person. That is no longer possible in New York state, which has reported more than 20,000 positive tests and has many times that number of people infected. But he said it remains doable in many other cities and towns.
"In places where you've got the cases way down, or there are no cases," he said, "aggressive testing will be needed."
The lack of testing continues to be a source of deep frustration across the country, with worried patients unable to find out whether they have the ordinary flu, the coronavirus or something else entirely. The availability of testing in regions that aren't hot spots still faces an array of bottlenecks, from shortages of cotton swabs to the capacity of the labs processing the tests.
Dr. Scott Gottlieb, the former head of the Food and Drug Administration under President Donald Trump, argued in a widely read Twitter commentary for a multipronged approach to fighting the virus, which will involve overcoming all of these hurdles and significantly stepping up testing nationwide. The current "shelter in place" orders, which have tens of millions of people in New York, California and other states limited to their homes and not going to work, he said, will ultimately have to be supplanted by a more targeted approach.
To do this, he wrote, the United States "must widely test our population" and "diagnose mild and even asymptomatic cases" with reliable tests that can be administered in doctors' offices. "We must have tools to identify and isolate small outbreaks so we can lean less heavily" on locking down whole swaths of society, Gottlieb wrote.
Trevor Bedford, a University of Washington virologist who has been directly involved in detecting and fighting his state's outbreak, offered a similar prescription in a recent series of tweets. Bedford's observations were prompted, in part, by a recent study by epidemiologists at Imperial College London that said countries had little alternative to maintaining strict restrictions on social contact until a vaccine is available, a process that could take 18 months. The study forecast as many as 1.1 million to 1.2 million deaths in the United States if officials backed off the sorts of measures taken by New York and California in recent days.
Bedford saidhe was not that "pessimistic," and he called for a strategy that "revolves around a massive rollout of testing capacity." Recent studies, he wrote, support the argument that a "significant" portion of the transmission of the virus arises from people whospread it before they feel sick. There also are people who infect others while never experiencing any symptoms of their own.
Something approaching universal testing would make it possible to significantly reduce such "transmission routes."
"If someone can be tested early in their illness before they show symptoms," Bedford wrote, "they could effectively self isolate and reduce onward transmission compared to isolation when symptoms develop."
He envisaged a future in which swabs are delivered to people's homes for quick return and in which drive-through testing is widely available to anyone with a car. "There are logistics involved in getting a result quickly," he wrote, "but it's really just logistics, which can be solved."
Bedford suggested an approach that appears to have worked in South Korea, which combined test results with "cell phone location data" on known positive cases, allowing notification of people who have been in proximity to confirmed cases to "self isolate and get tested."
A third pillar of Bedford's approach is a medical exam that does not yet exist — a blood test that can detect the presence of antibodies to COVID-19. Antibodies are created when the immune system successfully fights off an infection and people with them are "highly likely to possess immunity" and can "fully return to the workforce and keep society functioning."
That assumption, like many about the virus, remains the subject of research. For his part, Frieden said he was cautious about taking any action based on a test that detects antibodies. Does it mean the person is immune from a second infection? "We can't count on that," he said. "We don't yet know that."
The clash between the short-term and long-term views of testing were on vivid display in the press conference last week that made headlines for Trump's angry outburst at an NBC reporter.
Earlier in the briefing, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, sought to distinguish between the ultimate need for more tests with the immediate requirement that Americans stop gathering in workplaces, bars, streets and restaurants.
The extreme steps taken by California and New York, Fauci said, are "how you put an end to this outbreak."
"Testing is important," he said. "But let's not conflate testing with the action that we have to take. Whether or not you test, do this. I'm not putting down testing as an important issue, but people seem to link them so much that if you don't have universal testing, you can't respond to the outbreak. You really can."
Trump disparaged the notion of widespread testing as imagined by Bedford and others. "We don't want every American to go out and get a test. Three hundred and fifty million people," Trump said. "We don't want that. We want people that have a problem, that have a problem with they're sneezing, they're sniffling, they don't feel good, they have a temperature."
"It first struck me how different it was when I saw my first coronavirus patient go bad. I was like, Holy shit, this is not the flu. Watching this relatively young guy, gasping for air, pink frothy secretions coming out of his tube."
