More COVID-19 Quick Takes

May 7th, 2020 by Tom Lynch

Workers’ compensation and the disease

COVID-19 is presenting some interesting and perplexing issues for workers’ compensation. Among them are:

  1. Claims adjusters and Nurse Case Managers are far more familiar with injury claims than disease claims. Occupational disease claims are fuzzy, and work-relatedness is often difficult to determine. A broken arm on the shop floor is ever so much more cut and dried. Yesterday, Governor Gavin Newsom made this moot for California by signing an Executive Order that will make it easier for essential workers who contract COVID-19 to obtain workers’ compensations benefits. His order is in effect for 60 days and is retroactive to 19 March. Note Bene – his order establishes a rebuttable presumption and covers all workers deemed essential during the crisis; e.g., grocery workers, among others, as well as first responders and all health care workers. A rebuttable presumption means an essential worker who contracts COVID-19 does not have to prove work-relatedness. The burden is on the employer to prove the disease could not have been caused by work. California is one of a number of states that have taken action addressing workers’ compensation coverage for essential workers.
  2. But not all states have taken action in the same way. In fact, approaches vary considerably. Two issues treated differently among the states are: first, whether to establish a rebuttable presumption as described above; and, second, just who is essential. Some states say that while a number of occupations have been determined to be “essential” during COVID-19 (see Grocery Workers, above), only first responders and health care workers are essential enough to qualify for workers’ compensation if they come down with the disease. Labor unions say this is an issue of fairness, but since when has workers’ compensation been equally fair in all states? Consider loss of function awards, which vary tremendously across the nation.
  3. NCCI has jumped into the COVID 19 what if debate and projected various loss cost scenarios for the workers’ compensation insurance industry. All scenarios show increased losses, and some of the them are downright grim. In the worst case, 50% of all workers are infected and 60% of all claims are paid, in which case losses increase $81.5 billion, or 250% more than current total loss costs. Ouch! In the best case NCCI presents, there is no rebuttable presumption, only first responders and health care workers are eligible for workers’ compensation benefits, only 5% of them become infected, and only 60% of the claims are paid, which results in an increase in loss costs of $2 billion. The best case scenario is is not going to happen. See 1, above.
  4. And what about the poor employers and insurers who are going to foot the bill? Specifically, what about experience modification? One can almost say COVID-19 comes under the heading: An Act Of God. But the claims are going to be paid, so how does a confused insurer account for that in  the premium it’s going to drop on the head of John Q. Employer with a loud and painful thud?

Update on Long Term Care Facilities

I’ve addressed LTCFs here, here  and here, pointing out that there is no coordinated national reporting of LTCF COVID-19 cases or deaths. “One would think this cries out for federal data tracking conducted in a consistent manner across the nation.” Doesn’t seem to have happened yet.

The logical entity to track this is the Centers for Disease Control and Prevention (CDC), and maybe it is. But, then again, maybe it isn’t, because it won’t say. Yesterday, two Senate Democrats — Ron Wyden of Oregon and Bob Casey of Pennsylvania — called on the Trump administration to close this gap and commit to a timeline to release the information.

“There have been no signs that the Trump administration has an effective plan to address the tragedy that is taking place in America’s nursing homes,” they said in a joint statement.

It’s logical to assume that a disproportionate number of deaths would occur in LTCFs. The vulnerable elderly, many, perhaps most, with a number of comorbid underlying conditions, are packed together and present a breeding ground for the virus. Early on, this should have been apparent to the CDC. Why its talented scientists didn’t dive into this from Day 1 is beyond me.

We’ll continue to follow this.

Are We Learning From History, Or Repeating It?

Throughout history, infectious diseases have crippled societies. They have stymied progress and, in the best cases delayed, in the worst reversed, economic development and prosperity.

How have societies handled infectious disease pandemics throughout history, and are our actions in the midst of COVID-19 any better?

It’s true that our science puts us a quantum leap ahead of historical societies in terms of searching for therapies and a vaccine. Oh, the vaccine will happen, but between now and then are we dealing with our current infectious disease problem better than our ancestors?

Actually, no. Societies have long known that when a killing disease strikes on a grand scale the best thing to do is stay far away from other people. Quite literally, head for the hills. Trouble was, that wasn’t always possible due to urban densities and economic privation. Today, densely packed areas, especially cities, are the immediate hot spots, the poor and African Americans are disproportionately infected, and our mitigation efforts are the same as time immemorial.

Tomorrow, we’ll take a look at the history of pandemics, their societal effects and how we can learn from them as we move through and, we fervently hope, leave behind the scourge of COVID-19.

 

 

And Now For Something Completely New And Different: May Day!

May 1st, 2020 by Tom Lynch

“When the pandemic is over, our society will need to stop and think about who is essential and why should the delivery truck driver earn a tiny fraction of what is paid to the Executive Vice President for Interactive Synergy & Proactive Metrics?” ― Garrison Keillor

Boy, do we need a break. This dystopian, abnormal new normal is wearing us down.  Yesterday’s little broo-ha-ha in the Michigan Capital with wackadoodle white gunslingers roaming the gallery illustrates the point.

So, today we’ll take a break from all things COVID and bring you a touch of history. Stay with me, now.

