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Capt. Brett Crozier, fired this week from command of the aircraft carrier USS Theodore Roosevelt, joins a growing list of Navy officers who attempted to raise concerns about the safety of their ships and crew, only to pay with their jobs.
Crozier wrote a letter dated March 30 warning that an outbreak of the coronavirus on his ship was a threat to his crew of some 4,000 sailors unless they disembarked and quarantined.
“We are not at war, and therefore cannot allow a single sailor to perish as a result of this pandemic unnecessarily,” Crozier wrote. “Decisive action is required now.”
We do not know all the facts that prompted the letter. But we know that once it was published in the San Francisco Chronicle, the acting secretary of the Navy, Thomas Modly, relieved Crozier of command. Crozier, 50, had been a rising star in the officer corps. He will remain in the Navy at his current rank, though his career future is uncertain. In viral videos, Crozier’s sailors can be seen cheering him loudly as he disembarks the Roosevelt, alone, before driving away.
Navy experts believe that the cumulative effects of the service’s decisions over the past several years to punish those who speak out will result in silencing sailors with legitimate concerns about their health and safety.
“This may have the effect of chilling the responses of other commanding officers because it will be perceived, fairly or not, as a shoot the messenger scenario,” said James Stavridis, a retired admiral and former head of the United States Naval Institute, who called for an investigation into the circumstances surrounding the dismissal.
The Navy’s top officer, Adm. Mike Gilday, initially praised Crozier’s attempt to warn his superiors. But the next day, Thursday, Modly, the Navy’s civilian boss, reversed course, telling reporters that he fired Crozier because he lost confidence in the officer for not using a secure email network to properly route his complaint.
Crozier’s unclassified email wound up with 20 or 30 other individuals and at some point was provided to the Chronicle reporters. Modly said the public airing of the complaint had unnecessarily alarmed sailors and provided enemies with information that exposed weaknesses on one of the country’s most important warships.
As part of our 2019 investigation into the incidents in the Navy’s 7th Fleet, its largest overseas presence, ProPublica found repeated instances of frontline commanders warning superiors of risks the fleet was facing — a lack of training, exhausted crews, deteriorating ships and equipment. Those warnings, all sent through the normal chain of command, were met with indifference.
Disaster in the fleet struck in June 2017, after the USS Fitzgerald, a destroyer, collided with a cargo ship in the Sea of Japan. Two months later, a second destroyer, the USS John S. McCain, collided with an oil tanker in the Singapore Strait. The two accidents cost the Navy 17 sailors — the biggest loss of life in maritime collisions in more than 40 years.
Navy investigations laid blame on nearly the entire chain of command in the 7th Fleet, punishing commanders and sailors for failing to properly train and equip its crews and ships.
Adm. Joseph Aucoin, the head of the 7th Fleet, was fired. Vice Adm. Thomas Rowden, who oversaw training, was forced from his job. Cmdr. Bryce Benson, captain of the Fitzgerald, was recommended for court-martial.
But ProPublica reported that all three men had repeatedly tried to warn higher-ups of dangerous safety issues in the vaunted fleet, based at Yokosuka, Japan. They argued to their superiors that the Navy was running ships in the 7th Fleet too hard, too fast. Their warnings were dismissed.
Some of the Navy’s criminal cases against the officers collapsed after court rulings found possible bias in the Navy’s prosecution.
Benson, the Fitzgerald commander whose court-martial case was dismissed, said that Crozier “was right to strongly advocate for the safety of his crew and it was wrong for the SecNav [secretary of the Navy] to fire him for doing so.”
Senior leaders “continue to under-resource ships at sea and are slow to respond to commanders’ pleas for assistance,” said Benson, who is now retired. “From one tragedy to the next, senior Navy leaders continue to break faith with the fleet.”
Dismissing Crozier, Benson said, “sends a clear message to commanders: The authority and responsibility that you enjoy is yours alone and an absolute liability even when under resourced and thinly supported.”
Modly emphasized that he did not intend his actions to discourage officers from coming forward to report their concerns through the chain of command.
“I have no doubt in my mind that Capt. Crozier did what he thought was in the best interests of the safety and well-being of his crew. Unfortunately, it did the opposite,” Modly said at a press conference.
But Crozier’s firing has raised alarm anew that the Navy is more interested in its public image than in fixing problems raised by its sailors. It did not go unnoticed by fellow officers that Crozier was dismissed within two days of his letter becoming public. Such haste is unusual, and raised questions about the due process afforded to Crozier.
Some now believe that the cumulative effects of the Navy’s decisions over the past several years to punish those who speak out will silence sailors who have legitimate concerns about their health and safety.
“His removal sends a really strong message that coming forward will end people’s careers,” said Mandy Smithberger, a military expert at the Project on Government Oversight. “Before this I’d say that risk was more so implied through both social and professional retaliation. This is much more explicit.”
Crozier’s firing comes amid increased concern that the Pentagon is not acting quickly enough to protect whistleblowers. Glenn Fine, the principal deputy inspector general for the Defense Department, testified that the agency has shown a reluctance to punish officials who take punitive action against whistleblowers.
“We have seen a disturbing trend in the DoD disagreeing with the results of our investigations or not taking disciplinary action in substantiated reprisal cases without adequate or persuasive explanations,” Fine testified in January to the House Committee on Oversight and Reform. “Failure to take action sends a message to agency managers that reprisal will be tolerated and also to potential whistleblowers that the system will not protect them.”
Navy commanders may be fired at any time by their superiors. And the captains of Navy ships are uniquely responsible for any mishaps on their ships.
A study published earlier this year of more than 2,000 disciplinary cases found that Navy commanders were historically dismissed for “crimes of command” — such as a ship colliding with another vessel or running aground.
More lately, however, the study documented that it has become harder to tell if those punished are being disciplined less because of their performance and more because they had either internally or publicly called the Navy out for neglect.
“In the modern Navy,” wrote Capt. Michael Junge in the Naval War College Review, “a commander is most likely to be removed for personal misconduct or when the crime of command includes one or all of the following elements: death, press coverage, or significant damage to the Navy, whether materially or to its reputation.”
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The country’s top employers of emergency room doctors are cutting their hours — leaving clinicians with lower earnings and hospitals with less staff in the middle of a pandemic.
TeamHealth, a major medical staffing company owned by the private-equity giant Blackstone, is reducing hours for ER staff in some places and asking for voluntary furloughs from anesthesiologists, the company confirmed to ProPublica. Multiple ER providers working for a main competitor, KKR-owned Envision Healthcare, said their hours also are being cut.
Even as some hospitals risk running out of room to care for COVID-19 patients, demand for other kinds of health care is collapsing. This irony is straining the business models of hospitals and the companies that staff them with doctors and other medical professionals.
Most ER doctors aren’t direct employees of the hospitals where they work. Historically, the doctors belonged to practice groups that contracted with the hospitals. In recent years, private-equity investors started buying up and consolidating those practice groups into massive staffing companies.
Reduced hours are also hitting doctors employed by SCP Health, another medical staffing company backed by the investment firm Onex Corporation, according to internal memos obtained by ProPublica. US Acute Care Solutions, backed by the private-equity firm Welsh, Carson, Anderson & Stowe, said it’s cutting hours in some places while increasing staffing elsewhere.
The staffing companies said they’re responding to dropping revenue as non-coronavirus patients avoid the ER and hospitals cancel elective procedures. The companies also emphasize that they’re not cutting physicians’ hourly rates.
But by assigning fewer hours to doctors and other providers such as physician’s assistants and nurse practitioners, the companies are effectively paying them less. It also means that some hospitals have fewer clinicians working in the ER at a time.
“These actions are unacceptable and unnecessary,” Scott Hickey, president of the Virginia College of Emergency Physicians, said in a statement. “This is very likely the ‘calm before the storm’ of critically ill patients entering hospitals with COVID-19 symptoms. Who will be there waiting to save those lives?”
The steepest cuts so far have occurred at Alteon Health, whose private-equity backers are New Mountain Capital and Frazier Healthcare Partners. The company says ER visits are down as much as 40% nationwide. In addition to the benefits cuts that ProPublica first reported on Tuesday, Alteon is furloughing some clinicians for 30 days to six months and won’t guarantee any hours for part-time employees, according to company memos obtained by ProPublica.
“Anyone not willing or unable to share the burden will need to be terminated to preserve employment for those who really feel part of our team and care about their coworkers,” one manager wrote.
Alteon said its ER doctors and clinicians in places that are inundated with COVID-19 patients are working longer hours and being paid more. “We are doing all we can to provide the support to the people who are on the front lines of this fight right now and ensure we have resources for those who may be called on to do even more when surges come to their areas in the future,” the company said in a statement to ProPublica.
In an earlier statement posted on Alteon’s website, CEO Steve Holtzclaw said ProPublica’s earlier article “mischaracterized” Alteon’s actions, saying, “We have not cut clinical rates for providers in the field.” In fact, ProPublica reported that Alteon wasn’t cutting rates but was cutting hours, and fewer hours at the same rate amounts to lower earnings.
“It was worded in a way to make it sound like we weren’t affected by this, but by cutting our hours we are,” said an ER clinician who works for Alteon and has had hours reduced in a hospital with coronavirus patients. (The clinician, like others interviewed by ProPublica, spoke on the condition of anonymity because company policy prohibits their speaking publicly.) “When they’re saying clinician pay is not affected, it certainly is. That was a straight lie.”
The clinician added: “Health care workers are being applauded in the streets, and we are being stepped on by them.”
TeamHealth initially told ProPublica that it was “not instituting any reduction in pay or benefits.” However, the company is in fact paying some clinicians less in the form of reducing their hours. The company provided a new statement saying “we are not instituting any reduction in rate of pay or benefits as our emergency physicians face current challenges.”
An ER clinician who works for TeamHealth said, “I probably wouldn’t have complained as this situation is unprecedented, but to see TeamHealth blatantly lying is infuriating.”
TeamHealth said it has reduced hours in some markets but is maintaining staffing above current demand in anticipation of a future surge of COVID-19 patients. While the company is asking anesthesiologists to take furloughs that may be mandatory if there aren’t enough volunteers, TeamHealth said it’s also looking for ways for anesthesiologists to use their skills to help out in emergency rooms or intensive care units. Blackstone declined to comment.
While some ERs in New York are overflowing with coronavirus patients, in many places people are staying home instead of going to the hospital. Studies have repeatedly shown that much of the care provided in the emergency room is for non-life-threatening issues.
“We always try to match our clinician coverage to our patient flow and we have done our best to do the same in this unpredictable time,” Amer Aldeen, US Acute Care Solutions’ chief medical officer, said in a statement. The company has not laid off, furloughed, reduced pay rates or cut benefits for any employees, Aldeen said.
Two clinicians working for Envision Healthcare said they were experiencing reduced hours. The company and its owner KKR did not respond to repeated requests for comment.
At SCP, salaries for nurse practitioners and physician’s assistants will decrease in line with reduced hours, the company said in a memo on Thursday. Employees who don’t accept the change will be terminated, the memo said.
“We know that this time is also difficult and uncertain for each of you, and we want all employees to be able to focus on getting through this time with as little worry as possible about their pay and benefits while avoiding unnecessary exposure to COVID-19,” SCP executives said in the memo. “SCP Health is using its reasonable best efforts to retain all team members at this time in light of this unforeseeable pandemic.”
SCP spokeswoman Maura Nelson said the company is dealing with a 30% drop in patients nationwide while the patients its providers are treating are more seriously ill. “We are calibrating our clinical coverage accordingly, so that we can address more flexibly the needs of our client hospitals,” Nelson said. “This was a necessary adjustment as we weather this crisis, together.”
Hickey of the Virginia physicians group called on staffing companies to take advantage of relief in the recent stimulus packages such as the Paycheck Protection Program and Medicare Accelerated and Advance Payment Program. But Alteon said it had already taken into account those relief measures before cutting compensation and benefits. “We have factored these actions into our plan,” Holtzclaw said in his message to employees on Monday.
The pandemic’s strain on the economics of the health care industry is not limited to private-equity-backed staffing companies. Hospital operators are also announcing layoffs and pay cuts. Dallas-based Tenet Healthcare said it would furlough 500 staff members and borrow money.
“We have this crisis going on where hospitals need as many people as possible, and at the same time hospitals have to cut their budgets,” said Brandon Jones, a nurse anesthetist and part-owner of a practice group called Greater Anesthesia Solutions in the Phoenix area. “Doctors are being sidelined or they’re being let go completely.”
While Jones’ colleagues are out of work for elective surgeries, he said they’re redeploying their skills to help treat COVID-19 patients — in particular by intubating them for breathing machines, which puts providers at a high risk to catch the virus. They’re wearing hazmat suits donated by a nearby nuclear power plant, Jones said, and they’re helping out even when they can’t bill for it or stand to make much less than normal.
“We’re going to do it because it’s right,” he said.
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This article is co-published with The Texas Tribune, as part of an investigative partnership.
On Monday afternoon, paramedic Theresa Fitzpatrick inched her Dodge Dart through a brand new drive-in testing center for COVID-19 in the small South Texas border city of Edinburg, a dozen miles from the Rio Grande. She had been wracked for a week with a dry, hacking cough ever since picking up a patient who had just crossed the international bridge with similar symptoms.
But she hadn’t been able to get a test since seeing her doctor last week, until a local university opened up drive-thru testing sites in her home county on Monday.
“They haven’t been testing people, that’s the problem,” said Fitzpatrick, a mother of four who earns $16 an hour as a paramedic for a private EMS company. “It just seems like the forgotten man down here.”
Hours earlier, Dr. Martin Garza, a pediatrician and former president of the Hidalgo-Starr County Medical Society, spent his lunch break drafting a plea to border-area lawmakers for help finding more testing kits.
Garza noted that at-risk areas such as South Texas, with lower numbers of confirmed cases, are precisely where enhanced testing is needed to detect and prevent a fatal spread of the virus, as is unfolding in New York City, New Orleans and smaller cities like Athens, Georgia.
“We have all heard, ‘If (only) we had been able to test sooner,’” he wrote. “Well the ‘sooner’ is still available in our community.”
While many places across the country are struggling to get enough testing, the problems are magnified in the Rio Grande Valley. It has among the highest poverty rates in the state, nearly half of its residents don’t have health insurance and chronic health conditions are rife.
Two weeks ago, Texas Gov. Greg Abbott promised that all those who need a coronavirus test “will get one,” but public health officials, politicians and doctors up and down the Rio Grande say that hasn’t happened and they are scrambling to assemble sufficient testing kits. Hidalgo County, the largest in the Valley, is only able to process 20 government tests a day, officials said this week.
In the border city of Laredo, 80 miles upriver from the Rio Grande Valley, a cluster of residents died on four consecutive days starting Sunday, bringing the city’s COVID-19 death toll to five, just below that of the state’s largest city Houston as of Friday morning. The first four were women in their 60s to 97. The latest was a 43-year-old man. Health authorities say all five suffered from underlying health conditions.
Also troubling to local health leaders is that the highest percentage of the city’s 65 positive cases is the result of some form of community contact.
As Laredo reeled from the deaths, its Mexican sister city, Nuevo Laredo, announced its first two positive cases this week, including a 56-year-old man who had recently traveled to Dallas. Health experts believe cases in Mexico are vastly underreported because of almost nonexistent testing there.
Responding to the threat, some border cities took drastic steps, including setting up roadblocks to catch people violating orders to shelter in place and requiring masks inside public buildings.
In many ways, the situation along the Texas border reflects the chaotic manner that the second-largest state in the country, with the highest percentage of people lacking health insurance, has approached the issue of testing — and the pandemic itself. Unlike some governors, Abbott, a Republican, had declined to impose a mandatory statewide shelter-in-place order, instead urging counties to make their own decisions. On Tuesday, he did issue such an order urging most people to stay home.
Texas as a whole also has lagged when it comes to testing. It’s completed more than 50,600 tests so far, more than double what it had less than a week ago, but it still ranks among the lowest in the nation in per-capita testing, well behind other large states such as New York and California, according to a ProPublica analysis. At least 70 people have died in Texas.
Abbott’s spokesman, John Wittman, referred questions to the state’s Division of Emergency Management.
Seth Christensen, that agency’s spokesman, said in a statement that the state is available to assist “every mayor and county judge” across Texas. He said that swabs are in short supply nationally, but that the state is trying to procure more from the federal government and private companies.
He said private health care providers should also make an effort to obtain testing supplies through the private sector to “ensure we are leveraging every available avenue.”
To ward off the virus spreading across international borders, President Donald Trump has largely closed border crossings to “nonessential” travel, but epidemiologists say that’s not the solution to an epidemic that has likely already taken root on both sides of the Rio Grande.
“The answer is not closing the border,” said epidemiologist Benjamin King of the University of Texas at Austin. “It’s aggressive testing on both sides.”
Population at Risk
The Rio Grande Valley is a world away from the state’s largest regions, Houston and Dallas, which have seen the most cases. It is a sprawling mix of rural farmland and urban spread that is home to more than 1.3 million mostly Hispanic residents and shares river frontage with a bustling Mexican border region of factories, busy land crossings and outbreaks of drug cartel violence.
The Valley’s population is particularly vulnerable to the virus, experts say. About half a million Texas border residents live in so-called colonias across the U.S. side of the border, which often lack basic amenities such as running water. Roughly one in three people in the Rio Grande Valley is diabetic, a major risk factor for complications from COVID-19. And one in 10 of the state’s undocumented population lives in the region, with potential immigration consequences often making them fearful to seek help.
“My concern is not only that it is circulating without our knowledge, but we also have a population at high risk for severe disease,” said Dr. Joseph McCormick, an epidemiologist at the Brownsville campus of the University of Texas Health Science Center at Houston. “I don’t think it will take very long at all to overwhelm the facilities at our hospitals.”
Hidalgo County, the largest in the Rio Grande Valley, has about 2,000 hospital beds, compared with about 14,000 in Houston.
McCormick, who helped investigate the first-recorded Ebola outbreak in 1976, blamed the lack of testing on the state and federal government.
“The state is depending on the federal government to bring tests in and that hasn’t happened. … I don’t know why the state hasn’t done more,” he said. “Our folks are now relying more on private labs.”
“Some Very Sick People”
On Monday, UT Health RGV, which is part of the University of Texas Rio Grande Valley School of Medicine, began drive-thru testing in Brownsville and Edinburg.
In a few days, its hotline received almost a thousand calls and health workers were seeing “some very sick people,” said Dr. Linda Nelson, senior director of clinical operations heading the initiative. “Some of them can’t even talk on the phone without coughing.”
Dr. Rosemary Recavarren, a pathologist who oversees four hospital laboratories in the Rio Grande Valley, has been worried about this for weeks. She and her staff have been reaching out to the state health department and private testing companies since February, but they were told they were not a priority and that testing kits were allocated to areas much harder hit.
“We are not going to get testing for our machines until probably the end of April,” she said.
Eddie Olivarez, chief administrative officer for Hidalgo County’s health department, said only about 20% of COVID-19 testing in the region was being conducted by public labs, compared with 80% done through private institutions, because of capacity and because state criteria is more stringent on who can qualify for testing. Patients must have traveled and had known exposure to a confirmed case to be eligible for state tests, whereas private institutions allow more flexibility from each physician in recommending testing.
Olivarez said the Harlingen public health laboratory through which his county does testing can only process about 40 tests a day.
Chris Van Deusen, a spokesman for the Texas Department of State Health Services, said the agency had shipped more tests to the Rio Grande Valley on Wednesday and was working to start a “high-throughput” testing platform that would allow tests at a faster pace.
Most metropolitan areas in Texas rely on private hospitals for some in-house analysis of testing, but almost no hospitals in the Rio Grande Valley currently have that ability, Recavarren, the pathologist, said. They must either send swabs to public health laboratories, which comply with the state’s stricter criteria, or to private companies.
But as demand has skyrocketed across the country, companies are now overwhelmed and many Texas health workers said it can take days for results back from Quest Diagnostics and up to two weeks for LabCorp.
Quest Diagnostics said in a statement this week that between March 9 and April 1 it performed more than 400,000 COVID-19 tests across the country, “a sharp influx of test orders that continued to outpace our growing capacity.”
But it has since implemented a “higher throughput” diagnostic test at laboratories across the country, reducing the national backlog from 160,000 to 115,000 in a week.
“While we are more confident now in our ability to meet demand and report results for COVID-19 testing than in mid-March, when we were still ramping up capacity, this crisis is fluid and unpredictable, and so is the demand for COVID-19 testing,” the company said.
LabCorp said in a statement that it was also working “tirelessly” to increase capacity.
The lack of testing and delay in labs has even metropolitan areas with far more physicians and hospitals struggling.
Bexar County Judge Nelson Wolff, who oversees the state’s second-largest city of San Antonio, said its public laboratories can get results in a day, but when they send tests to Quest Diagnostics, it takes up to five days. More than 220 cases have been confirmed there with at least nine deaths, including a nursing home outbreak this week that killed one resident and infected at least 66 of the 84 residents.
In Harris County, home to Houston, the fourth-largest city in the nation, officials have struggled to open enough testing centers, receiving only enough supplies from the federal government for two publicly run sites in the county, testing 500 a day — far fewer than the 10 sites sought by Harris County Judge Lina Hidalgo, the region’s chief executive. The city of Houston has another two public testing sites able to jointly run another 500 tests daily.
The metropolitan area is also home to one of the country’s biggest medical centers, with many hospitals running in-house testing and analysis, including Houston Methodist, which can test about 250 patients in-house a day.
By Friday morning, at least 955 people in Houston and Harris County had tested positive — the most in the state — and at least 10 had died. The county is home to about 16% of the state’s 29 million residents.
Dr. Peter Hotez, a vaccine researcher and dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, has predicted Houston could follow New Orleans as a hot spot in the South. He thinks the Rio Grande Valley is also at risk, due to its high percentage of people living in poverty with diabetes and hypertension.
“Testing is crucial in poor neighborhoods, both on the border or in the urban core, that’s the most vulnerable populations,” Hotez said. “Wherever there is crowding and poverty, those are the areas I worry about the most.”
“A Tsunami Coming”
Starr County, an isolated, mostly rural county with one of the highest poverty rates in the state, bucked the border trend and was the first south of San Antonio to establish a drive-thru testing site in early March, thanks to a partnership between the county, university and a local businessman.
“Our testing here has not been short of anything,” Starr County Judge Eloy Vera said. “Anyone who needs to be tested is getting tested.”
The effort has paid off, local officials believe. The businessman is footing the first month’s bill, and the site has done about 300 tests, with just five people testing positive.
This week, Webb County, slammed with five deaths in four days, finalized a deal to bring 5,000 rapid tests to the Laredo area through a partnership with a local ER provider, Clear Choice ER.
City officials hoped to have the tests up and running by the end of this week, but on Friday announced they had determined the tests were not reliable and that Laredo police would investigate the validity of the kits’ FDA certification. Officials said they would continue “scouring the world for testing kits.”
Officials are feeling the pressure to slow the virus.
“We only have one shot at this,” Laredo City Manager Robert Eads said. “We have to get this right now.”
As testing increases and cases rise by the day, border officials brace for what lies ahead.
On Thursday, as 17 more people tested positive in Hidalgo County, including four children under the age of 5, county officials said there was now “clear evidence” of community spread. More than 630 in the county have now been tested, with at least 79 confirmed cases.
Fitzpatrick, the paramedic in Edinburg who struggled to get tested, learned Thursday she was not among them. She plans to return to her ambulance this weekend and hopes her department will receive more of the personal protective gear it needs.
“If we don’t do it, who’s going to do it?” she said. “There’s a lot more down here who will get sick.”