This article was first published on Saturday, March 21, 2020 in ProPublica.
As of Friday, Louisiana was reporting 479 confirmed cases of COVID-19, one of the highest numbers in the country. Ten people had died. The majority of cases are in New Orleans, which now has one confirmed case for every 1,000 residents. New Orleans had held Mardi Gras celebrations just two weeks before its first patient, with more than a million revelers on its streets.
I spoke to a respiratory therapist there, whose job is to ensure that patients are breathing well. He works in a medium-sized city hospital’s intensive care unit. (We are withholding his name and employer, as he fears retaliation.) Before the virus came to New Orleans, his days were pretty relaxed, nebulizing patients with asthma, adjusting oxygen tubes that run through the nose or, in the most severe cases, setting up and managing ventilators. His patients were usually older, with chronic health conditions and bad lungs.
Since last week, he’s been running ventilators for the sickest COVID-19 patients. Many are relatively young, in their 40s and 50s, and have minimal, if any, preexisting conditions in their charts. He is overwhelmed, stunned by the manifestation of the infection, both its speed and intensity. The ICU where he works has essentially become a coronavirus unit. He estimates that his hospital has admitted dozens of confirmed or presumptive coronavirus patients. About a third have ended up on ventilators.
His hospital had not prepared for this volume before the virus first appeared. One physician had tried to raise alarms, asking about negative pressure rooms and ventilators. Most staff concluded that he was overreacting. “They thought the media was overhyping it,” the respiratory therapist told me. “In retrospect, he was right to be concerned.”
He spoke to me by phone on Thursday about why, exactly, he has been so alarmed. His account has been condensed and edited for clarity.
“Reading about it in the news, I knew it was going to be bad, but we deal with the flu every year so I was thinking: Well, it’s probably not that much worse than the flu. But seeing patients with COVID-19 completely changed my perspective, and it’s a lot more frightening.”
This is knocking out what should be perfectly fit, healthy people.
“I have patients in their early 40s and, yeah, I was kind of shocked. I’m seeing people who look relatively healthy with a minimal health history, and they are completely wiped out, like they’ve been hit by a truck. This is knocking out what should be perfectly fit, healthy people. Patients will be on minimal support, on a little bit of oxygen, and then all of a sudden, they go into complete respiratory arrest, shut down and can’t breathe at all.”
They suddenly become unresponsive or go into respiratory failure.
“We have an observation unit in the hospital, and we have been admitting patients that had tested positive or are presumptive positive — these are patients that had been in contact with people who were positive. We go and check vitals on patients every four hours, and some are on a continuous cardiac monitor, so we see that their heart rate has a sudden increase or decrease, or someone goes in and sees that the patient is struggling to breathe or is unresponsive. That seems to be what happens to a lot of these patients: They suddenly become unresponsive or go into respiratory failure.”
The lung is filled with so much fluid, displacing where the air would normally be.
“It’s called acute respiratory distress syndrome, ARDS. That means the lungs are filled with fluid. And it’s notable for the way the X-ray looks: The entire lung is basically whited out from fluid. Patients with ARDS are extremely difficult to oxygenate. It has a really high mortality rate, about 40%. The way to manage it is to put a patient on a ventilator. The additional pressure helps the oxygen go into the bloodstream.
“Normally, ARDS is something that happens over time as the lungs get more and more inflamed. But with this virus, it seems like it happens overnight. When you’re healthy, your lung is made up of little balloons. Like a tree is made out of a bunch of little leaves, the lung is made of little air sacs that are called the alveoli. When you breathe in, all of those little air sacs inflate, and they have capillaries in the walls, little blood vessels. The oxygen gets from the air in the lung into the blood so it can be carried around the body.
“Typically with ARDS, the lungs become inflamed. It’s like inflammation anywhere: If you have a burn on your arm, the skin around it turns red from additional blood flow. The body is sending it additional nutrients to heal. The problem is, when that happens in your lungs, fluid and extra blood starts going to the lungs. Viruses can injure cells in the walls of the alveoli, so the fluid leaks into the alveoli. A telltale sign of ARDS in an X-ray is what’s called ‘ground glass opacity,’ like an old-fashioned ground glass privacy window in a shower. And lungs look that way because fluid is white on an X-ray, so the lung looks like white ground glass, or sometimes pure white, because the lung is filled with so much fluid, displacing where the air would normally be.”