First, a plug. For many years, Garrison Keillor has published The Writer’s Almanac, a refreshing and informative daily dollop of history and poetry that somehow finds its way to the inbox every morning. If you’re not a subscriber (it’s free), you will thank me if you become one. Today’s Writer’s Almanac told the story of May Day, all the way back to the 3rd century BC. Everyone thinks they know all about May Day, but maybe everyone should give that a rethink, especially when everyone reads about the Puritans’ views on the subject.

Here, from The Writer’s Almanac, is the story of May Day.

Today is May Day. Even though spring officially begins in March, today is the day that celebrates the height of spring, a day of spring festivities and celebrations. It is also a day to honor laborers.

Like many of our modern holidays, May Day has its roots in ancient, pagan celebrations.

Beginning in the third century B.C. in Rome, the festival Floralia, for the goddess Flora, was held in the days around May Day, April 28th to May 3rd. Flora was a goddess of flowers and fertility, and the festival was held to please her so that she protected flowers and other blossoming plants. There was a circus and theater performances, there were prostitutes and naked dancers, and a sacrifice to the goddess. Deer and goats were let loose to symbolize fertility, and beans and lupines were scattered for the same reason. Romans usually wore white tunics, but during Floralia, they got to wear bright colors.

In the Celtic British Isles, May Day was celebrated as the festival of Beltane, or Bealtaine or Bealtuinn — Bel was the Celtic god of light, and taine or tuinne meant fire. It was the summer half of the year — a time when the sun set later, when the earth and animals were fertile. Beltane lasted from sundown the night before to sundown on the first of May. On the eve of Beltane, people lit bonfires to Bel to call back the sun. People jumped over the fires to purify themselves, and they blessed their animals by taking them between bonfires before leading them to their summer pastures the next day. It was a day to walk around the property lines and assess your land for the summer season, to mend fences. Women washed their faces with the spring dew so that they would stay beautiful, and there was dancing, tournaments, parades, feasting, and general revelry. There were lots of flowers — men walked around the fires with rowan branches to keep evil spirits at bay, and May trees, or Maypoles, were set up covered in rowan or hawthorn flowers as a blessing. People danced around the Maypole, seen to be a phallic symbol to promote fertility, and villages would compete with each other to see who could produce the tallest maypole. Young couples went off into the forest to spend the night together and came back the next day with flowers to spread through the village. A young woman was crowned May Queen, and she would ride naked on horseback through the village.

Many of these celebrations continued as late as the 17th century — the Puritans were not too pleased, especially since so many young women went off into the woods and came back pregnant. Maypoles were made illegal in 1644.

Since the Puritans discouraged May Day, it was never a major holiday in America. In the late 19th century, May Day was chosen as the date for International Workers’ Day by the Socialists and Communists of the Second International to commemorate those who were hanged after the Haymarket Square riot, which occurred in Chicago in early May of 1886.

Direct Care Workers: Health Care’s Essential Underbelly

April 29th, 2020 by Tom Lynch

First, an update

Yesterday, we wrote about Long Term Care Facilities (LTCF) and the sad COVID-19 experience of Massachusetts’ nursing homes. As of this morning, 303 of the Commonwealth’s 386 nursing homes have had at least 2 cases, for a total of 10,031 cases statewide. Fifty-six percent, or 1,632, of all the Commonwealth’s COVID-19 deaths have happened to nursing home residents or staff.

Governor Charley Baker is a former CEO of Harvard Pilgrim health Care, one of the Commonwealth’s leading HMO  health care plans. So, it’s a given that Baker knows health care. But, even with that background, he, like all our governors, has been living through the tortures of Tantalus as they attempt to work with the administration in all things COVID-19.

Today, the governor announced he’s sending $130 million to help nursing homes deal with the crisis. He’s also enlisting 120 nurses to respond lickety split to nursing home emergencies. Moreover, his administration will be auditing LTCFs for compliance with new care criteria including mandatory testing of staff and residents, a 28 point infectious disease checklist, and PPE requirements. This is all good, but one hopes reality is not that this particular horse has escaped the barn and is now grazing four pastures over.

And what about those caregivers?

They call it “Direct Care.” The care that Certified Nursing Assistants (CNAs), home health aides, and personal care attendants provide America’s elderly and disabled. You’ll find them in nursing homes, residential care homes, hospitals, and plain, ordinary, everyday homes, the kind you and I live in. And they are essential workers.

All told, there are more than 1.3 million of them in the U.S., and the Bureau of Labor Statistics (BLS) projects the direct care industry will grow more than any other over the next decade, with a compound annual growth rate of 4.0. And they are essential workers.

They are also the least compensated workers, by far, in the health care sector. Here’s a graph from the BLS to illustrate the point:

The direct care workers are the pink dots. The isolated pink dot on the lower right refers to Certified Nurse Assistants. According to the Paraprofessional Health Institute (PHI):

The median hourly wage for home care workers in the U.S. is $10.49—a wage that, when adjusted for inflation, has remained virtually stagnant for the last 10 years. In turn, the median annual income for home care workers, most of whom work part-time or only during part of the year, is $13,800.[1]

Twenty-three percent of direct care workers live below the federal poverty line (FPL), as opposed to 7% of the rest of the population (which is abominable in its own right). Some of them might be caring for your parents or grandparents right now. Yes, they are essential workers.

Fifty-two percent of home care workers and 39 percent of nursing assistants rely on some form of public support, such as food and nutrition aid, Medicaid, or cash assistance. Moreover, because of low pay and irregular hours, it’s difficult for direct care workers to qualify or pay for employer-based or individual health coverage. Neither can they afford to stop working during COVID-19. They need the money, such as it is – and they are essential workers.

