Category: From California Healthline.org

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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A listener asked: ‘How do I remain cool when calling insurance companies?” So we called veteran self-defense teacher Lauren Taylor for advice. She leads Defend Yourself, an organization that works to empower people against violence and abuse. 

As Taylor teaches it, self-defense involves a lot more than hitting and kicking. It’s about standing up for yourself in all kinds of difficult situations. Striking that posture includes using your words, and we asked Taylor to talk us through her top strategies. This year, she used them in her own health insurance fight.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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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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In the middle of the night, Stefania Silvestri lies in bed remembering her elderly patients’ cries.

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“Help me.”

“Please don’t leave me.”

“I need my family.”

Months of caring for older adults in a Rhode Island nursing home ravaged by COVID-19 have taken a steep toll on Silvestri, 37, a registered nurse.

She can’t sleep, as she replays memories of residents who became ill and died. She’s gained 45 pounds. “I have anxiety. Some days I don’t want to get out of bed,” she said.

Now, as the coronavirus surges around the country, Silvestri and hundreds of thousands of workers in nursing homes and assisted living centers are watching cases rise in long-term care facilities with a sense of dread.

Many of these workers struggle with grief over the suffering they’ve witnessed, both at work and in their communities. Some, like Silvestri, have been infected with the coronavirus and recovered physically — but not emotionally.

Since the start of the pandemic, more than 616,000 residents and employees at long-term care facilities have been struck by COVID-19, according to the latest data from KFF. Just over 91,000 have died as the coronavirus has invaded nearly 23,000 facilities. (KHN is an editorially independent program of KFF.)

At least 1,000 of those deaths represent certified nursing assistants, nurses and other people who work in institutions that care for older adults, according to a recent analysis of government data by Harold Pollack, a professor at the School of Social Service Administration at the University of Chicago. This is almost certainly an undercount, he said, because of incomplete data reporting.

How are long-term care workers affected by the losses they’re experiencing, including the deaths of colleagues and residents they’ve cared for, often for many years?

Edwina Gobewoe, a certified nursing assistant who has worked at Charlesgate Nursing Center in Providence, Rhode Island, for nearly 20 years, acknowledged “it’s been overwhelming for me, personally.”

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At least 15 residents died of COVID-19 at Charlesgate from April to June, many of them suddenly. “One day, we hear our resident has breathing problems, needs oxygen, and then a few days later they pass,” she said. “Families couldn’t come in. We were the only people with them, holding their hands. It made me very, very sad.”

Every morning, Gobewoe would pray with a close friend at work. “We asked the Lord to give us strength so we could take care of these people who needed us so much.” When that colleague was struck by COVID-19 in the spring, Gobewoe prayed for her recovery and was glad when she returned to work several weeks later.

But sorrow followed in early September: Gobewoe’s friend collapsed and died at home while complaining of unusual chest pain. Gobewoe was told that her death was caused by blood clots, which can be a dangerous complication of COVID-19.

She would “do anything for any resident,” Gobewoe remembered, sobbing. “It’s too much, something you can’t even talk about,” describing her grief.

I first spoke to Kim Sangrey, 52, of Lancaster, Pennsylvania, in July. She was distraught over the deaths of 36 residents in March and April at the nursing home where she’s worked for several decades — most of them due to COVID-19 and related complications. Sangrey, a recreational therapist, asked me not to name the home, where she continues to be employed.

“You know residents like family — their likes and dislikes, the food they prefer, their families, their grandchildren,” she explained. “They depend on us for everything.”

When COVID-19 hit, “it was horrible,” she said. “You’d go into residents’ rooms and they couldn’t breathe. Their families wanted to see them, and we’d set up Zoom wearing full gear, head to toe. Tears are flowing under your mask as you watch this person that you loved dying — and the family mourning their death through a tablet.”

“It was completely devastating. It runs through your memory — you think about it all the time.”

Mostly, Sangrey said, she felt empty and exhausted. “You feel like this is never going to end — you feel defeated. But you have to continue moving forward,” she told me.

Three months later, when we spoke again, COVID-19 cases were rising in Pennsylvania but Sangrey sounded resolute. She’d had six sessions with a grief counselor and said it had become clear that “my purpose at this point is to take every ounce of strength I have and move through this second wave of COVID.”

“As human beings, it is our duty to be there for each other,” she continued. “You say to yourself, OK, I got through this last time, I can get through it again.”

That doesn’t mean that fear is absent. “All of us know COVID-19 is coming. Every day we say, ‘Is today the day it will come back? Is today the day I’ll find out I have it?’ It never leaves you.”

To this day, Silvestri feels horrified when she thinks about the end of March and early April at Greenville Center in Rhode Island, where up to 79 residents became ill with COVID-19 and at least 20 have died.

The coronavirus moved through the facility like wildfire. “You’re putting one patient on oxygen and the patient in the next room is on the floor but you can’t go to them yet,” Silvestri remembered. “And the patient down the hall has a fever of 103 and they’re screaming, ‘Help me, help me.’ But you can’t go to him either.”

“I left work every day crying. It was heartbreaking — and I felt I couldn’t do enough to save them.”

Then, there were the body bags. “You put this person who feels like family in a plastic body bag and wheel them out on a frame with wheels through the facility, by other residents’ rooms,” said Silvestri, who can’t smell certain kinds of plastic without reliving these memories. “Thinking back on it makes me feel physically ill.”

