Category: From California Healthline.org

BOULDER, Colo. — Brady Bowman, a 19-year-old student at the University of Colorado-Boulder, and two friends strolled down 11th Street, all sporting matching neck gaiters branded with the Thomas’ English Muffins logo. He had received an entire box of the promotional gaiters.

He thinks they are just more comfortable to wear than a face mask. “Especially a day like today, where it’s cold out,” he said, with the top of his gaiter pulled down below his chin.

More stylish? Perhaps. More comfortable? Maybe. But as effective? Not necessarily.

With states such as Colorado requiring face coverings indoors to prevent the spread of COVID-19, gaiters and bandannas have become popular accessories, particularly among college students and other young adults. Less restrictive than masks, they can easily be pulled up or down as needed — and don’t convey that just-out-of-the-hospital vibe.

But tests show those hipper face coverings are not as effective as surgical or cloth face masks. Bandannas, like plastic face shields, allow the virus to escape out the bottom in aerosolized particles that can hang in the air for hours. And gaiters are often made of such thin material that they don’t trap as much virus as cloth masks.

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As new COVID cases, hospitalizations and deaths surge upward heading into winter, many public health experts wonder whether it’s time to move beyond the anything-goes approach toward more standardization and higher-quality masks. President-elect Joe Biden reportedly is mulling a national face-covering mandate of some sort, which could not only increase mask-wearing but better define for Americans what sort of face covering would be most protective.

“Unlike seat belts, condoms or other prevention strategies, we have not yet standardized what we are recommending for the public,” said Dr. Monica Gandhi, an infectious disease specialist at the University of California-San Francisco. “And that has been profoundly confusing for the American public, to have all these masks on the market.”

Patchwork of Regulations

Masks have been shown to reduce the spread of respiratory droplets that contain the coronavirus. And the Centers for Disease Control and Prevention now says that masks not only help prevent people from infecting others but help protect the wearers from infection as well.

According to a recent analysis by the Institute for Health Metrics and Evaluation, implementing universal mask-wearing in late September would have saved nearly 130,000 American lives by the end of February.

Even so, many Americans still aren’t wearing masks. And in some states, they haven’t been required to do so.

At least 37 states and the District of Columbia have mandated face coverings but show wide variation in defining what qualifies. States such as Maryland and Rhode Island include bandannas or neck gaiters in their definitions, while South Carolina and Michigan do not, according to a KHN review of the orders. Some spell out the circumstances in which coverings must be worn or establish enforcement policies.

But according to Lawrence Gostin, a Georgetown University law professor, many states are not holding residents to those rules. Some state or local officials are choosing not to enforce them.

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“We have a patchwork of inconsistent rules and laws around the country,” Gostin said. “And when we are dealing with a nationwide pandemic, a patchwork just won’t get the job done.”

Cloth mask manufacturing was nearly nonexistent in the U.S. before the pandemic, so public health officials opted early in the year to stress the importance of wearing any face covering rather than trying to focus on one standard. As a result, Americans are wearing a hodgepodge of coverings, from home-sewn to commercial versions, with various levels of protection.

And what is worn matters. Dr. Iahn Gonsenhauser, an infectious disease specialist at the Ohio State University Wexner Medical Center, said face coverings generally fall into three categories of effectiveness. N95 masks (not those with valves), surgical masks and well-made cloth masks (constructed of tightly woven material, folded over two or three times, and properly covering the mouth and nose) are in the highly effective category.

Bandannas, neck gaiters and face shields lie at the other end of the spectrum, and most everything else falls in the middle.

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“Bandannas are typically a thinner material, so if they’re not doubled or tripled up, that can allow respiratory droplets, in particular, to move through the masks,” he said. “But the fact that they’re open along the bottom of the mouth and neck, if they’re not tucked into a shirt or something like that, also allows for a lot of that exhalation droplet to escape around the mask and become airborne.”

A plastic face shield can block larger droplets but won’t stop aerosolized particles from flowing beyond its edges.

The evidence around neck gaiters has been mixed, in part because so many materials and designs are used. But recent testing suggests even the thin material commonly used to make gaiters is nearly as effective as a cloth mask if doubled over.

“With few exceptions, the best mask is the mask that somebody is going to use regularly and consistently,” Gonsenhauser said. “It may be that the best technical mask is not going to be the mask that everybody’s going to be willing to wear all the time.”

Researchers at the National Institute for Occupational Safety and Health have found most of the commercially produced cloth masks block 40% to 60% of droplets, approaching the effectiveness of surgical masks.

“You can’t possibly test everything, but certainly one take-home message is that anything is better than nothing,” said William Lindsley, a NIOSH biomedical engineer. “We haven’t tested anything that has not worked.”

Call for Standardization

But Gandhi believes it’s time to raise the standards for masks, ramp up the production of disposable surgical masks and encourage, if not order, Americans to wear them. Early in the pandemic, the Trump administration reportedly considered sending masks to every American but ultimately decided against it.

Taiwan, on the other hand, invested in manufacturing and distributing surgical masks, and it has one of the lowest COVID death counts in the world: fewer than 10 deaths in a country of 24 million people.

“It makes more sense to standardize masks, to mass-produce surgical masks, which are not very expensive,” Gandhi said. “We’re spending a lot more on everything else.”

She said surgical masks might even reduce the severity of COVID-19. Gandhi and several colleagues recently wrote in a medical journal article that evidence suggests the less virus a person is exposed to, the less sick they become.

That’s been backed up in tests with lab animals exposed to the coronavirus and with humans exposed to other, less dangerous respiratory viruses.

Other evidence also supports that theory. While the CDC estimates about 40% of COVID cases are asymptomatic, outbreaks in food processing plants where workers were handed surgical or N95 masks as they entered showed a much higher proportion of infected workers never developed symptoms. That could explain why many Asian countries, where mask-wearing has been a cultural norm for decades, have been able to reopen their economies without seeing death rates as high as in the United States.

“Tokyo is a good example. It’s wide open, the people are walking around shoulder to shoulder, people are going to offices, people are going to school,” Gandhi said. “But they’re all masked and they have very low rates of severe illness.”

If she’s right, a national mandate calling for surgical masks could both reduce transmission and prevent serious disease.

