New research shows that over the past 50 years street cannabis across the world has become substantially stronger carrying an increased risk of harm.
As the novel coronavirus emerged in the news in January, Sarah Keeley was working as a medical scribe and considering what to do with her biology degree.
By February, as the disease crept across the U.S., Keeley said she found her calling: a career in public health. “This is something that’s going to be necessary,” Keeley remembered thinking. “This is something I can do. This is something I’m interested in.”
In August, Keeley began studying at the University of Illinois at Urbana-Champaign to become an epidemiologist.
Public health programs in the United States have seen a surge in enrollment as the coronavirus has swept through the country, killing more than 246,000 people. As state and local public health departments struggle with unprecedented challenges — slashed budgets, surging demand, staff departures and even threats to workers’ safety — a new generation is entering the field.
Among the more than 100 schools and public health programs that use the common application — a single admissions application form that students can send to multiple schools — there was a 20% increase in applications to master’s in public health programs for the current academic year, to nearly 40,000, according to the Association of Schools and Programs of Public Health.
Some programs are seeing even bigger jumps. Applications to Brown University’s small master’s in public health program rose 75%, according to Annie Gjelsvik, a professor and director of the program.
Demand was so high as the pandemic hit full force in the spring that Brown extended its application deadline by over a month. Seventy students ultimately matriculated this fall, up from 41 last year.
“People interested in public health are interested in solving complex problems,” Gjelsvik said. “The COVID pandemic is a complex issue that’s in the forefront every day.”
It’s too early to say whether the jump in interest in public health programs is specific to that field or reflects a broader surge of interest in graduate programs in general, according to those who track graduate school admissions. Factors such as pandemic-related deferrals and disruptions in international student admissions make it difficult to compare programs across the board.
Magnolia E. Hernández, an assistant dean at Florida International University’s Robert Stempel College of Public Health and Social Work, said new student enrollments in its master’s in public health program grew 63% from last year. The school has especially seen an uptick in interest among Black students, from 21% of newly admitted students last fall to 26.8% this year.
Kelsie Campbell is one of them. She’s part Jamaican and part British. When she heard in both the British and American media that Black and ethnic minorities were being disproportionately hurt by the pandemic, she wanted to focus on why.
“Why is the Black community being impacted disproportionately by the pandemic? Why is that happening?” Campbell asked. “I want to be able to come to you and say ‘This is happening. These are the numbers and this is what we’re going to do.’”
The biochemistry major at Florida International said she plans to explore that when she begins her MPH program at Stempel College in the spring. She said she hopes to eventually put her public health degree to work helping her own community.
“There’s power in having people from your community in high places, somebody to fight for you, somebody to be your voice,” she said.
Public health students are already working on the front lines of the nation’s pandemic response in many locations. Students at Brown’s public health program, for example, are crunching infection data and tracing the spread of the disease for the Rhode Island Department of Health.
Some students who had planned to work in public health shifted their focus as they watched the devastation of COVID-19 in their communities. In college, Emilie Saksvig, 23, double-majored in civil engineering and public health. She was supposed to start working this year as a Peace Corps volunteer to help with water infrastructure in Kenya. She had dreamed of working overseas on global public health.
The pandemic forced her to cancel those plans, and she decided instead to pursue a master’s degree in public health at Emory University.
“The pandemic has made it so that it is apparent that the United States needs a lot of help, too,” she said. “It changed the direction of where I wanted to go.”
These students are entering a field that faced serious challenges even before the pandemic exposed the strains on the underfunded patchwork of state and local public health departments. An analysis by AP and KHN found that since 2010, per capita spending for state public health departments has dropped by 16%, and for local health departments by 18%. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.
And the workforce is aging: Forty-two percent of governmental public health workers are over 50, according to the de Beaumont Foundation, and the field has high turnover. Before the pandemic, nearly half of public health workers said they planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons. Some public health workers are paid so little that they qualify for public aid.
Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, said government public health jobs need to be a “destination job” for top graduates of public health schools.
“If we aren’t going after the best and the brightest, it means that the best and the brightest aren’t protecting our nation from those threats that can, clearly, not only devastate from a human perspective, but from an economic perspective,” Castrucci said.