A University of Texas at Austin model of potential new COVID-19 hospitalizations released this week showed that depending on the measures taken by local officials, overall cases could reach between roughly 95,000 and 335,000 combined in the metro areas of Laredo, Brownsville and McAllen.
Hidalgo County Judge Richard Cortez, in his strongest words yet, warned “there is a tsunami coming. It hasn’t hit us yet.”
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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 Mecklenburg County, North Carolina — where Charlotte is — 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. Neither of those governments has published breakdowns of deaths by race.
“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.”
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Dire shortages of vital medical equipment in the Strategic National Stockpile that are now hampering the coronavirus response trace back to the budget wars of the Obama years, when congressional Republicans elected on the Tea Party wave forced the White House to accept sweeping cuts to federal spending.
Among the victims of those partisan fights was the effort to keep adequate supplies of masks, ventilators, pharmaceuticals and other medical equipment on hand to respond to a public health crisis. Lawmakers in both parties raised the specter of shortchanging future disaster response even as they voted to approve the cuts.
“There are always more needs for financial support from our hardworking taxpayers than we have the ability to pay,” said Denny Rehberg, a retired Republican congressman from Montana who chaired the appropriations subcommittee responsible for overseeing the stockpile in 2011. Rehberg said it would have been impossible to predict a public health crisis requiring a more robust stockpile, just as it would have been to predict the Sept. 11, 2001, terrorist attacks.
“It’s really easy to second-guess and suggest we didn’t do as much,” he said. “Why didn’t we have a protocol to protect the Twin Towers? Whoever thought that was going to happen? Whoever thought Hurricane Katrina was going to occur? You tell me what’s going to happen in 2030, and I will communicate that to congressmen and senators.”
There were, in fact, warnings at the time: A 2010 Centers for Disease Control and Prevention-funded report by the Association of State and Territorial Health Officials urged the federal government to treat public health preparedness “on par with federal and state funding for other national security response capabilities,” and said that its store of N95 masks should be “replenished for future events.”
But efforts to bulk up the stockpile fell apart in tense standoffs between the Obama White House and congressional Republicans, according to administration and congressional officials involved in the negotiations. Had Congress kept funding at the 2010 level through the end of the Obama administration, the stockpile would have benefited from $321 million more than it ended up getting, according to budget documents reviewed by ProPublica. During the Trump administration, Congress started giving the stockpile more than the White House requested.
By late February, the stockpile held just 12 million N95 respirator masks, a small fraction of what government officials say is needed for a severe pandemic. Now the emergency stash is running out of critical supplies and governors are struggling to understand the unclear procedures for how the administration is distributing the equipment.
The stockpile received a $17 billion influx in the first and third coronavirus stimulus bills that Congress passed in March. But there had not been a big boost in stockpile funding since 2009, in response to the H1N1 pandemic, commonly called swine flu.
After using up the swine flu emergency funds, the Obama administration tried to replenish the stockpile in 2011 by asking Congress to provide $655 million, up from the previous year’s budget of less than $600 million. Responding to swine flu, which the CDC estimated killed more than 12,000 people in the United States over the course of a year, had required the largest deployment in the stockpile’s history, including nearly 20 million pieces of personal protective equipment and more than 85 million N95 masks, according to a 2016 report published by the National Academies of Sciences, Engineering and Medicine.
“We recognized the need for replenishment of the stockpile and budgeted about a 10% increase,” said Dr. Nicole Lurie, who served as the assistant secretary for preparedness and response at the Department of Health and Human Services during the Obama administration. “That was rejected by the Republican House.”
Republicans took over the House of Representatives in the 2010 midterms on the Tea Party wave of opposition to the landmark 2010 health care reform law, the Affordable Care Act, also known as Obamacare. The new House majority was intent on curbing government spending, especially at HHS, which administered Obamacare.
Congressional Republicans, led by Mitch McConnell in the Senate and House Speaker John Boehner, leveraged the debt ceiling — a limit on the government’s borrowing ability that had to be raised — to insist that the Obama administration accept federal spending curbs. The compromise, codified in the 2011 Budget Control Act, required a bipartisan “super committee” to find additional ways to reduce the deficit, or else it would trigger automatic across-the-board cuts known as “sequestration.”
Even in the aftermath of the swine flu pandemic, the stockpile wasn’t a priority then. Without a full committee markup, Rehberg introduced a bill that provided $522.5 million to the stockpile, about 12% less than the previous year and $132 million less than the administration wanted. “Nobody got everything they wanted,” Rehberg said.
The Senate version of the funding bill offered $561 million for stockpile funding. Senators said they regretted the cuts even as they voted for the bill.
“In this bill we’re now getting into the bone marrow,” Tom Harkin, a Democrat from Iowa who then chaired the Senate appropriations committee, said at the markup. “Some of these cuts will be painful and unpopular.”
In the bill’s final version, Congress allocated a compromise $534 million for the 2012 fiscal year, a 10% budget cut from the prior year and $121 million less than the Obama administration had requested.
The next year, the “super committee” failed to secure additional savings demanded by the Budget Control Act, triggering the automatic, across-the-board cuts. This “sequestration” was an outcome that the leaders of both parties disliked — and blamed one another for.
“Did either party ever indicate sequestration was welcome, positive or desirable?” Dave Schnittger, Boehner’s deputy chief of staff at the time, told ProPublica. “Sequestration was conceived — not by Republicans, but by a Democratic White House — as a crude mechanism to compel the super committee to do its job. Republicans consistently advocated for reductions in mandatory spending programs that would have prevented sequestration from ever happening.” (Mandatory spending refers to entitlement programs such as Social Security and Medicare.)
McConnell’s office did not respond to requests for comment.
Katie Hill, a spokeswoman for Obama, pointed to numerousstatements he made in 2013 urging Republicans to compromise, warning that the sequester would weaken economic recovery, military readiness and basic public services.
Gene Sperling, then a top Obama economic adviser, said Republicans focused attacks on the HHS budget, along with the Departments of Labor and Education, which are grouped under the same appropriations subcommittee.
“The Labor/HHS budget is where a significant number of progressive priorities are, from Head Start to (the National Institutes of Health) to the Education Department,” Sperling said. “There’s just so much in there, so it is often the hot spot for where conservative budget hawks who don’t believe in public investment go hardest.”
Under sequestration, the CDC, which managed the stockpile at the time, faced a 5% budget cut. In its 2013 budget submission, HHS decreased its stockpile funding request from the previous year, asking for $486 million, a cut of nearly $48 million. “The SNS is a key resource in maintaining public health preparedness and response,” the administration said. “However, the current fiscal climate necessitates scaling back.”
The decrease caught Rehberg’s attention at a budget hearing to review the request.
“Disaster preparedness is something that has been very important to me,” he said at the hearing. “I just would like to have you explain how such a large reduction can possibly not impact the national preparedness posture.”
Then-HHS Secretary Kathleen Sebelius answered that the CDC would prioritize replacing expiring drugs such as smallpox vaccines and anthrax treatments.
The next year, the administration again proposed cutting the stockpile’s funding from the 2012 funding level, but it warned that reduced funding could result in “fewer people receiving treatment during an influenza pandemic.”
Congress did grant extra funding in response to emergencies, but even then, the stockpile was a small-ticket item. In 2014, the Obama administration asked for and received billions of dollars to respond to the Ebola outbreak, but only $165 million went to the CDC’s public health emergency preparedness programs, including the stockpile. And in 2016, Congress granted emergency funding to respond to the Zika virus, but it gave the CDC less than half of what the Obama administration requested.
“It’s clear that the administration prioritized the SNS in this (Zika) request and in the Ebola supplemental,” said Ned Price, who was a spokesman for the National Security Council in the Obama White House. “In the case of Zika, congressional Republicans sat on the request for the better part of a year.”
The stockpile’s mission has steadily expanded as it confronts new public health emergencies. With limited resources, officials in charge of the stockpile tend to focus on buying lifesaving drugs from small biotechnology firms that would, in the absence of a government buyer, have no other market for their products, experts said. Masks and other protective equipment are in normal times widely available and thus may not have been prioritized for purchase, they said.
“It just was never funded at the level that was needed to purchase new products, to replace expiring products and to invest in what we now know are the really necessary ancillary products,” said Dara Lieberman, director of government relations at the Trust for America’s Health, a nonpartisan public health advocacy and research group.
The sequestration and strict budget caps ended with budget deals in 2018 and 2019 — a bipartisan rebuke to the earlier restraints. “It’s a burden off our shoulders,” Senate Appropriations Chairman Richard Shelby, R-Ala., told reporters at the time. “In a troubled world, I think that was the wrong message.”
Yet non-defense spending still hasn’t fully recovered.
“One of the things that happened to public health preparedness was just the result of the general budget stringency we had,” said David Reich, a consultant working on federal appropriations issues for the Center on Budget and Policy Priorities. “We’re still seeing the results of that.”
During the Trump administration, the White House has consistently proposed cutting the CDC and the HHS Office of the Assistant Secretary for Preparedness and Response, which took over stockpile management from the CDC. Congress approved more stockpile funding than Trump’s budget requested in every year of his administration, for a combined $1.93 billion instead of $1.77 billion, according to budget documents.
The White House budget request for 2021, delivered in February as officials were already warning about the dangerous new coronavirus, proposed holding the stockpile’s funding flat at $705 million and cutting resources for the office that oversees it.
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There’s an overlooked reason why hospitals treating COVID-19 patients are so short of protective gear. In January, just before the pandemic hit the United States, a key distributor recalled more than 9 million gowns produced by a Chinese supplier because they had not been properly sterilized.
“At this time, we cannot provide sterility assurances with respect to the gowns or the packs containing the gowns because of the potential for cross-contamination,” Cardinal Health wrote to customers on Jan. 15. It added, “We recognize the criticality of our gowns and procedure packs to performing surgeries, and we apologize for the challenges this supply disruption will cause.”
The recall immediately forced the canceling of some elective surgeries. It also meant that supplies of medical gowns were already low when hospitals and state governments began desperately searching for protective gear to cope with the pandemic. Most gowns are supposed to be worn once and not reused. As some doctors and nurses have resorted to covering themselves with trash bags, raincoats and hazardous materials suits bought online, many health care workers have contracted the virus, further taxing already overwhelmed hospitals.
“Demand has gone up at a time when supply was already constrained,” said Bindiya Vakil, the chief executive of Resilinc, a Milpitas, California, firm that monitors supply chain disruptions worldwide. “Coronavirus made what was already a bad situation a lot worse.”
Colin Milligan, a spokesman for the American Hospital Association, said that the group’s members continue to experience shortages of medical gowns and that the Cardinal recall “has had a ripple effect.”
A Cardinal spokeswoman said that “the supply of surgical gowns should not impact the supply of PPE,” or personal protective equipment, for health care workers because they usually wear another type of outer garment, isolation gowns, when tending to coronavirus patients.
Cardinal received approval Tuesday from the federal government to donate the 2.2 million recalled gowns that remain in its inventory to the Strategic National Stockpile for distribution as isolation gowns. Each pallet must be “labeled in with a warning that the articles are for use for non-sterile apparel purposes only,” according to the approval letter.
The company is “working around the clock to meet the needs of healthcare providers so they can safely serve the patients who depend on them,” a Cardinal spokeswoman wrote in an email.
The shortage of gowns even before the coronavirus outbreak highlights the vulnerabilities of a U.S. health care system that depends on protective equipment largely made in other countries, led by China. The quality of gowns and other gear has been a recurring problem, including a dead insect in the packaging of a Cardinal gown, complaint records show. Replacing an overseas supplier can take months, and even if a new one is found quickly, it still has to ramp up production and arrange shipping.
“Unfortunately, like others, we are learning in this crisis that overdependence on other countries as a source of cheap medical products and supplies has created a strategic vulnerability to our economy,” U.S. Trade Representative Robert Lighthizer said at a meeting Monday. “For the United States, we are encouraging diversification of supply chains and seeking to promote more manufacturing at home.”
The recall also exposes flaws in how both companies and government regulators monitor the overseas manufacturers that produce much of the country’s inventory of protective medical gear. Because surgical gowns are considered a medical device, their quality is monitored by the U.S. Food and Drug Administration, which inspects manufacturing plants every two years.
A spokeswoman for Cardinal, which is based in Dublin, Ohio, said that it has a “broad and diverse manufacturing and supplier network” that includes the U.S. and is not dependent on any one locale. Cardinal is also one of the largest prescription drug distributors in the world. It had revenues in 2019 of more than $145 billion, making it the 16th largest company in the U.S., according to Fortune.
Cardinal chief executive Mike Kaufmann told Wall Street analysts in February that the company understood “the gravity” of the recall. He said it had hired outside experts to review Cardinal’s quality assurance procedures.
The company’s board has established a special committee to review management’s actions pertaining to the recall, according to Cardinal’s website. The outside experts continue to scrutinize the company’s practices, a spokeswoman said.
Of the recalled gowns, Cardinal had already distributed almost 8 million to health care facilities; the others had not reached customers. Some had been manufactured as early as the fall of 2018, the company has said. Cardinal does not have information on how many of the gowns were used but believes a majority of them were, a spokeswoman told ProPublica. Asked if any health workers or patients were infected as a result, she said that “we continue to track and analyze complaint data.”
The FDA last inspected the problematic Chinese plant in April 2018 and did not identify any violations, an agency spokeswoman said. Manufacturers are responsible for detecting problems and reporting them to the FDA, she said, adding that the Chinese company did not report any such issues during the period covered by the recall.
The January recall was not the first time Cardinal had a problem with the supplier, which it has identified as Siyang HolyMed Products Co. in Jiangsu province on China’s coast. Cardinal disclosed in a January press release that in the spring of 2018, around the same time the FDA was inspecting the Chinese company’s manufacturing facility, the company learned that Siyang outsourced some of its production to an unqualified facility. Cardinal tested products at the time and determined there was no reason to take further action such as a recall, it said.
Then, last Dec. 10, Cardinal received a tip that Siyang was making gowns at two sites that weren’t approved by the U.S. company or registered with the FDA, a Cardinal spokeswoman said. Ten days later, an on-site investigation confirmed the tip, she said.
In a Jan. 21 letter to customers, Cardinal said it couldn’t guarantee that the gowns were sterile because Siyang made some of them at locations that “did not maintain proper environmental conditions as required by law.” They were “commingled with properly manufactured gowns,” Cardinal said.
Phone and email attempts to contact Siyang were unsuccessful. The FDA said in January that it was investigating how the gowns may have been contaminated. An agency spokeswoman did not respond to questions about the status of that investigation.
Health care workers wear gowns to protect themselves from coming in contact with blood and other bodily fluids, microorganisms and particulate material. The gowns offering the highest level of protection are sterilized. A gown that is not properly sterilized increases the risk of infection, which can be transmitted to a patient during a procedure.
Health care workers use two kinds of medical gowns. Surgical gowns, like those sold by Cardinal, provide the highest level of protection and are more heavily regulated by the FDA. Isolation gowns, which are produced in larger amounts, are not sterilized but are appropriate for many interactions with COVID-19 patients. Both are in short supply right now as hospitals are quickly burning through any gowns they have and, in some cases, using already depleted supplies of surgical gowns when isolation gowns are unavailable.
The 9.1 million gowns recalled by Cardinal likely represent about 30% of the company’s global distribution, according to Premier, a Charlotte, North Carolina, company that negotiates prices on supplies bought by more than 4,000 hospitals and health care systems. The recall “absolutely contributed to the challenges that some of our hospitals are having treating their patients,” Chaun Powell, a group vice president at Premier, said. “That put burden on the supply chain prior to COVID outbreaks, and then the COVID outbreaks only exacerbated that issue.”
In the past two years, the FDA has received several complaints about the quality of Cardinal gowns. Adverse event reports filed with the agency include accounts of inadequate and improper protective wrapping on sterile gowns, holes in gowns, and blood soaking through the protective material. The reports disclosed to the public do not name the facilities or individuals reporting the product defects. Complaints have been filed about gowns purchased from distributors other than Cardinal as well.
In 2019, a hospital reported that a sterile gown arrived from Cardinal improperly wrapped, rendering it non-sterile. “This was noticed before it was opened to the surgical field; however, had it been opened it would have contaminated the entire field,” the report said. Ten days later, another report noted another packaging defect that could have caused contamination. “This is not the first time this has happened,” according to the report. “The gowns are coming from the manufacturer this way.”
In February, after the recall, a hospital found a dead insect in the packaging of a Cardinal sterile gown, according to a report filed with the FDA. The hospital said the gown was not part of the recall. The report noted there had been previous, unconfirmed reports of hair, gum and a cigarette butt found in Cardinal products labeled as sterile.
Cardinal did not respond to questions about the adverse event reports.
China is the source of 45% of all the protective medical garments imported to this country, according to an analysis last month by the Peterson Institute for International Economics. Other countries where gowns for U.S. health care workers are manufactured include Mexico, Thailand, Cambodia, Honduras and the Dominican Republic, according to the nonprofit ECRI Institute in Plymouth Meeting, Pennsylvania.
Another major distributor of surgical gowns, Medline Industries Inc., declined to answer questions about where its gowns are made. Attempts to contact another supplier, Halyard, were unsuccessful.
At a health care conference last month, Halyard’s parent company reported making surgical gowns at a plant in San Pedro Sula, Honduras.
For Cardinal, the recall has been a costly blow to its bottom line and reputation. The company’s operating earnings declined 34% in the second quarter ending Dec. 31, in part due to a $96 million charge related to the recall.
“We don’t know how this could affect our business going forward, and we’re hoping that it doesn’t,” Cardinal’s Kaufman said in a conference call with investment analysts in February. “But we know that we have created some pain.”
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As she sat Wednesday on the covered deck at the 4-Way Saloon in Sidell, overlooking the town grain elevator, Leslie Powell made her way down the list of tasks she had scribbled on her yellow notepad. Asking the utility company for a payment plan was first.
Powell’s husband, Mark, became owner of this busy little bar and grill in east-central Illinois just nine days before Gov. J.B. Pritzker ordered residents across the state to shelter in place in an attempt to halt the spread of the novel coronavirus outbreak.
Now, with the 4-Way closed to dine-in orders, and the couple’s savings spent on buying and fixing it up, the Powells face losing their business if they don’t receive state or federal aid. And that has reinforced a thought Powell has had before: Chicago should be separated from the rest of the state.
The idea of secession has long simmered in Illinois’ more rural and Republican counties, periodically flaring up around issues such as raising the minimum wage, the establishment of sanctuary cities for undocumented immigrants and gun ownership. And though Illinois’ secession movement — or, movements — isn’t exactly united, many who believe in the principle share a general sense of feeling underrepresented in a state dominated by Chicago’s Democratic stronghold.
The coronavirus outbreak, which has yet to touch some areas of the state, has become the most recent flashpoint, inspiring both serious promises to reintroduce secession on the ballot and Facebook memes that call for building a wall around Chicago.
Political experts say there is virtually no chance that the state will ever split, especially since it will require an act of Congress and lead to the likely election of two Republican senators to represent that new state. Still, the secession conversation is a dramatic expression of the much more widespread — and potentially dangerous — frustration with a sweeping governmental response to the pandemic that many question in areas where some homes sit acres apart and people predominantly travel by car, not public transportation.
“There’s nobody around here that’s got it,” Powell said. “We’re a farming community. We know how to wash our hands. We’re with pigs and cows and chickens. In this community, it’s really hard to comprehend.”
As of Thursday, 41 of Illinois’ 102 counties had yet to see a single case of COVID-19, according to the Illinois Department of Public Health. Experts caution that likely will change soon. Vermilion County, where Powell lives, reported its first two cases this week, officials there said.
On Tuesday, Pritzker announced he was extending the stay-at-home order through April. Many people said they are following it, even if their businesses and livelihoods are suffering.
At the same time, the response to the pandemic has exacerbated the feelings of some residents that the rest of the state is being forced to deal with Chicago’s problem. State Rep. Blaine Wilhour, a Republican from Effingham, said that he would like to see some regional accommodations considered to the shutdown measures, including the possibility of opening up some restaurants at half-capacity and allowing mom-and-pop stores to set up appointments.
“There’s obviously a big difference in how these broad policies affect Chicago, which is a very densely populated area, and how they affect my district,” Wilhour said.
Wilhour, along with six other Republican lawmakers, sent a letter to Pritzker last week asking for measures to help small businesses during the pandemic, including freezing the minimum wage for 18 months and implementing a sales tax holiday for the duration of the stay-at-home order.
While Wilhour said he understands the severity of COVID-19, he said the stay-at-home order has taken an enormous economic toll on his district. Residents are taking the safeguards seriously for now, he said, but they also see that the disease is not nearly as prevalent in their area as it is in Chicago.
“They see the trajectory of Illinois as not good, especially not good for people in our part of the state,” he said. “There’s a lot of pent-up anxiety about adversarial policies that are pushed down to benefit Chicago and they disproportionately don’t benefit us.”
One risk of that frustration is that people may feel less inclined to follow what they see as Chicago’s rules. Steve McNeil, who manages Rent One furniture and appliance store in West Frankfort, about 300 miles south of Chicago, said he’s concerned that some people are neither following Pritzker’s stay-at-home order nor social distancing guidelines. Though his store, part of a regional chain, remains open, he said he makes sure his staff sanitizes the store “on the hour, every hour.”
He can’t say all of his customers are taking similar steps, though.
“It’s very lackadaisical,” McNeil said. “A lot of people I don’t see taking the precautions seriously.”
McNeil said his store has seen unprecedented sales of washers, dryers, deep freezers and refrigerators — which he considers “essential items” and the reason he believes he’s allowed to stay open — and has felt heartened by the new role he sees his business providing during the crisis.
On Wednesday, McNeil’s Rent One store posted a photo on its Facebook page advertising its stock of lawn mowers: “Yard season has started and Rent One is here to help you get started. This bad boy is parked out front of the store so feel free to take a look at it TODAY!”
Rick Henson, who owns a barber shop in West Frankfort, closed Tuesday after business slowed because of the coronavirus. He now hopes to reopen next week, after he began getting calls from customers, many of whom are older people, city officials and local police officers, saying he’s a “needed commodity.”
Jared Gravatt, co-owner of Crown Brew Coffee Company in Marion, said he understands the need for the stay-at-home order but thinks the differences between Chicago and the rest of the state are “night and day.”
Gravatt said the county’s businesses are reeling from the shutdown. He and his business partner are organizing a virtual fundraising event on Friday to raise money and awareness for struggling businesses while encouraging people to abide by the stay-at-home order.
Even Gravatt, who said he recognizes the importance of protecting against the coronavirus outbreak, acknowledges the appeal of secession.
COVID-19 has “killed more businesses than it has people in this region,” he said.
Last year, State Rep. Brad Halbrook, a Republican from Shelbyville, filed legislation that urged Congress to declare Chicago the nation’s 51st state. The legislation stalled in the rules committee, where it found little support, but organizing around the issue continues. Once Pritzker’s stay-at-home order is lifted and people are able to gather again, “the interest will be as high as it’s ever been,” Halbrook said. “There’s no question about it.”
“They want to manage the entire state to suit Chicago,” Halbrook said. “They’re different lifestyles and different cultures. To do this one-size-fits-all management doesn’t work.”
John S. Jackson, a visiting professor at the Paul Simon Public Policy Institute at Southern Illinois University in Carbondale, points to similar secession movements in New York and California, where rural areas have animosity toward those states’ urban centers.
He called the perception of unequal resource distribution between Chicago and the rest of the state “a myth” that has existed for decades, and he said the stakes of that ideological divide are high during the coronavirus crisis.
“It’s a corrosive part of our culture,” Jackson said. “It has no chance at all of becoming law.”