Silvestri, who has three children, developed a relatively mild case of COVID-19 in late April and returned to work several weeks later. Her husband, Michael, also became ill and lost his job as a truck driver. After several months of being unemployed, he’s now working at a construction site.

Since July 1, the family has gone without health insurance, “so I’m not able to get counseling to deal with the emotional side of what’s happened,” Silvestri said.

Although her nursing home set up a hotline number that employees could call, that doesn’t appeal to her. “Being on the phone with someone you don’t know, that doesn’t do it for me,” she said. “We definitely need more emotional support for health care workers.”

What does help is family. “I’ve leaned on my husband a lot and he’s been there for me,” Silvestri said. “And the children are OK. I’m grateful for what I have — but I’m really worried about what lies ahead.”

The Navigating Aging column last week focused on how nursing homes respond to grief sweeping through their facilities.

Join Judith Graham for a Facebook Live event on grief and bereavement during the coronavirus pandemic on Monday, Nov. 16, at 1 p.m. ET. You can watch the conversation here and submit questions in advance here.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Betial Asmerom, estudiante de medicina de cuarto año en la Universidad de California-San Diego (UCSD), nunca había demostrado interés en ser doctora.

En su adolescencia, ayudó a sus padres, inmigrantes de Eritrea que hablaban poco inglés, a navegar el sistema de atención de salud en Oakland. Veía a médicos que eran irrespetuosos con su familia y que no se preocupaban por el tratamiento de la cirrosis, la hipertensión y la diabetes de su madre.

“Todas esas experiencias hicieron que no me gustaran los médicos”, dijo Asmerom.

“En mi comunidad siempre se decía: ‘Sólo ve al médico si estás a punto de morir’”.

Pero eso cambió cuando tomó un curso en la universidad sobre disparidades en salud. Se dio cuenta que otras comunidades de color sufrían lo mismo que su familia y amigos eritreos. Asmerom pensó que, como médica, podía ayudar a cambiar las cosas.

Hace tiempo que profesores y activistas estudiantiles de todo el país les piden a las escuelas de medicina que aumenten el número de estudiantes e instructores de comunidades poco representadas, para mejorar el tratamiento y fomentar la inclusión.

Pero para identificar las raíces del racismo y sus efectos en el sistema de salud, dicen, se deben hacer cambios fundamentales en los planes de estudio.

Asmerom es una de las muchas voces que piden una sólida educación antirracista. Exigen que las escuelas eliminen el uso de la raza como herramienta de diagnóstico, que reconozcan cómo el racismo sistémico perjudica a los pacientes, y que tengan en cuenta parte de la historia racista de la medicina.

Este activismo no es algo nuevo. White Coats for Black Lives (WC4BL), una organización dirigida por estudiantes que lucha contra el racismo en la medicina surgió a raíz de las protestas de Black Lives Matter en 2014.

Pero después del asesinato de George Floyd en Minneapolis, en mayo, las escuelas de medicina y las organizaciones médicas están bajo más presión para tomar medidas concretas.

Dejar de usar la raza como herramienta de diagnóstico

Durante muchos años, se ha enseñado a los estudiantes de medicina que las diferencias genéticas entre las razas tenían un efecto en la salud. Pero en los últimos años, estudios han encontrado que la raza no refleja eso de manera confiable.

El Instituto Nacional de Investigación del Genoma Humano observa muy poca variación genética entre las razas, y más diferencias entre las personas dentro de cada raza. Por eso, más médicos aceptan que la raza no es una diferencia biológica intrínseca, sino una construcción social.

Pero la doctora Brooke Cunningham, médica y socióloga en la Escuela de Medicina de la Universidad de Minnesota, señaló que en una idea difícil de abandonar. Forma parte de la manera en que los médicos diagnostican y miden las enfermedades, explicó.

Algunos médicos afirman que es útil tener en cuenta la raza cuando se trata a los pacientes; otros sostienen que conduce a prejuicios y a una atención deficiente.

Esas opiniones han llevado a una variedad de creencias falsas, como que los negros tienen la piel más gruesa, que su sangre se coagula más rápido que la de los blancos o que sienten menos dolor.

Cuando la raza interviene en los cálculos médicos, puede conducir a tratamientos menos eficaces y perpetuar las desigualdades basadas en la raza.

Uno de estos cálculos estima la función renal (eGFR, o la tasa estimada de filtración glomerular). El eGFR puede limitar el acceso de los pacientes negros a la atención médica porque el número utilizado para denotar la raza negra en la fórmula proporciona un resultado que sugiere que los riñones funcionan mejor de lo que lo hacen, según informaron recientemente los investigadores en el New England Journal of Medicine.

Entre otra docena de ejemplos que citan está una fórmula que los obstetras usan para determinar la probabilidad de un parto vaginal exitoso después de una cesárea, lo cual pone en desventaja a las pacientes negras no hispanas e hispanas, y un ajuste para medir la capacidad pulmonar usando un espirómetro, lo cual puede causar estimaciones inexactas de la función pulmonar para pacientes con asma o enfermedad pulmonar obstructiva crónica.