And what about direct care workers who are immigrants? Researchers from Harvard Medical School studied this in their June 2019 paper, “Care for America’s Elderly and Disabled People Relies on Immigrant Labor.” 

They wrote:

Using nationally representative data, we found that in 2017 immigrants accounted for 18.2 percent of health care workers and 23.5 percent of formal and nonformal long-term care sector workers. More than one-quarter (27.5 percent) of direct care workers and 30.3 percent of nursing home housekeeping and maintenance workers were immigrants. Although legal noncitizen immigrants accounted for 5.2 percent of the US population, they made up 9.0 percent of direct care workers. Naturalized citizens, 6.8 percent of the US population, accounted for 13.9 percent of direct care workers. In light of the current and projected shortage of health care and direct care workers, our finding that immigrants fill a disproportionate share of such jobs suggests that policies curtailing immigration will likely compromise the availability of care for elderly and disabled Americans. (emphasis added)

Nearly 15% percent (14.9%) of the foreign born workforce are college graduates, compared with 8.4% of the native born direct care workforce.

Many foreign born direct care workers are in the country with Temporary Protected Status (TPS), a status provided to nationals of certain countries, ten of them, experiencing problems that make it difficult or unsafe for their nationals to be deported there. In 2018, The Trump administration attempted to terminate the Temporary Protected Status for workers from a number of the designated countries, but courts have enjoined that for now. Nonetheless, that can’t be doing the workers’ mental health much good at the moment. And they are essential workers.

Nobody’s attacking direct care workers during COVID-19. They wouldn’t dare. After all, they are essential workers. But, if we ever get out of this healthcare fiasco, I don’t think it’s a wild stretch of the imagination to think if Donald Trump continues his  fervent anti-immigration polemic direct care workers will be marginalized even more than they already are.

They deserve better. They are essential.

 

The Long Term Care Industry: The Ice Under The COVID 19 Waterline

April 28th, 2020 by Tom Lynch

A sneak attack no one saw coming

The nation has come to realize that Long-Term Care Facilities (LTCF) are the number one breeding ground for COVID 19. To date, the best guess is that about 30% of all deaths from the disease happen in the LTCF world. But, as USA Today discovered when its journalists tried to quantify actual numbers, no one knows for sure. The absence of any coordinated, centralized, and focused effort (by the CDC, perhaps?) to track this data is another in a long list of unfortunate and tragic failures we can lay at the doorstep of 1600 Pennsylvania Avenue.

Some states, for example, Indiana, (where 31% of all COVID 19 deaths have occurred in LTCFs,) and Massachusetts (56%), have begun to try to gather the relevant data and publish it on their COVID 19 dashboards. However, most states have yet to take this step. Massachusetts has gone so far as to list the total of the COVID 19 cases in each of the state’s LTCFs by name – the list runs to five pages, 60 facilities per page.

The story of one such facility in Massachusetts is particularly sad. The Soldiers’ Home in Holyoke labels itself as “a state-funded, fully accredited health care facility that offers veterans quality health care, hospice care, including full-time residential accommodations, an on-site dental clinic, Veterans (sic) assistance center, and a multi-service outpatient department.” The Soldiers Home has always been held in high esteem for its excellent and compassionate care of military veterans. It has been one of God’s finer waiting rooms.

But in late March COVID 19 struck, and it struck hard. Here’s how the Boston Globe described it today:

In late March, when the first resident of the Soldiers’ Home in Holyoke died from the coronavirus, 226 residents lived at the elder care facility. Just over a month later, nearly 30 percent of them have died in one of the nation’s deadliest outbreaks, and another 83 have tested positive.

With 67 deaths linked to the coronavirus, the facility has a greater reported death toll than any other nursing home in New England, New York or New Jersey, or the long-term care facility in Kirkland, Wash., the initial epicenter of the US outbreak, according to a Globe review of cases.

The impact of this disease will be with us for a long time. The wounds to the nation’s physical and mental health will not heal anytime soon. As we flatten the Coronavirus curve, it is tempting to conclude we are at the beginning of the end. Nothing could be further from the truth. This is merely the beginning of the end of the beginning.

Tomorrow, a look at the least compensated people in our healthcare system, the myriad essential workers who care for the nation’s elderly and disabled.

Still More Covid 19 Quick Takes

April 27th, 2020 by Tom Lynch

The age problem

“You know you’re getting old when you stoop to tie your shoelaces and wonder what else you could do while you’re down there.” ― George Burns

Question: When will elderly people, say over the age of 70, dare to venture out of their present tightly-wrapped cocoons and back into general society?

Answer: I will go out on a very fat limb and suggest not anytime soon.

Today marks the 118th day since 31 December 2019, the day the World Health Organization (WHO) reported the first case of a “pneumonia of unknown cause” in Wuhan, China. It’s the 47th day since 11 March 2020, the day the WHO officially declared the newly named COVID 19 a pandemic. And it’s the 53rd day since 5 March 2020, the day the Workers’ Compensation Research Institute (WCRI) convened its annual conference in Boston.

John Ruser, WCRI’s President and CEO opened the conference by advising everyone to avoid shaking hands; elbow bumps were the order of the day, but social distancing was non-existent, about two feet was typical.

