Q2 2020 Bulletin: The New Normal by SCCMA

Official Magazine of the Santa Clara Medical Association

Vol. 26 | No. 2 Second Quarter 2020

This issue:

The New Normal The Bulletin | 1

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CONTENTS | Vol. 26 | No. 2 | Second Quarter 2020

In this issue SCCMA is a professional association representing over 4,500 physicians in all specialties, practice types, and stages of their careers. We support physicians like you through a variety of practice management resources, coding and reimbursement help, training, and up to the minute news that could affect your practice. The Bulletin is our quarterly publication.

SCCMA NEWS & ANNOUNCEMENTS Covid-19: Public Health, Pandemics, and People

Public Health Officials Are Our Covid Commanders, Treat Them with Respect 14 Should I still Consider Assisted Living for Loved Ones During the Covid-19 Pandemic? 16

Councilors El Camino Hospital of Los Gatos | Shahram S. Gholami, MD El Camino Hospital | OPEN Good Samaritan Hospital | Kirkor Barsoumian, MD Kaiser Foundation Hospital - San Jose | Priya Rao, MD Kaiser Permanente Hospital | Joshua Markowitz, MD O’Connor Hospital | David Cahn, MD Regional Medical Center | Heather Taher, MD Saint Louise Regional Hospital | Scott Benninghoven, MD Stanford Health Care/Children’s Health | John Brock-Utne, MD Santa Clara Valley Medical Center | Clifford Wang, MD

Features

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising.

Community News

Address all editorial communication, reprint requests, and advertising to: Mike Wamungu, Managing Editor 700 Empey Way San Jose, CA 95128 760/671-2337 Fax: 408/289-1064 mike@sccma.org

Many People of Color, Immigrants Among Over 1,000 US Health Workers Lost to COVID

How the pandemic casts physician burnout in new light

A Message from the President

Cindy Russell, MD

SCCMA Diversity and Inclusion Series

Classifieds

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A Message from the President How Do We Cope With COVID?

Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.” Marie Curie by Cindy L. Russell, MD

SCCMA President

Unprecedented

The novel COVID-19 outbreak was declared a pandemic by the World Health Organization on March 11, 2020. To date over 10 million people in 170 countries have had the disease and over 500,000 have lost their lives from COVID, about 140,000 in the United States alone. According to a Kaiser Health News report this includes the loss of over 600 front line U.S. health care workers. Right now, the first wave of COVID-19 has not even passed, and yet a second wave is appearing on the horizon. Orders for reopening are now being reevaluated and even reversed in many states. Although there is still no federal mandate on universal masking, many states have done so. Southern California is sending COVID cases to the Bay Area as they are now overwhelmed. As hospitalizations escalate, nurses and doctors are being recruited from out of state to pitch in. Information on COVID-19 diagnosis, treatment and outcomes is evolving rapidly, along with rules of social engagement. The headlines change daily and continue to test our resilience. Other issues have come in to play. Racial, Environmental and Healthcare Injustice

In the midst of COVID-19 the murder of George Floyd has put a racial injustice pin on every city’s corkboard. Mental health issues have come to the forefront and are in critical condition. What about the economy, our jobs, and are kids going back to school? Will we have enough PPE? Why are we so behind on testing and tracing? How do we all get through all this? We are living through a challenging time in history. COVID-19 is an unprecedented event in our lifetimes, in its global scale as well as its broad effects on lives and livelihoods. The viral pandemic that has emerged, has revealed the entrenched global pandemic in healthcare injustice that is in-

tertwined with economic, social and environmental injustices. We must look at this time in history as an opportunity to examine the interrelatedness of these issues in order to effect long term changes that will benefit all of humanity and the planet. A piecemeal band-aid approach will not afford lasting change. A holistic, comprehensive and ethical perspective will hopefully motivate us all to work together for durable change. Physicians Have a Moral Imperative

As medical professionals we have not only the ability to acutely care for Covid-19 patients and save lives, but we also have a moral imperative to shift the discussion from just treating diseases, to preventing them. Looking at the root causes of illness, including social determinants of health, will increase individual wellness and improve social wellbeing as well as reduce increasingly unsustainable healthcare costs. Physicians also have to take care of themselves to prevent burnout, a newly recognized epidemic. Many issues have come to light, and with education, leadership, hard work and collaboration, perhaps meaningful policy changes can be implemented. The “moment”, as they say, has turned into “a movement”. Public Education to Reduce the Spread of COVID-19

Leadership sets the stage for both our actions and our reactions. It is not practical or healthy to live in daily fear, however, it is important to maintain common sense measures to protect ourselves and thereby our communities. This will alleviate the COVID burden on healthcare resources so we can continue to have a viable healthcare system. Will we flatten the curve or fatten the curve to get back to our lives by this fall, or winter, or beyond? Our public health experts have mandated basic mitigation strategies such as face coverings, social distancing, sheltering-at-home and hand washing, as well as surface cleaning. We all need to take this seriously. Supporting Our Local Public Health Officials

Public health officials have taken the lead as experts, guiding us with both science and wisdom to reduce the spread of the coronavirus. They are under threat locally and nationally. The CDC collects, analyzes and widely shares The Bulletin | 3

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The Santa Clara County Medical Association Santa Clara County Medical Association (SCCMA) was founded in 1876 by a small group of physicians who understood it was their duty to fight for their patients and profession. Confronted with the challenges of rampant quackery, epidemics of contagious disease, and a desperate need to establish standards for the profession, physician leaders of the time called upon their colleagues to help them form the Medical Society of the County of Santa Clara “to develop, in the highest possible degree, the scientific truths embodied in the profession.”

OFFICERS

COUNCILORS

President Cindy Russell, MD

El Camino Hospital of Los Gatos Shahram S. Gholami, MD

President-Elect Martin Wong MD

El Camino Hospital OPEN

Past President Seema Sidhu, MD

Good Samaritan Hospital Kirkor Barsoumian, MD

VP-Community Health Lewis Osofsky, MD

Kaiser Foundation Hospital - San Jose Priya Rao, MD

VP-External Affairs Erica McEnery, MD

Kaiser Permanente Hospital Joshua Markowitz, MD

VP-Member Services Randal T. Pham, MD

O’Connor Hospital David Cahn, MD

VP-Professional Conduct Gloria, Wu MD

Regional Medical Center Heather Taher, MD

Secretary John Brock-Utne, MD

Saint Louise Regional Hospital Scott Benninghoven, MD

Treasurer Anh T. Nguyen, MD

Stanford Health Care/Children’s Health John Brock-Utne, MD

CHIEF EXECUTIVE OFFICER April Becerra, CAE

Santa Clara Valley Medical Center Clifford Wang, MD

Printed in U.S.A.