A la luz de estas investigaciones, los estudiantes de medicina piden a las escuelas que se replanteen los planes de estudio que tratan la raza como un factor de riesgo de enfermedad.

Briana Christophers, estudiante de segundo año en el Weill Cornell Medical College de Nueva York, dijo que no tiene sentido que la raza haga a alguien más propenso a las enfermedades, aunque los factores económicos y sociales jueguen un papel importante.

Naomi Nkinsi, estudiante de tercer año de la Escuela de Medicina de la Universidad de Washington en Seattle (UW Medicine), recordó haber asistido a una conferencia —junto a otras cuatro estudiantes negras en la sala— y haber oído que los negros son más propensos a enfermedades.

“Lo sentí muy personal”, expresó Nkinsi. “Ese es mi cuerpo, esos son mis padres, esos son mis hermanos. Ahora, cada vez que vaya a un consultorio, sentiré que no sólo no me consideran una persona completa, sino que soy físicamente diferente a todos los demás pacientes sólo porque tengo más melanina en la piel”.

Nkinsi ayudó en una exitosa campaña para excluir la raza del cálculo del eGFR en la UW Medicine, uniéndose a un pequeño número de otros sistemas de salud. Ella dijo que el logro, anunciado oficialmente a finales de mayo, se debió en gran parte a los incansables esfuerzos de los estudiantes negros.

Reconocer los efectos adversos del racismo en la salud

El Liaison Committee on Medical Education (LCME), órgano oficial de acreditación de las facultades de medicina de los Estados Unidos y Canadá, dice que se debe enseñar a los estudiantes a reconocer los prejuicios “en ellos mismos, en los demás y en el proceso de prestación de servicios de atención de la salud”.

Pero el LCME no exige explícitamente a las instituciones acreditadas que enseñen sobre el racismo sistémico en la medicina.

Esto es lo que los estudiantes y algunos profesores quieren cambiar.

El doctor David Acosta, jefe de diversidad e inclusión de la Asociación Americana de Escuelas de Medicina (AAMC, en inglés), reportó que cerca del 80% de las facultades ofrecen un curso obligatorio o electivo sobre disparidades en salud. Pero explicó que hay pocos datos sobre cuántas escuelas enseñan a los estudiantes a reconocer y combatir el racismo.

Un plan de estudios antirracista debería explorar formas de mitigar o eliminar el daño del racismo, indicó Rachel Hardeman, profesora de políticas de salud de la Universidad de Minnesota.

“Hay que pensar en cómo penetra esto en el aprendizaje de la educación médica”, dijo. Los cursos que profundizan en el racismo sistémico deben ser obligatorios, añadió Hardeman.

Edwin Lindo, profesor en la Escuela de Medicina de la Universidad de Washington, dijo que se debería adoptar un modelo interdisciplinario, permitiendo a sociólogos o historiadores dar conferencias sobre cómo el racismo perjudica la salud.

Acosta dijo que la AAMC ha organizado un comité de expertos para desarrollar un plan de estudios contra el racismo para cada nivel de la educación médica. Esperan hacer público su trabajo este mes y hablar con el LCME sobre el desarrollo e implementación de estándares.

“Nuestra próxima tarea es cómo persuadir e influenciar al LCME para que piense en añadir cursos de capacitación antirracista”, dijo Acosta.

Reconocer el racismo en el pasado y el presente de la educación médica

Los activistas quieren que sus instituciones reconozcan sus propios pasos en falso, así como el racismo que ha acompañado a los logros médicos del pasado.

Dereck Paul, estudiante de medicina en la Universidad de California-San Francisco, dijo que quiere que en todas las facultades se incluyan conferencias sobre personas como Henrietta Lacks, la mujer negra que se estaba muriendo de cáncer cuando le extrajeron células sin su consentimiento, que se utilizaron para desarrollar líneas celulares que han sido fundamentales en la investigación médica.

Asmerom puntualizó que quiere que la facultad reconozca el pasado racista de la medicina en las clases. Citó un curso introductorio de anatomía en su escuela que no señaló que en el pasado, cuando los científicos trataban de estudiar el cuerpo humano, los negros y otros grupos habían sido maltratados. “Es como, OK, ¿pero no vas a contar que sacaron de sus tumbas cuerpos de negros para usarlos en el laboratorio de anatomía?” preguntó.

Aunque a Asmerom le alegra ver que su facultad escucha las reivindicaciones estudiantiles, siente que los administradores deben reconocer sus errores del pasado reciente.

“Alguien tiene que admitir cómo se perpetuó el racismo anti-negro en esta institución”, dijo Asmerom.

Asmerom, una de las líderes de la Coalición Antirracista de la UCSD, aseguró que la administración ha respondido favorablemente hasta ahora a las demandas de la coalición de invertir tiempo y dinero en iniciativas antirracistas. Y se siente cautelosamente esperanzada.

“No me atrevo a aguantar la respiración hasta que vea cambios reales”, concluyó.

Esta historia fue producida por Kaiser Health News, un programa editorial independiente de la 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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A tidal wave of grief and loss has rolled through long-term care facilities as the coronavirus pandemic has killed more than 91,000 residents and staffers — nearly 40% of recorded COVID-19 deaths in the U.S.

And it’s not over: Facilities are bracing for further shocks as coronavirus cases rise across the country.