I mention the WCRI’s just-before-the-deluge conference because of one chart shown during it. This chart:

WCRI’s injury database shows about 40% of injured workers over the age of 60 have two or more comorbidities, which increase inexorably with age. Sort of like the way those of us who still have it have been watching the steady growth of the stuff on top of our heads over the last five or six weeks. My hair hasn’t been this long since 1980.

I thought of that chart this morning as I was beginning my new daily routine: studying various COVID 19 dashboards (more about that below). I was struck by two charts from the Commonwealth of Massachusetts that put the problem the elderly now face into stark relief. Here they are:

Massachusetts is not unique; COVID 19 does not respect state boundaries. One realizes this as one attempts to quantify the disease’s impact in the nation’s 15,600 nursing homes housing 1.4 million elderly and disabled people. A difficult task, as USA Today discovered when its journalists tried to investigated the issue (article dated 13 April):

At least 2,300 long-term care facilities in 37 states have reported positive cases of COVID-19, according to data USA TODAY obtained from state agencies. More than 3,000 residents have died.

The numbers eclipse those previously disclosed by the Centers for Disease Control and Prevention (CDC), which in late March estimated that 400 facilities had reported cases of the virus. But the new totals still represent an incomplete accounting due to the ongoing lack of widespread testing for the virus and inconsistent record-keeping from state to state. On the federal level, neither the CDC nor the Centers for Medicare and Medicaid Services is tracking the number of U.S. nursing homes with COVID-19 cases, or the number of total cases and fatalities in those facilities.

In Massachusetts, 56% of COVID 19 deaths have occurred in long-term care facilities. One would think this cries out for federal data tracking conducted in a consistent manner across the nation. One would think.

About those dashboards

Where are you getting your information on the daily spread of COVID 19? Where do you think most Americans are getting theirs? Could the answer be Twitter? Or Facebook? How about the daily White House Coronavirus Task Force briefings (Randy Rainbow beautifully summed up last Thursday’s, which was highly controversial and chock full of more than ordinary mediocrity)?

If you’re thinking of the CDC’s dashboard, you’ll find the data in a few places, not all in one, easy to navigate spot. For example, go here; or here; or here. You get the point. A lot of information, but you really have to dig.

There are national dashboards, which are organized well and highly informative. Two that I recommend are the Coronavirus Resource Center at Johns Hopkins University and the New York Times’s Coronavirus in the U.S.: Latest Map and Case Count. Updated frequently, at least daily, each is excellent. The Johns Hopkins dashboard is global in scope; the Time’s focuses on the U.S.

The Massachusetts dashboard is the best state-maintained dashboard I’ve found. Disclosure: I live in Massachusetts. However, the dashboard is truly exceptional. Take a look. Scroll through it. I think you’ll agree this should be a model for all others.

Where one gets information about COVID 19 matters, because of all the disinformation and outright lies being thrown up against the wall every day. Some of it will always stick, and this is too serious for that. The more we know about this disease, the more we ought to realize how much we really don’t know. Ignorance is not bliss. Benjamin Franklin said, “It is in the religion of ignorance that tyranny begins.”

 

The Sad Saga Of The Masks

April 22nd, 2020 by Tom Lynch

face masks

Michael Einhorn is CEO of Dealmed, a medical supply importer and distributor for the New York, New Jersey, Connecticut Tri-State area, the hottest COVID 19 spot in the U.S (so far).

Although Dealmed buys gowns, gloves and other medical supplies from manufacturers around the world, it gets all its masks from China. Prior to the COVID 19 pandemic, Einhorn would buy medical masks for about $.50 apiece. He would then, at a cost of around $15,000, or $.05 per mask, put 300,000, or so, of them on a container ship, which would reach the U.S. a couple of weeks later, whereupon, under contract, he would sell them for between $.70 and $.80 per mask, garnering a tidy, volume driven profit.

At the beginning of January, Einhorn’s world turned upside down thanks to an unfortunate series of events.

  1. On 8 January, the CDC announced “a pneumonia of unknown cause” was spreading in Wuhan, China. This greatly alarmed Einhorn. “It was then I knew that something shocking was happening”;
  2. On 25 January, the Chinese new Year, the Year of the Rat, began. Lasting 23 days, this is the major vacation period for Chinese workers. Think Paris is August;
  3. Wuhan is the “world capital” of medical mask manufacturing. All of Dealmed’s masks come from three companies within one hour’s drive of Wuhan;
  4. On 23 January, China issued the Wuhan (Hubei province) lockdown, which lasted 76 days until 8 April; and,
  5. The Chinese government allowed mask-manufacturing to begin again in early March, but all masks stayed in China to fight its own COVID 19.

Meanwhile, back on the home front, the COVID 19 tsunami was washing over America.

  • In early January, U. S. intelligence agencies began warning the Trump Administration that China wasn’t being honest about the scale of the crisis.
  • On 10 January, former Trump Homeland Security Advisor Tom Bossert urged action on COVID-19, saying,“We face a global health threat…a new kind of coronavirus.”
  • On 21 January,  The CDC’s Nancy Messonnier said in a congressional briefing that more cases were expected in the United States.”This is an evolving situation and again, we do expect additional cases in the United States”
  • On 28 January, former FDA Administrator Scott Gottlieb and Luciana Borio penned an op-ed in the Wall Street Journal offering a 4-point plan to prepare for COVID-19.
  • And on 29 January, both the New York Times and The Atlantic published articles detailing the woeful shortage of masks in the U.S., and reporting, in the words of the Times, “the hoarding has begun.”

