Thursday, July 23, 2020

Coronavirus News (188)

Pamela Miller, a nurse, at St. Joseph Medical Center in Houston on July 1, during a surge in coronavirus cases.

Why We’re Losing the Battle With Covid-19 The escalating crisis in Texas shows how the chronic underfunding of public health has put America on track for the worst coronavirus response in the developed world. ..........  the key to stopping a pandemic was preventing as many people as possible from landing in hospitals in the first place. ............   Decades of research shows that a robust national public-health system could save billions of dollars annually by reducing the burden of preventable illnesses and keeping the population healthier over all. But like most public-health departments across the country, Harris County’s was grossly underfunded. Shah likes to think of his fellow public-health practitioners as the offensive line of a football team whose fans know only the quarterback: clinical medicine. ..............  the pandemic of the century ........  Politics had won out far too often over sound science. As a result, the state’s reopening had been hasty and poorly coordinated. And now, a month and a half in, case counts were rising and intensive-care units were bracing for an onslaught. .........  In other countries, officials locked down entire cities and employed large-scale, high-tech surveillance programs to stop the virus from spreading. In the United States, decades of near-total neglect had left the entire public-health apparatus too weak and uncoordinated to mount even a fraction of that response. ............  Without any clear guidance or coherent national strategy, states were on their own. In March and April, governors found themselves bidding against one another for ventilators and personal protective equipment. In May, several states — not just Texas — rushed to reopen. And by late June, case counts were surging in at least 20 of them. ..............  The country was on track to achieve the least successful coronavirus response in the developed world, with the most total cases, the highest death toll and the worst projections for late summer and early fall: tens of thousands more deaths by year’s end .............  And that wasn’t even accounting for a possible “second wave.” Or for flu season or hurricane season, either of which would almost certainly worsen the current crisis. ...............  Public-health interventions work best when the forces of politics and culture are aligned behind them — when elected officials provide the necessary resources, and citizens abide by the necessary strictures. Even now, with hospitals filling up, such convergence seemed unlikely. ...........  The economy was in tatters now, and the virus was still spreading. ...............  In the past century, the largest gains in human health and life expectancy have come from public-health interventions, not medical ones. Clinical medicine — treating individual patients with medication and procedures — has registered enormous gains. Hepatitis C is now curable; so are many childhood cancers. Cutting-edge gene therapies are curing rare genetic disorders, and new technology is making surgeries of every kind safer. But even stacked against those triumphs, public health — the policies and programs that prevent entire communities from getting sick in the first place — is still the clear winner. “It’s saved the most lives by far, for the least amount of money,” Tom Frieden, a former director of the C.D.C., told me recently. “But you’d never guess that based on how little we invest in it.” ................. Social policies that mitigate economic inequality would be at the base of the pyramid, followed immediately by public-health interventions like improved sanitation, automobile-and-workplace-safety laws, clean-water initiatives and tobacco-control programs. Clinical medicine would be closer to the top. ........  Less than 3 percent of the country’s $3.6 trillion total annual health care bill is spent on public health; a vast majority of the rest goes to clinical medicine. ...............   Americans don’t like being told what to do. ................  We want to be protected from infectious diseases and dirty water and bad food and crazed gunmen. But not in a way that undermines our freedom. That ambivalence was baked into our public-health institutions from the start. ............  At the turn of the previous century, commissioned doctors had the same reputation for service and self-sacrifice as soldiers. .............  C.D.C. powers are limited. ..... “They treat the states like clients,” says Shelley Hearne, a professor of public health at Johns Hopkins University. “They provide funds and issue recommendations. But they don’t hold any feet to the fire.” ...........  the nation’s public-health apparatus. The system, the authors wrote, was arbitrary, reactive and wildly uneven from one part of the country to another. Crises tended to be addressed, or not, based on political will, not scientific knowledge. Investment in public-health programs was thin in many places, and the capacity to gather and analyze essential data was poor. Leadership was also weak and unstable, with health departments increasingly staffed by political appointees instead of career civil servants. And schools of public health had become too academic and divorced from the actual needs of public-health agencies. What’s more, the relationship between medicine and public health was plagued by “confrontation and suspicion.”........................   There also seemed to be no clear coordination among federal, state and local health departments nor much agreement on who was in charge of what. “Responsibilities have become so fragmented,” the authors wrote, “that deliberate action is often difficult if not impossible.” ..............  And if they could not contain the virus once they reopened, the entire shutdown would have been for nothing. ..........  Infectious-disease outbreaks were trickier. Viruses were invisible — and slow. It took weeks to know if any given decision was the right one, and in the meantime constituents clamored for officials to do less, not more. When Hidalgo erected a temporary field hospital in April so that intensive-care units would not be overwhelmed by a surge of coronavirus infections, Republican lawmakers accused her of wasteful overreaction. When she ordered the release of low-risk inmates from the county jail, in an effort to prevent an outbreak there, a district judge ordered the sheriff to ignore her edict. And when she made masks mandatory in all public spaces, Lt. Gov. Daniel Patrick singled her out for rebuke. ..........  