Category: From California Healthline.org

El gobernador de Florida, Ron DeSantis, trató de aliviar el temor a volar durante la pandemia en un evento con ejecutivos de aerolíneas y compañías de alquiler de autos.

“Los aviones simplemente no han sido vectores cuando se observa la propagación del coronavirus”, dijo DeSantis en el encuentro en el Aeropuerto Internacional Fort Lauderdale-Hollywood el 28 de agosto.  “La evidencia es la evidencia. Y creo que es algo que la gente puede hacer con seguridad “, agregó.

¿La evidencia es realmente tan clara?

La afirmación de DeSantis de que los aviones no han sido “vectores” de la propagación del coronavirus es falsa, según expertos. Un “vector” disemina el virus de un lugar a otro, y los aviones han transportado a pasajeros infectados a través de distintas regiones, lo que hace que los brotes de COVID-19 sean más difíciles de contener.

Joseph Allen, profesor asociado en la Universidad de Harvard y experto en exposiciones a virus, calificó a los aviones como “excelentes vectores para la propagación viral” en una llamada de prensa.

En contexto, DeSantis parecía estar haciendo hincapié en la seguridad de volar en avión en lugar del papel que desempeñaron los aviones en la propagación del virus de un lugar a otro.

Cuando se le consultó a la oficina del gobernador sobre datos que respaldaran los comentarios de DeSantis, el secretario de prensa Cody McCloud no presentó ningún estudio ni estadística. En cambio, citó el programa de rastreo de contactos del Departamento de Salud de Florida y escribió que “no ha proporcionado ninguna información que sugiera que algún paciente se haya infectado mientras viajaba en un vuelo comercial”.

El programa de rastreo de contactos de Florida se ha visto envuelto en una controversia sobre informes que denuncian que no tiene suficiente personal y que es ineficaz. CNN llamó a 27 residentes del estado que dieron positivo para COVID-19 y descubrió que solo cinco habían sido contactados por las autoridades de salud. (El Departamento de Salud de Florida no respondió a las solicitudes de entrevista).

Expertos aseguran que, en general, los aviones brindan ambientes seguros en lo que respecta a la calidad del aire, pero agregaron que el riesgo de infección depende en gran medida de las políticas que las aerolíneas puedan tener sobre los asientos de los pasajeros, el uso de máscaras y el tiempo de embarque.

Según indicaron, el riesgo de contraer el coronavirus en un avión es relativamente bajo si la aerolínea sigue los procedimientos de salud pública: hacer cumplir la regla de usar máscara, espaciar los asientos disponibles y examinar a los pasajeros enfermos.

“Si observas otras enfermedades, ves pocos brotes en aviones”, dijo Allen. “No son los semilleros de infección que la gente cree que son”.

Las aerolíneas señalan con frecuencia que los aviones comerciales están equipados con filtros de aire HEPA, recomendados por los Centros para el Control y Prevención de Enfermedades (CDC), que se utilizan en las salas de aislamiento de los hospitales.

Los filtros HEPA capturan el 99,97% de las partículas en el aire y reducen sustancialmente el riesgo de propagación viral. Además, el aire en las cabinas se renueva por completo entre 10 y 12 veces por hora, elevando la calidad del aire por encima de la de un edificio normal.

Debido a la alta tasa de renovación del aire, es poco probable que se contraiga el coronavirus de alguien sentado a varias filas de distancia. Sin embargo, sí podría ocurrir el contagio de alguien cercano.

“El mayor riesgo durante el vuelo sería si el pasajero se sienta cerca de alguien que pueda infectar”, dijo Richard Corsi, quien estudia la contaminación del aire en interiores y es decano de Ingeniería en Universidad Estatal de Portland.

También es importante señalar que los sistemas de filtración de alta potencia de los aviones no son suficientes por sí solos para prevenir brotes. Si una aerolínea no mantiene libres los asientos del medio ni hace cumplir rigurosamente el uso de máscaras, volar puede ser bastante peligroso. Actualmente, las aerolíneas nacionales que mantienen abiertos los asientos intermedios incluyen Delta, Hawaiian, Southwest y JetBlue.

La razón de esto es que las personas infectadas envían partículas virales al aire a un ritmo más rápido que el que los aviones las expulsan fuera de la cabina. “Siempre que tose, habla o respira, está enviando gotitas”, dijo Qingyan Chen, profesor de ingeniería mecánica en la Universidad Purdue. “Estas gotas están en la cabina todo el tiempo”.

Esto hace que las medidas de protección adicionales, como el uso de máscaras, sean aún más necesarias.

Chen citó dos vuelos internacionales anteriores a la pandemia donde las tasas de infección variaron según el uso de mascarillas. En el primer vuelo, ningún pasajero llevaba máscaras y un solo pasajero infectó a 14 personas mientras el avión viajaba de Londres a Hanoi, Vietnam. En el segundo vuelo, de Singapur a Hangzhou, en China, todos los pasajeros llevaban máscaras faciales.

Aunque 15 pasajeros eran residentes de Wuhan con casos sospechosos o confirmados de COVID-19, el único hombre infectado en el recorrido se había aflojado la máscara en pleno vuelo y había estado sentado cerca de cuatro residentes de Wuhan que luego dieron positivo para el virus.

Pero, aunque volar es una actividad de riesgo relativamente bajo, se debe evitar viajar a menos que sea absolutamente necesario.

“Cualquier cosa que te ponga en contacto con más personas aumentará el riesgo”, dijo Cindy Prins, profesora clínica asociada de Epidemiología en la Escuela de Salud Pública y Profesiones de la Salud de la Universidad de Florida.

El verdadero peligro de viajar no es el vuelo en sí. Sin embargo, pasar por el control de seguridad y esperar en la puerta de embarque es probable que ponga a la persona en contacto cercano con otros y aumente sus posibilidades de contraer el virus.

Además, abordar, cuando el sistema de ventilación del avión no está funcionando y las personas no pueden mantenerse alejadas entre sí, es una de las partes más riesgosas. “Reducir este tiempo es importante para bajar la exposición”, escribió Corsi. “Hay que llegar al asiento con la máscara y sentarse lo más rápido posible”.

Con todo, es demasiado pronto para determinar cuánta transmisión de persona a persona ha ocurrido en vuelos.

Julian Tang, profesor asociado honorario en el Departamento de Ciencias Respiratorias de la Universidad de Leicester, en Inglaterra, dijo que está al tanto de varios grupos de infecciones relacionadas con los viajes aéreos. Sin embargo, es un desafío demostrar que las personas contrajeron el virus en un vuelo.