The pandemic put that already-stressed public health workforce in the middle of what became a pitched political battle over how to contain the disease. As public health officials recommended closing businesses and requiring people to wear masks, many, including Dr. Anthony Fauci, the U.S. government’s top virus expert, faced threats and political reprisals, AP and KHN found. Many were pushed out of their jobs. An ongoing count by AP/KHN has found that more than 100 public health leaders in dozens of states have retired, quit or been fired since April.
Those threats have had the effect of crystallizing for students the importance of their work, said Patricia Pittman, a professor of health policy and management at George Washington University’s Milken Institute School of Public Health.
“Our students have been both indignant and also energized by what it means to become a public health professional,” Pittman said. “Indignant because many of the local and the national leaders who are trying to make recommendations around public health practices were being mistreated. And proud because they know that they are going to be part of that front-line public health workforce that has not always gotten the respect that it deserves.”
Saksvig compared public health workers to law enforcement in the way they both have responsibility for enforcing rules that can alter people’s lives.
“I feel like before the coronavirus, a lot of people didn’t really pay attention to public health,” she said. “Especially now when something like a pandemic is happening, public health people are just on the forefront of everything.”
KHN Midwest correspondent Lauren Weber and KHN senior correspondent Anna Maria Barry-Jester contributed to this report.
This story is a collaboration between The Associated Press and KHN.
This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
This story can be republished for free (details).
For years, Sharad Acharya’s frequent hikes in the mountains outside Denver would leave him short of breath. But a real wake-up call came three years ago when he suddenly struggled to breathe while walking through an airport.
An electrocardiogram revealed that Acharya, a Nepali American from Broomfield, Colorado, had an irregular heartbeat on top of the high blood pressure he already knew about. He had to immediately undergo triple bypass surgery and get seven stents.
Acharya, now 54, thought of his late father and his many uncles who have had heart problems.
“It’s part of my genetics, for sure,” he said.
South Asian Americans — people with roots in Nepal, India, Pakistan, Sri Lanka, Bangladesh, Bhutan and the Maldives — have a disproportionately higher risk of heart disease and other cardiovascular ailments. Worldwide, South Asians account for 60% of all heart disease cases, even though — at 2 billion people — they make up only a quarter of the planet’s population.
In the United States, there’s increasing attention on these risks for Americans of South Asian descent, a growing population of about 5.4 million. Health care professionals attribute the problem to a mix of genetic, cultural and lifestyle influences — but researchers are advocating for more resources to fully understand it.
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Rep. Pramila Jayapal (D-Wash.) is sponsoring legislation that would direct $5 million over the next five years toward research into heart disease among South Asian Americans and raising awareness of the issue. The bill passed the U.S. House in September and is up for consideration in the Senate.
The issue could gain more attention after Sen. Kamala Harris (D-Calif.) becomes the nation’s first vice president with South Asian lineage. Harris’ mother, Shyamala Gopalan, moved from India to the U.S. in 1958 to attend graduate school. Gopalan, a breast cancer researcher, died in 2009 of colon cancer.
A 2018 study for the American Heart Association found South Asian Americans are more likely to die of coronary heart disease than other Asian Americans and non-Hispanic white Americans. The study pointed to their high incidences of diabetes and prediabetes as risk factors, as well as high waist-to-hip ratios. People of South Asian descent have a higher tendency to gain visceral fat in the abdomen, which is associated with insulin resistance. They also were found to be less physically active than other ethnic groups in the U.S.
One of the nation’s largest undertakings to understand these risks is the Mediators of Atherosclerosis in South Asians Living in America study, which began in 2006. The MASALA researchers, from institutions such as Northwestern University and the University of California-San Francisco, have examined more than 1,100 South Asian American men and women ages 40-79 to better understand the prevalence and outcomes of cardiovascular disease. They stress that high blood pressure and diabetes are common in the community, even for people at normal weights.
That’s why, said Dr. Alka Kanaya, MASALA’s principal investigator and a professor at UCSF, South Asians cannot rely on traditional body mass index metrics, because BMI numbers considered normal could provide false reassurance to those who might still be at risk.
Kanaya recommends cardiac CT scans, which she said help identify high-risk patients, those who need to make more aggressive lifestyle changes and those who may need preventive medication.
Another risk factor, this one cultural, is diet. Some South Asian Americans are vegetarians, though it’s often a grain-heavy diet reliant on rice and flatbread. The AHA study found risks in such diets, which are high in refined carbohydrates and saturated fat.