Unlike other supporters, Collin Cliburn, a contractor and carpenter who lives outside Springfield, has led much of the state’s grassroots secession efforts. Cliburn describes his political views as “borderline old-school libertarian” and differentiates his effort from the “New Illinois” secession movement led by Halbrook as more populist and rogue than that of elected political leaders.
Cliburn hopes to collect enough local signatures to force the secession question onto statewide ballots as a referendum, county by county. So far, the strategy has paid off in Jefferson, Fayette and Effingham counties, which during the state’s March primaries voted more than 70% in a nonbinding referendum in favor of secession. While he believes, based on one-on-one conversations as well as the popularity of events he’s organized, that many in southern Illinois favor secession in practice, Cliburn said most are hesitant to vote for it.
To try to build support, Cliburn has turned to social media. He makes memes, shares local news stories and writes posts across a network of Facebook groups and pages he runs to amplify differences he sees between Chicago and the rest of the state.
“What I’m doing is creating a spider web,” Cliburn said.
That spider web, which he’s crafted to function as a sort of social media ecosystem of secession sentiment, includes “Illinois Separation,” a page Cliburn runs that has garnered nearly 27,000 Facebook likes; “Illinoyed,” a page for more general venting about the state, which has about 11,700 likes; and also dozens of county-level pages for local organizers. Lately, Cliburn said, he’s been using coronavirus news to bring attention to the effort to kick Chicago out of the state.
“Everything is about Chicago,” reads a March 24 post on the “Illinois Separation” page, above a news story about Chicago preparing for a “surge in bodies” because of COVID-19 deaths. “When the Governor speaks only Chicago people stand beside him, including their Mayor Lightfoot …” he wrote. “I’m sick and tired of everything being about Chicago.”
Another post, shared on the “Illinois Separation” page on March 25, shows an image of the state of Illinois with the Chicago-area blocked off with a line. “Make Illinois Great Again … build a wall !!” the graphic reads. Comments included individuals blaming Chicago for positive COVID-19 cases in their own counties and criticizing the shelter-in-place order in areas with few if any positive cases.
The post has nearly 800 likes and 400 shares.
Pritzker spokeswoman Jordan Abudayyeh called it “appalling” that people would focus on division instead of unity during a national crisis. The governor’s duty is to every single resident in Illinois, she said.
“When COVID-19 was first reported in Illinois, it was in one county and quickly spread to more than 50 in the days since,” Abudayyeh said. “Almost every day there is a new county reporting positive cases.”
The frustration that some rural residents feel about the shutdown, or at least their expectation that COVID-19 won’t reach them, may be short-lived.
Experts warn that the low numbers of confirmed COVID-19 cases may simply reflect a lack of testing. In some counties, less than two dozen people have been tested. Because coronavirus spreads first in large urban areas then expands, it’s probably only a matter of time before the rest of the state sees cases, said Dr. Jerry Kruse, Dean and Provost of Southern Illinois University School of Medicine in Springfield
“It’s almost like throwing a pebble into a pool and watching the waves radiate out,” said Kruse, who added that it’s a “virtual inevitability” the coronavirus will reach rural Illinois.
Metro East St. Louis and Sangamon County have already started to see the number of cases rise.
“You should assume that the coronavirus has come to your county,” said Monica Dunn, assistant administrator at Edgar County Public Health Department.
Christian County, about 30 minutes southeast of Springfield, is an example of how quickly the situation can turn.
The county of 32,000 did not see its first case of COVID-19 for more than six weeks after the outbreak hit Chicago. On March 19, the county learned of its first case. For the next week, nothing changed. On March 25, there was one more.
Then overnight, 11 new confirmed cases.
“When we didn’t have any cases, there was a real complacency going on,” said Denise Larson, Christian County public health administrator. Larson said she fears the low number of confirmed cases so far in nearby counties gives a false sense of security.
The outbreak happened at a subsidized apartment complex for seniors in Taylorville after a resident attended church with someone who had contracted the disease. All 22 residents of Rolling Meadows Senior Living Apartments were tested, officials said. Two additional cases have been confirmed, bringing the total number of confirmed cases at the complex to 13 as of Tuesday.
On Wednesday, the county announced two COVID-19 deaths, a man and woman, both in their 80s.
Eighty-five-year-old Peggy Wadkins, who has lived in Christian County for more than 60 years and at the apartment complex for 10, said she spends much of her time now on the phone with her family, including her more than 30 great-grandchildren.
While residents remain in quarantine, city and county officials are checking to see if they need groceries or medicine. This week, Wadkins put her walker in the doorway so a worker could place tissues, tylenol, lunch meat and bananas on the seat without coming into contact with her.
When Wadkins looks out her bedroom window, which overlooks the now vacant parking lot, she imagines a day when all of this has passed.
Later this spring, Alaska’s Bristol Bay will blossom into one of the largest annual salmon fisheries in the world.
The regional population of about 6,600 will triple in size with the arrival of fishermen, crews and seasonal workers on jets but also private planes and small boats, many traveling from out of state.
And yet the heart of the health care system in southwestern Alaska, in a corner of the state where the Spanish flu once orphaned a generation, is a 16-bed hospital in Dillingham operated by the Bristol Bay Area Health Corp. Only four beds are currently equipped for coronavirus patients. As of Wednesday the hospital had a few dozen coronavirus tests and for the entire Florida-sized region, tribal leaders said.
If those newly arrived workers need to quarantine for two weeks, as mandated by the state, residents said it’s unclear where everyone will hunker down. Local store shelves are already bare of Clorox, Lysol and rubber gloves.
Dillingham, the largest community in the Bristol Bay region with a population of 2,300, is 320 miles from Anchorage by air.
“We’re scared. … People come from all over the world for Bristol Bay fishing,” said Gayla Hoseth, second chief for the Dillingham-based Curyung Tribal Council. “There’s 7,000 of us who live here, and this hospital cannot handle the 7,000 of us if we get sick. Imagine (when) our population triples and quadruples in the summertime.”
Compounding matters, the hospital executive who ran daily operations for the health care system is out of a job after downplaying the coronavirus threat to colleagues.
A March 16 email from the executive — which repeated a conspiratorial meme suggesting the coronavirus is somehow a politically motivated phenomenon — set flame to a deep anxiety among some tribal leaders over the vulnerability of Alaska villages in a pandemic.
“Just a reminder that FLU kills many every year!” wrote Lecia Scotford, who was the chief operating officer. (The coronavirus is not like the flu. It appears to be more contagious and more lethal.)
The message soon began to circulate in the Bristol Bay region, drawing a blistering response from some tribal and local leaders.
Robert Clark, president and chief executive of Bristol Bay Area Health Corp., said Scotford’s last day was Monday. He would not say if she was fired, citing “personnel stuff,” but said “she was separated.”
Scotford did not respond to emails, phone calls and Facebook messages requesting comment. Her email to lists of “division managers” and “department managers” within the regional health organization also emphasized the need for calm, common sense and good hygiene, and for the hospital to be prepared to serve the public.
“That (email) was very concerning to me because that kind of lets people’s guard down,” Norman Van Vactor, president of the Bristol Bay Economic Development Corp., said in a phone interview.
Bristol Bay is a magnet for people in the summer, with a seasonal migration of about 13,000 workers for the lucrative fishing season. The commercial salmon fishery here is the largest in the state, but as of 2010, about 60% of earnings went to out-of-state permit holders.
Almost all the major Bristol Bay seafood processing companies are based in Seattle, an early hot spot for coronavirus, and two thirds of Bristol Bay processing workers live in West Coast states at other times of the year, according to the Institute of Social and Economic Research at the University of Alaska Anchorage.
“When it comes to wild salmon, we are over half the world’s sockeye and over half of the Alaska salmon value,” said Andy Wink, executive director for the Bristol Bay Regional Seafood Development Association.
The nonprofit industry group on Thursday issued an advisory urging the fleet to delay travel to Bristol Bay until May 1.
“Keep in mind, it is possible to carry this virus without symptoms and unknowingly infect others leading to overtaxed medical capacity and/or death(s),” the advisory said. “You do NOT want to be the outsider photographed or seen around town in public spaces if this situation turns for the worst,” the group warned its fishermen.
Wink said his nonprofit is working with local governments on a plan to avoid overcrowding Bristol Bay Area Health Corp. clinics and the Dillingham hospital with sick fishermen, processors and support workers.
“We are taking the stance that we don’t want to rely on the local clinics or if we do, the need to be bolstered substantially,” Wink said.
As the health care provider for the region, Bristol Bay Area Health Corp. operates the only regional hospital and the clinics in 21 surrounding villages. It employed 470 people and reported revenue of $76.7 million in 2017, according to a tax form that Scotford submitted to the IRS.
Clark, the health corporation chief executive, said the Dillingham hospital is seeking more equipment to meet the potential for coronavirus patients among the local and visiting fishing industry patients.
Chief nursing officer Lee Yale said the hospital had 37 tests on hand as of Wednesday, and that all tests performed had returned negative. The Dillingham facility has no ICU beds, four negative pressure rooms to treat COVID patients without infecting others, plus two ventilators for the region.
“We have staffing but if they get ill we will be in a tight spot,” she wrote in an email. “(The) fishing industry will devastate our surge plan and we can not support and cover our villages if this season opens.”
Meantime, for many in Bristol Bay, the looming COVID-19 threat recalls family histories of death and loss in the face of past epidemics.
“We are the survivors of the survivors of the orphans of the Spanish flu,” said Hoseth, the Dillingham tribe second chief.
Another member of the tribe, tribal administrator Courtenay Carty, said her great-grandmother was orphaned in Dillingham by the 1919 flu , and raised by teenage cousins, and her grandfather was orphaned by tuberculosis in the 1940s.
“The fact that all of our contemporary families are descendants of those children and few adults that survived 1919 is one of (the) major reasons why we are so passionate about protecting ourselves from this pandemic,” she said. “What is history to others is our tribal and familial identities.”
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For the first time since the enactment of the Refugee Act in 1980, people who come to the U.S. saying they fear persecution in their home countries are being turned away by Border Patrol agents with no chance to make a legal case for asylum.
The shift, confirmed in internal Border Patrol guidance obtained by ProPublica, is the upshot of the Trump administration’s hasty emergency action to largely shut down the U.S.-Mexico border over coronavirus fears. It’s the biggest step the administration has taken to limit humanitarian protection for people entering the U.S. without papers.
The Trump administration has created numerous obstacles over recent years for migrants to claim asylum and stay in the United States. But it had not — until now — allowed Border Patrol agents to simply expel migrants with no process whatsoever for hearing their claims.
The administration gave the Border Patrol unchallengeable authority over migrants seeking asylum by invoking a little-known power given to the Centers for Disease Control and Prevention, the U.S. public health agency, to ban the entry of people or things that might spread “infectious disease” in the U.S. The CDC on March 20 barred entry of people without proper documentation, on the logic that they could be unexamined carriers of the disease and out of concern about the effects if the novel coronavirus swept through Customs and Border Protection holding facilities.
U.S. immigration law requires the government to allow people expressing a “well-founded” fear of persecution or torture to be allowed to pursue legal status in the United States. The law also requires the government to grant status to anyone who shows they likely face persecution if returned to their homeland.
“The Trump administration’s new rule and CDC order do not trump U.S. laws passed by Congress and U.S. legal obligations under refugee and human rights treaties,” Eleanor Acer, of the legal advocacy group Human Rights First, told ProPublica. “But the Trump administration is wielding them as the ultimate tool to shut the border to people seeking refuge.”
Two weeks ago, the Trump administration hastily put in place a policy, which the internal guidance calls Operation Capio, to push the overwhelming majority of unauthorized migrants into Mexico within hours of their apprehension in the U.S.
The Trump administration has been publicly vague on what happens under the new policy to migrants expressing a fear of persecution or torture, the grounds for asylum. But the guidance provided to Border Patrol agents makes clear that asylum-seekers are being turned away unless they can persuade both a Border Patrol agent — as well as a higher-ranking Border Patrol official — that they will be tortured if sent home. There is no exception for those who seek protection on the basis of their identities, such as race or religion.
Over 7,000 people have been expelled to Mexico under the order, according to sources briefed by Customs and Border Protection officials.
The guidance, shared with ProPublica by a source within the Border Patrol, instructs agents that any migrant caught entering without documentation must be processed for “expulsion,” citing the CDC order. When possible, migrants are to be driven to the nearest official border crossing and “expelled” into Mexico or Canada. (The Mexican government has agreed to allow the U.S. to push back not only Mexican migrants, but also those from Guatemala, Honduras and El Salvador; the four countries account for about 85% of all unauthorized border crossings.)
Under the Refugee Convention, which the U.S. signed onto in 1968, countries are barred from sending someone back to a country in which they could be persecuted based on their identity (specifically, their race, nationality, religion, political opinion or membership in a “particular social group”).
The Trump administration has taken several steps to restrict the ability of migrants to seek asylum, a form of legal status that allows someone to eventually become a permanent U.S. resident. Until now, however, it has acknowledged that U.S. and international law prevents the U.S. from sending people back to a place where they will be harmed. And it has still allowed people who claim a fear of persecution to seek a less permanent form of legal status in the U.S. (In the last two weeks of February, 2,915 people were screened for humanitarian protection, according to the most recent statistics provided by U.S. Citizenship and Immigration Services.)
The Border Patrol guidance provided to ProPublica shows that the U.S. is acting as if that obligation no longer applies.
Customs and Border Protection, the agency that oversees the Border Patrol, said it would not comment on the document provided to ProPublica. Asked whether any guidance had been provided regarding people who expressed a fear of persecution of torture, an agency spokesperson said in a statement, “The order does not apply where a CBP officer determines, based on consideration of significant law enforcement, officer and public safety, humanitarian, or public health interests, that the order should not be applied to a particular person.”
That language does not appear in the guidance ProPublica received. Instead, it specifies that any exception must be approved by the chief patrol agent of a given Border Patrol sector. One former senior CBP official, who reviewed the guidance at ProPublica’s request, said that because there are so many levels of hierarchy between a chief patrol agent and a line agent, agents would be unlikely to ask for an exemption to be made.
The guidance offers some details of exceptions that Border Patrol should make on public-safety grounds — people with felony convictions, for example, are to be held in detention rather than being sent back — but none on health grounds.
In fact, the guidance provides no instructions on medical screening or care for migrants, making it impossible to know how such an exception would be made. (One source briefed by CBP on the policy said the agency said migrants would not be expelled if they showed symptoms of illness or claimed a medical issue, but there is no mention of this in the guidance ProPublica received.)
The guidance makes a single humanitarian exception: If a migrant, before expulsion, tells the Border Patrol agent that they fear torture in their home country, they can be kept in the U.S. and referred to U.S. Citizenship and Immigration Services, which evaluates claims for humanitarian protection, to see if they qualify for protection under the Convention Against Torture. But agents are not instructed to ask; the migrant has to volunteer the information “spontaneously.” Then, the Border Patrol agent is instructed to analyze whether the claim is “reasonably believable” — something they haven’t been trained to do.
As recently as last fall, the Trump administration acknowledged in court filings that it’s bound both to protect victims of torture under the Convention Against Torture and to protect victims of persecution under the Refugee Convention.
Even as it has erected bars to asylum — most notably, preventing anyone who crosses through Mexico from receiving asylum in the U.S. — it has continued to allow anyone entering the U.S. to seek a lesser form of legal status called “withholding of removal,” which allows an immigrant to stay in the U.S. but does not allow them to become a permanent resident. (Since the passage of the 1980 Refugee Act, federal law requires the executive branch to grant this status to anyone who can show it’s more likely than not they’ll be persecuted.)
The Operation Capio guidance does not mention the possibility that someone could be eligible for lesser protections instead of expulsion. Two sources briefed on the new policy confirmed that neither asylum nor withholding of removal is available to anyone subject to the CDC order.
In that briefing, CBP officials claimed that a migrant expressing any sort of fear is referred for screening to the U.S. Citizenship and Immigration Services, but that migrants will only pass that screening if they claim torture. However, the guidance doesn’t instruct Border Patrol agents to refer other types of claims to USCIS (and instructs them only to refer torture claims when they are “reasonably believable”).
In lawsuits challenging the administration’s asylum policies, Department of Justice lawyers have described withholding of removal as a “mandatory” form of protection — something it’s required to provide — while asylum is “discretionary.” In a brief filed last fall with the 9th U.S. Circuit Court of Appeals, the government wrote that “The United States has implemented its non-refoulement obligations” — the obligation not to send people back to danger — “by providing withholding of removal and CAT (Convention Against Torture) protection.”
Now, the U.S. is only providing one of the two — and only at the discretion of Border Patrol.
“If you read between the lines,” one congressional staff member briefed on the operation told ProPublica, “they’re saying that Title 42 (the chapter of the U.S. Code that includes the CDC’s quarantine power) supersedes Title 8 (which covers immigration law).” Title 42 doesn’t clearly state that the administration may suspend its obligations under immigration law, and the Trump administration hasn’t published any legal opinions or memos that make its case.
No legal challenges have yet been filed against the new policy. Lawyers told ProPublica that the secrecy of the policy has made it harder to compile a case against it.
The administration has argued that the risk of coronavirus spreading through Customs and Border Protection holding facilities — which aren’t equipped to deal with medical needs — justifies the mass-expulsion policy. Since putting the policy in place, the number of people crossing into the U.S. has dropped drastically, according to official CBP statistics circulated internally and provided to ProPublica, and there are only 330 people in CBP custody at last count, down from over 1,300 as of March 25.
The new guidance instructs agents to wear personal protective equipment at all times and not to use any Border Patrol vehicle to transport migrants that isn’t specifically designated for Operation Capio.
However, because the Operation Capio process doesn’t include medical screening, it will be impossible to know whether any migrants who are being expelled just in case they have the novel coronavirus are actually infected.
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This article is co-published with The Texas Tribune, as part of an investigative partnership.
HOUSTON — At least 25 parishioners filed into a beige-brick church here Wednesday evening and were handed rubber gloves at the door. A handwritten sign directed them to designated areas with seats that had been spaced 6 feet apart. Another sign laid out five things people should do to keep from spreading the new strain of coronavirus, including staying away if they felt sick.
The founding pastor of City on a Hill, Juan Bustamante, was in a particularly good mood. A day earlier, Texas Gov. Greg Abbott joined 30-plus other governors around the country in issuing a statewide stay-at-home order — though he declined to refer to it as such — that also designated religious services as essential. Under the order, Texans must stay home unless they work in certain business sectors or are grocery shopping, running must-do errands or exercising outdoors. Or going to church.
Abbott’s order came the same day the country’s top health experts estimated the deadly virus could kill between 100,000 to 240,000 Americans, and that’s assuming people across the country adhere to social distancing guidelines. Otherwise, the numbers could climb much higher, to more than 2 million dead.
Amid the rapid spread of COVID-19 in Texas — with nearly 4,700 confirmed cases and 70 deaths as of Thursday — many congregations across the state, large and small and of a variety of faiths, closed their doors of their own accord weeks ago and moved all services online.
But there are some religious groups in Texas — it’s unclear just how many — who say it’s their right to remain open because they believe they provide an essential service to their communities at a time of great need. And on Wednesday night, several houses of worship across the state welcomed parishioners.
Top scientists and public health experts have warned that religious services appear to be particularly conducive to COVID-19 transmission, with multiple documented cases of spread in houses of worship across the globe.
Harvard University epidemiologist Bill Hanage ticked off examples of virus transmission in houses of worship in London, South Korea, Singapore and the state of Georgia and said exempting religious services from shelter-in-place orders is “an incredibly bad idea.” Nearly four dozen people also were hospitalized in Washington state last week after they met for a two-and-a-half-hour choir practice in a church. Two members have died.
Vice President Mike Pence chimed in on Wednesday, saying in-person religious services — which have been deemed essential by more than a dozen states — should be limited to 10 people and held online if at all possible.
For Bustamante, closing the doors of the church he opened almost a decade ago was never an option.
That’s partly because half of his 100-plus parishioners don’t have internet access at home, he said, but more so because there’s no true replacement for in-person worship, particularly during a time of crisis.
“I truly believe the churches are first responders,” he said Wednesday before the evening service. “I have a deep conviction to keep going and keep standing for what we believe in.”
To him, people are more likely to catch and spread the virus at grocery or liquor stores, which are also exempt.
Bustamante was among three Houston-area pastors named in a petition filed on Monday with the Texas Supreme Court, along with conservative activist Steven Hotze, that asked the justices to strike down an order enacted by Harris County Judge Lina Hidalgo. The order, similar to others enacted by large Texas counties and cities, doesn’t consider religious services — or firearm sales — as essential, which the petition alleges is a constitutional violation.
Jared Woodfill, the attorney for Hotze and the pastors, said on Wednesday that he’s now getting calls “left and right” from churches that want to join the lawsuit — most are evangelical Christian, though a few are Catholic — and plan to continue, or resume, in-person services. At least five more had come on board in addition to the three that signed the petition, he said.
“All of the folks I work with are moving forward with services,” he said, noting the Easter holiday is coming up.
Hidalgo’s order is now seemingly moot, superseded by Abbott’s, though local officials have scrambled to figure out how exactly to interpret the governor’s directive. Some have said they take issue with the religious exemption and are still ordering religious leaders to cease in-person services while they assess the order.
San Antonio Mayor Ron Nirenberg called the governor’s exemption for religious services “concerning.” The order’s wording is confusing, he said, and seemed to conflict with advice from the Centers for Disease Control and Prevention, as well as his city’s orders.
“If we want to keep people alive, we’ve got to do services remotely,” particularly now, Nirenberg told ProPublica and The Texas Tribune. “We’re entering a very dangerous phase of community spread.”
The cities of Dallas and Fort Worth said they are also assessing the legality of Abbott’s order, with Fort Worth telling houses of worship they can’t hold in-person services.
But some conservative communities in the greater Dallas and Fort Worth region, like McKinney and Frisco, have already changed their regulations after a local religious liberties law firm encouraged them to.
McKinney Mayor George Fuller said he didn’t know of any churches that planned to hold in-person services and that the city is telling them to avoid it, but also that he supported “religious liberty and freedom.”
Later Wednesday, Abbott’s office released joint guidance with Texas Attorney General Ken Paxton that said houses of worship must be given special consideration for constitutional reasons and are indeed “essential services.” However, they must conduct activities online or at home “whenever possible” and some should avoid large gatherings, namely those located in areas with rapid community spread.
As for the 10-person gathering limit Abbott had previously imposed, it appears only to apply to churches located in areas with rapid community spread though Abbott’s office did not respond to a request for clarity.
“Houses of worship should work with counties and municipalities to evaluate the rate of local community spread and determine the appropriate level of mitigation strategies to implement,” the guidance said.
But Harvard’s Hanage said gatherings of any size are problematic. And the way people interact in churches, synagogues, mosques and other religious facilities — shaking hands, hugging, singing — appears conducive to what epidemiologists call “super-spreading events,” he said.
“We know that church services are places where this gets spread,” he said. “People need to understand that it’s a risk.”
Hanage said that congregations could possibly protect themselves by gathering outdoors — say, in a field — and ensuring parishioners keep their distance, but that “it’s hard to do it correctly.”
In Sacramento County, public health experts said on Wednesday that about a third of the 300-plus cases there can be linked to religious gatherings. That led to a special advisory banning worship services even though they already were not allowed under state shelter-in-place orders.
Beyond Christians, different faith groups in the Houston and San Antonio area continue to abide by the stricter guidelines, despite Abbott’s directive.
Some members of the Muslim, Christian, Jewish and Catholic communities consulted with one another and all came to the same conclusion, said Shariq Abdul Ghani, director of the Minaret Foundation, a Houston-based organization that focuses on building relationships through interfaith and civic engagement.
“Everyone has a feeling that for us, the faithful, our responsibility to our congregants is to keep them safe first and foremost,” he said. Many had adapted and moved services online using Facebook Live, Zoom and Google Hangouts.