Managing Editor Mike Wamungu

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, or SCCMA. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA of products or services advertised. The Bulletin and SCCMA reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Mike Wamungu, Managing Editor 700 Empey Way San Jose, CA 95128 760/671-2337 Fax: 408/289-1064 mike@sccma.org

CMA TRUSTEES - DISTRICT VII Thomas M. Dailey, MD

Kenneth Blumenfeld, MD 4 | The Bulletin

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vital data to advance science for the protection of public health on a national as well as global scale. Vital data on COVID hospitalizations has just been rerouted from the CDC to the Department of Health and Human Services, undermining the CDC and the ability of researchers and citizens to monitor this pandemic. The many hardships caused by the pandemic need to be considered. However, science free of political influence or prejudgment is important to make critical decisions. As the shelter-inplace orders are relaxed we need to follow our public health officials’ orders and recommendations to mitigate this virus. Public health officers who have tirelessly and courageously spoken out on our behalf are quitting under pressure, and others now require security guards at their homes. Any threats to our public health officials are unacceptable and essentially an attack on ourselves. Dismissing their advice will prolong and worsen this pandemic. We need to thank our own Santa Clara County public health leader, Dr. Sara Cody, and her team for providing strong leadership that has influenced other Counties’ and States’ responses to this public health crisis, especially important in a time of conflicting politics. She is an original hero. Opportunity

We will continue to live with uncertainty for many months while we learn to cope even longer with COVID. While we are waiting for science and observation to answer critical questions about this virus, we can change habits, build resilience and help each other in ways we would not have thought of before COVID-19 arrived. Communities have stepped in to offer support. Students are making 3D shields for healthcare workers and neighborhoods are sewing cloth masks for nursing home staff and residents. It is a stressful time from which we can learn; a time that provides an opportunity for us to coalesce around not only helping each other understand this virus, but

also addressing our role in social, environmental and economic inequalities to create a stable and healthy environment for our patients and ourselves. COVID-19 may help us build community and strengthen our relationship to the natural environment. We are not only living through history, we are learning our history and setting a new path for the future. We can transform this perfect storm into a calm resolve to change, recover and thrive. Working Together

The SCCMA along with the California Medical Association are working to provide assistance to physicians throughout the County in many areas including webinars on telehealth, finances and CME courses. The SCCMA has convened a COVID task force that will continue through the pandemic offering support to physicians and the community. The California Medical Association has also arranged for PPE from the State to be distributed to private practitioners in July and August 2020 through local medical associations, including the SCCMA. Other issues will arise in the months ahead, including a MICRA bill that will require the engagement of all physicians. We invite you to join us and share your ideas, knowledge and passion. Diverse physician involvement is the essential ingredient of the SCCMA’s success. I wish to thank Dr. Seema Sidhu for her generosity, hard work and critical leadership during this last year as president of the SCCMA, and look forward to working with her as I assume the presidency.

“Even calamities have a soul and can teach us a wise life.” Aristotle

Struggling to make sense of the current pandemic? Keep up with the latest COVID-19 news, research, and developments with by visiting our COVID-19 resource page: sccma.org/covid-19

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Covid-19:

Public Health, Pandemics and People

BY CINDY L. RUSSELL, MD SCCMA President

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“Start by Doing what is necessary; then do what is possible; and suddenly you are doing the impossible.” Saint Francis of Assisi

Face coverings and Airborne Transmission

Airborne transmission appears to be the dominant route of spread of COVID -19. Wearing a mask in public is the primary means of reducing airborne cough droplets. The Institute for Health Metrics and Evaluation at the University of Washington has a COVID-19 projection project. Their extensive data base indicates that a universal mask mandate is the most essential action people can embrace. They predicted in early July, that if this mandate is not more widely adopted, the trajectory for COVID deaths will rise in the U.S. by September rather than steeply slowing to allow us to open up schools and businesses. Zhang (2020) notes, “implementing face covering significantly shapes the pandemic trends worldwide.” Some feel it is their right not to wear a mask and others have difficulty wearing one, however, a simple cloth mask can change the curve of COVID-19.

Social Distancing

Social distancing also is important for containing spread by smaller exhaled airborne viral particles, and science tells us that the proper distance is 6 feet or more depending on our activities. Handwashing and GI Transmission

Handwashing was pioneered by Hungarian physician Dr. Ignaz Semmelweis in 1847 and drastically reduced maternal deaths after delivery. It still works. Research is now showing that fecal-oral transmission of COVID-19 may be substantial. Studies in China indicate that COVID-19 RNA was found in stool samples in 53% of cases of the disease and remained in stool samples in 23% of the cases even after nasal tests were negative (Wild 2020). This could account for some of the silent, symptomless and persistent transmission as well as reinfection. Sewage treatment plants are now used as a public health surveillance tool. They collect samples of wastewater to monitor pathogens and pollutants, keeping a hidden history of a population’s medications, drug use and coffee habits over time. Tests on wastewater in Massachusetts, the Netherlands (both preprint) and Italy have shown SARSCoV-2 in high titers during the pandemic. Another extraordinary finding in Barcelona sewage treatment plants is that COVID-19, was found in samples from March 2019, 9 months before the virus hit China (in preprint). Although about 75% of the sewage in the United States goes through municipal treatment plants, there can still be accidents. Untreated waste as well as pollutants can be released into surface waters, especially with combined sewer and storm water systems and with extreme precipitation. This can contaminate regional bodies of water. We are fortunate to have modern sewage systems in most of the United States but other developing countries are not so lucky. © Can Stock Photo / famveldman

s we follow the news and learn about COVID19, pandemics and public health we sometimes get confused as the unfolding science can seem to be contradictory at times. This puzzle of growing scientific information is pointing to answers which we may not have for months or years. We are finding out that virology is complex, just like human health and the environment. Many factors need to be examined to grasp a complete picture of the problem to be addressed. We now, however, see more clearly the intersection of public health issues with social, environmental and economic issues. Our roadmap through this is a winding road that has many side streets, and at whose intersections we must stop at, and clear before crossing. It is a good idea to wear our seatbelts and have compassion for ourselves and others on this bumpy road, where we often have to look in the rearview mirror. Issues to be addressed include transmission of the virus, civil engagement, racial disparity and environmental issues, while we also work to keep ourselves mentally and physically well.

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Washing hands with ordinary soap and water (not antibacterial soap) remains the most essential and best way to mechanically remove pathogens and reduce infections from viruses to methicillin resistant staph to food borne illness. Recent studies show handwashing may be more effective than hand sanitizers for coronaviruses. 20 seconds of thorough mechanical washing (and singing a catchy tune if you wish) is the magic time. The quality control of hand sanitizers has also come into question. Several new brands manufactured in Mexico by one company have recently been shown by the FDA to contain up to 81% methanol, a dangerous toxin, instead of alcohol, prompting consumers to now check the FDA website for advice before purchasing. Public Education on How to Use Disinfectants

There has been a sharp rise in calls to the poison control center related to disinfectants since the onset of COVID-19. Most of these were related to bleach. People have been mixing cleaning products, like vinegar and bleach, causing respiratory illness and children have been ingesting alcohol-based hand sanitizers. A startling survey of about 500 people conducted by the CDC in May 2020 showed that 39% of people stated they used high risk practices not recommended by the CDC for prevention of COVID -19 including applying bleach to fruits and vegetables, using household disinfectants on skin, inhaling vapors from cleaners or disinfectants or drinking or gargling with disinfectant solutions. This survey again highlights that science and scientists should weigh in heavily on the messaging. Racial Bias in Healthcare

We must recognize unconscious bias and work on policies to address this issue. Physicians are not only speaking out more on this subject, but also taking a knee inside and outside of medical facilities after the deaths of George Floyd and Breonna Taylor, among many others. “Hiding in Plain Sight” (Fayanju 2020) and “Stolen Breaths” (Hardeman et al 2020) provide us all a deep understanding of the problem, aiming to make the “invisible” visible. Racial disparities in healthcare highlight the complex origins of inequities in education, jobs and housing due to racism, with social stressors contributing to illness. These stressors, in turn, contribute to co-morbidities related to an increased rate of COVID morbidity. Pollution, Racism and COVID 19 Mortality

Pollution has been, not surprisingly, linked to an increased mortality in COVID-19 cases. A similar link was found in the