Two decades ago more than 90% of America’s masks for the healthcare community were made in the USA. But then, China entered the game. China with significantly lower manufacturing costs. The result: Now U.S. firms make only 5% of the masks we need. China has cornered the market.

So, in early January, when the fecal matter impacted the whirring instrument, Michael Einhorn was catapulted overnight into a new wild west style universe where everyone in the health care community all over the world was competing with each other for a finite number of masks.

Eventually, his Chinese manufacturers were willing to once again make his masks, but at greatly elevated prices. A mask that used to cost him $.50 was now $2.00, or more. Because of the urgent need, he could no longer use container ships; they took too long. Enter Air Freight. At first, “We were paying $40,000 to $60,000 for cargoes that were one-fourth what we’d put on container ships,” he says. “Then, the cargo planes were in such short supply that the cost went to $80,000 to $90,000.” Consequently, his total costs are now in the $3.50 to $6.00 range for masks, which he sells to his health care clients for about $5.00, which is more than six times higher than pre-COVID 19.

If you didn’t know any better, you’d think Einhorn is price gouging, but he’s not. The Chinese manufacturers and the air freight companies on the other hand….

People, this did not have to happen. Our federal government, yes, the Trump administration, should have seized control of this supply chain fiasco from the beginning and put in place a comprehensive and coordinated program to secure and distribute the essential medical equipment the nation was going to need during COVID 19.

If the Trump administration had done that governors would not have to compete with each other, hospitals would not have to compete with each other, and no one would have to compete with the federal government for a single mask.

And maybe, just maybe, a lot of health care heroes who have given their lives saving others would still be with us.

 

At The Heart Of COVID 19: Fear

April 16th, 2020 by Tom Lynch

 

“One fear creates a dereliction, which brings a greater fear, and there comes a point where the fear is too great and the human spirit just gives up…” – Wolf Hall, by Hilary Mantel.

“We have to remember the enemy is the virus. Not one another.” – Michigan Gov. Gretchen Whitmer.

The protests are ramping up. Over the last two days groups demanding governors reopen state economies have gathered to protest stay at home orders.

Protesters in Michigan, Kentucky, Ohio, Utah, North Carolina and Virginia have made their presence felt and voices heard. Timed to coincide with governors’ daily press briefings on COCVID 19, to varying degrees of success they tried to drown out the gubernatorial updates.

By far, the largest protest was yesterday in Lansing, Michigan where, for five miles, thousands of vehicles blocked traffic going into or out of the city. They also blocked all traffic heading to Sparrow Hospital, which meant hospital workers were denied access to the most important jobs in the nation: Treating COVID 19 victims. And, to make a bad situation worse, many, perhaps most, of the protesters were unmasked, standing around as if they’d never heard the term, “social distance.”

Here’s a pretty alarming photo from Ohio:

And this from Michigan:

Yes, those really are automatic weapons in the hands of angry protesters. People, this is a bad combination.

What in the name of Galen is going on here?

How about fear and insecurity?

When I was a commander in Vietnam, training, and lots of it, kept my unit alive. We trained for everything imaginable, and when bad things happened, we were scared, but prepared. Running toward danger is not an intuitive response. Training takes over in those situations. Here, in the midst of COVID 19, no one has any training, and that includes most of the health care workers on the front lines fighting this entirely new disease. Everyone is making it up as they go along, and our health care workers…excuse me, our health care heroes… are learning new things every day aimed at keeping people alive.

Americans have no training or experience to guide them through the stay at home period, however long it turns out to be. And so, they fearfully worry. About themselves, their kids, their parents and grandparents, and their jobs. Many of those jobs could be gone forever, and this scares them to their core. That, along with the open-ended nature of the stay at home orders, leads to fearing the worst.

People are looking for something to believe in, some hope, someone to blame, so, when right wing rabble rousers stoke their fears…

Defusing this growing powder keg starts at the top. The nation’s governors, with some notable exceptions, have stepped up and are doing all they can to keep their citizens alive. They have to, because Donald Trump and his administration have performed so poorly during the crisis. It is unfortunate, indeed, that the president cannot help himself from fanning the flames of his base. Yesterday’s protests were replete with Trump and MAGA hats, as well as, ironically, protesters calling the stay at home orders “tyranny.”

The protests without social distancing or masks are going to result in more infections and deaths. That is a terrible thing. And so unnecessary.

Governor Kristi Noem’s Magical Thinking

April 14th, 2020 by Tom Lynch

Once more unto the Covid 19 breech, dear friends, once more.

Ever been to South Dakota? Beautiful place. Miles and miles of rolling prairies. Postcard worthy. Home to Mount Rushmore, the Crazy Horse Memorial, and the Black Hills.  Remember the three-season HBO series Deadwood? The real city of Deadwood is in South Dakota, although how a place with 1,300 people gets to be a city is beyond me. But that’s rural America for you.

South Dakotans are hardy souls, rugged individualists. They have to be; there are less than 885,000 of them all spread out over 77,000 square miles. That’s about 11 people per square mile.