Workers are already emotionally drained and exhausted after staffing the front lines — and putting themselves at significant risk — since March, when the pandemic took hold. And residents are suffering deeply from losing people they once saw daily, the disruption of routines and being cut off from friends and family.

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In response, nursing homes and assisted living centers are holding memorials for people who’ve died, having chaplains and social workers help residents and staff, and bringing in hospice providers to offer grief counseling, among other strategies. More than 2 million vulnerable older adults live in these facilities.

“Everyone is aware that this is a stressful, traumatic time, with no end in sight, and there needs to be some sort of intervention,” said Barbara Speedling, a long-term care consultant working on these issues with the American Health Care Association and National Center for Assisted Living, an industry organization.

Connie Graham, 65, is corporate chaplain at Community Health Services of Georgia, which operates 56 nursing homes. For months, he’s been holding socially distant prayer services in the homes’ parking lots for residents and staff members.

“People want prayers for friends in the facilities who’ve passed away, for relatives and friends who’ve passed away, for the safety of their families, for the loss of visitation, for healing, for the strength and perseverance to hold on,” Graham said.

Central Baptist Village, a Norridge, Illinois, nursing home, held a socially distanced garden ceremony to honor a beloved nurse who had died of COVID-19. “Our social service director made a wonderful collage of photos and left Post-its so everyone could write a memory” before delivering it to the nurse’s wife, said Dawn Mondschein, the nursing home’s chief executive officer.

“There’s a steady level of anxiety, with spikes of frustration and depression,” Mondschein said of staff members and residents.

Vitas Healthcare, a hospice provider in 14 states and the District of Columbia, has created occasional “virtual blessing services” on Zoom for staffers at nursing homes and assisted living centers. “We thank them for their service and a chaplain gives words of encouragement,” said Robin Fiorelli, Vitas’ senior director of bereavement and volunteers.

Vitas has also been holding virtual memorials via Zoom to recognize residents who’ve died of COVID-19. “A big part of that service is giving other residents an opportunity to share their memories and honor those they’ve lost,” Fiorelli said.

On Dec. 6, Hospice Savannah in Georgia is going one step further and planning an online broadcast of its annual national “Tree of Light” memorial, with grief counselors who will offer healing strategies. During the service, candles will be lit and a moment of silence observed in remembrance of people who’ve died.

“Grief has become an urgent mental health issue, and we hope this will help begin the healing process for people who haven’t been able to participate in rituals or receive the comfort and support they’d normally have gotten prior to COVID-19,” said Kathleen Benton, Hospice Savannah’s president and chief executive officer.

But these and other attempts are hardly equal to the extent of anguish, which has only grown as the pandemic stretches on, fueling a mental health crisis in long-term care.

“There is a desperate need for psychological services,” said Toni Miles, a professor at the University of Georgia’s College of Public Health and an expert on grief and bereavement in long-term care settings. She’s created two guides to help grieving staffers and residents and is distributing them digitally to more than 400 nursing homes and 1,000 assisted living centers in the state.

A recent survey by Altarum, a nonprofit research and consulting firm, highlights the hopelessness of many nursing home residents. The survey asked 365 people living in nursing homes about their experiences in July and August.

“I am completely isolated. I might as well be buried already,” one resident wrote. “There is no hope,” another said. “I feel like giving up. … No emotional support nor mental health support is available to me,” another complained.

Inadequate mental health services in nursing homes have been a problem for years. Instead of counseling, residents are typically given medications to ease symptoms of distress, said David Grabowski, a professor of health care policy at Harvard Medical School who has published several studies on this topic.

The situation has worsened during the pandemic as psychologists and social workers have been unable to enter facilities that limited outsiders to minimize the risk of viral transmission.

“Several facilities didn’t consider mental health professionals ‘essential’ health care providers, and many of us weren’t able to get in,” said Lisa Lind, president of Psychologists in Long-Term Care. Although some facilities switched to tele-mental health services, staff shortages have made those hard to arrange, she noted.

Fewer than half of nursing home staffers have health insurance, and those who do typically don’t have “minimal” access to mental health services, Grabowski said. That’s a problem because “there’s a real fragility right now on the part of the workforce.”

Colleen Frankenfield, president and chief executive officer of Lutheran Social Ministries of New Jersey, said what staffers need most of all is “the ability to vent and to have someone comfort them.” She recalls a horrible day in April, when four residents died in less than 24 hours at her organization’s continuing care retirement community in northern New Jersey, which includes an assisted living facility and a nursing home.

“The phone rang at 1 a.m. and all I heard on the other end was an administrator, sobbing,” she remembered. “She said she felt she was emotionally falling apart. She felt like she was responsible for the residents who had died, like she had let them down. She just had to talk about what she was experiencing and cry it out.”

Although Lutheran Social Ministries has been free of COVID-19 since the end of April, “our employees are tired — always on edge, always worried,” Frankenfield said. “I think people are afraid and they need time to heal. At the end of the day, all we can really do is stand with them, listen to them and support them in whatever way we can.”

Coming Monday: The Navigating Aging column will look at the grief faced by long-term care workers as COVID-19 cases and deaths mount.

Join Judith Graham for a Facebook Live event on grief and bereavement during the coronavirus pandemic on Monday, Nov. 16, at 1 p.m. ET. You can watch the conversation here and submit questions in advance here.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

The night before I chopped off my hair, I got nervous.