2003 SARS outbreak. It is well established in the global scientific literature that chronic exposure to air pollutants is strongly associated with heart disease, stroke, lung disease, lung cancer and respiratory infections, along with a shortened lifespan. Brandt et al (2020) reviewed studies in China, India and the United States showing that air pollution was linked to an increase in both the severity and morbidity of COVID-19. It is also well known that in the United States the highest levels of pollution are in disadvantaged communities. Brandt’s (2020) research shows a strong association between COVID-19 death rates and particulate matter (PM2.5 and PM10), ozone, nitrogen dioxide and sulfur dioxide, from combustion of fossil fuels. Densely populated and polluted areas have a higher rate of COVID-19, however, some areas with the same population density, but with lower socioeconomic status, showed higher rates of fatalities. Brandt (2020) notes,“In Detroit, up to 75% of all COVID-19 fatalities were blacks, whereas in Chicago, more than 50% of COVID-19 cases and nearly 70% of COVID-19 deaths involve black individuals, although they make up only 30% of the population.” Other factors besides pollution are at work. What about other social determinants of health such as environmental toxic exposures, nutrition and Vitamin D, all of which can affect our immune system? Biesalski (2020) points out that Vitamin D, the sunshine vitamin, is essential for our immune systems, not only improving antimicrobial activity but also reducing pro-inflammatory cytokines. Vitamin D deficiency is a worldwide problem. Dancer (2015) found a strong correlation between vitamin D deficiency and acute respiratory distress syndrome (ARDS). While some recent research indicates that there may a correlation with COVID 19, the study did not measure vitamin D levels in COVID patients directly. The authors recommend universal vitamin D screening along with clinical trials. Social determinants of health, which are known root causes of chronic disease, mentioned above, combine with pollution to multiply the effect on COVID-19 mortality. Much more needs to be done to reverse these problems and provide meaningful long-term solutions. © Can Stock Photo / Subbotina

Washing Hands May be Better than Hand Sanitizers

The Environmental Lessons of COVID

The news related to COVID-19 reveals some unforeseen bright spots resulting from lockdowns. The world has slowed down. All our senses can detect it. The ground is quieter. We literally feel the quiet. Seismologists have measured the drop in the earth’s movement in populated parts of the world. They are better able monitor earthquakes and volcanic activity during this time.

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The oceans are quieter. Scientists have measured a significant reduction in underwater noise pollution. Off the coast of Vancouver there was 16% decrease. Although time will tell what the effects will be on the health of whales and other species, researchers found that the slowing down of shipping in the North Atlantic following 911, was associated with lower stress hormones in right whales. The skies are clearer in major cities. As cities and nations have adopted lockdowns to mitigate the spread of COVID-19 people cannot only breathe better, the view is discernibly improved, as skies clear of air pollution. Building facades with ancient patterns that have been seen only through a haze for decades, are now appreciated with a background of blue skies in London, Italy, Spain and India. Studies demonstrated that the reduction in vehicle travel and air travel resulted in substantial reductions of nitrous oxide and CO2. Reductions in air pollutants such as PM2.5 and ozone, while significant, were not as dramatic in some cases as expected. This is due to continued manufacturing, refineries, coal burning power plants and diesel trucks that are still on the road transporting essential goods. Telecommuting alone will not solve the problem of air pollution. Deeper issues of overconsumption, waste and fossil fuel use need to be addressed. We have learned that air pollution is a global public health problem that can be reversed. Let’s fix it!

Interest in renewable energy has spiked while investments in oil and gas have declined. Renewable energy is becoming cheaper than gas, so much so that gas pipelines and oil wells are

being shut down. Divestment in coal and oil is now considered prudent, due to financial risks as well as environmental harm. California leads the way in renewable energy, with policies in place for many years that have shifted us away from fossil fuels. As physicians we have supported efforts to reduce pollution and move to renewable resources that will also mitigate climate change. This has been done through legislative collaboration with the house of medicine locally and nationally. This will continue with an emphasis now on environmental justice. All the research that is being done now in the COVID slowdown will help us better understand human impacts on the environment as well as our own health.

“Just disconnect. Once in a day sometime, sit silently and from all connections disconnect yourself.” Yoda, Star Wars Physician Wellness and Burnout

Physician burnout has become a hidden epidemic and rising yearly. Recent surveys show that about 50% of MD’s suffer from this syndrome at one point or another in their career, described as experiencing a “state of mental exhaustion, depersonalization, and a decreased sense of personal accomplishment”. The responsibilities of work, especially if work-life conflicts arise, become overwhelming, leading to stress, which results in depression, thoughts of suicide, drug or alcohol abuse and divorce. Physicians who are more conscientious, motivated and

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dedicated are at increased risk of burnout, as they ignore their own personal wellness to take care of patients. Shanafelt (2012), in a landmark study, revealed that physicians are far more likely to suffer from burnout than other professions with a prevalence of 38% in physicians, versus 28% of the working population. Specialties that experience more burnout include emergency medicine and critical care (60%-70%). Burnout is also strongly correlated with an increased risk for major medical errors. There has been a notable shift from just reporting rising rates of burnout, to offering solutions and identifying root causes to prevent burnout. Exercise, meditation, spirituality and taking time off can certainly help, but addressing the underlying issues are much more sustainable. Burnout is a Problem of the Entire Health Care System

A review of 19 studies (Panagioti 2017) showed that there was small improvement with various interventions to relieve stress but that burnout is a problem of the entire health care system, rather than individual practices. The reorganization of the healthcare system and introduction of the electronic medical record have contributed to this and are being examined to assist and not stress physicians more. Shanafelt in 2009 worked with the American College of Surgeons to identify the root causes of burnout. They identified longer work hours, increased administrative duties, constantly changing rules, intensifying litigious environment, increased pressure to produce, decreased reimbursement, and pressure to learn new technology as underlying factors. The research found that surgeons who worked fewer hours per week experienced less burnout. For surgeons working less than 60 hours per week the prevalence was 30%, while those working more than 80 hours per week had a 50% prevalence of burnout. Interruption in family activities, missed meals and lack of time (and quality of that time) spent with their partner were also associated with burnout. All of these issues have contributed to doctors deciding to retire early. COVID and Hero Burnout

In this time of COVID-19, physicians as healers, are selflessly giving even more time and energy to their patients and their work, risking their lives to save the lives of others. Front line physicians are experiencing higher levels of stress. Anxiety arises from learning and following strict protocols, having to reuse or not having PPE, long hours, the uncertainty of viral surges, seeing colleagues become ill and succumb to COVID, and in addition, to concerns about risking family members health by unknowingly transmitting the virus. This is all under the shadow of economic decline that threatens the viability of physician’s practices. Health care professionals have never been held in such high esteem as now. Physicians and nurses are heroes; however, heroes can suffer burnout too. Physician groups and healthcare systems recognize the need for physical and mental health self-care and are providing resources to help build resilience. Wellness programs can significantly benefit physicians. They emphasize exercise, sleep, taking vacation breaks (where doctors are totally disconnected from patient care), as well as work modifications. Stanford, Kaiser, Sutter, local hospitals such as El

Camino Hospital and the California Medical Association offer valuable help and links to hotlines for MDs, who typically do not ask for help. Individual physicians routinely also do care for each other, carving out social time together to just talk, but currently it is accompanied by masks and shields or a Zoom format. Physician burnout coaches recommend

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Remember your mission Focus on the present Be realistic but stay positive Find meaning outside of work Find better balance between personal and professional lives • Practice self-care and self- compassion • Practice gratitude As we engage in critical conversations and create meaningful change, the solutions to these seemingly impossible problems will begin to unravel, allowing us to not only heal our patients, but also importantly, to heal ourselves, heal each other and heal the planet…possibly quicker than we thought possible. We must respect each other, the laws of science and the laws of nature along the way.