“We can’t wait,” Gandhi said. “We’ve had enough deaths from this infection. Our case fatality rates in a country of this degree of development are just tragic.”

It remains to be seen whether Americans will be more willing to wear dowdier, less comfortable but more effective masks to protect themselves and others. When Bowman, the Boulder college student, was asked if he was worried that his gaiter might not block as much of the virus as a face mask, he seemed unconcerned.

“As long as the other person is wearing a mask,” he said.

When he started researching a troublesome childhood infection nearly four decades ago, virologist Dr. Barney Graham, then at Vanderbilt University, had no inkling his federally funded work might be key to deliverance from a global pandemic.

Yet nearly all the vaccines advancing toward possible FDA approval this fall or winter are based on a design developed by Graham and his colleagues, a concept that emerged from a scientific quest to understand a disastrous 1966 vaccine trial.

Basic research conducted by Graham and others at the National Institutes of Health, Defense Department and federally funded academic laboratories has been the essential ingredient in the rapid development of vaccines in response to COVID-19. The government has poured an additional $10.5 billion into vaccine companies since the pandemic began to accelerate the delivery of their products.

The Moderna vaccine, whose remarkable effectiveness in a late-stage trial was announced Monday morning, emerged directly out of a partnership between Moderna and Graham’s NIH laboratory.

Coronavirus vaccines are likely to be worth billions to the drug industry if they prove safe and effective. As many as 14 billion vaccines would be required to immunize everyone in the world against COVID-19. If, as many scientists anticipate, vaccine-produced immunity wanes, billions more doses could be sold as booster shots in years to come. And the technology and production laboratories seeded with the help of all this federal largesse could give rise to other profitable vaccines and drugs.

The vaccines made by Pfizer and Moderna, which are likely to be the first to win FDA approval, in particular rely heavily on two fundamental discoveries that emerged from federally funded research: the viral protein designed by Graham and his colleagues, and the concept of RNA modification, first developed by Drew Weissman and Katalin Karikó at the University of Pennsylvania. In fact, Moderna’s founders in 2010 named the company after this concept: “Modified” + “RNA” = Moderna, according to co-founder Robert Langer.

“This is the people’s vaccine,” said corporate critic Peter Maybarduk, director of Public Citizen’s Access to Medicines program. “Federal scientists helped invent it and taxpayers are funding its development. … It should belong to humanity.”

Moderna, through spokesperson Ray Jordan, acknowledged its partnership with NIH throughout the COVID-19 development process and earlier. Pfizer spokesperson Jerica Pitts noted the company had not received development and manufacturing support from the U.S. government, unlike Moderna and other companies.

The idea of creating a vaccine with messenger RNA, or mRNA — the substance that converts DNA into proteins — goes back decades. Early efforts to create mRNA vaccines failed, however, because the raw RNA was destroyed before it could generate the desired response. Our innate immune systems evolved to kill RNA strands because that’s what many viruses are.

Karikó came up with the idea of modifying the elements of RNA to enable it to slip past the immune system undetected. The modifications she and Weissman developed allowed RNA to become a promising delivery system for both vaccines and drugs. To be sure, their work was enhanced by scientists at Moderna, BioNTech and other laboratories over the past decade.

Another key element in the mRNA vaccine is the lipid nanoparticle — a tiny, ingeniously designed bit of fat that encloses the RNA in a sort of invisibility cloak, ferrying it safely through the blood and into cells and then dissolving, thereby allowing the RNA to do its work of coding a protein that will serve as the vaccine’s main active ingredient. The idea of enclosing drugs or vaccines in lipid nanoparticles arose first in the 1960s and was developed by Langer and others at the Massachusetts Institute of Technology and various academic and industry laboratories.

Karikó began investigating RNA in 1978 in her native Hungary and wrote her first NIH grant proposal to use mRNA as a therapeutic in 1989. She and Weissman achieved successes starting in 2004, but the path to recognition was often discouraging.

“I keep writing and doing experiments, things are getting better and better, but I never get any money for the work,” she recalled in an interview. “The critics said it will never be a drug. When I did these discoveries, my salary was lower than the technicians working next to me.”

Eventually, the University of Pennsylvania sublicensed the patent to Cellscript, a biotech company in Wisconsin, much to the dismay of Weissman and Karikó, who had started their own company to try to commercialize the discovery. Moderna and BioNTech later would each pay $75 million to Cellscript for the RNA modification patent, Karikó said. Though unhappy with her treatment at Penn, she remained there until 2013 — partly because her daughter, Susan Francia, was making a name for herself on the school’s rowing team. Francia would go on to win two Olympic gold medals in the sport. Karikó is now a senior officer at BioNTech.

In addition to RNA modification and the lipid nanoparticle, the third key contribution to the mRNA vaccines — as well as those made by Novavax, Sanofi and Johnson & Johnson —- is the bioengineered protein developed by Graham and his collaborators. It has proved in tests so far to elicit an immune response that could prevent the virus from causing infections and disease.

The protein design was based on the observation that so-called fusion proteins — the pieces of the virus that enable it to invade a cell — are shape-shifters, presenting different surfaces to the immune system after the virus fuses with and infects cells. Graham and his colleagues learned that antibodies against the post-fusion protein are far less effective at stopping an infection.

The discovery arose in part through Graham’s studies of a 54-year-old tragedy — the failed 1966 trial of an NIH vaccine against respiratory syncytial virus, or RSV. In a clinical trial, not only did that vaccine fail to protect against the common childhood disease, but most of the 21 children who received it were hospitalized with acute allergic reactions, and two died.

About a decade ago, Graham, now deputy director of NIH’s Vaccine Research Center, took a new stab at the RSV problem with a postdoctoral fellow, Jason McLellan. After isolating and obtaining three-dimensional models of the RSV’s fusion protein, they worked with Chinese scientists to identify an appropriate neutralizing antibody against it.

“We were sitting in Xiamen, China, when Jason got the first image up on his laptop, and I was like, oh my God, it’s coming together,” Graham recalled. The prefusion antibodies they discovered were 16 times more potent than the post-fusion form contained in the faulty 1960s vaccine.