The mosques will continue to offer services for the elderly and underprivileged, considered essential, he said, but even that will be abiding by social distancing guidelines and only with the most essential volunteers.
Rabbi Mara Nathan, of San Antonio’s Temple Beth-El synagogue, said the congregation had been holding services in the sanctuary with just clergy and no members, until the mayor issued the city’s March 23 stay home order. Services have been held on Zoom since then, because it’s important “that we’re modeling the most careful kind of behavior we can,” Nathan said. In a way, that has provided members with a more intimate setting than watching services held in an empty sanctuary. “At the end of every service, we make sure to say, ‘We miss you,’ but we’re together,” she said.
Texas is far from the only state to deem religious services essential — more than a dozen others have done so, according to the National Governors Association. That includes states like New York, Massachusetts and Kansas that are led by Democratic governors. But those states still appear to be cracking down on churches that have services with zero social distancing guidelines, at least at the local level.
In states such as Florida and neighboring Louisiana, pastors have been arrested by local authorities after holding services with large groups of people.
Matt Woodfill, the younger brother of Jared, is one of the pastors that petitioned against Montgomery County Judge Mark Keough’s stay-at-home order, similar to Harris County’s.
Woodfill’s congregation, The Way Church, defied the county’s order last Sunday, when it held regular services, though he said they tried to spread people apart. Attendance was still down significantly, from a high of 200 to no more than 50 parishioners this past Sunday.
The church plans to hold drive-in services in their parking lot for Palm Sunday this weekend. He will stand on an outdoor stage, set up with a PA system and a band, while people can listen in their vehicles. This is a high season for churches, with Easter in another week, so Woodfill wants families to feel safe enough to attend services.
Oakwood Church in New Braunfels, a growing community along Interstate 35 between San Antonio and Austin, moved all services online for its 6,000 congregants two weeks ago, in response to orders from the city, according to Pastor Ray Still.
Coronavirus has already affected his congregation directly: parishioner T.J. Mendez died March 26 from COVID-19 at the age of 44. Mendez’s family was very active in the church; one of his daughters was an Oakwood staff member.
On Tuesday, Still drove to the Mendez home, where the rest of the family remains in quarantine. He stood outside his car and prayed with them.
The governor’s new order doesn’t change their plans to keep holding services online, he said.
“As Christian people, we’re taught to be respectful and respect authorities, and our authorities aren’t doing that because they want to hurt us, they’re doing that because they want to protect us,” Still said.
Alex Samuels of The Texas Tribune contributed reporting.
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Over the years, Elmhurst residents have learned to mostly ignore the bedraggled and destitute residents who quarrel over cigarettes and beg for change outside the Queens Adult Care Center.
But now, inside the worn brick building, are all the elements of an epidemiologist’s nightmare.
On March 22 came proof that the deadly coronavirus had made its way into the home when one of its residents, an 82-year-old former nurse, succumbed to COVID-19. Now, staffers say, another may have died and as many as a dozen more residents have been sent to the hospital for treatment. At least 20 are in some form of isolation within the center. Up to a dozen of its 100 or more workers are out sick with coronavirus symptoms, workers say, and the numbers seem to be changing all the time.
Since the coronavirus hit the U.S., most of the attention has been on nursing homes. But there are hundreds of adult homes like the one in Queens across the state. Many pack in a combustible mix of the sick, elderly patients alongside those with mental illness. They are free to come and go, with little understanding of the risks of infectious disease.
Now that the virus is inside the Queens home, it may be impossible to stop.
First there is the center’s location, just one block from the now-notorious Elmhurst Hospital, where 13 patients died from the coronavirus in a single day last week and dozens more wear masks and cough as they wait for hours in a line that trails down the sidewalk. The surrounding neighborhood has one of the highest rates of infection in New York City, according to data released by the city this week.
Then there are the residents. As many as 352 mentally ill or aging New Yorkers live in the home. Their ailments and age put them in the crosshairs of the coronavirus. Chronic obstructive pulmonary disease, which constricts airflow to the lungs, is rampant. So are diabetes and heart disease.
Inside there’s no escape from the roommate with a cough or fever. The residents, mostly poor with nowhere else to go, live side-by-side, cramped two to a bedroom — the sick, old and bedridden next to the mentally ill. Bathrooms are shared by groups of four. Every day there are at least three more opportunities for community spread, the center’s staffers say. Residents say they only began to eat their meals in their own rooms on Wednesday. Before that they were gathering to eat in groups of 50 or even 100 or more.
Many residents have cognitive limitations, making it difficult for them to absorb the severity of the coronavirus and the importance of staying indoors. Some residents, who staffers suspect are infected, wander freely through the center’s three floors and recreational rooms. They congregate in communal rooms thick with cigarette smoke. Others can be seen in the surrounding neighborhood, panhandling and picking through the trash. They can ask for masks at the front desk, but few bother.
Leon Hofman, the owner of the Queens Adult Care Center, and his lawyer said the center is following all guidelines from the New York Department of Health, which oversees the home, and they are “working tirelessly to address this challenging situation.”
One longtime resident, Robert Schettino, 70, said he tested positive for the disease this week. He said he self-quarantined in his room, just down the hall from the former nurse who died.
He said keeping the infection from spreading among his fellow residents may be impossible. “They don’t even wear shoes and socks, let alone gloves and masks,” he said.
Roughly half of the residents routinely shuffle down the street for appointments at a mental health clinic, potentially bringing or leaving with the virus.
“It’s an incubator,” said Jill Twohig, a mental health counselor who works with center residents at the clinic. “I don’t feel that the home is doing a good job controlling the residents, and I am terrified.”
Some frightened workers, dependent on the job and critical for the residents, said in interviews that they are flying blind. The home’s administration, the workers said, either doesn’t know or won’t tell them which residents are sick and which are not. Janitors and home health aides take a gamble each time they enter a room. Then they take that risk home to their families on public transportation or bring it back with them when they return.
“I think it’s out of everyone’s hands already,” said one worker, who now worries she has symptoms of the disease and has shared it with her family.
Denis Nash, a professor of epidemiology at the CUNY Graduate School of Public Health and Health Policy, called the circumstances at the home “really horrifying.”
The risk of viral conflagration at the Queens center, he said, “is likely no longer containable.”
Richard Mollot, the executive director of the Long Term Care Community Coalition, a New York-based elder care watchdog, was equally alarmed: “That is really, strikingly, frightening. I don’t know how else to put it. It’s hard to find a way to articulate how vulnerable residents are in this situation.”
One of the earliest outbreaks started at a nursing home in Kirkland, Washington, and spread in the community. But Mollot said adult homes like the Queens center are probably at more risk. They house people who are often medically frail enough to live in a nursing home, but with more freedom, less government oversight and, typically, less qualified staff.
“These homes can be very dangerous on a good day,” Mollot said. “And the good days are behind us for the time being. If I was a resident, I would be very concerned. If I were a family member, I would be very concerned. And if I were a member of that community, I would be very concerned.”
“The risk,” he said, “is enormous.”
In recent years, ProPublica has written extensively about conditions inside adult homes and their alternatives, including the Queens Adult Care Center. So when the pandemic arrived in New York, and Elmhurst became its epicenter, we began to call people who live and work in or near the facility.
When first contacted on March 25, Hofman said none of his workers were sick and only one resident was being treated for the virus at Elmhurst Hospital. At that point, ProPublica later learned, the first resident had already died.
Hofman then stopped returning calls, instead responding through emails sent by his lawyer, Kurt Bratten. The pair have defended the center’s response to the virus and suggested that the workers are exaggerating the danger.
On March 31, they said that only six residents, but no workers, had tested positive for COVID-19.
When ProPublica reminded Hofman and Bratten that many sick people can’t get tested, they said they did not have time to respond to additional questions.
In an email, they said the information gathered by ProPublica was “categorically false” and an article that contains it “will perpetuate fear and panic.”
At this point it may be impossible to capture current reality at the home, or at similar facilities across the country. Information that seems reliable and up-to-date one minute changes the next, usually for the worse.
In the last week, ProPublica interviewed three residents, four of Hofman’s employees and three current and former workers from a nearby mental health clinic.
Last Friday, workers said, five of their colleagues were out sick. By this Wednesday, they put that number at 12, though they acknowledged that some might just be steering clear of the home for their own safety. More show symptoms by the day, but none has been immediately tested, the workers said.
In wrenching terms, the workers discussed mounting fear and shame that they may have already infected their families with the virus. They said the home’s administration is not doing enough to protect them from infection and has been dishonest about the severity of the problem.
“These people don’t give a shit about us,” said one worker, who like all quoted in this story asked for their names not to be used for fear of losing their jobs.
Jonah Bruno, a spokesman for the New York Department of Health, which regulates the group home, would not say how many residents or workers are sick at the home or how many have died, citing patient privacy restrictions.
Perhaps even more chilling, Nash, the CUNY epidemiologist, said the crisis in Queens could easily unfold elsewhere. There are more than 500 adult care facilities scattered throughout New York state. In New York City alone, there are nearly two dozen, tucked away in low-rent neighborhoods that each house some 200 mentally ill and elderly residents. An infection in any one of them would be equally difficult to contain, Nash said.
Bruno said that across the state there are currently 399 COVID-19 positive cases in 106 facilities and 71 “associated deaths.”
On Monday, The Wall Street Journal reported that 15% of coronavirus deaths in New York state had occurred inside nursing homes. On Saturday, a neighborhood blog reported that an Upper West Side residence for seniors was being evacuated.
“These percolating situations are nightmare scenarios,” Nash said.
At the New York Psychotherapy and Counseling Center down the street from the group home, Twohig, 47, can trace the arc of her fear.
For nearly three years, she has worked in a windowless office inside the rundown clinic, where she helps 56 residents of the center. But over the past two weeks, she said her job has shifted from therapist to public health educator.
Usually she counsels patients on their troubles — helping them cope with medication side effects, disputes with roommates, loneliness and depression. But as concerns over the virus mounted, she began teaching them how to properly wash their hands, sneeze and cough into their elbows, stay away from others and use hand sanitizer.
On March 18, she said, it became clear her efforts were not enough. That afternoon, her supervisor, Kam Ng, gathered the staff to deliver some grim news.
The roommate of one of the clinic’s clients had tested positive for the coronavirus and was in the hospital. Twohig and her co-workers sat with their mouths agape. “It’s here,” she remembered thinking. After a pause, the group let loose a flurry of questions: Had the roommate been tested? Would they have to continue to come to work? The residents are supposed to come in for one session per week. What if the staff already had it?
Ng, Twohig said, didn’t have many answers.
She said Ng told them that his superiors said there would be no immediate changes to their policy: Residents would continue to come in for their regularly scheduled therapy sessions. They would use hand sanitizer before they entered the office and would keep the sessions short.
“We were in disbelief,” Twohig said. She went back into her office, shut the door and began to panic. “What the hell is going on?” she thought. “What are they not telling us?”
When she walked past the home that evening on her way back to the subway, several of the residents were still sitting outside, sitting next to each other, smoking cigarettes. None wore masks or gloves.
“The concept of the virus seems beyond the realm of their comprehension,” she said. “It’s just something they see on TV.”
On the train, its cars nearly empty, her heart rate quickened and reality sank in: She was now considered an “essential worker” in the middle of a pandemic.
Twohig avoided the clinic for the next three days, handling her sessions by phone. She spent the weekend inside her East Village apartment, watching cat videos and talking to friends on FaceTime.
The following Monday morning, she said Ng called to say that his bosses would allow her and the staff to work two days a week from home, but they’d need to come in for the other three.
Confoundingly, she said he reassured her that she would still do her sessions by phone, even from inside the clinic. The patients would come in, enter a separate room, and speak to her over a speaker phone.
Why, Twohig asked, couldn’t she just call her patients from home and avoid the risk of exposure on her 45-minute train commute?
She said Ng said his bosses believed her patients would be more likely to engage in the sessions knowing she was in the building. If the patients didn’t show, he said she could go into the group home and physically find them — a prospect she refuses to entertain.
Neither Ng nor Elliott Klein, the chief executive officer of New York Psychotherapy and Counseling Center, responded to calls and emails for this story.
In response to questions on Twohig’s situation, the New York Office of Mental Health, which regulates the clinic, said in a statement that “it had waived some regulations to make it easier for providers to serve their clients by phone.”
On her way to work Friday morning, Twohig said she saw one of her patients wandering to a bodega with a surgical mask dangling from his wrist. She called out to him, “Show me how you put it on.” He fumbled with a demonstration, then ambled off toward Broadway, the thoroughfare that cuts through Queens.
Later that day, Ng told her and the other staff that the patient in the hospital had died and that his roommate, their client, was still refusing medical attention because he insisted he had no symptoms.
Twohig could feel a pit form in her stomach. She asked if their client was being quarantined. Ng said no, and the pit in her stomach rose to her throat.
ProPublica separately learned that Shamshudin Karmali, an 82-year-old resident of the home, died on March 22. A relative confirmed the cause was the coronavirus. A worker at the home said Karmali had scarcely left the facility in the months before his death.
Reached by phone, Karmali’s former roommate, a 61-year-old man with paranoid schizophrenia, said he’d been told Karmali died because of the virus.
The man said he hadn’t changed his behavior after the coronavirus had hit the facility and killed his roommate. He said he’d watched the film “Son of Kong” that day with 15 other patients inside a TV room.
“They take my temperature,” he said of the staff. “I’m not worried.”
But just down the hall on the same floor, Schettino is. Five days after Karmali’s death, he spiked a fever that scared him into braving Elmhurst Hospital. A doctor there, he said, jammed a swab so far up his nose he started bleeding. “It’s like they hit your brain,” he said. Two days later, he said he learned he was positive for the coronavirus. Now isolated in his room, he said he is mostly worried about the workers.
He and one other resident said that the staff only recently started delivering meals directly to the residents’ rooms. Before that, every meal was a jostling opportunity to spread COVID-19.
“They stand outside the dining room within inches of each other like they never got fed before,” he said. “They tell them, ‘When you get in line, stay 6 feet apart.’ But I don’t know if they know what 6 feet means.’”
Crowded with people in poor health who receive scant services, adult homes have long been prime targets for highly infectious disease.
The Queens Adult Care Center is one of nearly two dozen homes with a long and troubled history in New York City. It is also one of the biggest.
In the 1970s, the homes were envisioned as a more humane alternative to the state’s notoriously abusive state psychiatric hospitals. But in the ensuing decades, they, too, devolved into centers of misery and neglect.
In 2002, The New York Times found that more than 1,000 people died inside the homes over a six-year period. Some threw themselves from rooftops. Others died of heat exposure in rooms with no air conditioning. Residents were warehoused and exploited for profit. The Queens Adult Care Center, then called Leben Home, was singled out as one of the worst.
The stories prompted a class-action lawsuit. After 10 years of litigation, a federal judge ordered the state to give adult home residents with mental illness a chance to live independently in their own apartments. But as ProPublica reported last year, the state also brokered a quiet deal with the adult homes. It gave them a second chance with a new, more lucrative population in the form of the elderly and infirm. The Queens Adult Care Center was one of more than a dozen facilities that took advantage of the offer. Now the two vulnerable groups live together in the facility.
Along the way, Hofman, the owner and operator of the center, positioned himself as a kind of adult home reformer. He took over the facility following the Times investigation, having earned praise from the state for improving other homes. He renamed it, made renovations, added rehabilitation rooms and increased staffing.
But now, some workers complain that the coronavirus is exposing gaps in the home’s care for patients, protections for workers and consideration for the surrounding community.
In interviews this week, four workers, who help feed, medicate and oversee the residents, said that the home’s managers appear primarily concerned with protecting themselves. Since the virus began to take hold in New York, the administrators have sequestered themselves in their offices, the workers said. They also use the more expensive and increasingly rare N95 masks, which offer more protection than the disposable, loose-fitting surgical masks distributed to staff.
Home health aides and cleaning staff only get one surgical mask per day, according to the workers. The workers have gloves but not protective gowns. Only residents who ask for masks receive them, and one worker estimated that maybe 2% bother to do so.
Hofman and his lawyer said the home has plenty of masks and everyone can get as many as they need. They said some staffers prefer the surgical masks over the N95s.
The workers said reliable information on who might be infected is difficult to come by, but last week they noted that kitchen workers were preparing separate meals for roughly 20 people who are not allowed to dine with the rest of the residents in the communal dining room
One worker believes that number should have been larger.
Early last week, one resident was coughing so heavily in a dining hall that he was struggling to breathe, according to a worker watching him. The worker tried to alert a supervisor repeatedly, but the supervisor ignored the man.
“I said this guy is sick, please remove him from the dining room. I have seen him here three times. He is coughing and sneezing in everyone’s face. He can’t even breathe,” the worker said. “And they just said, ‘OK, thank you for letting us know.’”
The worker said the man continued to show up in the dining hall afterward. And now several residents and workers are sick.
“There are no precautions in the building,” the worker said. “It’s going to spread throughout the whole building.”
Last week, two workers estimated that as many as eight residents were admitted to a hospital for coronavirus symptoms and five workers have stayed home with symptoms. Now one of those workers puts that estimate at a dozen each, though they note that historically residents are often sent to the hospital for a variety of reasons.
ProPublica spoke to one of the sick workers Saturday.
The worker had been home for nearly a week with a fever that rose to 101 degrees and throat pain that made it impossible to swallow. The worker relies on a wage of roughly $17 an hour but said the company was not paying for sick leave. In an email, the center’s lawyer said it was paying for sick time.
“The company treats us like we are nothing,” the worker said. “Like we are not even human beings.”
One worker has allegedly quit because she did not want to get her elderly parents sick. Another said that more workers might have the coronavirus but do not want to disclose their symptoms, because they are worried they won’t get their jobs back if they take time off.
“We are poor people,” the worker said. “We live on a salary of $15 or $16 an hour. We can’t afford to lose our jobs.”
All of them worry for the surrounding community.
“Why isn’t this door shut?” said one worker. “Why are these residents still able to go out into the community?”
The staff is also concerned that they are becoming vectors for the virus themselves. One clinic worker said she has to take two buses and two trains to get to work each day. She then goes home to her husband, children and mother.
“There is a risk for us and our families,” she said. “We don’t know exactly what to do. … Can you help us?”
Nash, the CUNY epidemiologist, grew increasingly concerned about the conditions at the Queens center as ProPublica shared the deteriorating conditions with him.
“The risk that there could be a substantial amount of serious illness, hospitalization and deaths due to COVID among the residents in this setting seems very high, given the age profile and what could be a high prevalence of underlying health conditions and smoking,” he said.
“We have seen a few very sad examples of what this could look like in New York state and around the country.”
Initially, he recommended ways to contain the virus: Quarantine anyone with a confirmed case or anyone who had close contact with a confirmed case. Communicate regularly with the Department of Health. Give residents and staff regular health checks and protective equipment. Limit movement between floors and rooms.
But by Sunday, Nash urged ProPublica to report the situation to the state and city departments of health. He said the government should intervene as soon as possible.
ProPublica forwarded Nash’s concerns to the state Health Department. In a statement, spokesman Bruno said, “All New Yorkers, including those who live in Adult Homes, should follow the state directions to limit exposure to COVID-19 by avoiding contact with others.”
The department, the statement said, was working with homes to make sure residents understood social distancing and the need to stay indoors, but it acknowledged that “Adult Home residents maintain a level of independence and are free to come and go like anyone else in the community.” Those who test positive or exposed to COVID-19 “must follow all state-issued quarantine guidance.”
In his sole conversation with ProPublica on March 25, Hofman, the center’s owner, gave a much different impression of his facility’s preparedness and conditions than those who work for him.
Hofman said he “got lucky’’ and he bought personal protective equipment for his staff before the crisis hit, and that “knock on wood” none of his workers were sick. He said many of his workers live in the neighborhood and didn’t have to rely on public transportation.
Hofman said he is following guidelines from the state Health Department, which recommend that in “areas of high concentrations of positive coronavirus cases, residents should be encouraged to remain at home” and that the home “must have staff available to screen residents for symptoms or potential exposure to someone with COVID-19.”
According to Bratten’s emails, only one resident was currently receiving medical treatment for COVID-19 at Elmhurst Hospital and no workers had tested positive. They would not say how many workers had called out sick with symptoms, nor how many residents had already received treatment at Elmhurst and come back or were sent to any other hospital.
A staff member, they wrote, takes the temperatures of workers before they start their shifts and residents who appear symptomatic. But Hofman said that he can’t prevent residents from leaving the facility if they want to.
“The home,” they wrote, “is doing an excellent job of maintaining a healthy and safe environment for its residents and staff.”
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As America’s coronavirus crisis has mushroomed, President Donald Trump has repeatedly touted the efforts of businesses to meet a desperate nation’s needs. “It’s been really amazing to see these big, strong, powerful — in some cases, very small companies, family-owned companies — step up and make a lot of great product for what we’re going through and what we will continue to be going through for a while,” Trump declared on March 24.
His press conferences have sometimes seemed like a parade of CEOs, from the leaders of retail and pharmaceutical giants like Walmart and Roche to chiefs of relative mites like MyPillow. Vice President Mike Pence and Ivanka Trump have chimed in, too, lauding one hotel chain for offering free rooms to doctors, nurses and medical first responders.
“America’s Private Sector is stepping up to help us be STRONG!” President Trump tweeted around the same time.
As for the president’s own private business? It doesn’t appear to be “stepping up.”
ProPublica examined the seven hotel properties and dozen U.S. country clubs owned by the Trump Organization and could find no sign that any are taking the sorts of civic-minded steps the president has urged.
One example is New York. As coronavirus cases multiplied, Gov. Andrew Cuomo asked hotel owners to donate their properties (already shuttered or largely empty) for emergency use by medical personnel or noncritical patients requiring isolation. By March 26, according to a list of “significant donations” posted on the governor’s website, six had agreed to do so, including the high-end Four Seasons, St. Regis and Plaza hotels. “Proud to see NY’s hotels stepping up!” the governor tweeted on March 26.
The Trump International Hotel and Tower, with 176 rooms and suites overlooking Central Park, is not among them. Instead, at a moment when New York City, enduring the nation’s worst pandemic onslaught, is under a shelter-in-place order, the Trumps’ Manhattan hotel remains open for paying guests. (Rooms, according to the hotel’s website, start at $525 a night.)
The New York governor’s list details 31 contributions from “major corporations, philanthropic organizations and celebrities” aimed at increasing the state’s “supply capacity” amid the pandemic’s surge. It includes donations from Goldman Sachs (195,000 masks); Facebook (2,500 gallons of hand sanitizer), and TV host Kelly Ripa and her husband ($1 million cash). The name “Trump” does not appear on the list.
ProPublica sent emails with specific questions to a spokesperson for the Trump Organization, as well as to executive vice presidents Donald Trump Jr., Eric Trump and Alan Garten. ProPublica also left voicemail messages for Donald Trump Jr. None responded.
It is possible that the Trumps have engaged in unseen acts of charity connected to the pandemic. The Trumps, however, have not been known to hide deeds for which they might receive favorable public attention.
New York is not the only example. In Chicago, the mayor’s office has made arrangements for more than 1,000 rooms at five hotels to be used by medical personnel and patients requiring isolation when the number of local cases peaks. The city is paying $175 a night for the space. The Trump International Hotel and Tower, with 339 rooms and suites, is not among them.
Samir Mayekar, Chicago’s deputy mayor for economic and neighborhood development, said the program, aimed at easing the burden on local hospitals, has received “an outpouring of support from dozens of interested hotels” in “an immense time of public need.” He said the city has enough interest to bring another thousand or more hotel rooms into the program if they’re needed. As for the Trumps’ Chicago hotel? “I’ve not seen that facility on the list,” Mayekar said.