This decision felt bigger than me, given all the weight that Black women’s hair carries. But after three months of wearing hats and scarves in a pandemic when trips to the hairdresser felt unsafe, I walked into a salon emotionally exhausted but ready to finally see my natural hair.

I thought a few tears would fall, but, as the last of my chemically straightened hair floated to the floor like rain, I felt cleansed. Free. I laughed hysterically as I drove away from the salon.

Friends and family cheered me on virtually, but my father quietly worried about my decision. My dad grew up in the Jim Crow South, where many women straightened their hair to land jobs, husbands and respect. Before my big chop, he never said much about my hair beyond the occasional compliment, which is why I was surprised when he issued a warning.

“Watch it out there. Your hair is cut now,” he blurted when he saw me walking out of the house.

My mother heard him but remained silent. She had her own set of concerns. She was worried about me looking less professional.

I also had to help my now 4-year-old daughter understand why I decided to go natural. We’ve watched the animated “Hair Love” a million times. We’ve read books like “Happy Hair” by Mechal Renee Roe, “I Love My Hair!” by Natasha Anastasia Tarpley and my personal favorite, “Don’t Touch My Hair!” by Sharee Miller.

Still, my daughter had a hard time adjusting to my new haircut, often asking when I planned to get my hair styled again. She preferred my extensions, saying she thought I looked more like a princess that way. I gently explained that my hair is a style — and the one I choose — even if it’s not long and straight.

My family’s emotions about my hair left me tangled.

Of course, the styling of Black hair has been fraught for centuries. The CROWN Act, which passed the U.S. House in September and is now pending in the Senate, is intended to protect Black people from discrimination in schools, housing and employment based on their hairstyle. But such a law, even if passed, cannot stop bigotry, bullets and the emotional battle that comes with being a Black woman in America as seen through something as simple as our hair.

I hadn’t considered talking to my daughter about how hair could affect her personal safety until my father broke his silence. A haircut shouldn’t influence your life expectancy.

On the night of my haircut, I drove to the store more aware of how others would perceive my new look. My father, however, was more worried about my safety because my silhouette could possibly be mistaken for a Black man’s frame.

We live in the Midwest, just outside St. Louis, where natural hair still makes a statement for Black women. If my buzz cut made me look more like a Black man, would the cops in our town treat me differently? In my dad’s eyes, my femininity increased my chances of making it home safely.

His comments also led to a conversation about the intersection between racism and sexism. Without reading the crucial work of scholar Kimberlé Crenshaw and other activists, my father intuitively understood that society has placed Black women in a blind spot, where our gender and our race make us invisible in many ways.

But that space isn’t safe, is it? A Eurocentric feminine hairstyle can’t protect Black women from the many deadly forms of racism.

Police officers can see us. Since 2015, at least 48 Black women have been killed by the police. I’m guessing the style of their hair didn’t matter to the officers pulling the triggers. In the past few years, the #SayHerName campaign has put a spotlight on their killings, but society still pays less attention to the police killings of Black women. While most people have heard of George Floyd, Michael Brown and Breonna Taylor, fewer know about Kathryn Johnston, Korryn Gaines and India Kager.

In death and life, our rights and our achievements don’t seem to hold as much weight compared with those of our male counterparts or our white ones. Yet, many Black women go to great lengths to be accepted in this country.

In the past few weeks, I’ve listened to other Black women in my life vent about their hair and navigating racism. We’ve shared our fears, hair horror stories and moments of victory. I’ve come to realize that my haircut wasn’t just about changing my style. It was also about reclaiming my crown after years of letting society control it.

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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Dr. Megan Ranney has learned a lot about COVID-19 since she began treating patients with the disease in the emergency department in February.

But there’s one question she still can’t answer: What makes some patients so much sicker than others?

Advancing age and underlying medical problems explain only part of the phenomenon, said Ranney, who has seen patients of similar age, background and health status follow wildly different trajectories.

“Why does one 40-year-old get really sick and another one not even need to be admitted?” asked Ranney, an associate professor of emergency medicine at Brown University.

In some cases, provocative new research shows, some people — men in particular — succumb because their immune systems are hit by friendly fire. Researchers hope the finding will help them develop targeted therapies for these patients.

In an international study in Science, 10% of nearly 1,000 COVID patients who developed life-threatening pneumonia had antibodies that disable key immune system proteins called interferons. These antibodies — known as autoantibodies because they attack the body itself — were not found at all in 663 people with mild or asymptomatic COVID infections. Only four of 1,227 healthy individuals had the autoantibodies. The study, published on Oct. 23, was led by the COVID Human Genetic Effort, which includes 200 research centers in 40 countries.

“This is one of the most important things we’ve learned about the immune system since the start of the pandemic,” said Dr. Eric Topol, executive vice president for research at Scripps Research in San Diego, who was not involved in the new study. “This is a breakthrough finding.”

In a second Science study by the same team, authors found that an additional 3.5% of critically ill patients had mutations in genes that control the interferons involved in fighting viruses. Given that the body has 500 to 600 of these genes, it’s possible researchers will find more mutations, said Qian Zhang, lead author of the second study.