“My mission is not merely to survive, but to thrive; and do so with some compassion, some humor and some style.” Maya Angelou Resources Covid-19: Public Health, Pandemics and People

• Exclusive: Nearly 600 — And Counting — US Health Workers Have Died Of COVID-19. Lost on the Frontline. Kaiser health news. June 6, 2020. https://khn.org/ news/exclusive-investigation-nearly-600-and-counting-ushealth-workers-have-died-of-covid-19/ • Institute for Health Metrics (IHME ). Ujiversity of Washington. COVID-19 Projections https://covid19. healthdata.org/united-states-of-america • West: Coronavirus-Related Restrictions By State. NPR. July 2, 2020. https://www.npr. org/2020/05/01/847416108/west-coronavirus-related-restrictions-by-state • CDC. Considerations for Wearing Cloth Face Coverings.https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html • Identifying airborne transmission as the dominant route for the spread of COVID-19. Zhang R eta al. May 16, 2020. https://www.pnas.org/content/early/2020/06/10/2009637117 • Universal Masking in Hospitals in the Covid-19 Era.NEJM. https://www.nejm.org/doi/full/10.1056/NEJMp2006372?query=recirc_mostViewed_railB_article • What is the evidence to support the 2-metre social distancing rule to reduce COVID-19 transmission? June 22, 2020. https://www.cebm.net/covid-19/what-is-theevidence-to-support-the-2-metre-social-distancing-rule-to-

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reduce-covid-19-transmission/ • COVID-19 Infects GI Tract, a Possible Route of Viral Transmission. David Wild. Infectious Disease Special Edition. March 6, 2020. https://www.idse.net/Emerging-Diseases/Article/03-20/GI-Tract-Possible-Route-ofTransmission-for-COVID-19-/57537 • COVID-19: faecal–oral transmission? Jordan Hinson. Nature Reviews in Gastroenterology and Hepatology. March 25, 2020. https://www.nature.com/articles/s41575020-0295-7 • Sentinel surveillance of SARS-CoV-2 in wastewater anticipates the occurrence of COVID-19 cases. Chavarria-Mira G et al. BMJ Yale. Preprint (not peer reviewed) https://www.medrxiv.org/content/10.1101/2020. 06.13.20129627v1 • Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. July 3, 2020. Bhowmick GD et al. Nature. NJP Clean Water. Published 03 July, 2020. https://www. nature.com/articles/s41545-020-0079-1#article-info. https:// www.nature.com/articles/s41545-020-0079-1 • Coronavirus was already in Italy by December, waste water study finds. June 19, 2020. https://www. bbc.com/news/world-europe-53106444 • Flushing the Toilet Has Never Been Riskier. Some of today’s sewers were built before bathrooms as we know them existed. It’s time to upgrade. The Atlantic. September 17, 2015. https://www.theatlantic.com/ technology/archive/2015/09/americas-sewage-crisis-public-health/405541/ • Extreme Precipitation and Emergency Room Visits for Gastrointestinal Illness in Areas with and without Combined Sewer Systems: An Analysis of Massachusetts Data, 2003–2007. Jagai J et al. Environmental Health Perspectives. September 2015. https://ehp.niehs.nih. gov/doi/10.1289/ehp.1408971 • SARS-CoV-2 titers in wastewater are higher than expected from clinically confirmed cases. BMJ Yale. (Preprint) June 2020. Wu F et al. https://www.medrxiv.org/content/10.110 1/2020.04.05.20051540v1 • Exercise and Fitness in the Age of Social Distancing During the COVID-19 Pandemic. Nyenhuis S et al. J Allergy Clin Immunol Pract. April 28, 2020. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC7187829/ • Knowledge and Practices Regarding Safe Household Cleaning and Disinfection for COVID-19 Prevention — United States, May 2020. CDC. June 12, 2020. https://www.cdc.gov/mmwr/volumes/69/wr/mm6923e2. htm • FDA Updates on Hand Sanitizers with Methanol. 7/2/20. https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-hand-sanitizers-methanol • Coronavirus: Expert says Scotland ‘could be Covid-free by end of summer. June 28, 2020. BBC News. https://www.bbc.com/news/uk-scotland-53192024’ • New Zealand’s Covid-19 isolation facilities under ‘extreme stress’, review finds. The Guardian. Jun 28, 2020. https://www.theguardian.com/world/2020/jun/28/

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new-zealands-covid-19-isolation-facilities-under-extreme-stress-review-finds Hiding in Plain Sight. A Piece of My Mind. Dec. 10, 2019. Oluwadamilola “lola” M. Fayanju, MD, MA, MPHS. JAMA. 2019;322(22):2173-2174 Stolen Breaths. Perspective. NEJM. Hardeman R et al. June 10, 2020. https://www.nejm.org/doi/full/10.1056/NEJMp2021072 Physician Burnout, Interrupted. Perspective. (Video link available in article) Pamela Hartzband, M.D., and Jerome Groopman, M.D. NEJM. May 1, 2020. https://www. nejm.org/doi/full/10.1056/NEJMp2003149?query=recirc_ inIssue_bottom_article The Pandemic Is Turning the Natural World Upside Down. The Atlantic. June 4, 2020. https://www.msn.com/ en-au/news/world/the-pandemic-is-turning-the-naturalworld-upside-down/ar-BB12clkZ COVID-19 and Racial/Ethnic Disparities. Hooper M et al. NEJM. May 11, 2020. https://jamanetwork.com/journals/ jama/fullarticle/2766098 WHO Ambient air pollution: Health impacts. https:// www.who.int/airpollution/ambient/health-impacts/en/ Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Cohen A et al. The Lancet. Volume 389, Issue 10082P1907-1918, MAY 13, 2017. https://www.thelancet. com/journals/lancet/article/PIIS0140-6736(17)30505-6/ fulltext Disparities in the Impact of Air Pollution. American Lung Association. April 20, 2020. https://www.lung.org/ clean-air/outdoors/who-is-at-risk/disparities Poor Communities Exposed to Elevated Air Pollution Levels. Tara Faily. 2016. NIEHS. https://www.niehs. nih.gov/research/programs/geh/geh_newsletter/2016/4/ spotlight/poor_communities_exposed_to_elevated_air_ pollution_levels.cfm Pollution made COVID-19 worse. Now, lockdowns are clearing the air. National Geographic. https://www. nationalgeographic.com/science/2020/04/pollution-madethe-pandemic-worse-but-lockdowns-clean-the-sky/ Coronavirus lockdown leading to drop in pollution across Europe. https://www.esa.int/Applications/Observing_the_Earth/Copernicus/Sentinel-5P/Coronavirus_lockdown_leading_to_drop_in_pollution_across_Europe Declines in air pollution due to COVID-19 lockdown show need for comprehensive emission ‎reduction strategies. UNECE. 2020. https://www.unece.org/info/ media/news/environment/2020/declines-in-air-pollutiondue-to-covid-19-lockdown-show-need-for-comprehensiveemission-reduction-strategies/doc.html Changes in U.S. air pollution during the COVID-19 pandemic. Jesse Berman and Keita Ebisu.Science of Total Environment. Vol 739. 15 October 2020, 139864. https://www.sciencedirect.com/science/article/pii/ S0048969720333842 **Does lockdown reduce air pollution? Evidence from 44 cities in northern China. Rui Bao and Acheng