Local companies and individuals have also donated $19 million to the Chicago Community COVID-19 Response Fund, according to Mayekar, which is supported by the mayor’s office and intended to assist nonprofits “serving our most vulnerable residents.” He said the Trumps’ businesses have not donated anything to date.
In Los Angeles, where Trump operates a golf club perched on a bluff overlooking the Pacific Ocean, the mayor has established two relief funds: The L.A. Emergency COVID-19 Crisis Fund and the Angeleno Fund. Their promoters and donors include Conan O’Brien and Russell Westbrook, according to a statement from Jeremy Bernard, who is heading up the fundraising effort. “To date, neither fund has received a donation from the Trump National Golf Club, Los Angeles, in Rancho Palos Verdes, California,” according to Bernard.
Trump’s properties, like Trump himself, have been slow to embrace medical experts’ advice for slowing the spread of the virus. In Florida, Trump’s Mar-A-Lago club, where the membership initiation fee is $200,000, remained open and seemingly disdainful of social distancing until March 21, after reports of coronavirus infections spread at crowded Trump fundraisers, a reception for Brazil’s president and a glittery party for Trump Jr.’s girlfriend, where guests danced in a conga line on March 7. This prompted Politico to describe the 20-acre resort as “a gilded petri dish.” (Eric Trump responded with a statement: “The safety of our members and guests are of our utmost importance. We are monitoring all of our businesses closely and are following the guidelines provided by the CDC.”)
Layoffs throughout the area’s resort sector sent less affluent residents of Palm Beach County reeling, prompting the Town of Palm Beach United Way to launch an emergency coronavirus fund. Marketing director Aleese Kopf said the special office for the nonprofit was established decades ago, explicitly “to raise money from millionaires and billionaires on Palm Beach island, where Mar-A-Lago is.” In Palm Beach County, she said, “it’s extreme poverty and extreme wealth.”
The Town of Palm Beach United Way helps fund 49 area social service agencies, and the pandemic has hit their clients hard, prompting residents and local businesses to contribute more than $400,000 to date. “It’s a very giving community,” Kopf said.
The group’s donors include both wealthy individuals and island clubs, including the Breakers, she said. But not Mar-A-Lago or the Trumps. “Many of our donors are members of Mar-a-Lago,” Kopf said. “They give. But we’ve never worked directly with the Trump Organization or the Mar-A-Lago Club. We’ve never been a part of their giving circle.”
Albermarle Estate, Trump’s Virginia lodge on the site of the Trump Winery, remained open until this week. The Charlottesville Albermarle Convention & Visitors Bureau, after approaching all area hotels, listed six that were providing special discounts to medical workers and first responders. Trump’s hotel is not among them.
In many of the communities where the Trumps have properties, emergency pandemic needs have already become clear. In Las Vegas, the Trumps’ 64-story, 1,282-room hotel shut down in mid-March, complying with a statewide order. Many of the hotels and casinos forced to abruptly close around that time provided huge quantities of unused food to the area’s Three Square Food Bank. The food bank has now opened six drive-through locations to safely meet dramatically increased need from the “food-insecure” in its six-county region, said Larry Scott, the nonprofit’s chief operating officer.
The total from the first two days after the hotel shutdown alone came to about 180 tons, according to Scott, with big donations coming from the MGM, Wynn, Boyd Gaming, Station Casinos and Caesars, among others — “most all” of the area hotels and casinos. Hotels have also made cash contributions. “We have been very richly blessed with financial donations from the hospitality industry,” Scott said.
The food bank has never received anything from the Trumps’ Las Vegas property. “No, they have not been a donor,” Scott said.
The Trump family also has a decidedly mixed record with regard to charitable giving. As The Washington Post first revealed, the Donald J. Trump Foundation raised all the funds it donated from 2009 onward from others — not from the Trumps themselves. Many of the donations were made to groups that held events at Trump’s properties.
The foundation was shut down in 2018, following a New York attorney general’s investigation and lawsuit that confirmed multiple episodes of improper self-dealing — charity expenditures made to promote his presidential campaign and to pay his business debts. (Trump denied any wrongdoing.) In a 2019 settlement, a state judge ordered Trump to give $2 million to eight approved charities, and his three adult children — all officers of the foundation — were required to undergo ethics training on the duties of nonprofit directors.
The Eric Trump Foundation has raised millions for terminally ill children at St. Jude hospital in Memphis, Tennessee. After Forbes reported that it had spent several hundred thousand dollars on events at Trump properties and had diverted donations to other causes, prompting another attorney general’s investigation, it replaced most of its directors in 2017 and renamed itself Curetivity. (At the time, Eric Trump said he was “disappointed” by the story and added: “It seems like there is a motive against either myself or my family.”)
Early last month, the White House announced that Trump was donating $100,000 — 25% of his presidential salary — to aid the coronavirus fight, by giving it to the Department of Health and Human Services. The money, however, wasn’t a new gift — just an allocation of his pledge, upon taking office, to forego any salary throughout his time in the White House.
The hotel industry has been among the hardest hit in corporate America, with many of the relatively few hotels that remain open enduring occupancy in the single digits. (Trump’s 263-room Washington hotel has had around 10 guests in recent days, according to John Boardman, who heads the D.C. affiliate of Unite Here, the union representing the hotel’s workers.) The industry’s trade group, the American Hotel and Lodging Association, urgently lobbied the Trump administration and Congress for federal bailout aid. (Trump has declined to answer questions about whether his private business would seek federal aid. Congressional Democrats added a provision aimed at explicitly barring him and son-in-law Jared Kushner from reaping such benefits, but the measure reportedly contains loopholes that might make it possible for their businesses to collect such money anyway.)
The hotel industry group has also promoted a national Hospitality for Hope program. According to the organization, it has identified 15,000 properties close to health care facilities that “are at the ready” to provide temporary housing for medical workers and first responders. The group has not publicly identified what hotel companies are participating and declined to respond to a question about whether any of the Trump hotels are participating.
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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 denounced excessive 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 spokeswoman Mary Benton said that price was commonplace but declined to provide further details.
“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.
That changed with the coronavirus outbreak. New York state invited 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 wrote to 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.”
La semana pasada, cuando una mujer que no hablaba inglés llegó a la sala de emergencias saturada de un hospital de Brooklyn, inicialmente la instalaron en una unidad para pacientes sin coronavirus.
El jueves, sin embargo, un médico cayó en la cuenta de que tenía fiebre y tos, y que debía recibir atención para COVID-19, así que la trasladó a la unidad de coronavirus con una advertencia: “Suerte, habla húngaro”.
La mujer falleció a la noche siguiente.
Un médico residente que la atendió cree que habría recibido mejor tratamiento si hubiera hablado inglés.
En la sala de emergencias, donde nunca nadie tiene suficiente tiempo y menos ahora, el residente dijo haber observado que nadie quería trabajar con un intérprete para capturar el historial médico de la paciente. Él mismo colocó su teléfono sobre el hombro de la mujer y llamó al servicio de interpretación por el altavoz. Le resultó difícil hablar y escuchar claramente debido al tapabocas N95 y por el casco que le cubría los oídos.
“Cuando me preguntaron qué idioma necesitaba” señaló, “pasé cinco minutos gritando una y otra vez, ‘¡Húngaro! ¡Húngaro!’ La operadora solo contestaba, ‘¿Español?’”
La paciente podría haber muerto aunque hablara inglés, pero este episodio y otros de la misma índole demuestran que las personas que hablan otros idiomas tienen desventajas en los hospitales neoyorquinos que actualmente están abarrotados y caóticos.
“Esperamos diez minutos en el teléfono para obtener un intérprete, y ese es tiempo valioso cuando estamos inundados”, dijo el residente. “Entonces, comenzamos a calcular en forma utilitaria y los pacientes más convencionales son los que reciben mejor atención”.
Incluso en una situación normal, las personas que no hablan inglés obtienen peores resultados de salud en gran diversidad de procedimientos rutinarios. También pueden tener dificultades para conseguir un intérprete. Algunos estudios muestran que los intérpretes profesionales cometen menos errores de importancia clínica que las personas no capacitadas como, por ejemplo, los familiares del enfermo.
Estas brechas aumentan en época de crisis. ProPublica habló con once empleados de servicios médicos de la ciudad de Nueva York acerca de sus experiencias en la atención de pacientes con coronavirus que no hablaban inglés. Aunque son empleados tanto de instituciones de alto nivel y sin fines de lucro de Manhattan, como de hospitales de la red de seguridad social de Brooklyn, todos describieron que la comunicación se rompe y se improvisa apresuradamente debido a las carencias.
Les preocupa que las barreras del idioma dejen a los inmigrantes contagiados de COVID-19 en una situación particularmente desesperada: solos, confundidos y sin la atención adecuada.
Un médico del Bronx describió cómo un colega, que trabajaba en la tienda de campaña para triage de su organización, trataba de evaluar a los pacientes usando la aplicación Google Translate de su teléfono inteligente.
En otra situación, el residente de la sala de emergencias de Brooklyn dijo que sabía suficiente español como para no utilizar a un intérprete al tomar el historial médico de una paciente de habla hispana que venía llegando. Sus síntomas no eran graves, pero ella le dijo que la habían operado del corazón hacía tres años, así que la admitió al hospital debido a ese factor de riesgo. Poco después se dio cuenta de que la cirugía había ocurrido cuando la paciente tenía tres años. Si lo hubiera sabido, la habría devuelto a su casa
El domingo pasado, un residente de otro hospital de Brooklyn atendió a una mujer que únicamente hablaba francés criollo. La mascarilla de oxígeno de la paciente impidió que el intérprete la entendiera por completo, dijo el residente, y fue claro que la mujer siguió bastante confundida. La enferma falleció al día siguiente.
Un médico de planta de un hospital de Manhattan describió cómo llama a los intérpretes por su celular antes de entrar a las habitaciones de los pacientes. Luego lo coloca dentro del bolsillo de su camisa para evitar que le caigan partículas del virus, se pone una bata protectora amarilla sobre el uniforme y entra a la habitación, manteniéndose a distancia del paciente. Todos esos pasos impiden que el paciente y el intérprete telefónico se escuchen bien. “Luego tenemos que decirles que tienen un virus que está matando a gente en todo el mundo”, agregó. “Les informamos que no pueden tener visitas ni salir de la habitación, y les cerramos la puerta”.
Según los datos del censo, aproximadamente 1 de cada 5 estadounidenses habla otro idioma aparte del inglés en su hogar. Entre los neoyorquinos, ese porcentaje es de un 49%. Además, con más de 40 mil casos de coronavirus confirmados en los confines de la ciudad de Nueva York, cuando se enferman los residentes que no dominan bien el inglés, los proveedores de atención médica enfatizan las muchas maneras en las que estas brechas del idioma podrían propiciar una atención deficiente. Los pacientes que están lo suficientemente bien para irse a su casa podrían entender mal las instrucciones al ser dados de alta, ocasionando que no sigan correctamente la cuarentena o que no regresen a la sala de emergencias si empeora su enfermedad. También sería posible cometer errores durante el triage por no detectar condiciones subyacentes.
Desde hace tiempo se ha entendido que la Ley de Derechos Civiles de 1964 exige que los hospitales que reciben fondos federales (como Medicare y Medicaid) proporcionen acceso a la interpretación de idiomas. También se sabe que el incumplimiento con esa pauta se considera “discriminación por origen nacional”. Los reglamentos que entraron en vigor en 2016, cuando se promulgó la Ley del Cuidado Asequible, reforzaron ese mandato. Hoy en día, los hospitales deben utilizar a “intérpretes calificados” y restringir el uso de familiares o personal bilingüe, pero no capacitado, para esa labor. Los pacientes incluso tienen derecho a demandar al hospital si esto no se lleva a cabo (existen excepciones, como cuando un familiar interpreta en plena emergencia).
Elena Langdon, exdirectora del Consejo Nacional de Certificación para Intérpretes Médicos, dijo que reconoce que en estos momentos los médicos quizás no puedan brindar atención con la calidad que desearían en todos los casos, pero que no se puede hacer a un lado la igualdad ni el derecho a la interpretación. “Aunque sea más difícil debido a la situación, no significa que no sea su obligación hacerlo”, agregó. “Se trata de un problema de salud pública”.
Langdon señaló que quizás los hospitales deban contar con personal de planta dedicado a coordinar el acceso a otros idiomas. Varios de los sistemas hospitalarios donde ocurrieron los ejemplos de este reportaje no devolvieron nuestras llamadas, ni contestaron el correo electrónico en el que les pedimos comentarios.
Los proveedores reconocieron que, aun en los momentos en que no hay pandemias, es frecuente que esas pautas no se cumplan, como cuando se permite que un nieto interprete en lugar de un profesional.
Sin embargo, en estos momentos ni siquiera esas opciones están disponibles. Muchos de los hospitales de la ciudad están prohibiendo las visitas, lo cual hace imposible que los familiares que hablan inglés ayuden a los pacientes a comunicarse. Los intérpretes en persona también corren el riesgo de infectarse o de infectar a los demás, y el uso del equipo de protección personal dificulta la comunicación telefónica.
Una enfermera de la unidad de terapia intensiva de un tercer hospital de Brooklyn, dijo que cuando necesita un intérprete llama a una operadora a través del teléfono con cordón azul largo que hay en cada habitación. Luego tiene que esperar a que haya un intérprete disponible, y el tiempo de espera varía según el idioma. El español es relativamente rápido, dijo; el mandarín se tarda de 10 a 15 minutos; los dialectos asiáticos menos comunes pueden tardar hasta más de una hora.
Ahora que se prohíben las visitas, a esta enfermera le preocupa que los pacientes no tengan quién hable por ellos y que sus familiares tampoco puedan mantenerse al tanto. “En este punto” informó, “no llamaremos a menos que necesitemos un consentimiento o si el paciente muere”.
La semana pasada, un hispanohablante poco mayor de 40 años fue internado en la unidad de terapia intensiva del hospital donde ella trabaja. El paciente parecía estar relativamente sano y, aunque tenía algo de sobrepeso, no presentó ningún trastorno médico subyacente, agregó la enfermera. Aun así, esta persona acabó poco después con un respirador artificial. Su esposa acudió al hospital a pesar de la restricción de visitas, pero ella hablaba aún menos inglés. “Su esposa no había podido verlo ni hablar con él”, explicó la enfermera. “Solo decía, ‘No entiendo, si estaba bien’. … Parte de nuestra labor de enfermería es acercarnos a un familiar que veamos así y explicarle qué está sucediendo. Pero estas conversaciones no suceden con los pacientes que necesitan interpretación. En esa situación, sencillamente no tengo tiempo”.
“Y luego falleció” agregó, “y tuvieron que informárselo a su esposa por teléfono”. No está segura si el hospital lo hizo por medio de un intérprete o si simplemente improvisaron.
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April has arrived. Americans, hunkered down while a pandemic rages, face what to do about their mortgage, their rent payment, their credit card bill and their other debts.
Local, state and federal governments have announced a variety of aid programs to help debtors through this dark period. But like the response to the coronavirus itself, the varying initiatives have been scattered and confused. Some governors acted to stop renters from being evicted weeks ago, while in other states the courts are still open, and meanwhile the federal government says it depends what kind of mortgage your landlord has. The answer to what kind of help can I get is a resounding, “It depends” — on what type of debt you’re talking about, who owns your debt and where you live. And on how long this societywide lockdown carries on. In short, it’s a mess.
Despite politicians’ pledges to help people out, most are still at the mercy of their bank, their landlord and debt collectors. This is why ProPublica is seeking to hear from readers, so we can report on what’s happening. If that’s you, please tell us your story.
When it comes to housing, the clearest thing that can be said is that most people are legally protected from being forcibly removed from their homes in the very near term. When it comes to other sorts of debts (with the major exception of most student loans, as we explain below), the federal government has provided no help.
The recently passed $2 trillion relief bill does involve both cash payments and larger unemployment insurance payments. That will keep some people afloat. We’ll be watching to see how many.
Below, we’ve given a quick overview of the three major types of financial obligations: mortgage, rent and other consumer debts. If you’re having trouble with a lender or landlord, take a look and please tell us how you’re faring.
The government has halted foreclosure filings or evictions until at least May 18, 2020.
For those seeking relief from mortgage payments, the main option initially is a forbearance, which would allow people to suspend their payments. To obtain a forbearance, borrowers will need to contact their mortgage servicer (the company that collects their payments) and simply say they are unable to make their payments because of the coronavirus crisis. No documentation should be necessary. The forbearance should also not result in a negative report to the credit bureaus.
Federal guidelines (which cover the two-thirds of mortgages that are government-backed) generally allow a forbearance of up to six months, which can be renewed.
“The critical issue is that ‘up to,’” said Julia Gordon, president of the nonprofit National Community Stabilization Trust. Many servicers are choosing to start with a three-month period, she said, which seems short, given the ongoing spread of the virus and depth of the economic damage. To get a further forbearance, borrowers will need to call again.
Wells Fargo is the largest mortgage servicer by far, processing payments for about $1.4 trillion in loans, according to Inside Mortgage Finance. Tom Goyda, a Wells spokesman, told us that the bank is granting an immediate 90-day payment suspension to affected mortgage borrowers who request it.
We asked what people should do if, as seems likely, Wells is overwhelmed with calls. Goyda told us that people could “send a message through online banking and request a payment suspension” and that confirmation should come in three to five days.
The payments missed during a forbearance will still be owed, and borrowers will have to contact their servicers towards the end of the forbearance to learn what’s next. One standard solution for government-backed loans is to extend the term of the loan to repay the missed payments. People whose income does not return to its prior level will need a more extensive loan modification to get affordable payments. That’s a much more complicated process, involving documentation.
Twelve years ago, when the last financial crisis hit, mortgage servicers, particularly the largest banks, made a bad problem worse. As ProPublically reported in story after story, servicers were inadequately staffed, frequently lost paperwork and made countless mistakes that cost people their homes. That was a crisis triggered by unscrupulous mortgage lending, and housing experts said that this time around there are important differences. The loans out there are pretty standard (without traps like sudden interest rate spikes), and borrowers generally have plenty of equity in their homes. Also, thanks to post-crisis reforms, there are now clearer rules about what servicers are supposed to do.
But we will be watching to make sure that servicers are following those rules, whether they are offering homeowners fair terms, and to see how they are treating their customers. So, homeowners, please let us know.
Other Consumer Debts
Here, the story is, unfortunately, simple. There is no federal program to specifically help with non-mortgage debts. The main exception is a provision in the recent $2 trillion coronavirus relief bill that will suspend payments for six months on federally backed student loans. Everyone else — those with payments for credit cards, auto loans, payday loans or anything else coming due — is on their own.
We hope readers will contact us to tell us whether lenders and collectors are working with them.
For the nation’s 44 million renters, the situation is more complicated.
First, for most tenants, some good news: Formal evictions have been halted for the next few months, thanks to a patchwork of protections on both the federal and local level.
On the federal level, the recent relief bill included a four-month moratorium on filing evictions and charging late fees to renters living in federally backed properties.
Meanwhile, on the state and local level, some governors and mayors have prohibited evictions for a period of time. So far, these orders are generally shorter in duration than the federal moratorium. However, in the near term, they could help out tenants who entered the eviction process before the federal ban went into effect on March 27, who aren’t covered by it. And in much of the country, the shutdown buys tenants some time. Since the courts in many places are closed through at least Easter, eviction cases are in limbo until they reopen.
But there are important caveats. The federal moratorium, for instance, doesn’t include millions of tenants whose landlords don’t participate in government programs or have federally sponsored loans. And the courts aren’t closed everywhere.
Tenant advocates also worry that landlords might still try informal ways of putting pressure on tenants, trying to force them out without having to go to court. In Texas, for instance, landlords are allowed to change the lock on delinquent tenants, although they are supposed to provide a key when asked, regardless of whether the tenant can pay. Newton Tamayo, an attorney with Lone Star Legal Aid, said that it used to be extremely rare for clients to contact him because they’d been locked out, but that he’d received several such calls in the past week.
Finally, pausing evictions only provides temporary help. Tenants who have fallen behind still face eventual crisis.
“We’re bracing ourselves for a deluge after this stay is up,” said Erica Taylor, who handles eviction cases for the Atlanta Volunteer Lawyers Foundation.
So, renters, please let us know what you’ve heard from your landlord or management company and how you’re making do.
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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 sent a 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 study in 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 paper last 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.
A study of 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 told CNN 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.
Christi Estrada has no idea when she’ll be able to visit her son again.
John Estrada, 33, has autism. He lives in a government-funded group home in Tucson, Arizona. In mid-March, Christi received a call informing her that John’s house was quarantined because of fears of COVID-19. He was not allowed to go to a day program where he worked one-on-one with a care provider, participated in games, drew on his iPad and went hiking and bowling. Christi was barred from visiting.
“He called and wanted me to pick him up and he doesn’t understand. He doesn’t understand anything about the coronavirus,” she said. “It’s just a real confusing time for him, and it’s hard to talk to him on the phone because it’s hard to know what to say.”
Rob Seaver is equally frustrated — but for different reasons. His daughter, Raegan, 19, also has autism and lives in a group home in Glendale, a Phoenix suburb. But administrators there have not imposed a lockdown. Rob is terrified that Raegan is going to get sick. The home is running low on toilet paper and hand sanitizer, he said. His frantic emails to state administrators went unanswered for days.
Arizona has a national reputation as one of the best states at providing services for people with intellectual disabilities. And yet residents, families and providers said that since the COVID-19 crisis exploded, they have received almost no guidance from the state’s developmental disability agency about how to best provide services and protection to stay safe and in business.
Uncertainty over the best practices for protecting the intellectually disabled from infection has led some providers to close their programs or divert aides from providing home visits. Some parents have been left to provide 24-hour care to children with intensive health needs. People with intellectual disabilities are struggling with unfamiliar and sometimes upsetting new routines.
“I don’t know how we can quarantine any one of our folks who tests positive in a congregate setting,” said Bob Bennetti, executive director of the Tucson Residence Foundation, which runs group homes and other residential facilities for adults with intellectual disabilities. “Frankly, I wouldn’t know what the hell to do. This goes beyond having a mask. Hospitals don’t have them, what makes you think a group home would have them?”
Arizona’s Division of Developmental Disabilities, or DDD, provided some instruction this week. Caregivers who were previously restricted to group settings can now offer treatment in clients’ homes.
Advocates, families and service providers say more must be done by the agency charged with providing care for people with intellectual disabilities. So far, there has been no official word on whether any group homes or intermediate care facilities in Arizona have experienced outbreaks of the disease.
“The world is tough for everyone right now. We recognize that. But the agencies that care for people with disabilities and the elderly are really an afterthought,” said Jon Meyers, executive director of The Arc of Arizona, an advocacy group. “We’re so ill-prepared to keep them safe it almost seems inevitable the numbers are going to be horrific.”
Brett Bezio, the DDD’s deputy press secretary, defended the agency’s response.
“DDD is actively monitoring service delivery and availability to ensure essential services continue,” Bezio said in a statement.
In mid-March, the governor closed public schools and the mayors of Tucson and Phoenix did the same with bars and restaurants. The state Department of Health Services implemented policies in nursing homes and assisted living facilities to promote social distancing and keep residents safe.
But the disability agency, which serves more than 35,000 people, including 4,000 or so living in group and developmental homes and around 8,000 in day programs, issued no such guidelines for the facilities under its purview.
Even on Tuesday, as the state prepared for a stay-at-home order from Gov. Doug Ducey, some group homes were quarantined, others were not, and families and providers reported shortages of personal protective equipment and food. Some day programs had closed, others remained open. Some services, like speech therapy, were being offered remotely.