“We have to understand the cultural nuances [with] an Indian vegetarian diet,” said Dr. Ronesh Sinha, author of “The South Asian Health Solution” and an internal medicine physician. “That means something totally different than … a Westerner who’s going to be consuming a lot of plant-based protein and tofu, eating lots of salads and things that typical South Asians don’t.”
But getting South Asians to change their eating habits can be challenging, because their culture expresses hospitality and love through food, according to Arnab Mukherjea, an associate professor of health sciences at California State University-East Bay. “One of the things South Asians tend to take a lot of pride in is transmitting cultural values and norms knowledge to the next generation,” Mukherjea said.
Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains. (Eli Imadali for KHN)The intergenerational transmission goes both ways, according to MASALA researchers. Adult, second-generation South Asian Americans might be the key to helping those in the first generation who are resistant to change adopt healthier habits, according to Kanaya.
In the San Francisco Bay Area, El Camino Hospital’s South Asian Heart Center is one of the nation’s leading centers for educating the community. Its three locations are not far from Silicon Valley tech giants, which employ many South Asian Americans.
The center’s medical director, Dr. César Molina, said the center treats many relatively young patients of South Asian descent without typical risk factors for cardiovascular disease.
“It was like the typical 44-year-old engineer with a spouse and two kids showing up with a heart attack,” he said.
The South Asian Health Center helps patients make lifestyle changes through meditation, exercise, diet and sleep. The nearby Palo Alto Medical Foundation’s Prevention and Awareness for South Asians program and the Stanford South Asian Translational Heart Initiative provide medical support for the community. Even patients in the later stages of heart disease can be helped by lifestyle changes, Sinha said.
Dr. Kevin Shah, a University of Utah cardiologist who co-authored the AHA study, said people with diabetes, hypertension and obesity are also at higher risk of COVID-19 complications so should now especially work to improve their cardiovascular health and fitness.
In Colorado, Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.
“Nowadays, I feel very, very good,” he said. “I’m hiking a lot.”
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The coronavirus pandemic has killed more than 246,000 people in the U.S., but it also has left hundreds of thousands of others grieving, and often feeling as if they have been robbed of the usual methods for dealing with the loss. For every person who dies of the virus, nine close family members are affected, researchers estimate. In addition to deep sadness, the ripple effects may linger for years as survivors deal with traumatic stress, anxiety, guilt and regret.
As the holidays approach, millions of people will be experiencing these losses afresh, as well as disruptions to comforting routines and beloved traditions.
Judith Graham, author of KHN’s Navigating Aging column, hosted a discussion on these unprecedented losses and dealing with the bereavement on Facebook Live on Monday. She was joined by Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City, and Diane Snyder-Cowan, leader of the bereavement professionals steering committee of the National Council of Hospice and Palliative Professionals.
Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn’t have the slightest interest in becoming a doctor when she was growing up.
As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland. She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.
“All of those experiences actually made me really dislike physicians,” Asmerom said. “Particularly in my community, the saying is, ‘You only go to the doctor if you’re about to die.’”
But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too. Asmerom came to believe that as a doctor she could help turn things around.
Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.
Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.
This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests. But now, as with countless other U.S. institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action.
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Debunking Race as a Diagnostic Tool
For many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more differences among people within each race. Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.
Dr. Brooke Cunningham, a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said. Some physicians claim it is useful to take race into account when treating patients; others argue it leads to bias and poor care.
Those views have led to a variety of false beliefs, including that Black people have thicker skin, their blood coagulates more quickly than white people’s or they feel less pain.
When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate). The eGFR can limit Black patients’ access to care because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.
In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.
Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.
“It was very personal,” Nkinsi said. “That’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”
Nkinsi helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.
Acknowledging Racism’s Adverse Effects on Health
The Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S. and Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.
This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities. But little data exists on how many schools teach students how to recognize and fight racism, he said.
An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.
“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.
Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.
Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.
“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.
Recognizing Racism in Medical Education’s Past and Present
Activists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements. Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.
Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. “It’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?” she said.
While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. “There needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.
Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.
“But I’m not going to hold my breath until I see actual changes,” she said.
Attorneys for GOP-controlled states seeking to kill the Affordable Care Act told the Supreme Court last week that at least some of the 12 million people who newly enrolled in Medicaid signed up only because of the law’s requirement that people have insurance coverage — although a tax penalty no longer exists.
The statement drew a rebuke from Justice Sonia Sotomayor, who said it belies reason. Several health experts also questioned the argument that poor people apply for Medicaid not because they need help getting health care but to meet the ACA’s individual mandate for coverage.