Interferons serve as the body’s first line of defense against infection, sounding the alarm and activating an army of virus-fighting genes, said virologist Angela Rasmussen, an associate research scientist at the Center of Infection and Immunity at Columbia University’s Mailman School of Public Health.

“Interferons are like a fire alarm and a sprinkler system all in one,” said Rasmussen, who wasn’t involved in the new studies.

Lab studies show interferons are suppressed in some people with COVID-19, perhaps by the virus itself.

Interferons are particularly important for protecting the body against new viruses, such as the coronavirus, which the body has never encountered, said Zhang, a researcher at Rockefeller University’s St. Giles Laboratory of Human Genetics of Infectious Diseases.

When infected with the novel coronavirus, “your body should have alarms ringing everywhere,” said Zhang. “If you don’t get the alarm out, you could have viruses everywhere in large numbers.”

Significantly, patients didn’t make autoantibodies in response to the virus. Instead, they appeared to have had them before the pandemic even began, said Paul Bastard, the antibody study’s lead author, also a researcher at Rockefeller University.

For reasons that researchers don’t understand, the autoantibodies never caused a problem until patients were infected with COVID-19, Bastard said. Somehow, the novel coronavirus, or the immune response it triggered, appears to have set them in motion.

“Before COVID, their condition was silent,” Bastard said. “Most of them hadn’t gotten sick before.”

Bastard said he now wonders whether autoantibodies against interferon also increase the risk from other viruses, such as influenza. Among patients in his study, “some of them had gotten flu in the past, and we’re looking to see if the autoantibodies could have had an effect on flu.”

Scientists have long known that viruses and the immune system compete in a sort of arms race, with viruses evolving ways to evade the immune system and even suppress its response, said Sabra Klein, a professor of molecular microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health.

Antibodies are usually the heroes of the immune system, defending the body against viruses and other threats. But sometimes, in a phenomenon known as autoimmune disease, the immune system appears confused and creates autoantibodies. This occurs in diseases such as rheumatoid arthritis, when antibodies attack the joints, and Type 1 diabetes, in which the immune system attacks insulin-producing cells in the pancreas.

Although doctors don’t know the exact causes of autoimmune disease, they’ve observed that the conditions often occur after a viral infection. Autoimmune diseases are more common as people age.

In yet another unexpected finding, 94% of patients in the study with these autoantibodies were men. About 12.5% of men with life-threatening COVID pneumonia had autoantibodies against interferon, compared with 2.6% of women.

That was unexpected, given that autoimmune disease is far more common in women, Klein said.

“I’ve been studying sex differences in viral infections for 22 years, and I don’t think anybody who studies autoantibodies thought this would be a risk factor for COVID-19,” Klein said.

The study might help explain why men are more likely than women to become critically ill with COVID-19 and die, Klein said.

“You see significantly more men dying in their 30s, not just in their 80s,” she said.

Akiko Iwasaki, a professor of immunobiology at the Yale School of Medicine, noted that several genes involved in the immune system’s response to viruses are on the X chromosome.

Women have two copies of this chromosome — along with two copies of each gene. That gives women a backup in case one copy of a gene becomes defective, Iwasaki said.

Men, however, have only one copy of the X chromosome. So if there is a defect or harmful gene on the X chromosome, they have no other copy of that gene to correct the problem, Iwasaki said.

Bastard noted that one woman in the study who developed autoantibodies has a rare genetic condition in which she has only one X chromosome.

Scientists have struggled to explain why men have a higher risk of hospitalization and death from COVID-19. When the disease first appeared in China, experts speculated that men suffered more from the virus because they are much more likely to smoke than Chinese women.

Researchers quickly noticed that men in Spain were also more likely to die of COVID-19, however, even though men and women there smoke at about the same rate, Klein said.

Experts have hypothesized that men might be put at higher risk by being less likely to wear masks in public than women and more likely to delay seeking medical care, Klein said.

But behavioral differences between men and women provide only part of the answer. Scientists say it’s possible that the hormone estrogen may somehow protect women, while testosterone may put men at greater risk. Interestingly, recent studies have found that obesity poses a much greater risk to men with COVID-19 than to women, Klein said.

Yet women have their own form of suffering from COVID-19.

Studies show women are four times more likely to experience long-term COVID symptoms, lasting weeks or months, including fatigue, weakness and a kind of mental confusion known as “brain fog,” Klein noted.

As women, “maybe we survive it and are less likely to die, but then we have all these long-term complications,” she said.

After reading the studies, Klein said, she would like to learn whether patients who become severely ill from other viruses, such as influenza, also harbor genes or antibodies that disable interferon.

“There’s no evidence for this in flu,” Klein said. “But we haven’t looked. Through COVID-19, we may have uncovered a very novel mechanism of disease, which we could find is present in a number of diseases.”

To be sure, scientists say that the new study solves only part of the mystery of why patient outcomes can vary so greatly.

Researchers say it’s possible that some patients are protected by past exposure to other coronaviruses. Patients who get very sick also may have inhaled higher doses of the virus, such as from repeated exposure to infected co-workers.

Although doctors have looked for links between disease outcomes and blood type, studies have produced conflicting results.

Screening patients for autoantibodies against interferons could help predict which patients are more likely to become very sick, said Bastard, who is also affiliated with the Necker Hospital for Sick Children in Paris. Testing takes about two days. Hospitals in Paris can now screen patients on request from a doctor, he said.