“Alguien que presenta síntomas de COVID-19 varios días después de llegar a su destino podría haberse infectado en casa antes de llegar al aeropuerto, mientras estaba en el aeropuerto o en el vuelo, o incluso al llegar al aeropuerto de destino, porque todo el mundo tiene un período de incubación variable”, dijo Tang.

Katherine Estep, vocera de Airlines for America, un grupo comercial de la industria centrado en Estados Unidos, dijo que los CDC no han confirmado ningún caso de transmisión a bordo de una aerolínea estadounidense.

La ausencia de transmisión confirmada no es necesariamente una prueba de que los viajeros estén seguros. En cambio, la falta de datos refleja el hecho de que Estados Unidos tiene una tasa de infección más alta en comparación con otros países, dijo Chen. Dado que tiene tantos casos confirmados, es más difícil determinar exactamente dónde alguien contrajo el virus.

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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New Mexico Health Connections’ decision to close at year’s end will leave just three of the 23 nonprofit health insurance co-ops that sprang from the Affordable Care Act.

One co-op serves customers in Maine, another in Wisconsin, and the third operates in Idaho and Montana and will move into Wyoming next year. All made money in 2019 after having survived several rocky years, according to data filed with the National Association of Insurance Commissioners.

They are also all in line to receive tens of millions of dollars from the federal government under an April Supreme Court ruling that said the government inappropriately withheld billions from insurers meant to help cushion losses from 2014 through 2016, the first three years of the ACA marketplaces. While those payments were intended to help any insurers losing money, it was vitally important to the co-ops because they had the least financial backing.

Lauded as a way to boost competition among insurers and hold down prices on the Obamacare exchanges, the co-ops had more than 1 million people enrolled in 26 states at their peak in 2015. Today, they cover about 128,000 people, just 1% of the 11 million Obamacare enrollees who get coverage through the exchanges.

The nonprofit organizations were a last-minute addition to the 2010 health law to satisfy Democratic lawmakers who had failed to secure a public option health plan — one set up and run by the government — on the marketplaces. Congress provided $2 billion in startup loans. But nearly all the co-ops struggled to compete with established carriers, which already had more money and recognized brands.

State insurance officials and health experts are hopeful the last three co-ops will survive.

“These are the three little miracles,” said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University, in Washington, D.C.

Maine Aided in Supreme Court Victory

The Maine co-op, Community Health Options, helped bring competition to the state’s market, which has had trouble at times attracting insurance carriers, said Eric Cioppa, who heads the state’s bureau of insurance.

“The plan has added a level of stability and has been a positive for Maine,” he said.

The co-op has about 28,000 members — down from about 75,000 in 2015 — and is building up its financial reserves, Cioppa said. Community Health Options is one of three insurers in the Obamacare marketplace in Maine, the minimum number experts say is needed to ensure vibrant competition.

Kevin Lewis, CEO of the plan, attributed its survival to several factors, including an initial profit in 2014, the year the ACA marketplaces opened, that put the plan on a secure footing before several years of losses. He also credited bringing most functions of the health plan in-house rather than contracting out, diversifying to sell plans to small and large employers, and securing lower rates from two health systems during a couple of difficult years.

Jay Gould, 60, a member who offers the plan to workers at his small grocery in Clinton, has been happy with the plan. “They have great customer service, and it’s good to know when I am talking to someone that they are from Maine,” he said.

Central Aroostook Association, a Presque Isle nonprofit that helps children with intellectual disabilities, switched to the co-op last year to save 20% on its health premiums, said administrator Tammi Easler. Having a Maine insurer means any issues can be dealt with quickly, she said. “They are readily available, and I never have to wait on hold for an hour.”

The co-op, which made a $25 million profit each of the past two years, has proposed dropping its average premiums by about 14% in 2021, Lewis said.

Community Health was one of the lead plaintiffs in the case before the Supreme Court and expects to get $59 million in back payments from the settlement.

The federal decision to suspend those so-called risk corridor payments — designed to help health plans recover some of their losses — was one of the factors that caused many of the co-ops to fail, Corlette said. Republican critics of the ACA, however, blame poor management by the plans and lack of oversight by the Obama administration.

Insurers are in talks with the Trump administration about whether the $13 billion due the carriers must be added to their 2020 balance sheet or could be counted toward operations from prior years. This year, insurers are generally banking large profits since many people have delayed non-urgent care because of the COVID-19 pandemic. Since the ACA limits insurers’ profit margins, adding that federal windfall to this year’s ledger might mean many insurers would have to pay out most of the money to their consumers. If the money is applied to earlier years, the insurers could likely keep more of it to add to their reserves.

Too Much Competition in New Mexico

The Supreme Court ruling came too late for New Mexico Health Connections, which lost nearly $60 million from 2015 to 2017. The co-op would have received $43 million in overdue payments, but, in an effort to raise needed cash, it sold that debt to another insurer in 2017 for a much smaller amount.

Marlene Baca, CEO of the co-op, which made a $439,000 profit in 2019, said its goal of bringing competition into the market was achieved, since five other companies will be enrolling customers this fall for 2021. Yet, that competition eventually led to the plan’s decision to end operations, announced last month.

With only 14,000 members, it made no sense to continue operating due to high fixed administrative costs, she said. Her plan was also hurt by the slumping economy this year, which pushed many state residents out of work and made more than 3,000 members eligible for Medicaid, the state-federal health program for the poor.

“We did our very best,” Baca said, noting that her company is closing with enough money to pay its outstanding health claims. Many other co-ops that shuttered were closed out by their states and unable to meet all their debts to health providers, she said.

Montana’s Co-Op Is Expanding

The Mountain Health Co-Op, with about 32,000 members, has just two competitors in its home state of Montana and four in Idaho.

A big factor behind its survival was that the plan received a $15 million loan in 2016 from St. Luke’s Health System, Idaho’s largest hospital provider, said CEO Richard Miltenberger. Although he wasn’t working for the co-op at that time, Miltenberger said, it is his understanding that the hospital wanted to help maintain competition in that marketplace.

The co-op is expecting $57 million from the Supreme Court victory.

“We are in excellent shape,” Miltenberger said. The plan, which paid back the St. Luke’s loan and made a $15 million profit in 2019, added vision benefits this year and is offering a dental exam benefit for next year. It’s also providing most insulin and medications for asthma and chronic obstructive pulmonary disease to members without any copayment to help ensure compliance.

The insurer is moving into Wyoming for 2021, which will end the Blue Cross plan monopoly in that state’s Obamacare marketplace, he said.