The point is vital to the Republicans’ case to overturn the ACA, an effort supported by the Trump administration. The states are trying to prove they were harmed by the 2010 health law — and thus have “legal standing” to challenge its constitutionality. They argue their Medicaid spending increased because of the mandate, even though Congress eliminated the tax penalty for not having health coverage in 2019. Even when the penalty existed, most poor people were exempt because of their low income.
Under the ACA, states can opt to expand Medicaid eligibility to all adults earning less than 138% of the federal poverty level, or about $17,600 for an individual. States and the federal government share the cost of their care.
If the states cannot prove they have standing, the justices can toss their case without ruling on its merits. The case also involves two individuals who purchased private insurance from Texas and are suing to have the law overturned.
The Medicaid costs issue was one of several ways Texas and other GOP-controlled states participating in the lawsuit say they were harmed by the ACA even after the individual mandate penalty was reduced to zero. Several justices, including conservatives Clarence Thomas and Amy Coney Barrett, posed questions about whether the states had standing.
The case heard last Tuesday, California v. Texas, was the third time the high court has taken up a major suit on the ACA. Republican attorneys general in 18 states and the Trump administration want the entire law struck down, a move that would threaten coverage for more than 20 million people, as well as millions of others with preexisting conditions, including COVID-19.
Even if the court rules the states have legal standing, the ACA opponents must prove the elimination of a penalty makes the entire law unconstitutional.
The Republican states assert that since the law was upheld under Congress’ taxing powers by the Supreme Court in 2012, once the tax penalty is gone, the entire law must fall, too.
A group of Democratic-controlled states led by California and the Democratic House of Representatives are urging the court to keep the law in place.
Sotomayor raised serious doubts about the plaintiffs’ Medicaid argument and whether the states had suffered injury.
“At some point, common sense seems to me would say: Huh?” Sotomayor told Kyle Hawkins, Texas’ solicitor general, who is leading the GOP states’ legal fight. She questioned whether it seemed reasonable that once Medicaid enrollees are told there is no tax penalty for people who don’t have coverage they would “enroll now, when they didn’t enroll when they thought there was a tax? Does that make any sense to you?”
Hawkins defended his case, saying states need to show that only one person signed up for Medicaid because of the individual mandate. “There’s a substantial likelihood of at least one person signing up for a state Medicaid program, which, of course, would cause at least one dollar in injury and satisfy the standing requirement,” he said.
He cited a Congressional Budget Office report issued in 2017, when lawmakers were considering the change in the penalty. It said some people would continue to buy insurance or seek coverage “solely because of a willingness to comply with the law,” even if the individual mandate penalty were eliminated.
Few surveys have asked Medicaid enrollees why they signed up for the program.
One of them, by University of Michigan researchers that same year, posed the question to 1,750 adults who had become eligible for Medicaid in the state as a result of the ACA expansion. The most common reasons respondents gave for enrolling were that they had lost other health coverage and had a medical condition that required care. Just 2% of respondents cited the need to avoid the individual mandate tax penalty.
With the tax penalty eliminated, legal and health policy experts said, it’s likely the share of respondents signing up for Medicaid because of the health coverage mandate has dropped closer to zero.
Richard Kay, a law professor emeritus at the University of Connecticut, said it’s clear most people don’t seek coverage because of the individual mandate — particularly since there is no longer a financial penalty. But there could be a few who still do.
“Do you stop at a stop sign if you are in the country and no one is around for miles?” he said. “It’s not impossible that some people get insurance just because the law requires them.”
Kay said there is no precise guidance on how courts decide whether a plaintiff has been penalized enough to prove it has legal standing. “It’s a very confused area of the law,” he said.
Pratik Shah, a Washington, D.C., attorney who represents America’s Health Insurance Plans, a trade group fighting to preserve the law, said the plaintiffs in the case have not proved standing.
“It does not make logical sense,” he said of the argument that state budgets were harmed by people signing up for Medicaid even after the individual mandate penalty was eliminated.
“It’s hard to see how the 2017 amendment to the health law would have forced more people into Medicaid,” he said. “If they weren’t signed up before, they would be less likely to get it without the penalty.”
The court is expected to rule on the case by the end of June.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
This story can be republished for free (details).
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.
This story can be republished for free (details).
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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.
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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.