Although only 10% of patients with life-threatening COVID-19 have autoantibodies, “I think we should give the test to everyone who is admitted,” Bastard said. Otherwise, “we wouldn’t know who is at risk for a severe form of the disease.”

Bastard said he hopes his findings will lead to new therapies that save lives. He notes that the body manufactures many types of interferons. Giving these patients a different type of interferon — one not disabled by their genes or autoantibodies — might help them fight off the virus.

In fact, a pilot study of 98 patients published Thursday in the Lancet Respiratory Medicine journal found benefits from an inhaled form of interferon. In the industry-funded British study, hospitalized COVID patients randomly assigned to receive interferon beta-1a were more than twice as likely as others to recover enough to resume their regular activities.

Researchers need to confirm these findings in a much larger study, said Dr. Nathan Peiffer-Smadja, a researcher at Imperial College London who was not involved in the study but wrote an accompanying editorial. Future studies should test patients’ blood for genetic mutations and autoantibodies against interferon, to see if they respond differently than others.

Peiffer-Smadja notes that inhaled interferon may work better than an injected form of the drug because it’s delivered directly to the lungs. While injected versions of interferon have been used for years to treat other diseases, the inhaled version is still experimental and not commercially available.

And doctors should be cautious about interferon for now, because a study led by the World Health Organization found no benefit to an injected form of the drug in COVID patients, Peiffer-Smadja said. In fact, there was a trend toward higher mortality rates in patients given interferon, although this finding could have been due to chance. Giving interferon later in the course of disease could encourage a destructive immune overreaction called a cytokine storm, in which the immune system does more damage than the virus.

Around the world, scientists have launched more than 100 clinical trials of interferons, according to clinicaltrials.gov, a database of research studies from the National Institutes of Health.

Until larger studies are completed, doctors say, Bastard’s findings are unlikely to change how they treat COVID-19.

Dr. Lewis Kaplan, president of the Society of Critical Care Medicine, said he treats patients according to their symptoms, not their risk factors.

“If you are a little sick, you get treated with a little bit of care,” Kaplan said. “You are really sick, you get a lot of care. But if a COVID patient comes in with hypertension, diabetes and obesity, we don’t say, ‘They have risk factors. Let’s put them in the ICU.’”

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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This story can be republished for free (details).

KHN Editor-in-Chief Elisabeth Rosenthal discussed how to manage unexpected health care costs with CBSN on Wednesday.

• Click here to watch Rosenthal on CBSN

KHN chief Washington correspondent Julie Rovner discussed the Affordable Care Act case before the Supreme Court with WBEZ’s “Reset” and WDET’s “Detroit Today” on Tuesday and with WHYY’s “Radio Times” on Wednesday.

• Click here to hear Rovner on WBEZ
• Click here to hear Rovner on WDET
• Click here to hear Rovner on WHYY
• Read Rovner’s “What to Know as ACA Heads to Supreme Court — Again“

KHN partnerships editor and senior correspondent Mary Agnes Carey discussed the ACA Supreme Court case on Newsy’s “Morning Rush” on Tuesday and on Connecticut Public Radio’s “Where We Live” on Nov. 6.

• Click here to watch Carey on Newsy
• Click here to hear Carey on Connecticut Public Radio

On Thursday, KHN correspondent Rachana Pradhan discussed with Newsy the challenges President-elect Joe Biden faces in trying to seat Food and Drug Administration leadership quickly to deal with the pandemic.

• Click here to watch Pradhan on Newsy
• Read Pradhan’s “As Nation Awaits Vaccine, Biden Is Under Pressure to Name New FDA Chief ASAP“

KHN senior correspondent Sarah Jane Tribble discussed KHN’s “Where It Hurts” podcast with Kansas Public Radio’s “KPR Presents” on Nov. 1.

• Click here to hear Tribble on Kansas Public Radio
• Tribble hosts “No Mercy,” the first season of “Where It Hurts.” Click here to listen to Chapter 1.

At the Stanford Graduate School of Business in Northern California, the stories got weird almost immediately upon students’ return for the fall semester. Some said they were being followed around campus by people wearing green vests telling them where they could and could not be, go, stop, chat or conduct even a socially distanced gathering. Others said they were threatened with the loss of their campus housing if they didn’t follow the rules.

“They were breaking up picnics. They were breaking up yoga groups,” said one graduate student, who asked not to be identified so as to avoid social media blowback. “Sometimes they’d ask you whether you actually lived in the dorm you were about to go into.”

Across the country in Boston, students at the Harvard Business School gathered for the new semester after being gently advised by the school’s top administrators, via email, that they were part of “a delicate experiment.” The students were given the ground rules for the term, then received updates every few days about how things were going. And that, basically, was that.

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In the time of COVID-19, it’s fair to say that no two institutions have come to quite the same conclusions about how to proceed safely. But as Harvard’s and Stanford’s elite MBA-granting programs have proved, those paths can diverge radically, even as they may eventually lead toward the same place.

For months, college and university administrators nationwide have huddled with their own medical experts and with local and county health authorities, trying to determine how best to operate in the midst of the novel coronavirus. Could classes be offered in person? Would students be allowed to live on campus — and, if so, how many? Could they hang out together?