Two 2013 papers the team published in Science earned them a runner-up prize in the prestigious journal’s Breakthrough of the Year award. Their papers, which showed it was possible to plan and create a vaccine at the microscopic structural level, set the NIH’s Vaccine Research Center on a path toward creating a generalizable, rapid way to design vaccines against emerging pandemic viruses, Graham said.

In 2016, Graham, McLellan and other scientists, including Andrew Ward at the Scripps Research Institute, advanced their concept further by publishing the prefusion structure of a coronavirus that causes the common cold and a patent was filed for its design by NIH, Scripps and Dartmouth — where McLellan had set up his own lab. NIH and the University of Texas — where McLellan now works — filed an additional patent this year for a similar design change in the virus that causes COVID-19.

Graham’s NIH lab, meanwhile, had started working with Moderna in 2017 to design a rapid manufacturing system for vaccines. In January, they were preparing a demonstration project, a clinical trial to test whether Graham’s protein design and Moderna’s mRNA platform could be used to create a vaccine against Nipah, a deadly virus spread by bats in Asia.

Their plans changed rapidly when they learned on Jan. 7 that the epidemic of respiratory disease in China was being caused by a coronavirus.

“We agreed immediately that the demonstration project would focus on this virus” instead of Nipah, Graham said. Moderna produced a vaccine within six weeks. The first patient was vaccinated in an NIH-led clinical study on March 16; early results from Moderna’s 30,000-volunteer late-stage trial showed it was nearly 95% effective at preventing COVID-19.

Although other scientists have advanced proposals for what may be even more potent vaccine antigens, Graham is confident that carefully designed vaccines using nucleic acids like RNA reflect the future of new vaccines. Already, two major drug companies are doing advanced clinical trials for RSV vaccines based on the designs his lab discovered, he said.

In a larger sense, the pandemic could be the event that paves the way for better, perhaps cheaper and more plentiful vaccines.

“It’s a silver lining, but I think we are definitely pushing forward the way everyone is thinking about vaccines,” said Michael Farzan, chair of the department of immunology and microbiology at Scripps Research’s Florida campus. “Certain techniques that have been waiting in the wings, under development but never achieving the kind of funding they needed for major tests, will finally get their chance to shine.”

Under a 1980 law, the NIH will obtain no money from the coronavirus vaccine patent. How much money will eventually go to the discoverers or their institutions isn’t clear. Any existing licensing agreements haven’t been publicized; patent disputes among some of the companies will likely last years. HHS’ big contracts with the vaccine companies are not transparent, and Freedom of Information Act requests have been slow-walked and heavily redacted, said Duke University law professor Arti Rai.

Some basic scientists involved in the enterprise seem to accept the potentially lopsided financial rewards.

“Having public-private partnerships is how things get done,” Graham said. “During this crisis, everything is focused on how can we do the best we can as fast as we can for the public health. All this other stuff is going to have to be figured out later.”

“It’s not a good look to become extremely wealthy off a pandemic,” McLellan said, noting the big stock sales by some vaccine company executives after they received hundreds of millions of dollars in government assistance. Still, “the companies should be able to make some money.”

For Graham, the lesson of the coronavirus vaccine response is that a few billion dollars a year spent on additional basic research could prevent a thousand times as much loss in death, illness and economic destruction.

“Basic research informs what we do, and planning and preparedness can make such a difference in how we get ahead of these epidemics,” he said.

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

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SANTA CRUZ, Calif. — For Tom Davis, being told by the state this week that he must close his Pacific Edge Climbing Gym for the third time in six months is beyond frustrating. The first time the rock-climbing gym and fitness center shut down, co-owners Davis and Diane Russell took out a government loan to pay employees. The second time, they were forced to lay everyone off — themselves included. Now, as they face another surge of COVID cases across California, he fears he may lose the business for good.

California’s ping-ponging approach to managing the virus — twice reopening large portions of the service-sector economy only to shut them again — doesn’t seem just or reasonable, Davis said. As of Tuesday evening, he was planning to defy the order, keeping the gym open but with additional restrictions on capacity.

“The government is essentially saying, ‘We’re just picking you to personally go bankrupt and all the people who work with you,’” said Davis. “Nobody can afford to live in Santa Cruz on unemployment.”

It’s a grim time in the pandemic. California has surpassed 1 million cases of COVID-19 and 94% of Californians — more than 37.7 million people — live in a county considered to have “widespread” infection. Santa Cruz is one of 41 California counties now under the most restrictive orders in the state’s four-tiered COVID blueprint for determining which businesses can stay open amid the pandemic, and under what proscriptions.

Until Monday, Santa Cruz was in the red tier — the second-most restrictive — meaning Pacific Edge could be open at 10% capacity. Now, its owners are being told to close entirely.

For business owners and workers, a backward slide on the blueprint represents yet another financial setback in a bleak year, leaving some residents angry, exasperated and wondering if this is really the best the state can do.

It’s a question reverberating nationwide as every state experiences a deadly rise in COVID cases and a growing number of hospitals say they are simply out of beds. Among states, California is performing relatively well, ranking 39th in cases per capita and 32nd in deaths, according to a New York Times tracker.

But even here, the virus is too pervasive in its spread — and the public health infrastructure too enfeebled — to make the reopening of businesses and schools an easy proposition. Some experts say that during a pandemic, when the virus is everywhere, the push and pull California businesses are enduring may be what success looks like in much of the U.S. for months to come.

“The yo-yo nature of this is a feature of the pandemic,” said Dr. Ashish Jha, dean of the School of Public Health at Brown University. “And in fact, when I look at really successful countries like South Korea, Taiwan and New Zealand, they all have a yo-yo feeling to them.”

Experts say a crucial factor in being able to reopen safely is getting cases low enough that time-tested public health tools like quarantines and contact tracing can work. Most U.S. hot spots, including broad swaths of California, have never achieved those low levels.

In California, Gov. Gavin Newsom, like many other governors, is trying to thread the needle, to keep cases to a minimum while also allowing many businesses to remain open. It’s a sensitive equation, said Dr. Aimee Sisson, public health officer for Yolo County.

“It’s really hard to dial in the balances of getting our economy going again, which is important for public health, and maintaining our health, which is important for the economy.”

And while California is doing better than many other states, said Cameron Kaiser, the health officer for Riverside County, it’s certainly not cause for celebration. “At this point we’re clearly doing better, but our trends are not good either. When you’re talking about the relative impact of different tragedies, I’m not sure you’d call that a success.”