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Committee on Energy and Commerce Subcommittee on Health. June 17, 2020. https://docs.house.gov/meetings/ IF/IF14/20200617/110812/HHRG-116-IF14-Wstate-BoydR-20200617.pdf • Vitamin D deficiency and co-morbidities in COVID-19 patients – A fatal relationship? Hans K Biesalski NFS Journal. 2020 Aug; 20: 10–21. https://www.ncbi. nlm.nih.gov/pmc/articles/PMC7276229/ • The Possible Role of Vitamin D in Suppressing Cytokine Storm and Associated Mortality in COVID-19 Patients. Daneshkhah A t al. MedRxiv. Notpeer Reviewed yet. https://www.medrxiv.org/content/10.1101/20 20.04.08.20058578v4 • Vitamin D Deficiency Contributes Directly to the Acute Respiratory Distress Syndrome (ARDS). Danc-

tality. Brandt E et al. J Allergy Clin Immunol. 2020 May 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204717/ • COVID-19 PM2.5. A national study on long-term exposure to air pollution and COVID-19 mortality in the United States. Wu X et al. Department of Biostatistics. Harvard T.H. Chan School of Public Health. Updated April 24, 2020. https://projects.iq.harvard.edu/covid-pm • Omission of air pollution from report on Covid-19 and race ‘astonishing’. The Guardian. June 7, 2020. https://www.theguardian.com/environment/2020/jun/07/ omission-of-air-pollution-from-report-on-covid-19-andrace-astonishing • The Injustice of Inequitable Disease Addressing Racial Health Inequities amid the COVID-19 Pandemic.Briefing Before the United States Congress House

er RC et al. Thorax. 2015 Jul;70(7):617-24. https://pubmed. ncbi.nlm.nih.gov/25903964/ • Prevalence of Vitamin D Deficiency and Its Associations with Skin Color in Pregnant Women in the First Trimester in a Sample from Switzerland. Richard A et al. Nutrients. 2017 Mar; 9(3): 260. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC5372923/ • Coronavirus lockdowns have changed the way Earth moves. A reduction in seismic noise because of changes in human activity is a boon for geoscientists. March 31, 2020. Elizabeth Gibney. https://www.nature.com/articles/ d41586-020-00965-x • Lull in ship noise after Sept. 11 attacks eased stress on right whales. Science Daily. Feb 8, 2012. https:// www.sciencedaily.com/releases/2012/02/120208132711.htm

Zang. Science of the Total Environment. Vol 731. 20 August 2020, 139052. https://www.sciencedirect.com/science/ article/pii/S0048969720325699 • Traffic Is Way Down Because Of Lockdown, But Air Pollution? Not So Much. May 19, 2020.https://www.npr. org/sections/health-shots/2020/05/19/854760999/trafficis-way-down-due-to-lockdowns-but-air-pollution-not-somuch • COVID-19, an opportunity to reevaluate the correlation between long-term effects of anthropogenic pollutants on viral epidemic/pandemic events and prevalence. Tsatsakis A et al. Food Chem Toxicol. 2020 Jul;141:111418. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7211730/ • Air pollution, racial disparities, and COVID-19 mor-

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• Cities witness reduced noise pollution during the COVID pandemic. March 6, 2020. http://www.eurocities. eu/eurocities/news/Cities-witness-reduced-noise-pollutionduring-the-COVID-pandemic-WSPO-BR6VCC • Measuring noise reduction in the ocean during the pandemic. May 11, 2020. Phys Org. https://phys.org/ news/2020-05-noise-reduction-ocean-pandemic.html • Airborne Nitrogen Dioxide Plummets Over China. NASA. https://www.earthobservatory.nasa.gov/images/146362/airborne-nitrogen-dioxide-plummets-over-china • Air pollution falls by unprecedented levels in major global cities during coronavirus lockdowns.April 23, 2020. https://www.cnn.com/2020/04/22/world/air-pollution-reduction-cities-coronavirus-intl-hnk/index.html • Unexpected air pollution with marked emission reductions during the COVID-19 outbreak in China. Le T et al. Science 17 Jun 2020. https://science.sciencemag. org/content/early/2020/06/16/science.abb7431 • The Financial Case for Fossil Fuel Divestment. IEEFA. July 2018. http://ieefa.org/wp-content/uploads/2018/07/Divestment-from-Fossil-Fuels_The-Financial-Case_July-2018. pdf

• Ensuring Mental Health Care During the SARSCoV-2 Epidemic in France: A Narrative Review. Chevance A et al. Encephale. 2020 Jun;46(3):193-201. https://pubmed.ncbi.nlm.nih.gov/32370982/ • COVID-19 reduces economic activity, which reduces pollution, which saves lives. Marshall Burke. Stanford professor of Earth Sciences . http://www.g-feed. com/2020/03/covid-19-reduces-economic-activity.html?m=1 • Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate HealthCare Disparities. Chapman E et al. J Gen Intern Med. 2013 Nov;28(11):1504-10. https://pubmed.ncbi.nlm.nih.gov/23576243/ • Physician Burnout: Are We Treating the Symptoms Instead of the Disease? John J Squiers et al. Annals of Thoracic Surg. 2017 Oct;104(4):1117-1122. https://www. annalsthoracicsurgery.org/article/S0003-4975(17)31097-4/ fulltext • Physician Burnout: Causes, Consequences, and (?) Cures. Herbert L. Fred and Mark S Scheid. Texas heart institute. 2018 Aug; 45(4): 198–202. https://www.ncbi.nlm. nih.gov/pmc/articles/PMC6183652/

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Public Health Officials Are Our COVID Commanders.

Treat Them With Respect.

As a veteran who served back-to-back tours in Iraq, I initially cringed when commentators compared the COVID-19 crisis to wartime — no bullets, no blood and no one volunteered for this. But after my months of reporting on the pandemic, it has become painfully clear this is like war. People are dying every day as a result of government decisions — and indecision — and the death toll is climbing with no end in sight. Less than six months into the pandemic, COVID-19 has al-

ready killed at least 183,000 Americans, more than triple the number who died in the Vietnam War, and far more than the wars in Iraq and Afghanistan combined. We are all being asked to make sacrifices for the good of our country. And we’re experiencing, as a nation, a deeply traumatic event. Like war, the toll will be felt for a long time. In California, local public health officials are leading the front lines in this battle against COVID-19, dictating strategy, issuing orders and developing tactics to carry out that

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strategy. Every day, they make gut-wrenching calls to protect our health and livelihoods, even if those decisions may inflict initial harm on the economy or contradict politicians and popular opinion. But instead of being celebrated for their difficult and dangerous work, as I was, they are now facing violent threats and political attacks from those who disagree with their tactics — such as requiring masks in public and ordering businesses and parks closed to prevent the spread of infection. I can’t imagine being afraid of the people I signed up to protect. When I interview them, often late at night, I hear in their voices that familiar mix of emotions that often come with war: exhaustion, anxiety and devotion to duty. “We’ve become easy scapegoats for people’s fear and anxiety during COVID-19,” said Dr. Gail Newel, the health officer for Santa Cruz County, who continues to face threats for issuing public health orders. The latest — a menacing email sent to her in late July calling her a “communist bitch” — prompted local law enforcement to recommend she get a guard dog and firearm to protect herself. “That weighs very heavily,” she said. I can’t imagine the burden. Although many of us serving in Iraq disagreed with the war, we remained dedicated to our mission and enjoyed broad support at home. I joined the military as a U.S. Army reservist in 1999 and was deployed on active duty to Iraq in early 2003, when it truly was like the Wild West. Serving first as logistics clerk and then the acting supply sergeant for a military police company out of San Jose, California, I helped ensure my military brothers and sisters had proper equipment. When the George W. Bush administration sent us to Iraq, for example, it did so without armoring our Humvees — a major failure that elevated our risk of being blown up by roadside explosives. Angela Hart served eight years in the U.S. Army Reserve, including more than one year on active duty in Iraq. She is shown here with her father, Alan Hart, in Fort Sill, Oklahoma, when she graduated from basic training in 2000. (The Hart family) I returned home in July 2004 and spent years putting the battlefield behind me as I transitioned to a career in journalism. But living through COVID-19 has resurrected those feelings of being at war. Now, just like then, there is an overall sense of fear and uncertainty because we don’t know when the crisis will end. We aren’t free to go about our lives as we once did and we yearn for the comforts we took for granted. We miss our loved ones we can’t see. We must remain hyper-vigilant to potential threats, and even make sure to don our “armor” when we leave our homes, except now it’s masks and gloves instead of helmets and flak jackets. There’s something that happens when you’re in a conflict zone — the air feels heavier. You can feel threats all around you, just waiting to strike. There’s deep anxiety for what the future holds, and you wonder whether you’ll be alive next week or next month. Living through COVID-19 has resurrected those feelings of being at war.