Wisconsin’s Mystery Donor

Wisconsin’s Common Ground Healthcare Cooperative was on the verge of ending operations in 2016 when it received a lifesaving $30 million loan, said CEO Cathy Mahaffey. The insurer has refused to identify the benefactor other than to say it was not a person or company doing business with the plan.

In 2018, Common Ground was the only health plan in seven northeastern Wisconsin counties, she said. Today, the co-op has about 54,000 members and faces competition from two to five carriers in the 20 counties where it operates.

Common Ground, which recorded a $73 million profit last year, expects to receive about $95 million from the Supreme Court case victory.

Wisconsin’s decision not to expand Medicaid under the health law has benefited the co-op because people with incomes from 100% to 138% of the federal poverty level ($12,760 to $17,609 for an individual) are ineligible for Medicaid and must stay with marketplace plans for coverage. In states that expanded Medicaid, everyone with incomes under 138% of the poverty level is eligible.

Another factor was its decision in 2016 to eliminate the broad provider network offering and sell a plan offering only a narrow network of doctors and hospitals, allowing it to benefit from lower rates from its providers, according to Mahaffey.

“We are very strong financially,” she said.

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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If your life these days is anything like mine, a pre-pandemic routine that included regular exercise and disciplined eating has probably given way to sedentary evenings on a big chair, binge-watching reruns of your favorite TV series while guzzling chocolate ice cream or mac ’n’ cheese.

But let’s not beat ourselves up about it. Several doctors I spoke with recently said most of their patients and many of their colleagues are struggling to maintain healthy habits amid the anxiety of the pandemic. “The Quarantine 15” (pounds, that is) is a real phenomenon.

The double challenge of protecting our health, including our immune systems, while battling unhealthy temptations “is a struggle everyone is dealing with,” says Dr. David Kilgore, director of the integrative medicine program at the University of California-Irvine.

Well before COVID-19, more than 40% of U.S. adults were obese, which puts them at risk for COVID-19’s worst outcomes. But even people accustomed to physical fitness and good nutrition are having trouble breaking the bad habits they’ve developed over the past five months.

Karen Clark, a resident of Knoxville, Tennessee, discovered competitive rowing later in life, and her multiple weekly workouts burned off any excess calories she consumed. But the pandemic changed everything: She could no longer meet up with her teammates to row and stopped working out at the YMCA.

Suddenly, she was cooped up at home. And, as for many people, that led to a more sedentary lifestyle, chained to the desk, with no meetings outside the house or walks to lunch with colleagues.

“I reverted to comfort food and comfortable routines and watching an awful lot of Netflix and Amazon Prime, just like everybody else,” Clark says. “When I gained 10 pounds and I was 25, I just cut out the beer and ice cream for a week. When you gain 12 pounds at 62, it’s a long road back.”

She started along that road in July, when she stopped buying chips, ice cream and other treats. And in August, she rediscovered the rowing machine in her basement.

But don’t worry if you lack Clark’s discipline, or a rowing machine. You can still regain some control over your life.

A good way to start is to establish some basic daily routines, since in many cases that’s exactly what the pandemic has taken away, says Dr. W. Scott Butsch, director of obesity medicine at the Cleveland Clinic’s Bariatric and Metabolic Institute. He recommends you “bookend” your day with physical activity, which can be as simple as a short walk in the morning and a longer one after work.

And, especially if you have kids at home who will be studying remotely this fall, prepare your meals at the beginning of the day, or even the beginning of the week, he says.

If you haven’t exercised in a while, “start slow and gradually get yourself up to where you can tolerate an elevated heart rate,” says Dr. Leticia Polanco, a family medicine doctor with the South Bay Primary Medical Group, just south of San Diego. If your gym is closed or you can’t get together with your regular exercise buddies, there are plenty of ways to get your body moving at home and in your neighborhood, she says.

Go for a walk, a run or a bike ride, if one of those activities appeals to you. Though many jurisdictions across the United States require residents to wear masks when out in public, it may not be necessary — and may even be harmful to some people with respiratory conditions — while doing strenuous exercise.

“It’s clearly hard to exercise with a mask on,” says Dr. Yvonne Maldonado, a pediatrician specializing in infectious diseases at Stanford University’s School of Medicine. “We go hiking up in the foothills and we take our masks with us and we don’t wear them unless somebody starts coming the other way. Then we will put the mask on, and then we take it off and we keep going.”

If you prefer to avoid the mask question altogether, think of your house as a cleverly disguised gym. Put on music and dance, or hula-hoop, Polanco suggests. You can also pump iron if you have dumbbells, or find a cable TV station with yoga or other workout programs.

If you search on the internet for “exercise videos,” you will find countless workouts for beginners and experienced fitness buffs alike. Try one of the seven-minute workout apps so popular these days. You can download them from Google Play or the Apple Store.

If you miss the camaraderie of exercising with others, virtual fitness groups might seem like a pale substitute, but they can provide motivation and accountability, as well as livestreamed video workouts with like-minded exercisers. One way to find such groups is to search for “virtual fitness community.”

Many gyms are also offering live digital fitness classes and physical training sessions, often advertised on their websites.

If group sports is your thing, you may or may not have options, depending on where you live.

In Los Angeles, indoor and outdoor group sports in municipal parks are shut down until further notice. The only sports allowed are tennis and golf.

In Montgomery County, Maryland, the Ron Schell Draft League, a softball league for men 50 and older, will resume play early this month after sitting out the spring season due to COVID-19, says Dave Hyder, the league’s commissioner.

But he says it has been difficult to get enough players because of worries about COVID.

“In the senior group, you have quite a lot of people who are in a high-risk category or may have a spouse in a high-risk category, and they don’t want to chance playing,” says Hyder, 67, who does plan to play.

Players will have to stay at least 6 feet apart and wear masks while off the field. On the field, the catcher is the only player required to wear a mask. That’s because masks can steam up glasses or slip, causing impaired vision that could be dangerous to base runners or fielders, Hyder explains.

Whatever form of exercise you choose, remember it won’t keep you healthy unless you also reduce consumption of fatty and sugary foods that can raise your risk of chronic diseases such as obesity, diabetes and hypertension — all COVID-19 risk factors.

Kim Guess, a dietitian at UC-Berkeley, recommends that people lay in a healthy supply of beans and lentils, whole grains, nuts and seeds, as well as frozen vegetables, tofu, tempeh and canned fish, such as tuna and salmon.

“Start with something really simple,” she said. “It could even be a vegetable side dish to go with what they’re used to preparing.”