Even as it frustrates some residents, California’s tiered reopening system has won praise nationally. The system draws on three COVID metrics to guide restrictions: new cases per population; the share of people tested for the coronavirus who are positive; and, in larger counties, an equity measure to ensure cases are low across the county, including in high-risk communities. Under revised guidelines released this week, county tier assignments can change from week to week — and more than once a week if data indicates a county is losing ground.

“We think it’s a best practice nationally and globally,” said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention. “This is not about closure — this is about adjusting what is open when.”

Still, the state blueprint isn’t perfect, health officers say. In its early stages, there were inconsistencies around which businesses could stay open. For example, nail salons were treated differently from hair salons, though the exposure conditions are fairly similar. The state has taken feedback, said Sisson, and tried to make improvements.

And perhaps the biggest weakness is how little data exists to determine which businesses present the greatest risks for exposure and transmission, said Sisson and other health officers. While restaurants and bars are broadly considered high-risk because people remove their masks while eating and drinking, not much is known about viral spread at places like gyms and movie theaters, where it’s possible to reduce occupancy and wear masks.

That’s part of what frustrates Davis in Santa Cruz. Pacific Edge has reduced occupancy to just 30 people in the sprawling old factory building and instituted a range of protective measures. “Compare that to Costco. I honestly believe we are just as safe if not safer than other businesses,” Davis said.

Measuring California’s success in navigating the pandemic depends on what your goal is, said Marm Kilpatrick, an infectious disease researcher at the University of California-Santa Cruz who has been advising local government and businesses, including Pacific Edge, on reopening. The state has prioritized both keeping businesses open and keeping cases down, which means neither can be done perfectly.

Still, he’s not sure the whiplash of openings and closings is the best the state can do. He worries the tiered system may inadvertently send the wrong signals: Again and again, public health officials have watched in dismay as residents whose counties move into less-restrictive tiers revert to socializing in large groups and shedding basic safety protocols like masks and social distancing — followed by a dangerous upsurge in infections and hospitalizations.

Dr. Mark Ghaly, the state’s Health and Human Services secretary, has acknowledged as much, stressing that cases are linked to both social gatherings and businesses. Ultimately, he said on Monday, the state is taking a “dual approach” that includes changes to business practices, and asking individuals to be disciplined in wearing masks outside the home, regularly sanitizing hands, staying 6 feet apart, and socializing outdoors and in small gatherings.

Meanwhile, the holiday season looms. The most recent spike in cases directly correlates to Halloween, several health officers said, just as previous spikes were linked to Memorial Day, the Fourth of July and Labor Day. With Thanksgiving, Christmas and New Year’s on the horizon, officials wonder whether they might have to recommend a farther-reaching stay-at-home order to keep cases under control.

“I’m very worried about Thanksgiving,” said Dr. Chris Farnitano, health officer for Contra Costa County. “The tradition of so many families is to get together with their extended families, and that means gatherings with groups of people, and that’s where the virus wants to spread.”

In addition, Farnitano said, given the realities of commerce and travel, what happens in other states affects California. “Having other states with the same restrictions would help California,” he said.

What’s really needed, several public health officials said, is a coordinated national message and strategy.

“I’m hoping we’re gonna have the new president come in and take the reins very firmly,” said Steffanie Strathdee, associate dean of global health at UC-San Diego. “He has the right people around him advising him. But, by then, winter will be half over and we’re going to be facing 400,000 deaths. Digging ourselves out of that mess is going to take awhile.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Nurse Leslie McKamey has gotten used to the 16-hour shifts, to skipping lunch, to the nightly ritual of throwing all her clothes in the laundry and showering as soon as she walks through the door to avoid potentially infecting her children. She’s even grown accustomed to triaging COVID patients, who often arrive at the emergency room so short of breath they struggle to describe their symptoms.

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But despite the trauma and exhaustion of the past eight months, she was shocked when North Dakota Gov. Doug Burgum said last week that health care workers who test positive for the coronavirus but do not display symptoms could still report to work. The order, in line with CDC guidance for mitigating staff shortages, would allow asymptomatic health workers who test positive to work only in COVID units, and treat patients who already have the virus.

But many feel the idea endangers the workers and their colleagues. It comes as North Dakota faces one of the worst outbreaks of COVID-19 and grapples with health care staff shortages.

“We’re worried about somebody dying, frankly, because we couldn’t get to them in time,” said McKamey, an emergency room registered nurse in Bismarck.

According to data from the COVID Tracking Project, more than 9,400 North Dakotans tested positive for COVID-19 last week alone. About 1 in 12 North Dakota residents have been infected with the virus; nearly 1 in 1,000 have died. In early November, the North Dakota Department of Health reported that there were only 12 open ICU beds in the state.

McKamey said Burgum’s order goes against everything she’s been taught as a nurse.

“If hospital administrators start forcing COVID-positive staff to go to work, it’s going to be very scary. We’re trained to do no harm, and asking COVID-positive, asymptomatic nurses to return to work is putting patients at risk. It’s putting fellow staff members at risk.”

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Nine months into the pandemic, it’s clear health care workers already face increased risks. Lost on the Frontline, a joint effort by The Guardian and KHN, is investigating the deaths of 1,375 health care workers who appear to have died of COVID-19 since the start of the pandemic. Nearly a third of those health care workers were nurses.

McKamey described long shifts in an emergency room that has begun taking on patients overnight because other wards of the hospital did not have the capacity to admit them. Nurses pick up extra shifts to cover for colleagues who have gotten sick and take on multiple critical patients at once.

It is a scene playing out in hospitals across the country, as the coronavirus spreads unabated. As of Monday, more than 11 million people in the United States had been infected with the virus, with health officials reporting 180,000 new infections in a single day. And the country is bracing for another milestone: It will soon surpass a quarter-million deaths from COVID-19.

Health care workers are overwhelmed and exhausted. According to a recent survey from the National Nurses United, more than 70% of hospital nurses said they were afraid of contracting COVID-19 and 80% feared they might infect a family member. More than half said they struggled to sleep and 62 reported feeling stressed and anxious. Nearly 80% said they were forced to reuse single-use PPE, like N95 respirators.