Donna Gallagher runs Southern Arizona Family Services, which houses the day program that John Estrada attended. She was able to transfer his caregiver from the day program to the group home, so that Estrada has care and structure during the day.
On Tuesday, Gallagher felt compelled to deny care to a family with a child with significant disabilities because some of the family members were sick with fever.
“I can’t send anybody in in good conscience,” Gallagher said.
Nicole Jorwic, national policy adviser for The Arc of America, said that Arizona joins other states that have had difficulty providing basic instructions to the intellectually disabled and their caregivers on how to adjust to the COVID-19 outbreak.
Several intellectually disabled people living in group homes in other states have already died or been sickened by COVID-19. ProPublica reported last week on the death of an elderly person with Down syndrome at a group home in Albany, Georgia, a small town in the southern part of the state that is struggling with an outbreak of COVID-19.
“Around the country we’re hearing real concern about basic health and safety,” Jorwic said. “Individuals with disabilities and their families are attempting to figure out this huge disruption in schedule and ways to eliminate the regression that it very likely could cause for a lot of folks.”
Even the most basic of preventative practices, such as social distancing and hand-washing, were neglected for weeks in some day programs and group homes in Arizona, according to parents.
Will Humble, the former director of the state’s Department of Health Services and current head of the Arizona Public Health Association, noticed in mid-March that there were no hygiene policies in place at the Scottsdale day program his son, Luke, who is 22 and has Down syndrome, was attending.
Humble bought one of the last thermometers in stock at his neighborhood Walgreens for use at the program. He took it upon himself to write up a hand-washing policy. Luke continued going to the day program for another week or so, until his parents decided to keep him home from both that and his independent living situation.
“They went a couple weeks without knowing what to do,” Humble said.
Seaver is grateful to the people who work with his daughter, Raegan, who can at times lash out and become physically violent.
“I know a lot of people are making this stuff up as they go, but at the end of the day, my God, nobody was ready for this, and it’s scary because Raegan is really barely able to deal with this stuff,” he said.
“What’s the preparedness plan if somebody in the house gets it? There’s none.”
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As patients infected with the novel coronavirus begin to overwhelm hospitals in parts of the country, and more medical staff become ill, states are asking retirees, recent medical school graduates and other health professionals to step into the breach.
New York City, the current epicenter of the pandemic with more than 44,915 cases, is recruiting medical volunteers with exhortations that recall World War I and World War II-era posters, “We want you for medical work now.”
But the city is offering those volunteers little assurance that the government will cover out-of-pocket medical costs if they contract COVID-19, which, even for a person with health insurance, could mean thousands of dollars in bills.
The uncertainty has some volunteers, like Alisa Baer, second-guessing offering their services.
Baer, 40, who lives in Manhattan, was a pediatrician before she retired from medicine in 2013. With her business advising parents on car seats effectively on hiatus, she decided to volunteer through ServNY, the state’s registry of licensed medical professionals who have signed up to help during emergencies. She was asked to report for service on Thursday at one of New York City’s hardest hit facilities, Elmhurst Hospital in Queens, where the emergency department has been bombarded with COVID-19 patients.
But she immediately raised a crucial concern. If she became ill, who would pay the out-of-pocket medical costs, which in her case would include a deductible of nearly $8,000 before her insurance would kick in.
“It scares me more than getting sick,” Baer said in an interview with ProPublica. “The worst case for me with no income coming in would be to get hospital bills in the thousands of dollars.”
On Wednesday, she received a call from an official at Elmhurst, who said her care would be covered at Elmhurst or another of the city’s public hospitals if she became ill. But with nothing in writing, Baer is still weighing the risk.
The uncertainty she and other volunteers face underscores how even vital contingency efforts, like ServNY, were not prepared for the calamitous effects of COVID-19 on the region’s health care infrastructure.
The New York City effort is being coordinated by its Medical Reserve Corps, which is part of a network organized by the federal Department of Health and Human Services.
The website for the city’s Medical Reserve Corps states that its volunteers will not be covered by health insurance or workers’ compensation, which can cover lost income and medical care for people with work-related injuries or illnesses.
Jill Montag, a spokeswoman for the New York State Health Department, which has been coordinating recruitment efforts throughout the state, said the agency believes the “vast majority of volunteers already have health insurance.”
Representatives from Mayor Bill de Blasio’s office did not respond to requests for comment, nor did the agency that runs the city’s public hospitals, NYC Health + Hospitals, which is placing volunteers throughout the city.
On Monday, California announced it would pay medical professionals who offered to bolster the state’s ranks in battling the novel coronavirus. That same day, New York Gov. Andrew Cuomo implored health workers across the country to come to New York and that the favor would be returned as other communities found themselves at the center of the crisis.
It was a point he reiterated in his briefing the following day. “This is going to be a rolling wave across the country. New York, then it’ll be Detroit, then it’ll be New Orleans, then it will be California,” Cuomo said on Tuesday.
Dr. Kristen Kent, president of the New York chapter of the American Academy of Emergency Medicine, said she has seen a lack of coordination in the public health response and she is not surprised that issues like health care coverage for volunteers are unresolved.
“It’s going to decrease the amount of volunteers that we have, and we’re going to lose the volunteers that we do have when they get sick,” she said. “They’re putting not only their health, but their financial wealth at risk by volunteering. They have to be kept safe, and if something goes bad, they need to be taken care of.”
With an executive order on Monday by Gov. Gavin Newsom, California hopes to enlist some of the state’s 37,000 retired medical professionals as well as others still working toward degrees or licenses. The state will make them temporary employees, not volunteers, and will offer pay and malpractice insurance coverage; the public health agency said it did not know if the temporary employees would be provided health insurance.
California has 8,813 confirmed cases and 187 deaths from the coronavirus as of April 1, according to a count maintained by Johns Hopkins University.
At least 27 states are also allowing retired or inactive physicians to volunteer as a part of the response to the coronavirus, and some have waived fees for licenses, according to tracking from the Federation of State Medical Boards. In Illinois, Gov. J.B. Pritzker issued a “call to action in the fight against COVID-19,” singling out former medical professionals who had recently retired or left to work in a different field.
Those volunteers will staff 12-hour shifts at an “alternate care facility” at the McCormick Place Convention Center in Chicago, with the first 500 beds expected to be ready by the end of the week. Administrators are “working with the Illinois Emergency Management Agency to determine” whether medical volunteers will be paid, reimbursed for travel and other expenses, or be covered by liability or workers compensation, according to the program website which was updated March 29. Officials from the Illinois Department of Public Health didn’t respond to requests for clarification.
The American Medical Association, the influential physicians advocacy group, released guidance on Monday for retired physicians who may be enlisted to provide care during the COVID-19 pandemic. While physicians are ethically obligated to ensure access to care, Patrice Harris, the AMA’s president, said older doctors should consider not only their own health, but the availability of protective equipment and the possibility of seeing patients remotely.
“As with all people in high risk age groups, careful consideration must be given to the health and safety of retired physicians and their immediate family members, especially those with chronic medical conditions,” Harris said in the statement.
Baer has talked with her family about the risks involved in volunteering, and she still wants to help her city even though she is certain she’ll end up infected.
“I think this is a time of need, and I’m less at risk than a 60-year-old,” she said, but “I shouldn’t be put in financial peril for volunteering.”
So she is hoping, she said, that the city will put in writing its promise to cover her medical care if she becomes ill while volunteering. Otherwise, she said, the risk is too great.
Esto es lo que pasó en la industria empacadora de carnes tan solo en la semana pasada:
Un inspector federal de higiene de alimentos, encargado de vigilar plantas procesadoras de carnes en la ciudad de Nueva York, murió por la enfermedad del novel coronavirus.
Un empleado de la industria avícola de Mississippi que trabajaba en la tercera empresa más grande de procesamiento de pollos de EE. UU., tuvo un resultado positivo en el análisis para detectar el virus. Eso ocasionó que media docena de sus compañeros se pusieran en cuarentena voluntaria. En Dakota del Sur, otro empleado de la productora de carne de cerdo más grande del mundo también tuvo un resultado positivo.
En Georgia, docenas de empleados abandonaron una planta avícola de Perdue Farms, exigiendo que la empresa hiciera más para protegerlos.
Incluso, el pasado viernes Tyson Foods le informó a ProPublica que “algunos miembros de su equipo” tuvieron un resultado positivo de la enfermedad.
Al tiempo que el COVID-19 se esparce por todo el país y se generan compras de pánico en los supermercados de uno y otro estado, también aumenta cada vez más la presión que se ejerce sobre la cadena de suministro de alimentos. No obstante, en industrias como las del empacado de carne, que a menudo dependen de empleados que desempeñan arduas labores en actividades hombro con hombro, los riesgos contra la salud de ese personal también se han elevado.
A través de entrevistas realizadas esta semana, empleados de la industria avícola y procesadora de carnes, incluidos algunos que están en el país sin autorización, comentaron con ironía que esta administración, que ahora enfrenta una pandemia, recientemente los etiquetó como “personal esencial”. Aun así, las normas de sus lugares de empleo y la necesidad de seguir moviendo alimentos los presionan a trabajar en gran proximidad hasta cuando están enfermos.
Tampoco está claro cómo las reglas federales, que tradicionalmente protegen a los empleados cuando se lesionan en el empleo, abordarán a este coronavirus potencialmente fatal.
“En la televisión escuchan acerca del distanciamiento social y algunos de ellos tratan de practicarlo en sus casas; sin embargo, luego llegan al trabajo y no lo pueden hacer”, dijo Roberto Mena, sacerdote que atiende a muchos empleados avícolas de la parroquia católica de San Miguel en Forest, Mississippi.
Muchas de las empacadoras de carne del país se rehusaron a contestar preguntas específicas acerca de cómo han tratado los casos de empleados infectados, o sobre lo que han hecho en sus plantas para tratar de mitigar el contagio de COVID-19. En ciertos casos, solo ofrecieron aserciones vagas de que están protegiendo a los empleados.
Hasta ahora, únicamente dos empresas empacadoras de carne, Tyson Foods y Cargill, anunciaron que están tomando la temperatura de todos los empleados para detectar a los que presentan señales del virus. Dos más dijeron que ya comenzaron a hacer lo mismo, pero, con la excepción de ciertas plantas sindicalizadas, los trabajadores de la industria avícola y de carnes raramente reciben un sueldo si se enferman.
En muchas empresas, incluida Tyson, los empleados reciben puntos disciplinarios cuando faltan por enfermarse. Debido a que dichos puntos pueden ocasionar un despido, algunos empleados le informaron a ProPublica que, tanto ellos como sus colegas, siguen trabajando aunque estén enfermos y aunque haya coronavirus.
“Todos tienen miedo”, dijo María, empleada de la línea de destripamiento de una planta de Tyson en Arkansas, quien pidió identificarse solo con su primer nombre. “El problema es que si la gente se enferma, no dicen nada porque necesitan el dinero, no quieren los puntos”.
En un correo electrónico, Tyson comunicó que recientemente había modificado sus políticas para permitir que los empleados que contraigan coronavirus, o que muestren síntomas, soliciten una licencia de corto plazo por discapacidad sin tener que pasar por un periodo de espera. “Esta situación cambia constantemente y seguimos considerando medidas adicionales para apoyar a nuestro equipo”, dijo Worth Sparkman, vocero de la empresa. “No queremos que se presente a trabajar ningún miembro que se sienta enfermo”.
Este mes, Tyson anunció que “eliminaría cualquier efecto disciplinario por faltar al trabajo debido a enfermedad”, pero María dijo que en su planta no ha cambiado nada.
Aun con el papel “esencial” que tienen los empleados de la industria avícola y de carnes, la ley relacionada con licencias por enfermedad que firmó el presidente Donald Trump la semana pasada no cubre a este personal debido a que exenta a las empresas con más de 500 empleados.
La tensión aumenta en virtud de la incertidumbre económica y los millones de personas que presentaron solicitudes de desempleo.
En Koch Foods de Mississippi, Ramírez, un inmigrante guatemalteco indocumentado que pidió ser nombrado solo con su apellido, señaló que una compañera de su sección se presentó a trabajar la semana pasada con una fuerte tos, pero que cuando ella se lo comentó a su supervisor le indicaron que no podría regresar. Ramírez comentó que el mensaje estaba claro, por lo que cuando él comenzó a sentirse mal unos días después, sencillamente no dijo nada y siguió trabajando.
“La gente se siente preocupada”, agregó, “porque si uno se presenta en el trabajo nos corren” si dicen que están enfermos.
También dijo que no tiene la opción de ir al médico porque no cuenta con seguro médico y teme que eso expondría su situación migratoria.
Koch Foods no contestó nuestras llamadas ni el correo electrónico en el que preguntamos acerca de sus políticas para empleados enfermos.
Aún antes del coronavirus, la industria de la carne se quejaba de la falta de mano de obra, ya que los sueldos bajos y las condiciones inclementes chocaban con un mercado laboral estrecho, fronteras aún más herméticas y reducciones drásticas en cuanto a la cantidad de refugiados que permite la administración de Trump, siendo estos el segmento principal del personal de muchas plantas.
Aunque no hay evidencia de que el coronavirus pueda transmitirse por los alimentos, estos empleados dicen que temen que puedan contagiarse entre ellos, aunque vistan bata de carnicero y guantes de látex, y aunque las plantas se estén desinfectando todas las noches.
Si eso llega a suceder, se podría eliminar uno de los elementos más importantes de la cadena nacional de suministro de alimentos, justo cuando este segmento lucha para mantenerse al ritmo de una mayor demanda, dijeron los empleados y sus defensores. En la semana del 15 de marzo, y de acuerdo con un análisis de la industria, las ventas de carne en los supermercados (con excepción de las carnes frías) subieron un asombroso 77%.
Para satisfacer la demanda, las empresas se apresuraron a añadir turnos adicionales de fin de semana y cambiaron las líneas para producir aves completas y cortes de carne de res más grandes. Bajo presión de los sindicatos, y en vista de los aumentos de sueldo en supermercados y almacenes, algunas empresas como Cargill y National Beef anunciaron una bonificación de $2 dólares por hora que recibirán sus empleados durante las próximas semanas, cuya intención es retenerlos y recompensarlos por quedarse en tiempos difíciles.
Los ejecutivos de las empresas dijeron que los estantes vacíos no son señal de que haya carencia de alimentos, y que tienen la capacidad de afrontar el incremento en la demanda, ayudados, en parte, por una menor exigencia de los restaurantes que recibieron órdenes de cerrar.
“Nuestro enfoque principal es que nuestras plantas sigan operando para poder alimentar al país”, declaró en CNN Dean Banks, presidente de Tyson. “Las plantas están trabajando a toda su capacidad”.
Incluso ciertos analistas indican que aunque una planta se vea obligada a cerrar si hay un brote del virus, esta industria es suficientemente grande para absorber la pérdida, ya que cuenta con más de 500 mil empleados y 4 mil rastros y plantas procesadoras en todo el país.
Tim Ramey, analista jubilado de la industria alimentaria, indicó que si sucede un brote “podría haber trastornos importantes” en la producción de una empresa. Sin embargo, añadió que tanto supermercados como restaurantes compran carne de muchos proveedores y otra planta podría cubrir la deficiencia.
“Hay muchas maneras en las que se pondría en riesgo el suministro de mano de obra”, dijo Ramey. “Dudo que sean suficientes para desorganizar el abastecimiento de alimentos”.
No obstante, nadie sabe qué sucedería si varias plantas tuvieran brotes.
El precedente más atinado puede ser el de las redadas de migración, con las cuales se han clausurado temporalmente ciertas plantas avícolas y de carnes en los últimos 25 años. En los meses posteriores a las clausuras, dichas plantas tuvieron dificultades para encontrar empleados nuevos y acelerar la producción, aunque las líneas de abastecimiento siguieron alimentando a los Estados Unidos.
Algunos inmigrantes que se vieron atrapados en esas redadas ahora se sorprenden de que el país dependa de ellos. El verano pasado, después de terminar su turno destripando miles de pollos, Ramírez encendió su televisor y vio espantado cómo los agentes de migración entraron a la zona central de Mississippi para capturar a cientos de sus compañeros de trabajo durante una de las operaciones migratorias más grandes de la administración de Trump.
Durante las semanas posteriores, Ramírez vio a los tres hijos de un compañero detenido que se resguardaron solos en su casa; él temía ser el siguiente. Fue fácil sentirse desechable, agregó, sobre todo cuando Trump elogió las redadas como una “disuasión muy buena”.
Ahora, cuando Ramírez ve los noticieros, Trump menciona a estos empleados como elementos “críticos”, diciéndoles que “tienen una responsabilidad especial de mantener su horario normal de trabajo”.
“No entiendo. Si nos necesitan tanto, pregunta Ramírez “¿por qué no se preocupan por nosotros?”.
En las últimas décadas, los rastros de pollos, cerdos y ganado se han automatizado cada vez más, aunque varias de las tareas de la línea de descuartizado todavía deben hacerse a mano. En la sección de las plantas avícolas donde se cuelgan aves vivas, los empleados trabajan dentro de una sala con luz ultravioleta, amontonados alrededor de un pasadero desde el cual sujetan a los pollos por las patas para colgarlos en grilletes.
En otra sección, conocida como el “deshuesadero”, trabajan muy de cerca con otros, rebanando pollo crudo para convertirlo en pechugas y tiras de pechuga. La proximidad es tal, que a veces hay quien llega a cortar a un compañero con su cuchillo.
En las plantas de cerdos, los empleados trabajan tan amontonados que hace un poco más de una década, dos docenas de empleados de una fábrica de Minnesota sufrieron una enfermedad neurológica por inhalar cerebro de cerdo en aerosol, el cual entraba por el aire proveniente de una estación cercana que fabricaba un ingrediente utilizado en espesadores para comida frita.
Entonces, aunque desde el presidente hasta SnoopDogg supliquen que todos se queden en su casa y eviten estar en grupos de más de diez personas, a los empleados de la industria avícola y de la carne se les exige que hagan lo contrario.
ProPublica pidió a las empresas de carne más grandes del país que reporten lo que están haciendo para lograr el distanciamiento social. Cargill, la cual produce miles de millones de libras anuales de carne de res y pavo para supermercados y restaurantes, fue la única empresa que dijo que está haciendo algo además de escalonar las horas de entrada y de descanso. Daniel Sullivan, vocero de esa empacadora de carnes con sede en Minnesota, dijo que aumentaron el espaciamiento en las áreas de la fábrica y colocaron particiones en la cafetería.
La línea de destripamiento donde trabaja María, la empleada de Tyson, no tiene tanta gente como otras partes de la fábrica por tratarse de un proceso altamente automático. Sin embargo, ella dijo que debido a que los empleados no pueden dejar la línea a menos que se trate de una emergencia, a menudo se topa con grupos de muchas personas cuando salen rápidamente al baño durante los descansos. La empresa colocó desinfectantes de manos en la entrada de la planta, añadió, pero adentro los baños no siempre tienen toallas de papel.
A medida que se publican los casos de COVID-19 en las plantas, los empleados temen que este sea solo el comienzo.
El pasado lunes, Sanderson Farms, la tercera empresa avícola más grande del país, informó que uno de sus empleados de la planta de McComb, Mississippi, tuvo un resultado positivo del virus. Sanderson agregó que el área de trabajo de esa persona era solo una mesa de procesamiento pequeña. En respuesta a este hecho, la empresa notificó a todo su personal y envió a cuarentena con goce de sueldo a otros seis empleados de esa sección.
La empresa no contestó nuestras llamadas ni correos electrónicos solicitando información adicional.
El jueves, un empleado de la planta de Smithfield Foods, productora de carne de cerdo en Sioux Falls, Dakota del Sur, también tuvo un resultado positivo. La empresa informó al diario Argus Leader que el área de trabajo de ese empleado, así como las demás áreas comunes, habían sido “desinfectadas minuciosamente”. Sin embargo, no comentó nada acerca de los empleados que pudieron haber entrado en contacto con ese compañero.
Hay aún menos detalles acerca del inspector federal de alimentos que falleció a causa del virus. Sonny Perdue, Secretario de Agricultura de EE. UU., declaró que se sentía “terriblemente triste al escuchar” que uno de los empleados del departamento había muerto debido a la enfermedad, y agradeció a “todos los trabajan en las líneas del frente de la cadena de suministro de alimentos”. El departamento no indicó en qué plantas trabajó ese inspector específicamente, ni lo que se había hecho para notificar a las personas que entraron en contacto con él o para ponerlas en cuarentena.
Paula Schelling, representante de inspectores de alimentos del sindicato American Federation of Government Employees (Federación Americana de Empleados Gubernamentales), dijo que el Servicio de Seguridad e Inspección de Alimentos de la USDA debe hacer más para proteger a los empleados de primera línea.
“El Servicio de Seguridad e Inspección de Alimentos (Food Safety and Inspection Service, FSIS) no está haciendo nada para proteger a ningún empleado que está trabajando en el sector”, agregó. “Solo dicen que están siguiendo las pautas de los CDC. ¿Qué significa eso para nosotros?”
La inquietud de que las empresas de carnes no estén revelando información también hace que aumente la ansiedad en varias plantas. Los empleados que abandonaron la planta de Perdue en Georgia dijeron que la agitación comenzó porque los supervisores no tomaron en cuenta la preocupación de que algunos empleados seguían trabajando después de haber estado en contacto con personas con coronavirus.
“No nos dicen nada”, comentó Kendilyn Granville ante un reportero de televisión afuera de la planta el pasado lunes. “Ningún tipo de compensación, nada, ni siquiera más limpieza, nada de sueldo extra… nada. Estamos arriesgando la vida por el pollo”.
Diana Souder, vocera de Perdue, dijo que la mayoría de los empleados que abandonaron la planta regresaron después de hablar con los gerentes.
“Sabemos que muchos se sienten ansiosos durante estos tiempos de incertidumbre, y estamos haciendo todo lo posible para cuidar a nuestros asociados, al mismo tiempo que continuamos la producción de alimentos seguros y confiables”, agregó.
Típicamente, cuando los trabajadores se sienten inseguros, pueden quejarse ante la Administración de Seguridad y Salud Ocupacionales (Occupational Safety and Health Administration, OSHA). Sin embargo, en estos momentos no es claro cómo responderá la OSHA a las quejas relacionadas con el coronavirus. Dicha dependencia, cuyo personal se ha mermado con la administración de Trump, publicó directrices para los empleadores, pero no cuenta con una norma específica relacionada con el virus y no ha dicho cómo podría interpretar su cláusula del deber general, misma que requiere que los empleadores mantengan sus instalaciones laborales libres de peligros reconocidos que podrían ocasionar muertes o “daños físicos graves”.
Los empleadores solo tienen la obligación de notificarle a OSHA cuando un empleado queda hospitalizado, o si sufre una amputación o muere en el trabajo. Pero, debido a la variedad de las reglas, habrá empleadores que quizás deban notificar a los departamentos de salud de sus estados y localidades.
Hubo empleadores que comenzaron a ofrecer sueldo adicional a medida que fueron aumentando los casos esta semana. Perdue dijo que daría un aumento de $1 dólar por hora a todos sus empleados que trabajan por hora durante varias semanas. Hormel, productora de Spam, dijo que ofrecería una bonificación de $300 dólares a sus empleados de tiempo completo y $150 a los asociados de tiempo parcial.
United Food and Commercial Workers, el sindicato que representa a más de 250 mil empleados de la industria del procesamiento de alimentos, dijo el jueves que había negociado aumentos adicionales de sueldos y prestaciones, incluida una bonificación de $600 dólares en mayo para los miembros que trabajan en JBS, la segunda empacadora más grande a nivel nacional y que incluye pollo de la empresa Pilgrim’s Pride. Cameron Bruett, vocero de JBS, no informó si la empresa también otorgaría esa cantidad a los empleados no sindicalizados.