With about 182,000 people, Sioux Falls is the most populous city in South Dakota. Virginia-based Smithfield Foods, the city’s fourth largest employer, is the third largest pork processor in the country, producing 18 million food servings a day. Two days ago, Smithfield announced it was closing down and ceasing operations indefinitely after more than 300 of its 3,700 workers tested positive for COVID 19. More than 550 independent family farmers supply the plant. This is a huge blow to Sioux Falls and South Dakota, as well as a kick in the gut to the nation’s food supply and supply chain.

This morning, Sioux Falls Mayor Paul TenHaken gave a passionate press briefing about the current situation and the horror he sees coming if drastic mitigation efforts don’t happen. The Mayor reported that in the last three days, the number of COVID 19 cases have been 149, 182 and 218, respectively. He would like to issue a stay at home order. Trouble is, the South Dakota legislature has stripped him of much of his authority to do so. He has to “request approval” from the legislature, which requires a seven-day notice period. Today, he made his request, and the earliest his order can take effect is 21 April. In the Mayor’s words, “This is crap. A shelter-in-place order is needed now. It is needed today,”

The Mayor is taking his action, the only action he can take, because the state’s governor refuses to issue such an order.

Which brings us to Governor Kristi Noem and her magical thinking.

Noem did, by Executive Order, compel everyone over the age of 65 to stay at home, except for essential travel. That’s only 14% of the state’s population. For everyone else, well, they can do what they want. She acknowledges her action could result in around 70% of South Dakotans contracting COVID 19, but she said it is not up to government to tell people how to behave. “The people themselves are primarily responsible for their safety,” she said. “They are the ones that are entrusted with expansive freedoms.”

As we have just seen in Sweden, this type of governing puts one firmly on the path to doom.

It appears Noem may be the only person in South Dakota who actually believes this idiotic laissez faire attitude is correct. Mayors like Sioux Falls’s TenHaken and Rapid City’s Steve Allender have joined with 160 county and city leaders who have petitioned her to declare a statewide public health emergency. In addition, more than 30,000 front-line health care workers have sent their own petition to Noem demanding she order people to stay at home.

Thus far, Noem seems to be an “n” of one. Drastic mitigation, Noem said disparagingly, reflected a “herd mentality.” It was up to individuals — not government — to decide whether “to exercise their right to work, to worship and to play. Or to even stay at home.”

So, what happens when, not if, the rancid COVID 19 flower blooms in South Dakota in the next week of two?

Among 44,000 cases in China, about 15% required hospitalization and 5% ended up in critical care. In Italy, the statistics so far are even more dismal: More than 50% of infected individuals have required hospitalization and about 10% have needed treatment in the ICU.

Nearly half the population of South Dakota lives in cities. That’s about 431,000 people. New York’s experience showed us COVID 19 spreads much more readily through densely packed populations. Consequently, it is logical to presume the cities of South Dakota are where it will strike more fiercely. If, because of Noem’s inaction, COVID 19 infects only 10% of that population, more than 43,000 cases will happen. If only 20% of those cases require hospitalization, the state will need 8,600 hospital beds.

As of 2019, South Dakota had 2,735 hospital beds; Sioux Falls,1,159. According to the 2019 State Physician Data Workforce Report, South Dakota has 240 doctors per 100,000 people, or about 1,920 in the entire state. The number of ICU beds is unknown.

South Dakota could be in for a monumentally rough ride.

 

 

More COVID 19 Quick Takes

April 7th, 2020 by Tom Lynch

Offered without comment. None needed.

“The notion of the federal stockpile was it’s supposed to be our stockpile, It’s not supposed to be state stockpiles that they then use.” – Jared Kushner, the president’s son-in-law and adviser, at a White House briefing last Thursday, 2 April.

The federal stockpile of you know what.

I know, I know. You’re saying, “What? Another piece on the federal government’s inept performance to get masks and ventilators to the states?”

Yup. Some seemingly dead horses need new beatings when new facts emerge, and, as John Adams said 250 years ago when defending British soldiers on trial for their roles in the Boston Massacre, “Facts are stubborn things.”

But first, a word about the Associated Press (bet you didn’t see that one coming).

The AP, founded 173 years ago, is a cooperativeunincorporated association. Its members are U.S. newspapers and broadcasters. Its 3,200 employees operate out of 263 bureaus in 106 countries. It’s won 53 Pulitzer Prizes since the prize was created in 1917, and its AP Stylebook is the gold standard for reporters. Although everyone makes mistakes, and the AP is no exception, it exemplifies what news reporting ought to be.

Yesterday, the AP reported on its investigation into federal purchasing contracts for COVID 19 Personal Protective Equipment (PPE) and Ventilators. The investigation showed that:

As the first alarms sounded in early January that an outbreak of a novel coronavirus in China might ignite a global pandemic, the Trump administration squandered nearly two months that could have been used to bolster the federal stockpile of critically needed medical supplies and equipment.

A review of federal purchasing contracts by The Associated Press shows federal agencies largely waited until mid-March to begin placing bulk orders of N95 respirator masks, mechanical ventilators and other equipment needed by front-line healthcare workers.

By that time, hospitals in several states were treating thousands of infected patients without adequate equipment and were pleading for shipments from the Strategic National Stockpile.