Inaction at the state and federal levels have left many health care workers feeling abandoned. When Gov. Burgum issued the order that infected but asymptomatic nurses could report to work in COVID units, North Dakota had not implemented any kind of statewide mask mandate, despite expert guidance that such a measure could significantly reduce transmission of the virus.

Tessa Johnson is a registered nurse at a Bismarck nursing home and president of the North Dakota Nurses Association, which issued a statement last week denouncing Burgum’s order that infected nurses continue to work.

She said the state could have done much more to ensure patients don’t become infected in the first place. “We’ve asked and asked and asked for a mask mandate, and that hasn’t happened,” she said Thursday.

On Friday night, Burgum did an about-face and issued a mask mandate, ordering individuals to cover their faces when inside businesses, indoor public settings and outdoor public settings where physical distancing may be impossible.

“Our doctors and nurses heroically working on the front lines need our help, and they need it now,” he said in a press statement.

Still, Johnson said there’s a disconnect between what health care workers are experiencing inside North Dakota’s health facilities, and how the general population perceives the virus. And that even before Burgum’s comments, some of her colleagues felt they had to choose between taking all precautions and limited time off. “One of my closest friends, also a health care worker, said to me the other day, ‘There’s no way I will ever get tested unless I’m very sick, because I don’t want to use my paid leave.’”

McKamey, the ER nurse, said she hasn’t had time to process the stress of the past several months. She’s focused on staying healthy, gearing up for what she anticipates will be a difficult winter and keeping her patients alive. “We are willing to break our backs and work as hard as we physically can,” McKamey said. “But then to ask us to come in as a potential infectious source is just stunning.”

As the novel coronavirus emerged in the news in January, Sarah Keeley was working as a medical scribe and considering what to do with her biology degree.

By February, as the disease crept across the U.S., Keeley said she found her calling: a career in public health. “This is something that’s going to be necessary,” Keeley remembered thinking. “This is something I can do. This is something I’m interested in.”

In August, Keeley began studying at the University of Illinois at Urbana-Champaign to become an epidemiologist.

Public health programs in the United States have seen a surge in enrollment as the coronavirus has swept through the country, killing more than 246,000 people. As state and local public health departments struggle with unprecedented challenges — slashed budgets, surging demand, staff departures and even threats to workers’ safety — a new generation is entering the field.

Among the more than 100 schools and public health programs that use the common application — a single admissions application form that students can send to multiple schools — there was a 20% increase in applications to master’s in public health programs for the current academic year, to nearly 40,000, according to the Association of Schools and Programs of Public Health.

Some programs are seeing even bigger jumps. Applications to Brown University’s small master’s in public health program rose 75%, according to Annie Gjelsvik, a professor and director of the program.

Demand was so high as the pandemic hit full force in the spring that Brown extended its application deadline by over a month. Seventy students ultimately matriculated this fall, up from 41 last year.

“People interested in public health are interested in solving complex problems,” Gjelsvik said. “The COVID pandemic is a complex issue that’s in the forefront every day.”

It’s too early to say whether the jump in interest in public health programs is specific to that field or reflects a broader surge of interest in graduate programs in general, according to those who track graduate school admissions. Factors such as pandemic-related deferrals and disruptions in international student admissions make it difficult to compare programs across the board.

Magnolia E. Hernández, an assistant dean at Florida International University’s Robert Stempel College of Public Health and Social Work, said new student enrollments in its master’s in public health program grew 63% from last year. The school has especially seen an uptick in interest among Black students, from 21% of newly admitted students last fall to 26.8% this year.

Kelsie Campbell is one of them. She’s part Jamaican and part British. When she heard in both the British and American media that Black and ethnic minorities were being disproportionately hurt by the pandemic, she wanted to focus on why.

“Why is the Black community being impacted disproportionately by the pandemic? Why is that happening?” Campbell asked. “I want to be able to come to you and say ‘This is happening. These are the numbers and this is what we’re going to do.’”

The biochemistry major at Florida International said she plans to explore that when she begins her MPH program at Stempel College in the spring. She said she hopes to eventually put her public health degree to work helping her own community.

“There’s power in having people from your community in high places, somebody to fight for you, somebody to be your voice,” she said.

Public health students are already working on the front lines of the nation’s pandemic response in many locations. Students at Brown’s public health program, for example, are crunching infection data and tracing the spread of the disease for the Rhode Island Department of Health.

Some students who had planned to work in public health shifted their focus as they watched the devastation of COVID-19 in their communities. In college, Emilie Saksvig, 23, double-majored in civil engineering and public health. She was supposed to start working this year as a Peace Corps volunteer to help with water infrastructure in Kenya. She had dreamed of working overseas on global public health.

The pandemic forced her to cancel those plans, and she decided instead to pursue a master’s degree in public health at Emory University.

“The pandemic has made it so that it is apparent that the United States needs a lot of help, too,” she said. “It changed the direction of where I wanted to go.”

These students are entering a field that faced serious challenges even before the pandemic exposed the strains on the underfunded patchwork of state and local public health departments. An analysis by AP and KHN found that since 2010, per capita spending for state public health departments has dropped by 16%, and for local health departments by 18%. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.

And the workforce is aging: Forty-two percent of governmental public health workers are over 50, according to the de Beaumont Foundation, and the field has high turnover. Before the pandemic, nearly half of public health workers said they planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons. Some public health workers are paid so little that they qualify for public aid.

Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, said government public health jobs need to be a “destination job” for top graduates of public health schools.

“If we aren’t going after the best and the brightest, it means that the best and the brightest aren’t protecting our nation from those threats that can, clearly, not only devastate from a human perspective, but from an economic perspective,” Castrucci said.

The pandemic put that already-stressed public health workforce in the middle of what became a pitched political battle over how to contain the disease. As public health officials recommended closing businesses and requiring people to wear masks, many, including Dr. Anthony Fauci, the U.S. government’s top virus expert, faced threats and political reprisals, AP and KHN found. Many were pushed out of their jobs. An ongoing count by AP/KHN has found that more than 100 public health leaders in dozens of states have retired, quit or been fired since April.

Those threats have had the effect of crystallizing for students the importance of their work, said Patricia Pittman, a professor of health policy and management at George Washington University’s Milken Institute School of Public Health.