Whatever first steps you decide to take, now is a good time to start eating better and moving your body more.

Staying healthy is “so important these days, more than at any other time, because we are fighting this virus which doesn’t have a treatment,” says the Cleveland Clinic’s Butsch. “The treatment is our immune system.”

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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Barbara Faubion’s boss, an insurance broker, used to tell clients: “Listen, you don’t need to be on the phone for four hours with Blue Cross Blue Shield. Let us do that. I have a person.”

Faubion was that person. And she got up every day psyched to go to work, which she said puzzled her friends.

“They’d go, ‘You love your job?!? You spend your whole day talking to an insurance company. Are you kidding me?’”

She was not kidding. Faubion loved to win — and she was really, really good at untangling other people’s health insurance problems.

Now she’s going to teach us some of what she knows.

So why doesn’t every health insurance broker have someone like Faubion on staff? ProPublica reporter Marshall Allen has that answer; there are big clues in his 2019 story about industry commissions and bonuses.

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

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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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This story can be republished for free (details).

Dr. Chris Kjolhede is focused on the children of central New York.

As co-director of school-based health centers at Bassett Healthcare Network, the pediatrician oversees about 21 school-based health clinics across the region — a poor, rural area known for manufacturing and crippled by the opioid epidemic.

From ankles sprained during recess to birth control questions, the clinics serve as the primary care provider for many children both in and out of the classroom. High on the to-do list is making sure kids are up to date on required vaccinations, said Kjolhede.

But, in March, COVID upended the arrangement when it forced schools to close.

“It was like, holy smokes,” he said, “what’s going to happen now?”

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Schools play a pivotal role in U.S. vaccination efforts. Laws require children to have certain immunizations to enroll and attend classes.

But this academic year, to prevent COVID-19 from spreading, many school districts have opted to start classes online. The decision takes away much of the back-to-school leverage pushing parents to stay current on their children’s shots, said Dr. Nathaniel Beers, member of the Council on School Health for the American Academy of Pediatrics. If schooling is not happening in person, said Beers, who also led multiple roles in the District of Columbia Public Schools system, “it is harder to enforce.”

Public health officials have relied on schools as a means to control vaccine-preventable diseases for over a century. Vaccination laws that require immunizations to enter school first emerged in the 1850s in Massachusetts as a means to control smallpox, as the Centers for Disease Control and Prevention has noted.

Every state requires children to receive certain vaccinations against illnesses like polio, mumps and measles before entering the classroom or a child care center, unless the child has a medical exemption. Some states allow people to opt children out of vaccinations for religious or philosophical reasons, although these exemptions have been associated with outbreaks of otherwise well-controlled diseases like measles.

“If they get behind or they don’t get specific vaccines they need, kindergarten is a real catch point to get them up to speed and make sure they’re up to date,” said Claire Hannan, executive director of the Association of Immunization Managers.

At the local level, the responsibility of tracking whether students are compliant generally falls on the school nurse. If one is not present, a clerical worker or administrator does the job, said Linda Mendonca, president-elect of the National Association of School Nurses. Usually, school systems face a deadline for checking every child’s record and reporting compliance to government health officials, she said.

How districts choose to hold noncompliant children accountable varies, Beers said. Some schools work with parents to set up appointments with a provider. Some isolate children in a classroom, he said, and some are so strict that “you can’t even walk through the door unless you are appropriately immunized.”

The COVID-19 pandemic has resulted in steep declines in vaccinations. In May, a report from the CDC showed a sharp drop in the number of orders submitted to the Vaccines For Children program, a federal initiative that purchases vaccines for half the children in the U.S. A second release revealed similar trends — vaccination coverage in Michigan declined among all milestone ages, with the exception of immunizations given at birth, which are generally done in a hospital.

Making Backup Plans

In Pennsylvania, for instance, the state health department in July suspended vaccine requirements for two months after the start of the school year. In addition to causing delays in doctors’ offices, the state said, the pandemic may also prevent school and public health nurses from holding in-school “catch-up” vaccination clinics.

“The department cannot stress enough that as soon as children can be vaccinated, they should be,” said Nate Wardle, press secretary for the state’s health department, in a written statement. However, the lockdown order prompted by COVID meant “that there was a several month period in some parts of the state where well-child visits were not occurring.”

Members of the American Academy of Pediatrics, the National Association of School Nurses and the Association of Immunization Managers said the grace periods are a prudent step to account for the pandemic’s effect on pediatric care. The majority of children already have some protection from diseases from previous vaccines, they said.

Additionally, Beers acknowledged that closing schools — among other actions like restricting travel and shuttering large gathering spaces — make children less likely to contract or spread illnesses that typically incubate in classrooms. For example, according to CDC data, measles has essentially disappeared — 12 cases had been reported as of Aug. 19 this year, compared with 1,282 throughout 2019.

However, schooling will eventually resume in person, which will also bring back the risks of illnesses moving through classrooms, Beers said. And school systems may be less forgiving of children who enter the classroom without the needed vaccinations.

“What would be an immense shame is if schools reopen in person and children are back together and we start getting outbreaks of other diseases that are preventable based on immunizations,” he said.

School-based health centers in New York are actively contacting parents about vaccinations. In Cooperstown, Kjolhede reached out to every superintendent soon after the lockdown in March to ask if the clinic could remain open. All but one said no.

The staff then set up telehealth appointments and phoned students who needed in-person care to arrange visits — including those who needed a vaccine before the start of this school year, he said. Luckily, the health center that remained open had a door that allowed patients to enter the clinic without walking through the school.

Several hours away, Dr. Lisa Handwerker is grappling with how to tackle the problem that hundreds of students across her six school-based health clinics in New York City have missed a required vaccine.

The city’s health department gave her a list of students in her care who needed additional immunizations, she said. Over 400 children were missing the second dose to prevent meningococcal meningitis, generally given to teens and young adults ages 16 to 23. Because the department used data from the last academic year to compile the list, Handwerker has no information about new students. Some families left the city because of the lack of income and resources caused by the pandemic.

“We had difficulty with at least half of the kids on our vaccine list,” Handwerker said. “Then when we reached families, they were reluctant to leave their houses.”

A Shot at Normalcy

That wasn’t the case for Tracey Wolf, a mother of two who visited the doctor recently to get her son Jordan vaccinated for measles, mumps, rubella and HPV before starting the seventh grade. He will be attending middle school in Dunedin, Florida, in person, said Wolf, 38.