Public health officers are shouldering the added anxiety that duty brings. For much of the pandemic, Gov. Gavin Newsom has pushed the responsibility — and blame — of reopening largely onto counties and the state’s 61 local health officers, who have worked for months without days off, giving up time with their families to attack this crisis head-on. I have interviewed dozens of them. Some have broken into tears while talking with me, and worry chokes their voices as they lament problems with testing or explain how they don’t have enough supplies or contact tracers to safely reopen. They felt rushed into lifting stay-at-home restrictions in May and June, yet they had no choice in the face of pressure from politicians and suffering residents and businesses. After years of severe underfunding, public health agencies don’t have the money or resources to deploy an adequate response. They’re also wrestling with the guilt and trauma that come with making decisions that affect people’s lives and livelihoods. “It has been hard on all of us,” acknowledged Sacramento County’s health officer, Dr. Olivia Kasirye. “We’re getting phone calls daily from people saying they’re going bankrupt and they can’t pay their rent and they have loved ones who are dying that they can’t see.” I know how that feels, having been conflicted about our long-term strategy in the Middle East and the harm we inadvertently inflicted on innocent civilians. But I can’t imagine being afraid of the people I signed up to protect. Public health officials have become targets of aggressive and personal attacks. Some have seen their photos smeared with Hitler mustaches, while others have had their personal phone numbers and home addresses circulated publicly, prompting the need for round-the-clock security. “Imagine treating American soldiers and military families with the kind of hatred and disrespect that local health officers are facing,” said Dr. Charity Dean, unprompted, a day after she left her job as one of the top public health officials in the Newsom administration. “They’re the ones taking all the risk, and it makes me angry to see how they’ve been treated.” Since the start of the pandemic, at least eight career public health officials in California have resigned, and more are considering it. But most are soldiering on. Mimi Hall, Newel’s boss and Santa Cruz County’s top public health official, told me law enforcement is investigating a threatening letter addressed to her that was allegedly signed by a far-right anti-government extremist group. In response, Hall considered retiring early. But she didn’t want to abandon her troops and wasn’t going to let fear stop her from doing her job. So she had a perimeter fence and home security system installed over the weekend — and reported for work promptly Monday morning. Yes, we are waging a life-or-death battle in which innocent people are hurt, but it’s these battle-scarred public health officers who are making deeply personal sacrifices to steer us to safety. We commemorate military leaders with medals and parades. Why not treat our public health officials with the same level of appreciation? Angela Hart: ahart@kff.org, @ahartreports

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Should I Still Consider Assisted Living for My Loved Ones During the COVID-19 Pandemic? BY ANGELA HART

The coronavirus pandemic has affected nearly everyone’s daily lives across the United States to some extent, but the senior community has been hit especially hard due to their increased risk of contracting a serious case of the virus. In the U.S., there have been over 120,000 confirmed cases, and over 2,000 deaths at the time of writing – a number that’s expected to rise. According to the Centers for Disease Control (CDC), older adults are especially at risk. According to a March 26th report the fatality rate for adults between 75 and 84 ranges from 4% to 11% and the fatality rate for adults 85 and older ranges from 10% to 27%. If you have an older loved one, COVID-19 may put you in a tough situation due to their increased risk. Seniors need to be even more diligent about social distancing than the rest of the population. This distancing can make it difficult to determine how to handle your loved one’s care while also keeping them safe, especially if they require daily assistance or care. While it may seem that group environments like assisted living facilities are not the right choice right now, for many, it’s still the best option. Considering the enhanced safety measures senior living communities are taking, moving into a senior community may make more sense than living alone and not getting adequate care. To help seniors and their loved ones make this vital decision, we’ve outlined alternative care options for seniors, as well as which seniors should still consider assisted living. Additionally, this report provides an in-depth look at what senior living communities are doing and how you can help prevent the spread of the coronavirus. Determining the Appropriate Care Options

Coronavirus spreads easily from person-to-person, a phenomenon known as “community spread,” which makes apartment complexes and senior living communities an environment in which the virus can thrive. This may make some people hesitant to move their loved one into an assisted living facility right

now, even if their loved one needs care. However, it’s important to note that remaining in the home can pose risks for seniors, too, whether they live alone or with family. While residential care facilities like assisted living communities are implementing strict health and safety measures to prevent community spread, it may be harder to implement the same kinds of policies in your own home. For example, if your elderly loved one lives with you, someone who lives in the home could pick up the virus while running errands and unknowingly pass the virus to your older loved one. Or, if the senior’s main family caregiver gets sick, the family may need to choose whether to potentially pass the illness onto their older loved one or to leave their loved one temporarily without care. Additionally, seniors who live alone will most likely be completely isolated for the foreseeable future as people follow social distancing guidelines. This can present dangers for both physical and mental health. When you consider the steps that senior communities are taking, such as enacting strict social distancing rules and other safety protocols, and the fact that residents do not need to leave for essentials, your loved one may be safer there right now. Senior living communities also have several caregivers on staff, ensuring that residents will not have to go without care in the event that someone on the staff is unable to work during the virus outbreak. Who is a Good Fit for Residential Care During Coronavirus? If your loved one is not currently living in a residential care facility, you may have put plans to move them in on pause. But, for many seniors, assisted living is still the right choice. In general, the following people are good candidates for assisted living: • Seniors who need regular assistance with the activities of daily living such as eating, bathing, and dressing • Seniors who live alone and have a medical condition that may require urgent attention

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What to Look for in an Assisted Living Community

While many senior living communities have risen to the challenge of protecting their residents’ health and safety at all costs, not everyone is taking the proper precautions. The coronavirus pandemic highlights the importance of carefully filtering out communities that don’t maintain the highest standards of cleanliness and preventative safety measures. As a senior living referral service, Caring.com takes this responsibility very seriously. We are committed to helping you and your loved ones find the care you need at a community that has the highest standards of coronavirus preparedness. Below, we’ve listed some of the precautions many communities are taking. If you are considering moving your loved ones into a community, we highly recommend that you review the following list, and find out what steps the community is taking. Proper Precautions for Assisted Living Communities

The following are a few of the steps many senior living communities are taking to protect their residents. It’s important to note that you should always make sure to follow the latest guidance from the CDC and local government directives, and be sure that you are taking action based on reliable information directly from the source.