It also inspired more citizens to take matters into their own hands. In mid-May, a handful of shops began reopening with the help of heavily armed militias who stood guard in an effort to discourage officials from interfering. ........  By Memorial Day weekend, Texas was almost fully reopened. The state had not met its own criteria for keeping the coronavirus in check. No one seemed certain about whether or how to enforce the social-distancing edicts that remained. And, while Harris County’s case counts had plateaued, case counts in other parts of the state were rising. ............  In the mid-1800s, even as American cities grappled with repeated cholera outbreaks, some officials balked at the expense of sanitation departments and municipal water systems, preferring instead to blame the poor for choosing to live in filth. And during the flu pandemic of 1918, public-health edicts were often subsumed by politics. The mayor of Pittsburgh, for example, ended a ban on public gatherings, not because the city was out of danger but because he had an election coming up and his constituents wanted to celebrate the Armistice with a parade. The city went on to suffer a spike in flu cases, even as the virus waned elsewhere. ....................  These powers were often employed cruelly; quarantines in particular were aimed at minorities who were considered dirty and disease-carrying by nature. During an 1892 typhus outbreak in New York City, for example, Russian Jews were rounded up — some of them literally pried from the arms of distraught family members ...... and forcibly quarantined on an East River island downwind of the city garbage dump. ..................  It was commonly held at the time that Eastern European Jews carried typhus fever. Very few of those who were quarantined turned out to have typhus, but six ultimately died from illnesses related to unsanitary quarantine conditions. ....................   In 1900, when plague emerged in San Francisco, Asian residents were prevented by armed police battalions from leaving the city’s Chinatown section, while European-Americans continued to come and go freely. And Black and brown Americans were often excluded from emerging public-health programs altogether, even as their bodies were used in experiments that advanced the science underpinning those very programs. In an effort to learn more about syphilis, for example, the U.S. Public Health Service withheld treatment from scores of syphilitic Black men in and around Tuskegee, Ala., lying to them about the nature of the study they were participating in and causing many to suffer and die from the disease long after a cure was available. ..............  in the 1940s, in an effort to determine whether penicillin could prevent sexually transmitted infections, the U.S. Public Health Service experimented on prisoners, prostitutes, soldiers and mental patients in Guatemala, infecting them with sexually transmitted diseases without informing them or seeking their consent. .................  “From there, we see growing libertarian rejection of public-health law and less and less exercise of public-health police powers,” Parmet says. “Now we’re in a once-in-a-century global pandemic, and everyone’s scrambling to figure out what the state can and can’t do to protect the public.” ...............  By then, just about all businesses were open at some level, and case counts were rising with alarming speed. Shah felt as though he were trapped in the driver’s seat of a car with a stuck accelerator. “It’s like we’re shouting out the window, trying to tell everyone, ‘Hey, this thing is out of control,’” he told me. “But we can’t do anything to slow it down.” .............  America was a paradox — a beacon of science embedded in a culture increasingly suspicious of scientists ...........    something much more fundamental would also have to change. The coronavirus pandemic has laid bare gnawing questions at the core of America’s many divisions: Are we willing to trust science and scientists in a crisis? What, exactly, do we want from our government? And what are we willing to sacrifice for one another? ............ the anti-mask set is hard to ignore, in part because it speaks to a broader current of American life. “People have grown comfortable putting their individual rights ahead of the needs of their community” ...............     A common complaint among public-health workers is that this “neglect, panic, repeat” cycle makes it impossible to prevent crises instead of merely responding to them. ...........  a new and bitter reality: Because of the economic crisis, which was triggered by the current pandemic, which was worsened by a lack of public-health investment, public-health agencies will probably suffer more budget cuts in the coming years. ........... “It’s a lot of isolated departments across the country, saying, ‘Oh, we’ll just keep doing God’s work over here, and if our budget gets cut again, we’ll just make do somehow.’” .............  “No one is going to vote for you or name a hospital wing after you because you kept them from getting something that they didn’t think they were susceptible to in the first place,” Frieden says. “The people who cure diseases are glorified, not the people who prevent them.” ..............  And the same stories that played out in Wuhan and Lombardy and Seattle and New York were beginning anew. And not only in Texas. In more than 35 states, including some that had previously brought their outbreaks under control, daily case counts are rising, positivity rates are rising and new grim records are being set — and then quickly surpassed. People in Texas, Florida, California and New Jersey are bracing for a second wave of outbreaks in the fall, even as the first wave has yet to fully recede. 

8 Hospitals in 15 Hours: A Pregnant Woman’s Crisis in the Pandemic Her baby was coming, and her complications were growing more dangerous. But nowhere would take her — an increasingly common story as India’s health care system buckles under pressure.
A Multibillion-Dollar Opportunity: Virus-Proofing the New Office Tech, catering and design companies are rushing to sell employers on fever scanners, box lunches and office floor-planning apps for social distancing. But it’s too soon to tell if they will work.

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