The President has said repeatedly that the states should be purchasing the PPE they need to confront the virus and that the stockpile is a last resort (see the Jared Kushner quote, above). On 19 March Trump said of the federal government, “We’re not a shipping clerk.” Trouble is, we now have a situation where:

  • The stockpile is nearly empty, because Trump, under constant criticism from the governors, was forced to distribute much of it;
  • The federal government is now buying all the PPE and ventilators it can find all over the world;
  • The states continue to try to buy, scrounge, or borrow PPE and ventilators wherever they can; and,
  • Everybody’s competing with each other for the stuff, driving up prices, creating a seller’s market (think price gouging as an art form).

What’s going on in the Situation Room?

CNN is reporting a “heated disagreement” over the weekend in the Situation Room about the efficacy of the anti-malaria drug hydroxychloroquine. Multiple sources told the network Donald Trump’s top trade adviser Peter Navarro, recommending widespread use of the drug,”feuded with other officials over the drug’s unproven effectiveness to treat coronavirus.” In particular, Navarro took great exception to Dr. Anthony Fauci, Director of NIH’s National Institute for Allergy and Infectious Diseases, a post he’s held since 1984, telling him there was no data to indicate hydroxychloroquine is in any way effective, let alone safe, for treating COVID 19. CNN reports Navarro came to the meeting armed with documents he said proved his point, but which Dr. Fauci called anecdotes, and anecdotes are not data. Apparently, Dr Fauci saying to Navarro, who is not a member of the White House Task Force, “What are you talking about?” was particularly upsetting to the Trade Advisor.

Asked about the exchange today on CNN’s “New Day” Monday morning, Navarro claimed he is qualified to disagree with Dr. Fauci about COVID 19, despite not working in the health care field, because he has a PH.D. and is a Social Scientist. According to Merriam-Webster, Social Science is “a branch of science that deals with the institutions and functioning of human society and with the interpersonal relationships of individuals as members of society.” Surely that qualifies Dr. Navarro to recommend unproven medical treatments for the hundreds of thousands of current and projected victims of COVID 19 and to hijack the Task Force’s valuable time in the Situation Room. Split hairs are thicker than Navarro’s logic.

On the other hand.

This morning, Maggie Haberman, of the New York Times reported that Navarro warned the administration late in January that the “coronavirus crisis could cost the United States trillions of dollars and put millions of Americans at risk of illness or death.” Navarro wrote in a memo that a “lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”

Too bad Navarro couldn’t prevail in that discussion back in January. We give him points for trying.

And what about those masks?

China is the world’s leading producer of surgical masks, turning out 50 to 60 million of them per day. When COVID 19 happened, China increased production to – get ready for this – 200 million per day. But because the pandemic originated in China, most of those masks stayed there. When the pandemic eased in China, masks once again began flowing, albeit more slowly and at greater cost, to the rest of the world, which, by that time, was already in the throes of the pandemic. Masks became the new gold.

Yesterday, NPR’s Mary Louise Kelly interviewed Mike Bowen, Co-Owner and Executive Vice President of Prestige Ameritech, located in North Richmond Hills, Texas. Mr. Bowen’s firm is the largest domestic maker of healthcare masks in this country. Governments, the healthcare industry, and companies from all over the world are asking him and the other American mask makers to supply them with masks, given the Chinese have turned down the spigot. During the interview, Bowen was discouraged and discouraging about his firm’s success prospects in picking up the Chinese slack to produce more masks. According to Health and Human Services Secretary Alex Azar, as of 10 March, the U.S only had about 1% of the 3.5 billion masks it needs to combat this pandemic. Bowen said every day he gets more than 400 emails asking for masks. But he can’t provide what he doesn’t have. He said, “It’s not like flipping a switch.” Machines have to be built, employees hired and trained. And when this is over, what does he do with the new machines and the new workers when demand has dropped off?

Bowen told Kelly he has been here before, during H1N1, when he built new machines, hired and trained workers and, after the scare was over, nearly went bankrupt. He had to lay off 150 people and moth-ball his machines. He’s afraid that’s what will happen again, as are all the other mask manufacturers.

And why is that? Bowen says because his masks are made in America, they are more expensive than masks made in Mexico and China. Consequently, until COVID 19, his firm had, in his words, “zero masks” going to federal agencies. Prestige has repeatedly bid on federal contracts for masks with HHS and DOD, but has never succeeded, because of cost.

Even going all out, 24/7, Bowen claims there is no way on God’s Green Earth he, and all the other mask-making companies, will ever be able to get all the masks COVID 19 requires to American health care workers. Sobering, indeed.

On that happy note, I leave you until next time.

 

 

 

CoVid 19 Quick Takes

April 3rd, 2020 by Tom Lynch

 

Quote of the day: “To put it bluntly, the U.S. economy went from full speed to full stop — and millions of workers were not wearing seat belts.” – Josh Lipsky, director of global business and economics policy at the Atlantic Council, a nonpartisan think tank.

 

Keeping up with all things CoVid 19 is like swimming through Semolina. It takes a lot of fortitude and stamina. But here goes, anyway.

The states versus the nation

Examining the national response to CoVid 19….no, wait, we don’t have a national response. We have close to 60 responses, one for each of the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands and the other US territories. If you don’t think they’re all on their own, just ask Andrew Cuomo. He said yesterday that none of the governors were currently screaming for states rights. They all want help, they all want national leadership, and they want it yesterday, maybe last week. Look at Ron DeSantis, Governor of Florida. For weeks, under withering criticism and through the debacle of Spring Break on the beaches, he refused to issue a Stay At Home order. Said the state didn’t need it. His excuse? The White House hadn’t told him to do it. But yesterday it did, so he did. Well, actually, the White House “recommended” it. DeSantis made a point of saying he “cleared it with the President.”