It seemed nonsensical to keep Jordan, 13, from his classmates when he already plays baseball and hangs out with his friends, she said. His grades also slipped last spring when the COVID threat transformed his classroom into a computer.

She also took her 6-month-old Ethan for his immunizations. When asked whether she was afraid of going into her doctor’s office, she replied, “Not more than going to the grocery store.”

Regardless of whether a child starts school at home or in the classroom, immunization experts stressed the importance of vaccinating a child on time. The schedules factor in a child’s stage of development to maximize the vaccine’s effectiveness. That said, it is preferable that children get their vaccines from their regular doctor to prevent lost immunization records and additional shots, said Beers.

Yet on Aug. 19, the Department of Health and Human Services released a statement allowing pharmacists to provide childhood immunizations for children ages 3 to 18.

When Tamarack Dispensary opened in the northwestern Montana city of Kalispell in 2009, medical marijuana was legal but still operating on the fringes of the conservative community.

Times have changed. Owner Erin Bolster no longer receives surprised or puzzled looks when she tells people what she does. Now, her business sponsors community events and was recently nominated as a top marijuana provider by a local newspaper.

“We’ve become a normal part of the community, and it feels good that the community has finally accepted us,” Bolster said.

How far that acceptance goes will be tested when voters in Montana and a handful of other states this fall decide whether to legalize recreational or medical marijuana. Five of the six states with ballot questions lean conservative and are largely rural, and the results may signal how far America’s heartland has come toward accepting the use of a substance that federal law still considers an illegal and dangerous drug.

Since Colorado first allowed recreational use of marijuana in 2014, 10 other states have done the same. Most are coastal, left-leaning states, with exceptions like Nevada, Alaska and Maine. An additional 21 states allow medical marijuana, which must be prescribed by a physician.

This year, marijuana advocates are using the November elections to bypass Republican-led legislatures that have opposed legalization efforts, taking the question straight to voters.

Advocates point to a high number of petition signatures and their own internal polling as indicators that the odds of at least some of the measures passing are good.

One unknown is what role the pandemic will play in the marijuana measures’ fate. Demand for marijuana appears to be rising with people feeling stressed and isolated by COVID-19 lockdown measures, according to a United Nations report on the implications of COVID policies on drug manufacturing, distribution and use. That increased use could work in advocates’ favor.

Mississippi and Nebraska voters will decide on medical marijuana measures.

South Dakota will be the first state to vote on legalizing both recreational and medical marijuana in the same election.

Montana, Arizona and New Jersey, all medical marijuana states, will consider ballot measures in November to allow recreational sales, a move opponents consider evidence of a slippery slope.

“This is how all these states have gotten recreational marijuana. They start with medical,” said Ed Langton, a member of the Mississippi Board of Health, who opposes his state’s legalization efforts.

If all or most of the ballot questions pass, that will leave only a handful of states that have not legalized marijuana in some way, potentially putting pressure on federal lawmakers to change national policy. For now, growers and sellers can’t use banks or credit cards or export their products.

The Marijuana Policy Project is helping to coordinate the Montana legalization effort. Its deputy director, Matthew Schweich, said the organization does so only when polling suggests at least half of voters would support the measure.

“It’s becoming normalized for people,” Schweich said. “People know that other states are legalizing it and the sky has not fallen.”

An effort to legalize marijuana in rural, conservative states would have been an uphill battle even a few years ago. But several factors have worked toward changing attitudes there, Schweich said.

They include a gradually increasing acceptance in red states of neighbors that have legalized recreational pot — and seeing the tax revenue that legal marijuana brings. But perhaps the biggest catalyst toward normalizing pot use is having an established medical marijuana program, Schweich said.

After 15 years, Montana’s medical cannabis program is firmly rooted and has survived several legislative attempts to restrict it or shut it down. According to the Montana Department of Public Health and Human Services, more than 500 marijuana providers were serving 38,385 people as of July, which represents nearly 4% of the state’s population.

A survey conducted by the University of Montana earlier this year found that 54% of respondents thought marijuana should be legalized for recreational use, up from 51% the year before. Six years earlier, a Montana State University-Billings poll found that 60% of residents were against legalization.

Changing attitudes could also stem from states’ changing demographics. An analysis of census data by the Montana Free Press in 2019 found that 53% of Montanans 25 and older were born outside the state.

Among them is Brandon Powers, who moved to Montana from Missouri last year. Powers supports legalization and believes its passage will depend largely on who turns out.

“If people like me dominate the polls, then it will pass. But if people like my neighbor who thinks ‘the [marijuana] they have today is just too powerful’ dominate the polls, then it will fail,” he said.

In Mississippi, 20 medical marijuana bills have failed over the years in the Statehouse. This year, 228,000 state residents signed petitions in support of a medical marijuana initiative to allow possession of up to 2.5 ounces of marijuana to treat more than 20 qualifying medical conditions.

In response, lawmakers put a competing measure on the ballot that would restrict marijuana use to terminally ill patients and require them to use only pharmaceutical-grade marijuana products.

Jamie Grantham, spokesperson for Mississippians for Compassionate Care, called the measure an effort by the state to split the vote and derail legalization efforts.

“I’m passionate about this because it’s a plant that God made and it can provide relief for those who are suffering,” said Grantham, who described herself as a conservative Republican. “If this is something that can be used to help relieve someone’s pain, then they should be able to use it.”

But opposition is starting to build. Langton, the Mississippi Board of Health member, is working with Mississippi Horizon, a group fighting legalization. Langton said he opposes the original initiative because he believes it’s “overly broad” and would allow dispensaries within 500 feet of schools and churches. It could also put Mississippi on a path toward legalized recreational use, he said.

He added: “They say that marijuana is a natural plant, but poison ivy is natural, too. Just because something is natural doesn’t mean it is good for you.”

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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El doctor Chris Kjolhede está enfocado en los niños del centro de Nueva York.

Como codirector de los centros de salud escolares de Bassett Healthcare Network, el pediatra supervisa alrededor de 21 clínicas de salud escolares en toda la región, una zona rural pobre conocida por sus fábricas y paralizada por la epidemia de opioides.

Desde un esguince de tobillo en el recreo hasta preguntas sobre el control de la natalidad, las clínicas sirven como proveedoras de atención primaria para muchos estudiantes, dentro y fuera del aula.

La meta principal es asegurarse que los niños estén al día con las vacunas obligatorias, dijo Kjolhede.

Pero, en marzo, COVID revocó el acuerdo cuando obligó a cerrar las escuelas.

Lo primero que me pregunté, dijo Kjolhede, fue: “¿qué va a pasar ahora?”.