Varias empresas avícolas y de carnes, entre ellas Tyson, Smithfield, Sanderson y Koch, no han anunciado aumentos ni bonificaciones.
El viernes pasado, Perdue le comentó a ProPublica que comenzaría a tomarle la temperatura a los empleados de sus plantas. Bruett dijo que JBS estableció “estaciones de triage” afuera de las suyas para tomarles la temperatura a los empleados y detectar síntomas. Aun así, no es claro si revisarán a todos los empleados o únicamente a los que muestren señales del virus.
Entretanto, Venceremos, grupo defensor de derechos de los trabajadores avícolas del noroeste de Arkansas, inició una petición solicitando que Tyson y otras empresas procesadoras proporcionen licencia con goce de sueldo por enfermedad a sus empleados, en estos momentos en que el coronavirus comienza a expandirse a las zonas rurales de Estados Unidos.
“Todos se están dando cuenta de que son esenciales y han sido esenciales para el país”, dijo Magaly Licolli, una de las dirigentes del grupo. “Ahora es tiempo de que todos exijan sus derechos justos. Es lo que hemos alegado todo este tiempo. Ellos son los que abastecen al país”.
Actualización del 30 de marzo de 2020: La gráfica de este reportaje se actualizó para incluir información adicional de la empresa Cargil.
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Pregnant nurses and doctors say they are being forced to go to work with no formal accommodations or extra protections to keep them safe from the coronavirus, even though they are immunocompromised and data is still emerging about the risks of fetal transmission.
Dozens of pregnant medical workers reached out to ProPublica, saying they were weighing whether to stay in jobs they view as dangerous or quit, which could add to the burdens of their beleaguered colleagues. Many said they didn’t have paid sick or maternity leave and couldn’t afford to take a break. Because some spoke out against employers or were threatened with firing if they spoke about COVID-19 cases at their facilities, their names have been withheld.
One nurse, in a psychiatric hospital in a hot spot area, said a co-worker tested positive for the virus and others were exposed, but the hospital has refused to test employees until they develop a fever or a cough. “You still have to come to work unless you have symptoms,” she said. She was told she cannot wear a mask, something reserved only for staffers whose patients have tested positive.
“I said, ‘If you don’t know who is positive, what about that?’ No answer.”
A nurse at a long-term care facility asked her supervisors if she could do the paperwork-heavy parts of her job from home. “They told me no and said if I did stay home, they would fire me,” she said. Alarmed by the fact that staff had little to no personal protective equipment, she asked if she could keep her office door closed. “They said no, I had to be available to the other staff.”
Over the weekend, she developed a cough, a sore throat and a slight but concerning fever. “I’m terrified,” she said.
The American health care workforce is overwhelmingly female — about 90% of nurses and home health aides are women — and at any given time, an unknown number of them, likely in the thousands, are pregnant. Many of those nurses, doctors and medical support staff continue to provide front-line patient care as the pandemic unfolds — whether they want to or not and without knowing the long-term consequences for their babies.
A Lack of Data, Guidelines for Pregnant Workers
The recommendations for protecting pregnant health care workers confronting COVID-19 are loose and broad. Meanwhile, the research on coronavirus and pregnancy is changing quickly, with the latest reports creating a new sense of urgency.
Based on very limited published data, the Centers for Disease Control and Prevention and professional physicians’ groups have said that so far, pregnant women don’t appear more susceptible to catching the virus than nonpregnant women. Mothers-to-be may be more likely to develop severe respiratory illness because of their weakened immune systems and diminished lung capacity, as has proved to be the case with H1N1 flu and SARS, but it’s not yet clear to what extent the same may be true of COVID-19.
Even less is known about the effects of the coronavirus in the first trimester, although high fever in general as been associated with miscarriage and fetal anomalies. Some babies born to women with COVID-19 symptoms in China have been premature. In a report on the coronavirus in seven pregnant patients in New York City, four women had to be hospitalized, and two — both asymptomatic at the time of delivery, and both with significant preexisting conditions — required treatment in the intensive care unit. Neither of the babies born to those mothers tested positive for the virus.
Until very recently, researchers were confident that the virus isn’t passed from mother to baby in utero. But new, small-scalestudies from China suggest that so-called vertical transmission can’t yet be ruled out.
“Now that there’s some emerging evidence, it may be time to have that conversation for a pregnant mom to take extra precautions,” said Suzanne Baird, a board member of the Association of Women’s Health, Obstetric and Neonatal Nurses and nursing director for the consulting group Clinical Concepts in Obstetrics. “It’s time to start addressing this for our pregnant moms working as health care providers. It is essential that pregnant women are protected in the workplace.”
At the moment, the CDC’s guidance for pregnant health care workers is scant. The agency states that if the staffing is available, medical facilities “may want to consider limiting exposure of pregnant [providers] to patients with confirmed or suspected COVID-19, especially during higher risk procedures.” The American College of Obstetricians and Gynecologists reiterates the CDC position and does not currently recommend shifting pregnant health care workers away from direct patient care based on coronavirus alone. “Pregnant women do not appear to be at higher risk of severe disease related to COVID-19,” the ACOG statement, dated March 23, says.
But in other countries, OB-GYN organizations have been more proactive. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommends that, “where possible, pregnant health care workers be allocated to patients, and duties, that have reduced exposure to patients with, or suspected to have, COVID-19 infection.” The equivalent body in the U.K. revised its policy in late March, saying all pregnant women “should be offered the choice of whether to work in direct patient-facing roles.” For those in their third trimester (later than 28 weeks) or who have an underlying health condition, the organization “strongly recommend[s]” they avoid directly working with patients.
In a statement to ProPublica, Dr. Christoper Zahn, ACOG’s vice president of practice activities, said the U.K. and Australian recommendations are “based on historical data that is not specific to COVID-19.” He said ACOG’s approach is “to make recommendations based on data specific to COVID-19 and medical evidence.” To that end, “We are actively monitoring data on pregnant women and COVID-19 and are in frequent contact with the CDC and other experts in order to provide the most up-to-date information regarding the effects of the virus.”
Unanswered Worries, Imperfect Workarounds
ProPublica reached out to more than a dozen hospital and health care systems across the country requesting their written policies on pregnant workers during the coronavirus pandemic. Only two responded. In California, Stanford Medicine recommends that its pregnant health care workers limit direct care of patients with confirmed or suspected COVID-19 “whenever possible,” a spokesperson wrote. Employees in their 37th week of pregnancy or beyond are urged to avoid in-person patient care altogether. Baylor Scott & White Health in Texas says it is following the CDC guidelines; pregnant or breastfeeding health care workers “have the option, but are not required, to request exemption from caring for a lab-confirmed COVID-19 patient.”
Mostly, pregnant doctors and nurses told us that their employers have chosen to interpret the absence of information and guidance as a reason to let them continue working as normal — even when they raise concerns. “The lack of data … does not mean there is no risk, which is the impression I have gotten so far from my medical colleagues, which worries me,” wrote a primary care doctor in her ninth month.
When an ICU nurse at a large regional medical center told her manager that she felt uncomfortable doing bedside work, she says her concerns weren’t addressed. “While she was sympathetic, she was like, ‘We have a lot of people who are uncomfortable with this,’” said the RN, who is in her second trimester. Accommodations have been made for staff with conditions such as cystic fibrosis, but the nurse has been told that they do not have the “organizational backing” to do the same for pregnant workers until their ninth month. The nurse said she’d be willing to take unpaid leave, “but it’s not something that has been offered. I think they’re too worried about staffing.” A plea to her OB-GYN for a letter that might help her make her case to her supervisor was rejected; the doctor works for the same medical system. “It seems they are operating as an arm of HR and not as my medical provider,” the nurse said.
A surgery resident in the South said she has had to rely on the kindness of her colleagues to keep her out of harm’s way. “Based on the hospital where I am rotating, I feel relatively safe because of the people I work with who say: ‘Maybe don’t come into this room.’ ‘We’ll take care of this,’” she said.
Even when organizations attempt to accommodate pregnant workers, they may not have the larger public health picture in mind. An RN for a nursing home company said she’s five months pregnant and the facilities where she normally works have suspected cases of COVID-19. To protect her, she was reassigned to visit home hospice patients to dole out medications and change medical dressings. “Probably over half of patients have respiratory problems,” she said. “Not only do I fear for myself and my unborn child, I’m worried about compromising those patients.”
One recent assignment, the nurse said, “I had to refuse because the patient had just come off a unit that had positive COVID-19 cases.” The homes are sometimes crowded with family members who have come to say their goodbyes. “With all these people around, I don’t know who’s been exposed. The more patients I visit, the more the risk is increasing.”
Battles for Personal Protection
Expectant mothers need to be especially vigilant about taking protective measures because pregnancy suppresses the immune system. But pregnant health care workers are encountering the same PPE shortages and institutional roadblocks as other front-line providers.
“We’re wearing gloves for any contact with any patient,” the home hospice nurse said. “We’ve been given hand sanitizer and told to Lysol our shoes and to change our clothes before going home. We’ve been given one mask and told we had to reuse it — not an N95 mask, just a basic mask. When we’re not using the mask, we’ve been told, put it in a Ziploc bag, put it in our car. We were told basically to use it until it falls apart.”
At a large trauma center, an ER nurse in her second trimester was assigned to work the triage desk for several shifts in a row as the coronavirus began to infiltrate her community. “I was surprised,” she said. “Why on earth would they put a pregnant woman out there sorting through patients who might be sick?” At first, she didn’t complain, because it’s difficult to turn down assignments. The next shift, “I finally reminded them: ‘I’m pregnant. I’m really uncomfortable doing this,’” and they said, ‘OK.’”
The next battle was over masks. She was reprimanded when she wore a surgical mask while outside a patient’s room. “They said no one could wear masks unless they were in direct contact from aerosolized droplets from a person who was confirmed or highly suspected to have the virus. They said pregnancy wasn’t a high-risk category and didn’t have any bearing on the COVID situation.” She felt compelled to take off her mask and didn’t wear one the next shift, either. Within a few days, the entire staff was so worried that almost everyone was wearing surgical masks.
For an East Coast nurse who is halfway through her pregnancy, the problem wasn’t just that her hospital refused to limit her interactions with patients who might have been exposed to the virus or to offer adequate PPE. “My OB refuses to write me a note to require my employer to provide additional protection for me.” She had been planning to work through the end of her pregnancy, but the anxiety became too overwhelming. “To protect myself and my baby, I chose to start maternity leave early and I no longer work at the hospital.”
One internist in her second trimester works as a traveling doctor in hospitals across the country. In her case, wearing a mask constantly to protect against accidental exposure isn’t the answer. “I tried it for one or two patients, but the protective gear really changes the physician-patient interaction,” she said. “My glasses fog up. The patients can’t hear me; I have shortness of breath because I’m pregnant, and I can’t speak. It scares them, and I think it’s important to provide a sense of security for people who are coming into the hospital already scared.”
The director of her current hospital has agreed that she should be allowed to avoid potential COVID-19 cases. But that doesn’t mean she’s safe. “Throughout the day I get called from the ER to admit patients. We get a lot of respiratory cases and pneumonia. If I get a call for a COVID rule-out, I can’t give that patient to somebody else, I just go do it,” she said. “I think in general my colleagues all have this mentality that exposure is imminent.”
Unable to Stay Home
Health care providers who want to leave their jobs, or take a break, are finding they don’t have the resources to do so. For some, paid time off and maternity leave are not a given. Some are single parents or have spouses who have been laid off. It remains unclear how the Coronavirus Aid, Relief and Economic Security Act will affect their options.
“I didn’t plan on being pregnant, but once it happens, this is where I’m at,” said the traveling doctor, whose job is financially lucrative but pays by the shift. She’s due to give birth this summer: “I’m not planning on quitting, it’s just not reasonable. I need health insurance, I need money. I’m fortunate in that I am actually still allowed to make money right now.”
The psychiatric nurse working from a coronavirus hot spot finds herself with minimal paid time off. She works for a large hospital that won’t be required to give her extra leave under the new federal legislation. Though she recently requested and received 14 days of medical leave, she knows she’ll soon have to return to a job that remains risky. “COVID cases are increasing every day,” she said. “Now it’s everywhere in the hospital.”
A few women who spoke with ProPublica have opted to stop working, a decision that often carries as much guilt as relief. “I feel almost ashamed to not feel comfortable to serve my community right now,” said Lauren Paz, a nurse at a large regional hospital in central Oregon who is eight months pregnant with her second child. “It’s an ethical dilemma. I want to serve. In this profession, we have a duty to serve and I want to be there. It pains me.”
But her husband is also on the front lines as a paramedic, and they have a 1-year-old at home. When the hospital began rationing face masks, she decided to stop working at 28 weeks and spent three weeks on the sidelines. “The kicker for me are the unknowns surrounding the baby,” she said. “I would take that risk for myself any day, but I will not take that risk for an unborn child who doesn’t have that choice.”
After several weeks off the job, she spoke with her supervisors about her concerns. They’re working to reassign her to the hospital system’s 24-hour COVID-19 hotline, a job she can do from home. She said she’s pleased with their responsiveness.
But she couldn’t rely on hospital policies or the CDC to help her locate the best way forward. “I have to be my own advocate,” she said.
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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.
“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.”
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When a woman who didn’t speak English arrived at the overrun emergency room of a Brooklyn hospital last week, she was initially placed in a unit for patients who didn’t have the coronavirus.
But on Thursday, a doctor realized she had a cough and fever and should be treated for COVID-19. The doctor brought her over to the coronavirus unit with a warning: “Good luck. She speaks Hungarian.”
She died the following night.
A medical resident who treated her believes she would have gotten better care if she spoke English.
In the ER, where no one has enough time, particularly now, the resident said he could tell that no one wanted to work with an interpreter to take down the woman’s medical history. He placed his phone on the woman’s shoulder and dialed the interpreter service on speakerphone. Between the N95 mask covering his mouth and the helmet covering his ears, it was difficult to speak clearly and to hear.
“When they asked what language,” he said, “I spent five minutes just yelling: ‘Hungarian! Hungarian!’ And they were like, ‘Spanish?’”
The woman may have died even if she spoke English, but the episode and others like it demonstrate how those who speak a foreign language are at a disadvantage in New York City’s chaotic and crowded hospitals.
“It takes 10 minutes of sitting on the phone to get an interpreter, and that’s valuable time when you’re inundated,” the resident said. “So this utilitarian calculus kicks in. And the patients that are most mainstream get the best care.”
Even in normal times, those who don’t speak English have worse health outcomes for a range of routine procedures and can struggle to gain access to interpreters. Some research also shows that professional interpreters make clinically significant errors substantially less often than ad hoc interpreters, such as family members.
Those gaps are magnified in times of crisis. ProPublica spoke to 11 New York City health care workers about their experiences caring for coronavirus patients who didn’t speak English. While their employers ranged from top-tier nonprofit facilities in Manhattan to safety net hospitals in Brooklyn, they all described broken communication and hastily improvised stopgaps.
They’re worried that language barriers will leave immigrants with COVID-19 in a particularly dire situation: alone, confused and without the appropriate care.
One doctor in the Bronx described a colleague working in his facility’s triage tent, trying to assess patients using the Google Translate app on his smartphone.
In another situation, the Brooklyn emergency room resident said he felt comfortable enough with Spanish that he decided to forgo an interpreter while taking the medical history of an incoming Hispanic patient. Her symptoms weren’t severe, but he thought she told him she had heart surgery three years ago, so he admitted her into the hospital because that put her at risk. Later, he realized she’d said she had heart surgery when she was 3 years old. If he had known that, he would’ve sent her home.
A resident at another Brooklyn hospital treated a woman on Sunday who only spoke French Creole. The oxygen mask over her face meant the interpreter couldn’t fully understand her, the resident said, and the patient clearly remained very confused. She died the next day.
A Manhattan hospital-based physician described how he calls interpreters on his cellphone outside patients’ rooms and places the phone in his breast pocket so it doesn’t get covered in virus particles. Then he puts on a yellow protective gown over his scrubs and enters the room, standing at a distance from the patients. But all of these steps make it hard for the patient and the interpreter to hear each other. “Then we tell them they have a virus that is killing people all over the world,” he said. “We tell them they can’t have any visitors, they can’t leave the room. And then we shut the door.”
About 1 in 5 Americans speaks a language other than English at home, according to census data. Among New Yorkers, it’s 49%. But with more than 40,000 confirmed coronavirus cases within New York City limits, when residents without a strong grasp of English get sick, providers point to a number of ways the language gap could lead to worse care. Patients well enough to go home may misunderstand their discharge instructions, causing them to not quarantine properly or to not return to the ER if they take a turn for the worse. Mistakes could be made during triage, as underlying conditions get overlooked.
The Civil Rights Act of 1964 has long been understood to require hospitals to provide access to language interpretation if they receive federal funding (such as Medicare and Medicaid), with failure to do so considered “discrimination by national origin.” Regulations put in place in 2016 to implement part of the Affordable Care Act bolstered that mandate. Hospitals now must use a “qualified interpreter” — patients have the right to sue if they don’t — and the use of family members and bilingual but untrained staff is restricted. (There are exceptions, like translating through family members in emergencies.)
Elena Langdon, former chair of the National Board of Certification for Medical Interpreters, said she recognizes doctors may be unable to always provide the quality of care they’d like to right now, but that equity and the right to interpretation can’t fall by the wayside. “While it’s made more difficult by the situation, it doesn’t mean you don’t have to do it,” she said. “It’s a public health issue.”
She said hospitals may need to have a staff member on site dedicated to coordinating language access. Several hospital systems at which the examples in this story occurred did not return emails or phone calls seeking comment.
Even outside of pandemics, providers acknowledge these provisions are often violated, like by having a grandchild translate instead of a professional.
Such options are now unavailable, however. Many hospitals in the city have prohibited visitors, making it impossible for English-speaking family members to help patients communicate. In-person interpreters would be at risk of infecting themselves or others, and the use of personal protective equipment makes talking on the phone hard.
An ICU nurse in a third Brooklyn hospital said that at her facility, when she needs an interpreter, she calls an operator through a big, blue corded phone installed in each room. Then she sits on hold until an interpreter becomes available. The wait time depends on the language. Spanish is relatively fast, she said; Mandarin takes 10 or 15 minutes; some uncommon Asian dialects take over an hour.
Now that visitors are forbidden, the nurse worries, patients are left without advocates, and the family is kept out of the loop. “At this point,” she said, “we’re not going to call unless we need consent or they die.”
Last week, a Spanish speaker in his early 40s was admitted into the hospital’s ICU where the nurse works. He seemed relatively healthy, and while he was a little overweight, he had no underlying health conditions, the nurse said. Nevertheless, he soon was on a ventilator. Despite the hospital’s policy against visitors, his wife showed up and she spoke less English than her husband did. “His wife hadn’t been able to see him or talk to him,” the nurse explained. “She kept just saying: ‘I don’t understand. He was OK.’ … It’s part of our job as nurses to go up to a family member you see like that and explain what’s going on. But these conversations aren’t happening with translation patients. In this scenario, I don’t have the time.”
“And then he died,” she said. “And they had to tell her over the phone.” She’s not sure if the hospital used an interpreter or just winged it.
Lizzie Presser, Maya Miller and Sean Campbell contributed reporting.
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HARDEEVILLE, S.C. — Every day during what seems like an endless quarantine, Judith Persutti assigns herself a chore. So far she’s washed the curtains and dusted the miniblinds in the little country house where she is sheltering in place with her oldest granddaughter.
Stop to rest when the fatigue sets in. Lie down when the pain becomes too much.
And, of course, check the mail.
She’s waited more than a month for a letter to come from the state’s Medicaid agency telling her whether she will be reinstated on the federal-state health insurance program for low-income families or individuals who are aged, blind or disabled.
Now, with South Carolina — like states throughout the nation — suddenly consumed by an unprecedented crisis that has the country’s health and wealth in a vise grip, Persutti wonders if her letter will ever come. The safety net is already severely strained, and she realizes the tangled bureaucracy handling her appeal now is scrambling on so many urgent fronts that resolving individual problems is likely to get pushed to the bottom of the pile.
“Medicaid is stalling in hopes I catch the virus,” she quipped in a recent text message, her gallows humor not lost to the stress of the pandemic.
In the span of a few weeks, the 64-year-old, whose grandchildren occasionally call her “nanosaurus,” has gone from barely thinking about COVID-19 — or really even knowing what it was — to losing sleep over yet another threat to her health.
She has osteoarthritis and fibromyalgia, hypertension and asthma. She’s supposed to take a mix of prescription medications for pain, inflammation, blood pressure and anxiety, but she can’t afford them all.
She squeezes by on $739 a month in Social Security and an additional $149 in food stamps; her platinum-gray hair has grown into a bob because she can no longer spare the price of upkeep on a beloved pixie cut. And the pain from squatting, standing or walking for long periods has made it impossible for her to hold a job.
There was a brief moment in the fall when the state gave her Medicaid, saying she qualified based on her disabilities and low income. It lasted a month. Then, the state took it away with little explanation other than it had made a mistake.
Determined to fight the decision, she appealed, traveling about two and half hours to the state capital, Columbia, to prove that she is disabled to a hearing officer at an administrative proceeding. It was just before the global pandemic erupted in the U.S., spreading fear of the novel contagion as far as Persutti’s one-stoplight town.
Persutti is one of the country’s 28 million uninsured adults, many with chronic illnesses that make them particularly vulnerable to the dangers of COVID-19. The Affordable Care Act was meant to give access to insurance to all Americans. But 14 states, including South Carolina, have declined to expand Medicaid qualifications under Obamacare. And even for those who seem to qualify, like Persutti, actually getting and maintaining Medicaid can be a byzantine, frustrating, even futile process.
Now, isolated with her 27-year-old granddaughter Karlie, she knows that her age and chronic health conditions make her especially vulnerable to a virus that has no cure, antiviral drug or vaccine. And without Medicaid, she faces it all with no health insurance.
Persutti must have gone through eight drafts of her testimony the night before her hearing to appeal the state’s termination of her Medicaid coverage. Sitting in her bedroom sanctuary, with windows overlooking a backyard near the Savannah River that often fills with grazing deer, she crossed through lines, ripped out notebook pages and tossed them aside. How to describe the ways chronic pain has forced her to modify her life?
Finally, she arrived at a summary and wrote it into a purple-and-white floral notebook:
Although I possess the skills to work in an office setting, I’m unable to sit or stand for any length of time due to the pain in my hips and knees from the osteoarthritis. I also have fibromyalgia, which being so unpredictable, as to when a flare up will hit, I cannot commit to a set schedule. I have been prescribed medication. But I cannot drive, let alone stay focused on the job while taking it. So it’s like a Catch-22 situation.
The coronavirus was only a distant rumble as she prepared for the hearing, something then seeming to affect only faraway places like China and Italy. Folks in her town, a largely rural area a short drive from the luxury resorts of Hilton Head Island, were barely noticing. President Donald Trump, who visited the state the night before the first-in-the-south Democratic presidential primary, was still calling the disease “a hoax” stirred up by political rivals and a distrustful news media.
Persutti watched a conservative wave sweeping Columbia, touting work requirements that would make it harder to get Medicaid, which cost about $7.7 billion in 2019 — or about 17% of its budget — in a state that has historically taken a harsh view toward public benefits. And it bothers Persutti, who is white, that at times it seems “different races other than just white ones, plain white ones, Caucasian … are targeted.” About 46% of the state’s Medicaid recipients are black, 40% are white and 9% are Hispanic.
South Carolina recently received approval from the Trump administration to impose work requirements on nondisabled adult Medicaid recipients, a change the state estimated would reduce the rolls by as many as 7,100 recipients.