“Our students have been both indignant and also energized by what it means to become a public health professional,” Pittman said. “Indignant because many of the local and the national leaders who are trying to make recommendations around public health practices were being mistreated. And proud because they know that they are going to be part of that front-line public health workforce that has not always gotten the respect that it deserves.”

Saksvig compared public health workers to law enforcement in the way they both have responsibility for enforcing rules that can alter people’s lives.

“I feel like before the coronavirus, a lot of people didn’t really pay attention to public health,” she said. “Especially now when something like a pandemic is happening, public health people are just on the forefront of everything.”

KHN Midwest correspondent Lauren Weber and KHN senior correspondent Anna Maria Barry-Jester contributed to this report.

This story is a collaboration between The Associated Press and KHN.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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For years, Sharad Acharya’s frequent hikes in the mountains outside Denver would leave him short of breath. But a real wake-up call came three years ago when he suddenly struggled to breathe while walking through an airport.

An electrocardiogram revealed that Acharya, a Nepali American from Broomfield, Colorado, had an irregular heartbeat on top of the high blood pressure he already knew about. He had to immediately undergo triple bypass surgery and get seven stents.

Acharya, now 54, thought of his late father and his many uncles who have had heart problems.

“It’s part of my genetics, for sure,” he said.

South Asian Americans — people with roots in Nepal, India, Pakistan, Sri Lanka, Bangladesh, Bhutan and the Maldives — have a disproportionately higher risk of heart disease and other cardiovascular ailments. Worldwide, South Asians account for 60% of all heart disease cases, even though — at 2 billion people — they make up only a quarter of the planet’s population.

In the United States, there’s increasing attention on these risks for Americans of South Asian descent, a growing population of about 5.4 million. Health care professionals attribute the problem to a mix of genetic, cultural and lifestyle influences — but researchers are advocating for more resources to fully understand it.

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Rep. Pramila Jayapal (D-Wash.) is sponsoring legislation that would direct $5 million over the next five years toward research into heart disease among South Asian Americans and raising awareness of the issue. The bill passed the U.S. House in September and is up for consideration in the Senate.

The issue could gain more attention after Sen. Kamala Harris (D-Calif.) becomes the nation’s first vice president with South Asian lineage. Harris’ mother, Shyamala Gopalan, moved from India to the U.S. in 1958 to attend graduate school. Gopalan, a breast cancer researcher, died in 2009 of colon cancer.

A 2018 study for the American Heart Association found South Asian Americans are more likely to die of coronary heart disease than other Asian Americans and non-Hispanic white Americans. The study pointed to their high incidences of diabetes and prediabetes as risk factors, as well as high waist-to-hip ratios. People of South Asian descent have a higher tendency to gain visceral fat in the abdomen, which is associated with insulin resistance. They also were found to be less physically active than other ethnic groups in the U.S.

One of the nation’s largest undertakings to understand these risks is the Mediators of Atherosclerosis in South Asians Living in America study, which began in 2006. The MASALA researchers, from institutions such as Northwestern University and the University of California-San Francisco, have examined more than 1,100 South Asian American men and women ages 40-79 to better understand the prevalence and outcomes of cardiovascular disease. They stress that high blood pressure and diabetes are common in the community, even for people at normal weights.

That’s why, said Dr. Alka Kanaya, MASALA’s principal investigator and a professor at UCSF, South Asians cannot rely on traditional body mass index metrics, because BMI numbers considered normal could provide false reassurance to those who might still be at risk.

Kanaya recommends cardiac CT scans, which she said help identify high-risk patients, those who need to make more aggressive lifestyle changes and those who may need preventive medication.

Another risk factor, this one cultural, is diet. Some South Asian Americans are vegetarians, though it’s often a grain-heavy diet reliant on rice and flatbread. The AHA study found risks in such diets, which are high in refined carbohydrates and saturated fat.

“We have to understand the cultural nuances [with] an Indian vegetarian diet,” said Dr. Ronesh Sinha, author of “The South Asian Health Solution” and an internal medicine physician. “That means something totally different than … a Westerner who’s going to be consuming a lot of plant-based protein and tofu, eating lots of salads and things that typical South Asians don’t.”

But getting South Asians to change their eating habits can be challenging, because their culture expresses hospitality and love through food, according to Arnab Mukherjea, an associate professor of health sciences at California State University-East Bay. “One of the things South Asians tend to take a lot of pride in is transmitting cultural values and norms knowledge to the next generation,” Mukherjea said.

Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains. (Eli Imadali for KHN)

The intergenerational transmission goes both ways, according to MASALA researchers. Adult, second-generation South Asian Americans might be the key to helping those in the first generation who are resistant to change adopt healthier habits, according to Kanaya.

In the San Francisco Bay Area, El Camino Hospital’s South Asian Heart Center is one of the nation’s leading centers for educating the community. Its three locations are not far from Silicon Valley tech giants, which employ many South Asian Americans.

The center’s medical director, Dr. César Molina, said the center treats many relatively young patients of South Asian descent without typical risk factors for cardiovascular disease.

“It was like the typical 44-year-old engineer with a spouse and two kids showing up with a heart attack,” he said.

The South Asian Health Center helps patients make lifestyle changes through meditation, exercise, diet and sleep. The nearby Palo Alto Medical Foundation’s Prevention and Awareness for South Asians program and the Stanford South Asian Translational Heart Initiative provide medical support for the community. Even patients in the later stages of heart disease can be helped by lifestyle changes, Sinha said.

Dr. Kevin Shah, a University of Utah cardiologist who co-authored the AHA study, said people with diabetes, hypertension and obesity are also at higher risk of COVID-19 complications so should now especially work to improve their cardiovascular health and fitness.

In Colorado, Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.

“Nowadays, I feel very, very good,” he said. “I’m hiking a lot.”

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The coronavirus pandemic has killed more than 246,000 people in the U.S., but it also has left hundreds of thousands of others grieving, and often feeling as if they have been robbed of the usual methods for dealing with the loss. For every person who dies of the virus, nine close family members are affected, researchers estimate. In addition to deep sadness, the ripple effects may linger for years as survivors deal with traumatic stress, anxiety, guilt and regret.