Las escuelas juegan un papel fundamental en los esfuerzos de vacunación en los Estados Unidos. Las leyes requieren que los niños tengan ciertas vacunas para inscribirse y asistir a clases.

Pero para evitar que COVID-19 no siguiera propagándose, muchos distritos escolares han optado por comenzar el año académico en internet.

La decisión neutraliza en muchos casos el impulso de los padres por vacunar a sus hijos para el regreso a la escuela, dijo el doctor Nathaniel Beers, miembro del Consejo de Salud Escolar de la Academia Americana de Pediatría.

Beers, quien también ocupó varios roles en el sistema de Escuelas Públicas del Distrito de Columbia, agregó que si la educación no es en persona, “es más difícil de hacer cumplir los requisitos”.

Los funcionarios de salud pública han confiado en las escuelas como un medio para controlar las enfermedades prevenibles por vacunas durante más de un siglo. Las leyes de vacunación surgieron por primera vez en la década de 1850 en Massachusetts como un medio para controlar la viruela, según cuentan los Centros para el Control y Prevención de Enfermedades (CDC).

Todos los estados requieren que los niños reciban ciertas vacunas contra enfermedades como la poliomielitis, las paperas y el sarampión antes de empezar el año escolar o al jardín de infantes, al menos que el niño tenga una exención médica.

Algunos estados permiten a las personas optar por no vacunar a los niños por razones religiosas o filosóficas, aunque estas exenciones se han asociado con brotes de enfermedades que de otro modo estarían bien controladas, como por ejemplo el sarampión.

“Cuando entran al sistema, en preescolar, es donde se detecta si están atrasados con sus vacunas”, dijo Claire Hannan, directora ejecutiva de la Asociación de Administradores de Inmunización.

A nivel local, la responsabilidad de rastrear si los estudiantes cumplen con los requisitos de vacunación generalmente recae en la enfermera de la escuela. Si no, un oficinista o administrador hace el trabajo, dijo Linda Mendonca, presidenta electa de la Asociación Nacional de Enfermeras Escolares.

Si no los cumplen, algunas escuelas trabajan con los padres para programar citas con un proveedor de salud. Otras aíslan a los niños en el aula, y otras son tan estrictas que “ni siquiera puedes cruzar la puerta a menos que estés debidamente inmunizado”, dijo Beers.

La pandemia de COVID-19 ha provocado una baja dramática en la vacunación. En mayo, un informe de los CDC mostró una fuerte caída en la cantidad de pedidos al programa Vaccines For Children, una iniciativa federal que compra vacunas para la mitad de los niños del país.

Un segundo comunicado reveló tendencias similares: la cobertura de vacunación en Michigan disminuyó entre todas las edades, con la excepción de las vacunas que se administran al nacer, que generalmente se dan en el hospital.

En Pennsylvania, por ejemplo, el Departamento de Salud estatal suspendió en julio los requisitos de vacunas durante dos meses después del inicio del año escolar.

“El departamento no puede enfatizar más que hay que vacunarse lo antes posible”, dijo Nate Wardle, secretario de prensa del departamento de salud de ese estado, en una declaración escrita. Sin embargo, la orden de permanecer en casa por COVID hizo que durante meses los consultorios pediátricos no hicieran citas con niños sanos.

Beers reconoció que el cierre de las escuelas, entre otras acciones como restringir los viajes y cerrar grandes espacios de reunión, hace que los niños sean menos propensos a contraer o propagar enfermedades que generalmente se incuban en las aulas. Por ejemplo, según los datos de los CDC, el sarampión prácticamente ha desaparecido: se habían reportado 12 casos hasta el 19 de agosto de este año, en comparación con 1,282 en 2019.

“Lo que sería una gran vergüenza es que las escuelas vuelvan a abrir en persona y los niños vuelvan a estar juntos y empecemos a tener brotes de otras enfermedades que se pueden prevenir con vacunas”, agregó.

Los centros de salud de las escuelas de Nueva York se están comunicando activamente con los padres sobre las vacunas. En Cooperstown, Kjolhede se acercó a todos los superintendentes poco después del cierre en marzo para preguntar si la clínica podía permanecer abierta. Todos menos uno dijeron que no.

Luego, el personal concertó citas de telesalud y llamó a los estudiantes que necesitaban atención en persona para concertar visitas, incluidos aquellos que necesitaban una vacuna antes del comienzo de este año escolar, dijo. Afortunadamente, el centro de salud que permaneció abierto tenía una puerta que permitía a los pacientes ingresar a la clínica sin caminar por la escuela.

A varias horas de distancia, la doctora Lisa Handwerker está lidiando con la forma de abordar el problema de que cientos de estudiantes en sus seis clínicas de salud en las escuelas de la ciudad de Nueva York no han recibido vacunas mandatorias.

El departamento de salud de la ciudad le dio una lista de estudiantes bajo su cuidado que necesitaban vacunas adicionales, dijo. A más de 400 niños les faltaba la segunda dosis para prevenir la meningitis meningocócica, que generalmente se administra a adolescentes y adultos jóvenes de 16 a 23 años. Debido a que el departamento usó datos del último año académico para compilar la lista, Handwerker no tiene información sobre nuevos estudiantes. Algunas familias abandonaron la ciudad por la falta de ingresos y recursos provocada por la pandemia.

“Tuvimos dificultades con al menos la mitad de los niños en nuestra lista de vacunas”, dijo Handwerker. “Luego, cuando hablamos a las familias, se mostraron reacias a salir de sus casas”.

Ese no fue el caso de Tracey Wolf, una madre de dos hijos que visitó al médico recientemente para vacunar a su hijo Jordan contra el sarampión, las paperas, la rubéola y el VPH antes de comenzar el séptimo grado. Asistirá a la escuela secundaria en Dunedin, Florida, en persona, dijo Wolf, de 38 años.

Parecía una tontería mantener a Jordan, de 13 años, alejado de sus compañeros de clase cuando ya juega béisbol y sale con sus amigos, dijo. Sus calificaciones también bajaron la primavera pasada cuando la amenaza COVID transformó su salón de clases en una computadora.

También llevó a su hijo de 6 meses a recibir sus vacunas. Cuando se le preguntó si tenía miedo de ir al consultorio de su médico, respondió: “No más que ir al supermercado”.

Independientemente de si un niño comienza la escuela en casa o en el aula, los expertos en inmunización enfatizaron la importancia de vacunar siguiendo el calendario de inmunizaciones. Esas fechas tienen en cuenta la etapa de desarrollo del niño para maximizar la eficacia de la vacuna. Dicho esto, es preferible que los niños reciban las vacunas de su médico habitual para evitar la pérdida de los registros de vacunación y las vacunas adicionales, completó Beers.