Visitor restrictions Many senior living communities are currently instructing any would-be visitors not to enter and to postpone their visit if they have recently been sick or are showing any signs of illness. Anyone who has been exposed to someone who is sick, whether with coronavirus or another illness, within the last two weeks is also being asked not to enter most senior living facilities at this time. In some areas, communities are not allowing any visitors at all. Facilities that are allowing visitors are requiring all people to wash their hands or use hand sanitizer immediately upon entering the facility. The goal is to eliminate the risk of visitors bringing coronavirus or any other type of immune-weakening illness into the facility. Staff are being instructed to stay home if they have symptoms of any type of illness In addition to restricting visitors who may be sick, staff members are also being instructed to stay home if they are exhibiting any symptoms of coronavirus or the cold, flu, or any other illness. Because in most communities staff members spend time with many different residents throughout the day, if a staff member is sick, the likelihood of them passing the illness along to multiple recipients is high. Thus, it is especially important that staff do not work when there’s any chance that they may be sick and could introduce an illness to the facility. Postponing activities and limiting access to communal spaces Because residents live in apartment-style units and tend to eat, relax, and congregate in communal areas, it can be difficult to implement social distancing in senior care communities. To help prevent the spread of coronavirus, some facilities are postponing or altering group activities for the foreseeable future and closing common areas or restricting access to these areas to limited hours. This gives staff more time to adequately clean the areas. Enhanced cleaning procedures While senior living facilities always need to maintain cleanliness, right now, facilities are adhering to more strict cleaning procedures. The CDC recommends that long-term care facilities frequently clean any and all frequently-touched surfaces and shared areas with hospital-grade disinfectants. If facilities are choosing to leave common areas open for residents, they should be especially diligent in disinfecting surfaces like couches and shared exercise equipment multiple times throughout the day. Resident assessments Facilities are regularly screening residents for any symptoms of coronavirus, specifically respiratory distress. Daily screening can help facilities catch any cases of coronavirus early and prevent further community spread. In addition to daily health screenings, facilities are scheduling regular hand washings throughout the day. For more information about steps communities are taking, © Can Stock Photo / Choreograph

• Seniors who have dementia, Alzheimer’s, or another form of memory impairment, as this can make it difficult to follow hygiene protocols • Seniors living with any family members who are unable to social distance or isolate (i.e., medical professionals, grocery workers) • Seniors who live with any family member who has traveled internationally in the last two weeks • Seniors who live in a home with other people who are not isolating and the senior does not have their own bedroom and/or bathroom where they can isolate Who Should Consider Alternative Care Options? While assisted living is a good fit for many seniors, it is not the right choice for everyone. Below are some situations in which seniors should seek other care options: • Seniors who only need occasional help around the house, or only need help for a short period of time may be better suited for home care until the coronavirus pandemic is over. • Seniors who have an extensive support system of loved ones who can provide care while remaining isolated to prevent exposure to the coronavirus may be better off temporarily putting off a move to a senior living community. • Seniors who are exhibiting any symptoms of coronavirus, cold, or flu should hold off on moving into an assisted living facility until medically cleared by a doctor to help protect other residents

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here are a few examples of communities that are taking important precautions to protect their residents: • Brookdale Senior Living • Sunrise Senior Living • Enlivant Alternative Care Options

As previously mentioned assisted living may not be the right choice for everyone. Whether because of cost or needs, some seniors may be better suited for one of these other options to keep them healthy during the COVID-19 pandemic. In-home care can provide seniors with assistance they need without breaking social distancing guidelines If a senior needs more care than their loved ones can provide or their normal caregiver is unable to be with them due to illness, in-home care is a great option. Seniors should be practicing social distancing as much as possible, but receiving care from a healthy individual should not pose much risk, so long as the home care aide has not been exposed to coronavirus themselves and is following CDC protocols. The CDC strongly encourages health care workers to practice proper hand hygiene, specifically the use of hand sanitizer with greater than 60% ethanol or 70% isopropanol. The CDC says that the active ingredients in these recommended alcohol-based hand sanitizers can inactivate viruses that are genetically related to COVID-19. Nursing homes provide higher-level medical care for high-risk seniors Assisted living facilities have limits on how much medical care they can provide, typically just offering basics such as first-aid and medication management. For seniors with more complex medical needs, a nursing home is a better option, especially during the coronavirus pandemic. Seniors with underlying health conditions, in particular, should be in an environment where they’re able to receive high-level medical care at all times. As reported by Stat News, a study of the comorbidity of COVID-19 and other health conditions found that those with a chronic disease like diabetes or kidney disease have a 79% higher risk of requiring intensive care for or dying as a result of coronavirus. Assistive technology devices ensure that isolated seniors who live independently can still get help in an emergency Following social distancing protocols, caregivers and family members are likely checking in on their older loved ones in person less frequently. If you’re worried about a senior who will be spending more time alone than they usually do, a medical alert system can provide you with peace of mind and your loved one with an easy way to get help if they are alone during an emergency. You can also utilize everyday technology like video chatting to stay connected with your loved one. Devices such as an echo show can facilitate a daily family “check-in” video chat to ensure that your older loved one is feeling well and has all of their needs met. What You Can Do to Limit the Spread

Though there is currently no cure or vaccination for coronavirus, there are preventative measures that all people can take to help prevent the spread of the virus. In long-term care communities, these strategies are even more important. The following strategies, recommended by the Centers for Disease Control and Prevention, are the first line of defense against spreading coronavirus.

Use proper “hand hygiene” techniques While everyone knows that washing their hands is important, there are special “hand hygiene” measures that one should take if they’re spending time in a long-term care facility. According to the CDC, this includes using alcohol-based hand sanitizer immediately before and after touching a patient and/or their surrounding environment, washing hands with soap and warm water for 20 seconds minimum, and wearing and changing gloves regularly (though gloves are not a substitute for proper hand hygiene). Clean your phone and avoid touching your face One thing that everyone should be doing- whether or not they interact with seniors – is to avoid touching their face, especially mouth, nose, and eyes. Pathogens can easily enter our bodies via our mouth, nose, and eyes, so keeping your hands away from these areas can help protect you from infection. Another key is to disinfect your phone, which can easily pick up germs and pass them to your body while you hold it near your face to speak. Do not allow family or friends to visit if sick While it may be hard to turn visitors away, those in longterm care communities should be wary of having any family or friends visit while they’re sick. Even if the person is not carrying coronavirus, introducing a common cold or flu into the senior care community environment may make other residents more susceptible to contracting COVID-19. And if you have a loved one living in a long-term care community and suspect you may be coming down with a bug, it’s best to stay home until your symptoms have cleared up. You may also want to talk to your doctor to make sure your symptoms are not contagious before visiting your loved one out of extra precaution. Prevent exposure in the community The following general measures are recommended by the CDC to reduce transmission of infection: • Diligent hand washing, particularly after touching surfaces in public (use of hand sanitizer that contains at least 60 percent alcohol is a reasonable alternative if the hands are not visibly dirty) • Respiratory hygiene (eg, covering the cough or sneeze) • Social distancing of at least 6 feet • Avoiding crowds (particularly in poorly ventilated spaces) if possible and avoiding close contact with ill individuals • Cleaning and disinfecting objects and surfaces that are frequently touched – the CDC has issued guidance on disinfection in the home setting In particular, older adults and individuals with chronic medical conditions should be encouraged to follow these measures. Here are a couple of other tips: • Individuals who are caring for patients with suspected or documented COVID-19 at home should wear a tightly fitting medical mask and use gloves when in the same room as that patient and should change upper clothing after each exposure. • Individuals who become ill (eg, with fever and/or respiratory symptoms) should stay home from school or work. Have more questions? Caring.com works closely with senior living communities to know their latest policies and procedures. Our Family Advisors are available to answer any questions you may have and connect you to specific communities: (800) 9731540. As always, our services are free to you. The Bulletin | 19

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Many People of Color, Immigrants Among Over 1,000 US Health Workers Lost to COVID BY DANIELLE RENWICK The Guardian and Shoshana Dubnow

More than 1,000 front-line health care workers reportedly have died of COVID-19, according to Lost on the Frontline, an ongoing investigation by The Guardian and KHN to track and memorialize every U.S. health care worker who dies from the coronavirus. Earlier this month, the organizations published a major interactive database. It is the most comprehensive accounting of U.S. health care workers’ deaths in the country. EXPLORE OUR DATABASE

KHN and The Guardian are tracking health care workers who died from COVID-19 and writing about their lives and what happened in their final days. The virus has taken a disproportionate toll on communities of color and immigrants — and health workers haven’t been spared. Guardian and KHN reporters have published profiles of 177 of the 1,079 victims we have identified based on obituaries, news reports, social media posts and other sources. Of those 177, 62.1% were identified as Black, Latino, Asian/Pacific Islander or Native American, and 30.5% were born outside the United States. Both figures support findings that people of color and immigrants (regardless of race) are dying at higher rates than their white and U.S.-born counterparts. TELL US A HEALTH WORKER’S STORY

This project between The Guardian and KHN aims to document the life of every health care worker in America who dies from COVID-19. If you have a colleague or loved one we should include, please share their story. These figures track with other research. According to a Harvard Medical School study published in The Lancet Public Health last month, health care workers of color were more likely to care for patients with suspected or confirmed COVID-19 and nearly twice as likely as their white counterparts to test positive for the coronavirus.