As the holidays approach, millions of people will be experiencing these losses afresh, as well as disruptions to comforting routines and beloved traditions.

Judith Graham, author of KHN’s Navigating Aging column, hosted a discussion on these unprecedented losses and dealing with the bereavement on Facebook Live on Monday. She was joined by Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City, and Diane Snyder-Cowan, leader of the bereavement professionals steering committee of the National Council of Hospice and Palliative Professionals.

Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn’t have the slightest interest in becoming a doctor when she was growing up.

As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland. She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.

“All of those experiences actually made me really dislike physicians,” Asmerom said. “Particularly in my community, the saying is, ‘You only go to the doctor if you’re about to die.’”

But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too. Asmerom came to believe that as a doctor she could help turn things around.

Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.

Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.

This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests. But now, as with countless other U.S. institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action.

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Debunking Race as a Diagnostic Tool

For many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more differences among people within each race. Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.

Dr. Brooke Cunningham, a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said. Some physicians claim it is useful to take race into account when treating patients; others argue it leads to bias and poor care.

Those views have led to a variety of false beliefs, including that Black people have thicker skin, their blood coagulates more quickly than white people’s or they feel less pain.

When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate). The eGFR can limit Black patients’ access to care because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.

In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.

Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.

“It was very personal,” Nkinsi said. “That’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”

Nkinsi helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.

Acknowledging Racism’s Adverse Effects on Health

The Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S. and Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.

This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities. But little data exists on how many schools teach students how to recognize and fight racism, he said.

An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.

“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.

Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.

Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.

“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.

Recognizing Racism in Medical Education’s Past and Present

Activists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements. Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.

Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. “It’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?” she said.

While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. “There needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.

Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.

“But I’m not going to hold my breath until I see actual changes,” she said.

Attorneys for GOP-controlled states seeking to kill the Affordable Care Act told the Supreme Court last week that at least some of the 12 million people who newly enrolled in Medicaid signed up only because of the law’s requirement that people have insurance coverage — although a tax penalty no longer exists.

The statement drew a rebuke from Justice Sonia Sotomayor, who said it belies reason. Several health experts also questioned the argument that poor people apply for Medicaid not because they need help getting health care but to meet the ACA’s individual mandate for coverage.

The point is vital to the Republicans’ case to overturn the ACA, an effort supported by the Trump administration. The states are trying to prove they were harmed by the 2010 health law — and thus have “legal standing” to challenge its constitutionality. They argue their Medicaid spending increased because of the mandate, even though Congress eliminated the tax penalty for not having health coverage in 2019. Even when the penalty existed, most poor people were exempt because of their low income.

Under the ACA, states can opt to expand Medicaid eligibility to all adults earning less than 138% of the federal poverty level, or about $17,600 for an individual. States and the federal government share the cost of their care.

If the states cannot prove they have standing, the justices can toss their case without ruling on its merits. The case also involves two individuals who purchased private insurance from Texas and are suing to have the law overturned.

The Medicaid costs issue was one of several ways Texas and other GOP-controlled states participating in the lawsuit say they were harmed by the ACA even after the individual mandate penalty was reduced to zero. Several justices, including conservatives Clarence Thomas and Amy Coney Barrett, posed questions about whether the states had standing.

The case heard last Tuesday, California v. Texas, was the third time the high court has taken up a major suit on the ACA. Republican attorneys general in 18 states and the Trump administration want the entire law struck down, a move that would threaten coverage for more than 20 million people, as well as millions of others with preexisting conditions, including COVID-19.

Even if the court rules the states have legal standing, the ACA opponents must prove the elimination of a penalty makes the entire law unconstitutional.

The Republican states assert that since the law was upheld under Congress’ taxing powers by the Supreme Court in 2012, once the tax penalty is gone, the entire law must fall, too.

A group of Democratic-controlled states led by California and the Democratic House of Representatives are urging the court to keep the law in place.

Sotomayor raised serious doubts about the plaintiffs’ Medicaid argument and whether the states had suffered injury.

“At some point, common sense seems to me would say: Huh?” Sotomayor told Kyle Hawkins, Texas’ solicitor general, who is leading the GOP states’ legal fight. She questioned whether it seemed reasonable that once Medicaid enrollees are told there is no tax penalty for people who don’t have coverage they would “enroll now, when they didn’t enroll when they thought there was a tax? Does that make any sense to you?”

Hawkins defended his case, saying states need to show that only one person signed up for Medicaid because of the individual mandate. “There’s a substantial likelihood of at least one person signing up for a state Medicaid program, which, of course, would cause at least one dollar in injury and satisfy the standing requirement,” he said.

He cited a Congressional Budget Office report issued in 2017, when lawmakers were considering the change in the penalty. It said some people would continue to buy insurance or seek coverage “solely because of a willingness to comply with the law,” even if the individual mandate penalty were eliminated.

Few surveys have asked Medicaid enrollees why they signed up for the program.

One of them, by University of Michigan researchers that same year, posed the question to 1,750 adults who had become eligible for Medicaid in the state as a result of the ACA expansion. The most common reasons respondents gave for enrolling were that they had lost other health coverage and had a medical condition that required care. Just 2% of respondents cited the need to avoid the individual mandate tax penalty.

With the tax penalty eliminated, legal and health policy experts said, it’s likely the share of respondents signing up for Medicaid because of the health coverage mandate has dropped closer to zero.

Richard Kay, a law professor emeritus at the University of Connecticut, said it’s clear most people don’t seek coverage because of the individual mandate — particularly since there is no longer a financial penalty. But there could be a few who still do.

“Do you stop at a stop sign if you are in the country and no one is around for miles?” he said. “It’s not impossible that some people get insurance just because the law requires them.”

Kay said there is no precise guidance on how courts decide whether a plaintiff has been penalized enough to prove it has legal standing. “It’s a very confused area of the law,” he said.

Pratik Shah, a Washington, D.C., attorney who represents America’s Health Insurance Plans, a trade group fighting to preserve the law, said the plaintiffs in the case have not proved standing.

“It does not make logical sense,” he said of the argument that state budgets were harmed by people signing up for Medicaid even after the individual mandate penalty was eliminated.

“It’s hard to see how the 2017 amendment to the health law would have forced more people into Medicaid,” he said. “If they weren’t signed up before, they would be less likely to get it without the penalty.”