“The complexity of the task and the enormity of the task really can’t be overstated,” said Dr. Sarah Van Orman, head of student health services at the University of Southern California and a past president of the American College Health Association. “Our first concern is making sure our campuses are safe and that we can maintain the health of our students, and each institution goes through that analysis to determine what it can deliver.”

With a campus spread over more than 8,000 acres on the San Francisco Peninsula, Stanford might have seemed like a great candidate to host large numbers of students in the fall. But after sounding hopeful tones earlier in the summer, university officials reversed course as the pandemic worsened, discussing several possibilities before finally deciding to limit on-campus residential status to graduate students and certain undergrads with special circumstances.

The Graduate School of Business sits in the middle of that vast and now mostly deserted campus, so the thought was that Stanford’s MBA hopefuls would have all the physical distance they needed to stay safe. Almost from the students’ arrival in late August, though, Stanford’s approach was wracked by missteps, policy reversals and general confusion over what the COVID rules were and how they were to be applied.

Stanford’s business grad students were asked to sign a campus compact that specified strict safety measures for residents. Students at Harvard Business School signed a similar agreement. In both cases, state and local regulations weighed heavily, especially in limiting the size of gatherings. But Harvard’s compact emerged fully formed and relied largely on the trustworthiness of its students. The process at Stanford was unexpectedly torturous, with serial adjustments and enforcers who sometimes went above and beyond the stated restrictions.

Graduate students there, mobilized by their frustration over not being consulted when the policy was conceived, urged colleagues not to sign the compact even though they wouldn’t be allowed to enroll in classes, receive pay for teaching or live in campus housing until they did. Among their objections: Stanford’s original policy had no clear appeals process, and it did not guarantee amnesty from COVID violation punishments to those who reported a sexual assault “at a party/gathering of multiple individuals” if the gathering broke COVID protocols.

Under heavy pressure, university administrators ultimately altered course, solicited input from the grad student population and produced a revised compact addressing the students’ concerns in early September, including the amnesty they sought for reporting sexual assault. But the Stanford business students were already unsettled by the manners of enforcement, including the specter of vest-wearing staffers roaming campus.

According to the Stanford Daily, nine graduate students were approached in late August by armed campus police officers who said they’d received a call about the group’s outdoor picnic and who — according to the students — threatened eviction from campus housing as an ultimate penalty for flouting safety rules. “For international students, [losing] housing is really threatening,” one of the students told the newspaper.

The people in the vests were Event Services staff working as “Safety Ambassadors,” Stanford spokesperson E.J. Miranda wrote in an email. The staffers were not on campus to enforce the compact, but rather were “emphasizing educational and restorative interventions,” he said. Still, when the university announced the division of its campus into five zones in September, it told students in a health alert email that the program “will be enforced by civilian Stanford representatives” — the safety ambassadors.

The Harvard Business School’s approach was certainly different in style. In July, an email from top administrators reaffirmed the school’s commitment to students living on campus and taking business classes in person in a hybrid learning model. As for COVID protocols, the officials adopted “a parental tone,” as the graduate business education site Poets & Quants put it. “All eyes are on us,” the administrators wrote in an August email.

But the guts of the school’s instructions were similar to those at Stanford. Both Harvard and Stanford severely restricted who could be on campus at any given time, limiting access to students, staff members and preapproved visitors. Both required that anyone living on campus report their health daily through an online portal, checking for any symptoms that could be caused by COVID-19. Both required face coverings when outside on campus — even, a Harvard missive said, in situations “when physical distancing from others can be maintained.”

So far, both Harvard and Stanford have posted low positive test rates overall, and the business schools are part of those reporting totals, with no significant outbreaks reported. Despite their distinct delivery methods, the schools ultimately relied on science to guide their COVID-related decisions.

“I feel like we’ve been treated as adults who know how to stay safe,” said a Harvard second-year MBA candidate who requested anonymity. “It’s worked — at least here.”

But as the experiences at the two campuses show, policies are being written and enforced on the fly, in the midst of a pandemic that has brought challenge after challenge. While the gentler approach at Harvard Business School largely worked, it did so within a larger framework of the health regulations put forth by local and county officials. As skyrocketing COVID-19 rates across the nation suggest, merely writing recommendations does little to slow the spread of disease.

Universities have struggled to strike a balance between the desire to deliver a meaningful college experience and the discipline needed to keep the campus caseload low in hopes of further reopening in 2021. In Stanford’s case, that struggle led to overreach and grad-student blowback that Harvard was able to avoid.

The fall term has seen colleges across the country cycling through a series of fits and stops. Some schools welcomed students for in-person classes but quickly reverted to distance learning only. And large campuses, with little ability to maintain the kind of control of a grad school, have been hit tremendously hard. Major outbreaks have been recorded at Clemson, Arizona State, Wisconsin, Penn State, Texas Tech — locations all over the map that opened their doors with more students and less stringent guidelines.

In May, as campuses mostly shut down to consider their future plans, USC’s Van Orman expressed hope that universities’ past experiences with international students and global outbreaks, such as SARS, would put them in a position to better plan for COVID-19. “In many ways, we’re one of the best-prepared sectors for this test,” she said.

Six months later, colleges are still being tested.