Sin embargo, el 19 de agosto, el Departamento de Salud y Servicios Humanos (HHS) emitió una declaración que permite a los farmacéuticos administrar vacunas infantiles a niños y adolescents de 3 a 18 años.

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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Si en estos tiempos tu vida es como la mía, aquella rutina pre-pandémica que incluía ejercicio regular y una alimentación disciplinada probablemente ha dado paso a noches sedentarias en en el sofá, a atracones de televisión mientras te comes un helado de chocolate o macarrones con queso.

Pero no nos castiguemos por ello. Varios médicos con los que hablé recientemente me dijeron que la mayoría de sus pacientes, y muchos de sus colegas, están luchando por mantener hábitos saludables en medio de la ansiedad de la pandemia. “La cuarentena de 15” (el número de libras ganadas) es un fenómeno real.

El doble desafío de proteger nuestra salud, incluyendo nuestro sistema inmunológico, mientras se confrontan las tentaciones poco saludables “es una lucha con la que todos estamos lidiando”, dijo el doctor David Kilgore, director del programa de medicina integral de la Universidad de California-Irvine.

Mucho antes de COVID-19, más del 40% de los adultos en los Estados Unidos eran obesos, lo que los pone en riesgo de sufrir las peores consecuencias de la infección. Pero incluso las personas acostumbradas a mantener una buena forma física y una buena nutrición tienen problemas para romper los malos hábitos que han desarrollado en los últimos cinco meses.

Karen Clark, residente de Knoxville, Tennessee, descubrió el remo competitivo no hace mucho y sus múltiples entrenamientos semanales quemaban cualquier exceso de calorías que consumiera. Pero la pandemia lo cambió todo: ya no podía reunirse con sus compañeros de equipo para remar y dejó de hacer ejercicio en el YMCA.

De repente, se quedó encerrada en casa. Y, como para mucha gente, eso significó un estilo de vida más sedentario, encadenada al escritorio, sin reuniones fuera de la casa ni paseos para ir a  almorzar con los colegas.

“Me dediqué a comer comida fácil y reconfortante, a hacer rutinas cómodas y a ver una gran cantidad de Netflix y Amazon Prime, como todo el mundo”, contó Clark. “A los 25 años, cuando subía 10 libras dejaba de tomar cerveza y helado por una semana. Pero cuando ganas 12 libras a los 62, perderlas es un largo camino”.

Empezó ese camino en julio, cuando dejó de comprar papitas fritas, helados y otras golosinas. Y en agosto, redescubrió la máquina de remar en su sótano.

Pero no te preocupes si te falta la disciplina de Clark, o no tienes una máquina de remar. Todavía puedes recuperar algo de control sobre tu vida.

Una buena manera de empezar es establecer algunas rutinas diarias básicas, ya que en muchos casos eso es exactamente lo que la pandemia se ha llevado, señaló el doctor W. Scott Butsch, director de medicina para la obesidad en el Instituto Bariátrico y Metabólico de la Clínica Cleveland. Butsch recomienda “estructurar” el día con actividad física, que puede ser tan simple como una corta caminata en la mañana y una más larga después del trabajo.

Y, especialmente si tienes niños en casa que estudian a distancia este otoño, prepara tus comidas al principio del día, o incluso al principio de la semana, dijo Butsch.

Si no has hecho ejercicio durante un tiempo, “comienza despacio y gradualmente sube hasta donde puedas tolerar un ritmo cardíaco elevado”, recomendó la doctora Leticia Polanco, del South Bay Primary Medical Group, al sur de San Diego. Si tu gimnasio está cerrado o no puedes reunirte con tus compañeros de ejercicio habituales, hay muchas maneras de hacer que tu cuerpo se mueva en casa y en el vecindario, dijo.

Sal a caminar, a correr o a andar en bicicleta, si alguna de esas actividades te atrae. Aunque muchas jurisdicciones a lo largo de los Estados Unidos requieren que los residentes usen máscaras cuando están en público, puede no ser necesario —e incluso puede ser dañino para algunas personas con condiciones respiratorias— mientras se hace ejercicio.

“Está claro que es difícil hacer ejercicio con una máscara puesta”, expresó la doctora Yvonne Maldonado, pediatra especializada en enfermedades infecciosas de la Facultad de Medicina de la Universidad de Stanford. “Vamos de excursión a las colinas y llevamos nuestras máscaras con nosotros y no las usamos a menos que alguien se acerque. Entonces nos ponemos la máscara, y luego nos la quitamos y seguimos adelante”.

Si prefieres evitar el tema de la máscara, piensa en tu casa como un gimnasio ingeniosamente disfrazado. Pon música y baila, o haz hula-hoop, sugirió Polanco. También puedes levantar pesas, o encontrar una estación de televisión por cable con yoga u otros programas de entrenamiento.

Si buscas en Internet “videos de ejercicios”, encontrarás innumerables entrenamientos tanto para principiantes como para aficionados al fitness con experiencia. Prueba una de esas aplicaciones de entrenamientos de siete minutos tan populares en estos días. Puedes descargarlas de Google Play o del Apple Store.

Si extrañas la camaradería de hacer ejercicio con otros, los grupos virtuales de fitness pueden parecer un mal sustituto, pero pueden proporcionar motivación y responsabilidad, así como entrenamientos de vídeo en vivo con personas que piensan de la misma manera. Una forma de encontrar tales grupos es buscar “comunidad virtual de fitness”.

Muchos gimnasios también ofrecen clases digitales de fitness y sesiones de entrenamiento físico en vivo, a menudo anunciadas en sus sitios web.

Si lo tuyo son los deportes de grupo, puedes tener opciones o no, dependiendo de donde vivas.

En Los Ángeles, los deportes grupales en el interior y exterior en los parques municipales se han clausurado hasta nuevo aviso. Los únicos deportes permitidos son el tenis y el golf.

En el condado de Montgomery, Maryland, la Ron Schell Draft League, una liga de softball para hombres de 50 años o más, se reanudará a principios de este mes después de la temporada de primavera debido a COVID-19, dijo Dave Hyder, el comisionado de la liga.

Pero señaló que ha sido difícil conseguir suficientes jugadores debido a la preocupación por COVID.

“En el grupo de mayores, hay mucha gente que está en una categoría de alto riesgo o puede tener un cónyuge en una categoría de alto riesgo, y no quieren arriesgarse a jugar”, explicó Hyder, de 67 años, que sí piensa jugar.