The court is expected to rule on the case by the end of June.

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

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CHICAGO — Ben Barnes has slept in abandoned buildings, hallways and alleys. For the past year or so, he’s been staying at the city’s largest homeless shelter, Pacific Garden Mission, in the shadows of the famous skyline.

“I’ve always considered myself homeless because I don’t have a home,” he said on a recent crisp, fall day in the shelter’s sun-splashed courtyard. But he’s fortunate, said Barnes, 44. He’s never had to sleep outside when it was below zero or snowy. He always found a friend’s place, building or shelter to crash in. He knows others aren’t so lucky.

As winter approaches, hundreds — perhaps thousands — of people in this city of nearly 3 million are living on the streets: some in encampments, others hopping from corner to corner. And the numbers could grow without more federal aid and protections amid economic pressures from the pandemic.

This year, the coronavirus has forced homeless shelters to limit the number of beds they can offer. Pacific Garden Mission, for instance, is operating at roughly half its normal capacity of 740. And COVID-19 cases are rising as temperatures drop.

“What happens if we’re in the midst of a pandemic and a polar vortex happens?” said Doug Schenkelberg, executive director of the Chicago Coalition for the Homeless. “We’re trying to keep the contagion from spreading and keep people from dealing with hypothermia. Is there the infrastructure in place that can handle that type of dual crisis?”

Cold-weather cities across the nation are seeking creative ways to cautiously shelter homeless people this winter. Exposure to the elements kills individuals staying outside every year, so indoor refuges can be lifesaving. But fewer options exist nowadays, as coronavirus concerns limit access to libraries, public recreation facilities and restaurants. And in official shelters, safety precautions — spacing out beds and chairs, emphasizing masks and hand-washing, testing — are critical.

“The homeless check off most boxes in terms of being the most susceptible and most vulnerable to the COVID-19 pandemic, and most likely to spread and most likely to die from it,” said Neli Vazquez Rowland, founder of A Safe Haven Foundation, a Chicago nonprofit that has been operating a “medical respite” isolation facility for homeless individuals with the coronavirus.

Demand for shelter could grow. Stimulus checks helped stave off some of the pandemic’s initial economic pain, but Congress has stalled on additional relief packages. And though the Trump administration has ordered a moratorium on evictions for tenants who meet certain conditions through the end of the year, a group of landlords is suing to stop the ban. Some states have their own prohibitions on evictions, but only Illinois, Minnesota and Kansas do in the Midwest.

At the Guest House of Milwaukee, a publicly funded homeless shelter in Wisconsin, the pandemic complicates an already challenging situation.

“We’re like many communities. We never really have completely enough space for everybody who is in need of shelter,” said Cindy Krahenbuhl, its executive director. “The fact that we’ve had to reduce capacity, and all shelters have, has created even more of a burden on the system.”

She said outreach teams plan to connect individuals living outside with an open bed — whether at a shelter, a hotel or an emergency facility for homeless people at risk for COVID — and get them started with case management.

“The reality is we’ve got to make it happen. We’ve got to have space for folks because it’s a matter of life and death. You cannot be outside unsheltered in this environment too long,” said Rob Swiers, executive director of the New Life Center in Fargo, North Dakota, where the average high in January is 18 degrees.

His shelter, Fargo’s largest, plans to use an insulated, heated warehouse to provide roomy sanctuary for clients.

In Minnesota’s Ramsey County, home to St. Paul, an estimated 311 people are living on the streets, compared with “dozens” at this time in 2019, according to Max Holdhusen, the county’s interim manager of housing stability. The area just had a record snowfall for so early in the year.

The county has been using hotel rooms to make up for the reduction in shelter beds, and recently agreed to lease an old hospital to shelter an additional 100 homeless people.

The city of Chicago has set up emergency shelters in two unused public school buildings to replace beds lost to social distancing. As it does every winter, the city will also operate warming centers across Chicago, although this year with precautions such as spacing and masking.

In September, the city directed more than $35 million in funding — mostly from the federal CARES Act for coronavirus relief — to an “expedited housing” program aiming to get more than 2,500 people housed in the next few years. The initiative plans to financially incentivize landlords to take risks on renters they might normally avoid, such as those with criminal histories or poor credit. The nonprofit in charge, All Chicago, is also hosting “accelerated moving events,” in which its staffers descend on a shelter, encampment or drop-in center and work to house everyone in that facility.

“In the ideal world, we would have permanent housing for them,” said Dr. David Ansell, senior vice president of community health equity at Chicago’s Rush University Medical Center. “That is the only way we can protect people’s health. That’s the fundamental health issue. It’s a fundamental racial justice issue. It’s a fundamental social justice issue.”

Even though Black people make up only a third of Chicago’s population, they account for roughly three-fourths of those who are homeless, according to the city’s count.

Dr. Thomas Huggett, a family physician with Lawndale Christian Health Center on the city’s largely impoverished West Side, also called safely sheltering and housing people this winter a racial equity issue.

“We know that people who are African American have a higher prevalence of hypertension, of diabetes, of obesity, of smoking, of lung issues,” he said. “So they are hit harder with those predisposing conditions that make it more likely that if you get coronavirus, you’re going to have a serious case of it.”

Then add the cold. Dr. Stockton Mayer, an infectious disease specialist from the University of Illinois Hospital in Chicago, said hypothermia doesn’t increase the chances of contracting the virus but could aggravate symptoms.

As of Sept. 30, according to All Chicago, 778 people were unsheltered in the city. However, that number includes only people who are enrolled in homelessness services, and other estimates are even higher.

Some homeless people who plan to live outside this winter said they worry about staying warm, dry and healthy in the age of COVID-19. Efren Parderes, 48, has been on the streets of Chicago since he lost his restaurant job and rented room early in the pandemic. But he doesn’t want to go to a shelter. He’s concerned about catching the coronavirus and bedbugs, and doesn’t want to have to obey curfews.

He recently asked other unsheltered people what they do to keep warm during the winter. Their advice: Locate a spot that blocks the wind or snow, bundle up with many layers of clothing, sleep in a sleeping bag and use hand warmers.

“This is going to be the first time I’ll be out when it’s really cold,” he said after spending a largely sleepless night in the chilly October rain.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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