The U.S. health system also relies heavily on immigrant health workers, who account for almost 1 in 5 health workers. Immigrant health workers tend to work in the most vulnerable communities: A 2018 study found that high-poverty areas tend to have more foreign-trained doctors than do wealthier regions, for example. Among those lost were Corrina and Cheryl Thinn, sisters who worked in a clinic in the Navajo Nation in northern Arizona. They shared an office, lived in the same home, helped raise each other’s children and died just weeks apart. Dr. James “Charlie” Mahoney, a Brooklyn pulmonologist, was one of only a handful of Black students at his medical school in the 1970s. He was remembered as a “legend” at his hospital. Dr. Reza Chowdhury, an internist in the Bronx, was a beloved figure in the city’s Bangladeshi community. He didn’t charge copays when his patients were low on cash and gave out his home phone number so they could call with medical questions. And Milagros Abellera, remembered by colleagues as a “mother hen,” was one of the dozens of nurses from the Philippines who succumbed to the virus in the United States. In addition to disparities based on race and origin, our researchers found that of the 177 workers profiled so far from the Lost on the Frontline database: At least 57 (32%) were reported to have had inadequate personal protective equipment (PPE). The median age was 57 and ages ranged from 20 to 80, with 21 people (12%) under 40. Roughly 38% — 68 — were nurses, but the total also includes physicians, pharmacists, first responders and hospital technicians, among others You can read their stories and those of other healthcare workers here. And if you know of a health care worker who died of COVID-19, please share their story with us. This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. The Bulletin | 21

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How the pandemic casts physician burnout in new light ANDIS ROBEZNIEKS Senior News Writer, American Medical Association

he COVID-19 pandemic is exacerbating the national public health problem of physician burnout and weakening patients’ tie to the essential physician care they need to manage chronic conditions. These are among the insights that AMA President Susan R. Bailey, MD, shared during an online program hosted by The Atlantic magazine examining how COVID-19 exposed longstanding inequities and deficiencies in the nation’s health care system. “Burnout has been a problem amongst physicians and other health care workers for years,” said Dr. Bailey, an allergist and immunologist from Fort Worth, Texas, during a panel on “The Health of the Health Care System,” which was moderated by author and Emmy Award-winning journalist John Donvan. “The AMA has been studying this very closely and developing tools for physicians, and it was one of my personal priorities for my presidency—and then coronavirus changed everything,” she added. “But, in a way, it really didn’t, because burnout is a more important subject than ever.”

Burnout in the Bronx

Appearing with Dr. Bailey was Philip Ozuah, president and CEO of Montefiore Medicine in the Bronx, who told of the impact of losing 27 colleagues to COVID-19. “It’s not simply losing a colleague,” Ozuah said. “It’s also having seen many of our colleagues on ventilators prone in the ICU for weeks. These are folks that you work with and you see them in that state struggling to breathe.” But, he added, there was no time for staff to grieve or reflect because so many people needed their help. One way to cope, he said, is to focus on the thousands of lives that were saved. In addition, Montefiore implemented support measures that included “everything we could think of.” This included a hotline for people who needed to talk, rest-and-relaxation options, rental cars, free parking, free meals, plus hotel rooms and laundry service “so people didn’t have to worry about taking the virus home.” Donvan mentioned to Dr. Bailey that his wife is a primary care physician and noted that, one on hand, she’s very tired. On the other, “her sense of mission” has never been higher. “Yes, it does bring into focus why we went into medicine in the first place, which was to help others, to heal the sick, and

to do the very best we can,” Dr. Bailey replied. “But you reach a certain point where you are running on fumes and you’re not sure how much you have left to give.” In addition, physicians are at risk for developing COVID-19 and becoming ill themselves, she added. Learn more about why doctors’ big COVID-19 worry is keeping their families safe. Struggles in the Lone Star State

Dr. Bailey’s home state of Texas is experiencing a surge of COVID-19 patients. She recently discussed this in an “AMA COVID-19 Update” daily video and put out a joint statement with Diana L. Fite, MD, president of the Texas Medical Association, urging their fellow Texans to be safe. “This virus is highly contagious and shows no signs of going away,” Drs. Bailey and Fite said. “Until we have a vaccine, our only option is incredible, unyielding vigilance—wear a mask, exercise safe physical distancing, and wash your hands or use hand sanitizer regularly.” During the Atlantic program, Dr. Bailey referenced what was happening in Texas and how the timing of the surge has acted to further complicate an already highly stressful situation. “Our surge occurred around the first of July, at the start of a new academic year, which is always a time of stress and challenge,” Dr. Bailey said. “I’m still very comfortable about the quality of care people are getting, but it’s an extra burden on the system. And I think that we have to be extra aware of the special, psychological as well as physical needs of our health care workforce to help get them through this.” Dr. Bailey’s segment was preceded in the Atlantic program by an interview with Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases. Dr. Fauci, whom Dr. Bailey called one of her heroes, also alluded to the issue of physician burnout during the pandemic. “This is a real challenge,” he said. “This is a major challenge in public health. And it’s something that we really have got to pay attention to.” When asked how he was doing personally, Dr. Fauci assured his interviewer that he was doing fine. “I am running a bit on fumes, but as I say, the fumes are really thick, and it’s enough to keep me going,” he said. Learn more from Dr. Fauci about why the COVID-19 resur-

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gence has come with fewer deaths so far. Deferred services create long-term concern

As some physicians battle a pandemic surge, others are facing economic strife as their patient volume plummeted or they have to cope with a ceaseless struggle to obtain personal protection equipment (PPE) for themselves, their staff and their patients. “It’s an interesting spectrum,” Dr. Bailey said. “Physicians that are hospital-based that are working harder than they’ve ever worked in their lives, and physicians that have either been shut down by their local authorities, or by elective procedures not being done and they don’t have any patients, and they’re struggling to keep the doors open and keep their staff.” Dr. Bailey noted how the AMA is working with physicians to obtain funds from the federal Paycheck Protection Program and other government relief efforts. But, beyond that, patients continue to isolate themselves and some are fearful of returning to their doctor’s office. This has led to a “a pent-up demand of services that have not been done and needs that have not been met,” Dr. Bailey said. This is resulting in women not getting mammograms, children not getting immunizations and patients with diabetes or hypertension not having their chronic conditions properly managed. “We’re very concerned about the long-range implications that that is going to have for the care of chronic health,” Dr. Bailey said. The AMA offers resources to help physicians manage their own mental health and well-being during the COVID-19 pandemic and provides practical strategies for health system leadership to consider in support of their physicians and care teams during COVID-19.

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