Los jugadores tendrán que situarse, al menos, a 6 pies de distancia y usar máscaras mientras estén fuera del campo. En la cancha, el catcher es el único jugador que debe usar una máscara. Esto se debe a que las máscaras pueden empañar las gafas o resbalar, causando un deterioro de la visión que podría ser peligroso para los corredores de base o los jardineros, explicó Hyder.

Sea cual sea la forma de ejercicio que elijas, recuerda que no te mantendrá sano a menos que también reduzcas el consumo de alimentos grasos y azucarados que pueden aumentar el riesgo de enfermedades crónicas como la obesidad, la diabetes y la hipertensión, todos ellos factores de riesgo de COVID-19.

Kim Guess, dietista de la Universidad de California en Berkeley, recomienda que las personas consuman un suministro saludable de frijoles y lentejas, granos enteros, nueces y semillas, así como vegetales congelados, tofu, tempeh y pescado enlatado, como el atún y el salmón.

“Empieza con algo realmente simple”, recomendó. “Incluso podría ser un acompañamiento de verduras que vaya con lo que están acostumbrados a preparar”.

Sean cuales sean los primeros pasos que decidas dar, ahora es un buen momento para empezar a comer mejor y a mover más tu cuerpo.

Mantenerse sano es “muy importante hoy en día, más que en otros tiempos, porque estamos luchando contra este virus que no tiene tratamiento”, apuntó Butsch de la Clínica Cleveland. “El tratamiento es nuestro sistema inmunológico”.

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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Hopefully, summer won’t end the way it began. Memorial Day celebrations helped set off a wave of coronavirus infections across much of the South and West. Gatherings around the Fourth of July seemed to keep those hot spots aflame.

And now Labor Day arrives as those regions are cooling off from COVID-19. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, warned Wednesday that Americans should be cautious to avoid another surge in infection rates. But travelers are also weary of staying home — and tourist destinations are starved for cash.

“Just getting away for an hour up the street and staying at a hotel is like a vacation, for real,” says Kimberly Michaels, who works for NASA in Huntsville, Alabama, and traveled to Nashville, Tennessee, with her boyfriend to celebrate his birthday last weekend.

Lifting Restrictions for Summer’s End

In time for the tail end of summer, many local governments are lifting restrictions to resuscitate tourism activity and rescue small businesses.

Nashville, for instance, gave the green light to pedal taverns this week, allowing the human-powered bars-on-wheels to take to the streets again. “They’re not Nashville’s favorite group, frankly. But fairness requires this protocol change to take place,” Mayor John Cooper said, noting the city’s dramatic reduction in new cases. This week, the city also raised the attendance cap on weddings, funerals and other ceremonies.

Elsewhere, Virginia Beach tried to get some leniency for its struggling restaurants over the holiday weekend. But Virginia Gov. Ralph Northam rejected pleas from the mayor, at the encouragement of Fauci. The country’s top health official has encouraged governors to keep restrictions in place to avoid another holiday-related surge.

“Sometimes, as we start to lift restrictions, the impression that people get is ‘Oh, that must mean it’s safe,’” says epidemiologist Melissa McPheeters of Vanderbilt University. “We want to make sure we don’t give that impression, because this disease has not gone anywhere.”

Some communities have gone the other direction and reimposed restrictions, especially for the three-day weekend. Santa Barbara, California, has banned sunbathing to avoid another surge in cases.

Schooling Screws Up COVID Circles

There’s also a new X-factor with summer’s last holiday weekend. In many states, schools have resumed in-person classes. So families and friends meeting up are now more likely to expose each other to the virus, even if they tried to keep a tight circle over the summer.

“If those bubbles now have kids that went back to school and are interacting with others or they’ve gone back to sports and the bubble has since expanded, that ability to be safely together in a gathering is probably less likely,” says epidemiologist Bertha Hidalgo of the University of Alabama-Birmingham.

And yet, getting together safely — preferably outdoors — is still worth a try, Hidalgo says. She says people’s mental health needs a boost to get through the next few months.

“If you can do the safe things now before winter hits and that cold weather hits, then you’ll be more resilient to get through any bad times that may come,” she says.

In drivable destinations like Nashville that have welcomed visitors throughout the pandemic, tourism has not bounced back entirely. But on some weekend nights, the neon-soaked tourist district can draw a crowd.

This week, Vaj Vemulapalli and his girlfriend, of Dallas, turned back to their hotel after feeling uncomfortable with how tightly people were packed together.

“We crave the social interaction, the going out to bars and everything,” he says. “But at the end of the day, our general stance is it’s not worth getting [COVID-19] just to get a drink.”

Those crowds have limits, though, as Kimberly Michaels and birthday boy Marcus Robinson discovered. They arrived in Nashville fashionably late, masked up and ready to responsibly party. But after they checked into their hotel, they discovered that everything has to shut down by 10:30.

“It’s crazy. It was like the twilight zone,” Robinson says. “We went in [to the hotel], the streets were full. Got dressed, come downstairs. Like, where did everybody go? Like, did something happen? But we didn’t know, because we’re not from here.”

Still, as time goes by, some travelers are willing to take more risks to get back to activities that feel normal.

Suzette Ourso lives outside New Orleans and flew to Nashville for her first out-of-town trip since the pandemic hit. She says she’s cautious, wearing her mask whenever near anyone else.

“I keep hand sanitizer in my purse now. That’s something I’ve never really done before,” she says. “But you can die tomorrow riding in your vehicle. So you can’t live your life in fear, either.”

Ourso has a trip to the beach planned for later in the month.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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Although the coronavirus pandemic shut down many organizations and businesses across the nation, KHN has never been busier ― and health coverage has never been more vital. We’ve revamped our Behind the Byline YouTube series and brought it to Instagram TV.

Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts — all while staying safe.

Heidi de Marco – “At Least I Got the Shot”

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Photojournalist Heidi de Marco’s stunning images transport viewers to two California hospitals near the U.S.-Mexico border where the influx of patients with COVID-19 overwhelmed local intensive care units in late May. To capture these scenes at El Centro Regional Medical Center in Imperial County and Scripps Mercy Hospital Chula Vista in San Diego County, de Marco donned personal protective equipment and followed each facility’s safety guidelines. Still, she acknowledges, the work increased her risk of exposure to the coronavirus. She also risked bringing the virus home to her family. For her it was worth the risk, in order to give readers a window on health care in the midst of a pandemic — and to share her work with the world.