Contrast DeSantis’s actions with those of Mario Cuomo, Jay Inslee, Gavin Newsom, JB Pritzker, Gretchen Whitmer, Janet Mills, Charley Baker, and Mike DeWine. They’ve all been on their own, but they’ve been decisively responsible, and their constituents will one day thank them.

Every governor is reacting, and reacting is the right word, differently. It’s like watching an Athenian Trireme in the Mediterranean with all 170 oarsmen rowing at different speeds.

Don’t believe me? Let’s look at Stay At Home orders. Here’s a New York Times map showing state Stay At Home orders from 30 March, four days ago:

And here’s the same map as of yesterday, four days later:

The nation’s Governors are all having to act like European Prime Ministers, many of whom have issued travel restrictions and sealed borders. A week ago, Rhode Island’s Governor Gina Raimondo began letting New Yorkers into her state only if they would self-quarantine for 14 days, and she had the National Guard at the border to enforce the order.

All Governors would like their constituents to view them as Horatius At The Bridge, but Covid 19 is likely not the particular bridge they would have in mind. They need national leadership, not national cheerleading. Absent that, they’ve been forced to step into the void, some, like DeSantis, very reluctantly.

Trouble coming for the southeast

Vann R, Newkirk, II, has a terrific piece in this week’s The Atlantic looking at the public health difficulties facing young people, made even more severe by CoVid 19, in America’s southeastern states. Newkirk says:

So far, about one in 10 deaths in the United States from COVID-19 has occurred in the four-state arc of Louisiana, Mississippi, Alabama, and Georgia, according to data assembled by the COVID Tracking Project, a volunteer collaboration incubated at The Atlantic….The coronavirus is advancing quickly across the American South. And in the American South, significant numbers of younger people are battling health conditions that make coronavirus outbreaks more perilous.

Some context is needed. A new study by the World Health Organization (WHO), endorsed and published by the National Academies of Science, Engineering and Medicine ranks America at or near the worst in just about every mortality rate category you can think of when compared with the other 16 wealthiest countries. U.S. Health in International Perspectives: Shorter Lives, Poorer Health paints a grim picture that should concern us all.

Now, look at the health of people in the deep south, particularly young people, who, according to a new study by the Kaiser Family Foundation, have more comorbidities than young people anywhere else in the country. Those comorbidities put them at much greater risk of becoming seriously ill if they contract CoVid 19.

According to Newkirk:

If you define Oklahoma as part of the South, southern states fill out the entirety of the top 10 states in percentage of population diagnosed with hypertension by a doctor. Southerners are more likely to suffer from chronic diseases than other Americans—even as Americans are more likely to suffer from chronic diseases than citizens of other countries with comparable wealth.

Imagine you have a big barrel full of apples. Inside that barrel is a smaller barrel with apples your farm stand might label “seconds.” Inside that “seconds” barrel is a third and smaller barrel with apples your farm stand wouldn’t ever sell. The third barrel is health in the deep south.

The USNS Comfort

Remember this photo?

That’s the USNS Comfort, the 1,000 bed ship Donald Trump, to great fanfare, sent to New York to help with the serious hospital bed shortage, getting worse every day.

I’m guessing not too many people knew that the Comfort’s orders prohibit treating CoVid 19 patients. As President Trump said when he sent her on her way, “By treating non-infected people remotely on the ship, it will help to halt very strongly the transmission of the virus.” Note the words, “non-infected.”

So far, the Comfort has taken in three of New York’s patients. It’s kind of a Catch 22 thing. The ship can only take patients not infected with CoVid 19, but without sufficient testing, the ship’s clinicians won’t know if anyone actually has the disease, or not. Result: three patients. “If I’m blunt about it, it’s a joke,” said Michael Dowling, the head of Northwell Health, New York’s largest hospital system.

And finally – Getting back to the deep south

The American Association of Medical Colleges is out with its 2019 State Physician Data Workforce Report,

This annual report examines the supply of physicians in the United States. It documents the number of physicians per 100,000 inhabitants of every state. I’m proud, (I think) to report my home state, the Commonwealth of Massachusetts, takes the Gold Medal with 449.5 doctors per 100,000 people. On the other end of the scale, coming in at Number 50, is Mississippi with 191.3. I would love to know what goes on in Mississippi. It seems to be at or near the bottom of anything you can name.

Here are how all the southern states rank:

State                                MDs/100K                       Rank

Mississippi                       191.3                                50

Oklahoma                        206.7                                48

Arkansas                          207.6                                47

Alabama                           217.1                                43

Texas                                224.8                                41

Georgia                            228.7                                39

South Carolina                 229.5                                38

Kentucky                          230.9                                36

Tennessee                        253.1                                29

North Carolina                255.0                                28

Louisiana                          260.3                                27

Florida                              265.2                                23

Given that New York, which is begging for retired clinicians and clinicians from other states to come and help with its CoVid 19 fight, and given that New York, with 375.1 doctors per 100,000 people, ranks Number 3 on the list, just behind Massachusetts and Maryland, how do you think a state like poor Mississippi is going to fair when the full weight of this virus lands on it with a loud thud?

I hope all of you hermits have a safe weekend!