Other states were doing the same; 10 received federal approval, though court injunctions paused implementation in most of them.
And in the midst of all that, Persutti needed to convince South Carolina’s health agency to add her back to the rolls, that stripping her coverage after only a month was unjustified.
For years, Persutti had worked two jobs at once, raising her daughters alone. Her days started before sunrise when she’d make dinner, put it in the refrigerator, then bike to her customer service job at a carpet cleaning company. At shift’s end, she’d bike to a supermarket deli, work until 10 p.m., and then pedal home, where she often collapsed fully clothed across the bed.
“I look back on it, and I don’t know how I did it. I never rested. Never,” she said.
Then she worked for 16 years for a friend’s cab company — first as a driver, then as a dispatcher — until sitting for 12-hour shifts became untenable.
“I remember the last night I dispatched,” she recalled. Her leg hurt so bad she had to be helped to her car. “I told them, don’t ask me anymore.”
She retired, and her long quest to secure Medicaid began soon after. She first applied in July 2018. It took the state nine months to begin vetting her application and an additional six months to approve her.
While she briefly had coverage, she began making the doctors appointments to get caught up on some tests and procedures. Then, a letter dated Nov. 26 arrived around Thanksgiving abruptly canceling her coverage. The explanation: “You do not meet the rules of age or disability.”
The letter mentioned her constitutional right to appeal. The Supreme Court in 1970 ruled that state and federal governments can not deprive anyone of public benefits without giving them the opportunity to adjudicate their case at a fair hearing.
The Trump administration has cited the right to a hearing as one of the “guardrails” protecting “vulnerable” Medicaid beneficiaries while moving to save money by making it harder to enroll. In November, CMS Administrator Seema Verma said imposing work requirements would help beneficiaries live “a life that knows the dignity of a job.” Now, amid the COVID-19 outbreak, the administration loosened Medicaid rules allowing states to respond more freely to the crisis, and new federal laws say states can’t kick someone off Medicaid or make enrollment more difficult (such as by imposing work requirements) until the public health emergency designation ends. So anyone who was enrolled in South Carolina’s Medicaid as of March 18 gets to keep it for now, according to the state.
To “help stop the spread of COVID-19” while still fulfilling “its critical public health mission,” South Carolina’s Department of Health and Human Services said in a statement Tuesday that it’s closed local eligibility offices to walk-ins but is maintaining normal business hours and opened its call center on Saturday so people can “complete any action they would” normally do in person over the phone or online or through the mail.
The state said it is trying to make provisions to continue hearings and appeals to ensure “the civil rights of our members … during this period of important social distancing” but did not answer questions about the status of pending cases.
Persutti appealed South Carolina’s rejection, but most people on Medicaid in the state — and elsewhere — never do. Just over 1 million people are on Medicaid in South Carolina, a state that processes applications and eligibility reviews by the tens of thousands annually. Last year, according to the state, 3,711 appeals were requested but only 101 hearings were held. It’s an eligibility and appeals system whose own employees have criticized it as being error-filled and opaque, creating delays for people needing coverage. Too many hands touch a single case file, said a 2017 report, and each time a file is given to a different employee, the chance of error increases. The result, the report said, is that “some clients are receiving benefits they are not qualified for and some are not receiving benefits when they should be.”
South Carolina’s DHHS said late last month that it’s dedicated to an “environment of continuous improvement.” And partly as a result of the feedback from state Medicaid managers studying various parts of the system, the agency has opened three new processing centers and created a team to review eligibility determinations.
Persutti no longer drives, so her daughter and Karlie took her to the hearing, where she used a walker to step into the Jefferson Square government building. At the time, the interstate to Columbia still bustled and people were unaware of what was about to hit.
Persutti imagined her hearing taking place in a formal courtroom before a panel of “old men smoking stogies.” Instead, she and Karlie faced Colleen Clark, the presiding hearing officer, and Jan Easton, who represented the state, in an unremarkable 11th-floor conference room with a box of tissues on the table.
The hearing took about an hour. And the language at times — many times — was so dense, technical and jargon-filled that Clark often stopped to translate it into something comprehensible.
Clark’s questions probed Persutti’s thick medical file, including at least two different medical evaluations done at different times that reached different conclusions about her ability to return to work. “I can’t give you a reason” why, Easton said of the discrepancy.
As for Persutti: What’s an average day like? (Unpredictable.) How many bad days in a month? (At least 10.) Was the walker you are using prescribed by a doctor? (No.) Pain medications? (Yes.) Are they controlled substances? (Some.) Did you sign for them? (Yes.)
“I do have a question,” Karlie interjected. “She was sent an acceptance letter, and then a month later it was overturned.”
Clark said the agency “accidentally approved you.” She called it “a processing error in your favor.”
As the hearing wrapped up, Clark said it might take a while to reach a decision and a letter would be sent to her home, typically in 30 days although there’s no set time frame.
Persutti returned to Hardeeville hopeful and started watching her mailbox as the world abruptly shifted.
It’s hard for Persutti to feel optimistic as time passes — and not just because of COVID-19.
Three days after her Medicaid hearing, a letter came from the South Carolina Department of Social Services saying the state gave her too much in food stamps last year, overpaying her by about $42 a month and demanding its money back.
It took a week of phone calls and paperwork to sort out the miscalculation so that she did not have to repay it.
Then came a phone call from her doctor’s office, which has a sliding pay scale for uninsured patients like Persutti.
The doctor wanted to make sure she was up to date with her prescriptions and cautioned her to stay inside.
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Like many homeless people in the United States, Carmen Morris was already in the throes of a crisis before the deadly COVID-19 epidemic began.
In December, she moved into The Sophia Way, an all-women’s homeless shelter in Bellevue, Washington, near Seattle and roughly 6 miles from the suburban nursing home that was the site of the first known COVID-19 outbreak in the country.
Living spaces in the shelter were already tight, but they have become even tighter as managers have sought to implement social distancing and head off infection among the 80 women who are served by the shelter’s programs and the 35 people who work there.
“We’re kind of cooped up, honestly,” Morris, 49, said. “We’re already a population that already has a lot on our plate, with regards to who are we, what are we doing.”
And as New York, Los Angeles and other cities try to prevent the spread of COVID-19 among homeless people, officials are likely to discover what the Seattle area already has — that social distancing is much harder to implement among people who often have little choice but to eat and sleep in close, communal settings, like shelters and tent encampments.
“In order to survive on the street, what a lot of homeless people do is they live communally, they share food, they share drugs, they share cigarettes,” said John Olson, a physician who works with homeless people receiving opioid treatment in the Seattle area. “There’s a lot of behaviors that put them at unique risk that aren’t going to change overnight.”
The result is this will be a very hard population to keep from becoming seriously ill. And while many cities and counties, including Seattle and King County, are ramping up temporary isolation, quarantine and recovery facilities, they still might not be enough.
Social distancing is “damn near impossible” in the shelter, said Alisa Chatinsky, the executive director of The Sophia Way. “We don’t have the space.”
“A Cauldron of Homelessness Risk”
Long before the Seattle area became a hot spot for the United States’ COVID-19 epidemic, the region was in the eye of the West Coast’s homelessness crisis. King County, which includes Seattle and Bellevue, has the third-largest homeless population in the country, behind New York and Los Angeles.
Homelessness in cities along the West Coast has been steadily rising for years, the culmination of more than three decades of shrinking safety net programs, coupled with rising costs of living, rents and home prices.
Places like Seattle, which have spent the last several years working to move people out of homelessness into permanent housing, must now rapidly pivot and focus on simply keeping homeless people alive.
That’s difficult under any circumstance. The homeless population nationally is aging and especially vulnerable to disease. In Seattle, as in cities across the country, the places where homeless people used to spend their days — libraries, coffee shops and even some shelters — have abruptly closed or dramatically contracted their hours in response to the outbreak.
“Trying to prepare for handling something like this on top of a massive homelessness crisis, that has a huge unsheltered component to it, makes it beyond daunting,” said Daniel Malone, executive director of the nonprofit organization that oversees one of Seattle’s largest shelters for homeless single adults, the Downtown Emergency Service Center. “It may prove to be the thing that undoes us, I guess, that we can’t deal with the massive [COVID-19] health crisis because it’s coming on top of another health crisis.”
And homeless numbers are likely to grow as unemployment surges.
“It’s like a cauldron of homelessness risk that is brewing as a result of the economic effects of the virus,” said Dennis Culhane, a leading researcher in homelessness and a professor at the University of Pennsylvania.
Culhane co-authored a paper published last week, in which he and other researchers estimate another 400,000 shelter beds will be needed to address the needs of the U.S. homeless population during the COVID-19 pandemic. One-quarter of those would simply be to increase social distancing in existing shelters.
Seattle and King County are adding roughly 630 new beds for isolation and quarantine or assessment and recovery, and the state of Washington has made $30 million available for counties to help their homeless populations. Last week, California Gov. Gavin Newsom announced $100 million for communities to increase homeless shelter capacity and emergency housing, with the state predicting 60,000 homeless people could be affected by the virus and another 12,000 hospital beds needed for them.
Culhane estimates the need at much more: Seattle and King County would need more than 9,000 new beds; New York City would need almost 21,000; and Los Angeles County would need nearly 63,000 new beds, based on Culhane’s projections.
Creating those beds would cost $11.5 billion in federal funds, Culhane and his co-authors estimate, on top of what is already annually spent in this country on homelessness — money that mostly comes from state and local governments and private donors.
Nowhere to Go
In the annual single-night count last year, nearly 570,000 people were estimated to be homeless nationwide, a 3% increase from 2018. One-third of them were unsheltered, meaning they lived in camps, on the streets, in vehicles or in abandoned buildings.
Homeless encampments are communal spaces by necessity. Often more than one person shares a tent.
Some homelessness experts worry the Trump administration could use the virus’s spread as a justification for removing homeless encampments, based on comments the president has made about cracking down on camps in California. However, the Centers for Disease Control and Prevention on Sunday explicitly advised against removing encampments during the COVID-19 outbreak, because such action can “cause people to disperse throughout the community and break connections with service providers” and increase “potential for infectious disease spread.”
Homeless shelters pose their own sets of challenges, with people sleeping on mats on the floors or in bunk beds. Even some of Seattle’s so-called enhanced shelters, where there are fewer people to a room, are still tight spaces.
Then there are the demographics of the homeless population. Last year, 40% of the 1 million people the National Health Care for the Homeless Council served were over 50. Chronic homelessness itself accelerates the aging process. Many in the homeless services community consider a 50-year-old homeless person to be elderly, said Bobby Watts, CEO of the National Health Care for the Homeless Council. Homeless people often suffer from chronic sleep deprivation and stress, and they aren’t in control of their nutrition. Respiratory illnesses are common.
That means homeless shelters are facing a two-pronged fight in their effort to hold off COVID-19: finding ways to isolate those showing symptoms, but also isolating those who would be most likely to become severely ill.
That’s been difficult, even in places like King County, where officials are racing to set up additional facilities in the coming days and weeks.
A significant number of homeless people are also dealing with mental illness that may make understanding the outbreak challenging. Others have just been through too much already. They’ve experienced extreme trauma, hunger, loss and diseases that could easily kill them. Some are simply confused why their day shelters are closing, as homeless service providers reduce hours and close drop-in centers.
“There is nowhere for them to go right now,” said Dietra Clayton, director for client services and shelter programs at the Sophia Way.
That’s a major concern long-term, as the virus requires continued social distancing and sheltering at home.
Olson, the doctor who works with homeless patients, said people used to mill about the day shelter where he sometimes worked.
“Now there’s just a lot of people walking down the street and poking their head in,” he said, but they have to be turned away. “That loss of the human connection in the community is something I worry a lot about.”
“These Are Your Mothers, These Are Your Grandmothers”
For one 55-year-old woman who moved into the Sophia Way just two weeks ago, the closures related to the coronavirus have only compounded an already stressful life. The woman, who asked not to be identified because she was fleeing an abusive ex-husband, used to go to public libraries during the day to avoid the harassing remarks of men she encountered on the street. COVID-19 has stolen almost every option she had, except maybe a park. “It makes it a lot harder for homeless women,” the woman said.
The Sophia Way has shifted to a 24/7 model to try to meet the needs of all of its clients. Now, all three programs the shelter runs — a day center program, an overnight emergency shelter and an extended stay residence for 21 women — are operating under the same roof.
Precautions that public health officials might recommend, like taking clients’ temperatures, are challenging.
“If we took their temperature and I would say to you, ‘Looks like you have a fever and we’re going to isolate you,’” Chatinsky said, “many of them will just leave and they’ll go sleep in the woods.”
And Chatinsky can’t imagine telling her clients to leave if they are sick. About 40% of the women have some kind of physical or emotional disability. Reflecting the larger homeless population, roughly one-third are over the age of 55, the vast majority of them experiencing homelessness for the first time, Chatinsky said: “We have women coming in and shuffling with walkers. These are your mothers, these are your grandmothers.”
Morris, the Sophia Way resident who arrived in December, is coping as best she can. She rushed to the library and the Goodwill before both had to close to pick up a handful of new books to read. Prize-winners, she called them, books that make you think. No Danielle Steele.
She and her fellow shelter residents have made hand washing parts of their daily routine. After so many years of hardship, she’s found comfort here and friends who will give her a warm embrace.
But COVID-19 has stopped even those simple gestures. It’s elbow bumps now.
“I miss the hugs,” Morris said. “I miss good hugs.”
For Chatinsky, the situation is deteriorating. The shelter is out of gloves, masks and disinfectant. It is running an additional $20,000 a week in expenses, to meet the demands of the virus. On Tuesday morning, one of her case managers abruptly announced she was leaving and headed back to New York to be with her family.
Chatinsky wonders if it’s only a matter of time before the virus not only affects how her clients and staff live but threatens their actual lives.
“I’ve been staying strong up until now and now I just feel like I’m melting,” Chatinsky said, as she cried. “We haven’t lost anybody yet. And I say yet. Because, it’s going to happen.”
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More than 160 million Americans have been urged to stay home in what the World Health Organization has declared a global pandemic. Nonessential businesses and schools in states like New York, Illinois and California have shuttered. In parts of the country, coronavirus patients are flooding hospitals.
Yet listeners of Mark Levin’s syndicated radio program heard on March 16 that much of the furor is a politically motivated overreaction. “I don’t want to be part of the hype machine,” Levin said. One of the country’s most-listened-to talk radio hosts, Levin averages 11 million listeners a week, according to the trade publication Talkers. “People on TV who lied to you about Russia and the Ukraine and so forth, trashing the president, using this as another opportunity to hype and dramatize their agenda.”
Levin, a prominent conservative commentator, called the virus a “serious” matter. But he also emphasized that the death toll from the “Wuhan coronavirus” was significantly lower than that from the seasonal flu in the U.S. “We have 30,000 deaths this flu season,” he said, according to a ProPublica review of broadcasts since March 10.
Levin’s attitude isn’t unusual on talk radio. Several hosts, including at least four of the 12 most listened to as measured by Talkers, have downplayed the threat of the coronavirus and criticized efforts to blunt its spread, according to broadcast archives from TVEyes.com and the nonprofit Cortico. Even after President Donald Trump declared a national emergency on March 13, some hosts groused that aggressive measures to contain the disease were a political ploy to undercut the president or ram through unpopular Democratic legislation.
Although the hosts conceded that some level of concern about COVID-19 is justified, their skepticism could deter their audiences from self-quarantining, social distancing and other behavioral changes that health officials say are necessary. As recently as last week, some Americans continued to gather on Florida beaches, revel in spring break festivities or otherwise ignore guidance. A World Health Organization spokeswoman warned Tuesday that the U.S. could become the next epicenter of the global pandemic, Reuters reported.
“When you turn something that is not political, like a disease, into a political question, you remove the legitimacy of trustworthy sources that tell you what to do,” said Yotam Ophir, a University at Buffalo professor who studies the effect of media in health and science. “If everything is measured on how it will affect my favorite politician, then everything becomes a game. This could become really dangerous.”
Several hosts, like Levin, compared COVID-19 to the seasonal flu even though epidemiologists say it has a higher mortality rate and could cause hundreds of thousands of deaths in the U.S. Also, unlike the flu, COVID-19 has no vaccine or approved treatment. Trump himself on Monday echoed the talk show commentary, arguing that the economic shutdown should be lifted because deaths from a “very active flu season” and from car accidents are “far greater than any numbers we’re talking about” of coronavirus deaths. “That doesn’t mean we’re going to tell everybody, ‘No more driving of cars,’” Trump said. (About 100 people a day die in car accidents in the U.S. — about one-seventh of the fatality rate from coronavirus in Italy. In addition, an injury or death from a car accident is not transmitted to someone who wasn’t involved.)
Mike Gallagher, another popular conservative talk radio host, reiterated Trump’s point. “The president is right,” Gallagher told listeners Tuesday morning. “The cure can’t be worse than the disease, and we’re going to have to make some difficult tradeoffs.”
Asked about his remarks, Gallagher said Tuesday afternoon that he wanted to clarify them. “In my mind I was thinking, ‘What does this look like 9, 12, 18 months from now? What does a Mom-and-Pop do who has to close for the next 6-8 months?’” he said. “It’s that kind of tradeoff. I didn’t mean any kind of tradeoff between human life and business. Human life is tantamount.” Gallagher described the past week as a “sea change for my listeners,” who “started out skeptical and dubious, and we need to own that. I just don’t think anybody could envision what this felt like and what this was going to be like.”
Other talk show hosts have likened the current pandemic to the H1N1 swine flu, which did not prompt school shutdowns or stay-at-home orders. For instance, a caller to Wendy Bell’s radio show on Pittsburgh’s KDKA on March 19 alleged the news media chose not to “hype” swine flu because it would have destroyed the economy during the burgeoning financial crisis. “Amen,” Bell interjected. She added, “It wasn’t just the media, though. It was a difference in president. So you have [Barack] Obama, who they fiercely defended.”
Bell continued: “Why the fervor to cover this like the plague when legitimately we lost 13,000 Americans? Where was the breathless coverage then? … Why wasn’t the market a complete disaster?” she told her listeners. Experts warn that the coronavirus is more lethal and appears to spread more easily than H1N1.
“You’ve got smart callers on this show, I’ll tell ya what,” Bell said before going to commercial break. KDKA has about 142,000 listeners, according to Nielsen.
Bell defended her stance in an email to ProPublica on Monday. “We’d had a total of 200 US deaths from Covid when I said that last week,” Bell wrote. “Compare the numbers. We’ve already had between 18,000 and 22,000 H1N1 deaths this flu season. And it’s been the deadliest for children (particularly ages 0 to 4) in decades.” In fact, as of March 14, there were 149 pediatric deaths from flu, the highest since 262 in 2009-10, according to the Centers for Disease Control and Prevention.
“Where’s the panic? The stock market crash? The breathless news coverage? The strict preventive measures? People sheltering in place? The task force? The social distancing? Answer. There hasn’t been any. Why? Connect the dots. You can’t pin seasonal flu on the president. Covid? It’s what Democrats are doing, plain and simple,” she continued.
Levin did not respond to attempts to contact him through Cumulus Media, the radio network that broadcasts his show, and via Fox News Channel, where he hosts a weekly show. Soon after we reached out to him, he attacked ProPublica in a series of tweets to his 2 million followers. “You can see how radical this phony ProPublica news operation truly is,” Levin wrote.
Joe “Pags” Pagliarulo, who says he has 4.5 million listeners, was similarly skeptical about the coronavirus. “Is it important-to-know information? Yes. Is it important to get the word out? Of course. Is it important to take precautions? 100%,” he said on March 13, the day Trump declared a national emergency. “Should we be doing what we’re doing right now — and I don’t mean us on this show, I mean in this country, on the globe, when it comes to this pandemic? No. I think that it’s overblown for political reasons.”
“I’ve treated this seriously and have offered solid advice and information to my listeners this entire time,” Pagliarulo wrote in an email to ProPublica on Sunday. “But I’ve made it perfectly clear that the early freakout and attacks on the president to make political gains were real and completely uncalled for.” He asked why news reports haven’t covered allegations that House Speaker Nancy Pelosi tried to “guarantee” abortion funding in an early coronavirus bill. PolitiFact found no evidence that Pelosi took any such action.
In Green Bay, Wisconsin, local talk radio host John Muir — whose show promises “a dose of the facts” — told listeners on March 18 that stay-at-home orders meant forcing people to “fork over money and spend time behind bars simply because you refuse to go along with a nonsensical overreaction to a disease that has affected 1,300 Americans.” The U.S. now has more than 44,000 confirmed cases of COVID-19, which is considered an undercount because of delays in ramping up testing. There have been no reports of anyone being jailed in the U.S. for violating a shelter-in-place order.
He continued his comparison of the “Chinese virus” to the seasonal flu and H1N1. “Donald Trump was not the president during the deadly 2009 H1N1 spread, so there was not this elitist desire to tank the U.S. economy as there is now with the coronavirus since it is Donald Trump’s reelection year,” he told listeners on News Talk WTAQ.
By Tuesday, Wisconsin health officials reported more than 400 confirmed cases, quadrupling what it was during Muir’s broadcast. Muir did not respond to a request seeking comment.
George Noory, host of the overnight radio show Coast to Coast AM on weekdays, blamed the press on March 17: “They are contributing to the hysteria, which has caused the entire planet to basically shut down.” Noory, who Talkers says has an audience of 10.5 million, told ProPublica this week that he’s been telling his audience that the coronavirus is “the flu on steroids. It’s serious. But the media is creating hysteria by blowing the figures out of proportion. The media’s not putting that into perspective.”
While adopting Trump’s description of COVID-19 as a “Chinese virus,” some hosts have gone further, accusing China of engaging in biological warfare — an allegation for which no evidence has surfaced. Perhaps the country’s best-known talk radio host, Rush Limbaugh, whom Trump awarded the presidential medal of freedom during his recent State of the Union address, suggested this theory in late February. “It probably is a Chicom laboratory experiment that is in the process of being weaponized,” Limbaugh said, invoking a shorthand for Chinese communist. “All superpower nations weaponize bio-weapons.”
Paradoxically, in the same broadcast, Limbaugh equated the coronavirus with the common cold. (Again, the coronavirus is far deadlier than both the common cold and the seasonal flu.) Limbaugh did not respond to a request for comment through Premiere Networks, which carries his show.
The far-right provocateur Alex Jones called it a “man-made virus” — a widely debunked conspiracy theory — on his internet radio show March 20.
“This was hyped up. … We can tell this was going to be huge, going to be dangerous. The virus is man-made, it is killing people. But the disproportionate media hype, saying Trump did bad and trying to shut down our market. … This is really going to destroy confidence and cause a depression,” Jones, who runs the conspiracy-driven website InfoWars, said.
Called “almost certainly the most prolific conspiracy theorist in contemporary America” by the Southern Poverty Law Center, Jones has fueled fantastical claims that the school shooting in Newtown, Connecticut, was a hoax. Prominent social media companies, including Facebook, have barred him from their platforms.
“You’ve got all these globalist cheerleaders, on television,” Jones said, “hyping the fall of the economy, foaming at the mouth.”
Jones didn’t respond to a request for comment. By implementing economic shutdowns and social distancing, government officials heeded the advice of epidemiologists who say that these are among the most effective ways to slow an epidemic.
Some prominent right-wing hosts have taken a sharply different tone. Steve Bannon, Trump’s former chief strategist, who has his own radio show, warned this week on Fox News that he’d recommend a “full shutdown” because the country was running out of time.
“Drop the hammer. Don’t mitigate the virus. Don’t spread the curve,” he said Sunday. “Shatter the curve and go full-hammer on the virus right now with a full shutdown.”
Lucas Waldron, Caroline Chen, and Alice Wilder contributed reporting.