This severity ... is usually more typical of someone who has a near drowning experience ... or people who inhale caustic gas.
“With our coronavirus patients, once they’re on ventilators, most need about the highest settings that we can do. About 90% oxygen, and 16 of PEEP, positive end-expiratory pressure, which keeps the lung inflated. This is nearly as high as I’ve ever seen. The level we’re at means we are running out of options.
“In my experience, this severity of ARDS is usually more typical of someone who has a near drowning experience — they have a bunch of dirty water in their lungs — or people who inhale caustic gas. Especially for it to have such an acute onset like that. I’ve never seen a microorganism or an infectious process cause such acute damage to the lungs so rapidly. That was what really shocked me.”
You’ll try to rip the breathing tube out because you feel it is choking you ...
“It first struck me how different it was when I saw my first coronavirus patient go bad. I was like, Holy shit, this is not the flu. Watching this relatively young guy, gasping for air, pink frothy secretions coming out of his tube and out of his mouth. The ventilator should have been doing the work of breathing but he was still gasping for air, moving his mouth, moving his body, struggling. We had to restrain him. With all the coronavirus patients, we’ve had to restrain them. They really hyperventilate, really struggle to breathe. When you’re in that mindstate of struggling to breathe and delirious with fever, you don’t know when someone is trying to help you, so you’ll try to rip the breathing tube out because you feel it is choking you, but you are drowning.
“When someone has an infection, I’m used to seeing the normal colors you’d associate with it: greens and yellows. The coronavirus patients with ARDS have been having a lot of secretions that are actually pink because they’re filled with blood cells that are leaking into their airways. They are essentially drowning in their own blood and fluids because their lungs are so full. So we’re constantly having to suction out the secretions every time we go into their rooms.”
I do not want to catch this.
“Before this, we were all joking. It’s grim humor. If you are exposed to the virus and test positive and go on quarantine, you get paid. We were all joking: I want to get the coronavirus because then I get a paid vacation from work. And once I saw these patients with it, I was like, Holy shit, I do not want to catch this and I don’t want anyone I know to catch this.
“I worked a long stretch of days last week, and I watched it go from this novelty to a serious issue. We had one or two patients at our hospital, and then five to 10 patients, and then 20 patients. Every day, the intensity kept ratcheting up. More patients, and the patients themselves are starting to get sicker and sicker. When it first started, we all had tons of equipment, tons of supplies, and as we started getting more patients, we started to run out. They had to ration supplies. At first we were trying to use one mask per patient. Then it was just: You get one mask for positive patients, another mask for everyone else. And now it’s just: You get one mask.
“I work 12-hour shifts. Right now, we are running about four times the number of ventilators than we normally have going. We have such a large volume of patients, but it’s really hard to find enough people to fill all the shifts. The caregiver-to-patient ratio has gone down, and you can’t spend as much time with each patient, you can’t adjust the vent settings as aggressively because you’re not going into the room as often. And we’re also trying to avoid going into the room as much as possible to reduce infection risk of staff and to conserve personal protective equipment.”
Even if you survive ... it can also do long-lasting damage.
“But we are trying to wean down the settings on the ventilator as much as possible, because you don’t want someone to be on the ventilator longer than they need to be. Your risk of mortality increases every day that you spend on a ventilator. The high pressures from high vent settings is pushing air into the lung and can overinflate those little balloons. They can pop. It can destroy the alveoli. Even if you survive ARDS, although some damage can heal, it can also do long-lasting damage to the lungs. They can get filled up with scar tissue. ARDS can lead to cognitive decline. Some people’s muscles waste away, and it takes them a long time to recover once they come off the ventilator.
“There is a very real possibility that we might run out of ICU beds and at that point I don’t know what happens if patients get sick and need to be intubated and put on a ventilator. Is that person going to die because we don’t have the equipment to keep them alive? What if it goes on for months and dozens of people die because we don’t have the ventilators?
“Hopefully we don’t get there, but if you only have one ventilator, and you have two patients, you’re going to have to go with the one who has a higher likelihood of surviving. And I’m afraid we’ll get to that point. I’ve heard that’s happening in Italy.”
