This is a pretty loaded topic. Breaking this one up into several parts. In this post I’m addressing limitations to medical accessibility, such as uninsured rates, caregiving, and religious exemption from government advised or required disease control practices, such as social distancing. Let’s talk about human behavior and how that may impact the vulnerability of your location in the United States to coronavirus.
Accessibility, Uninsured Rates, and Alternative Medicine
There are many reasons Americans are uninsured. Being uninsured will ultimately lead to limited access to healthcare. Due to decisions that were made regarding how to implement mandated healthcare, the poor were punished for not being able to afford exorbitantly priced healthcare. I don’t care who you blame for it not working. Point is, it didn’t, and now we’re sunk. You may notice a similarity between the map above and the maps in my previous post on the closure of rural hospitals and poverty. Texas and Oklahoma are currently set up to be the two of the hardest hit states by coronavirus because these are uninsured populationsthat feel they cannot seek already-limited healthcare (because hospitals closed). This means that they turn to alternative medicine at home and don’t call a doctor due to the cost. Alternative medicine, though potentially complementary (waiting on research), doesn’t involve providing ventilators to people drowning from their own viral lung inflammation. Alternative medicine doesn’t necessarily involve reporting confirmed cases to the state, either.
Luckily, telemedicine is slowly stepping up the game at reducing costs and improving accessibility, but until we have Point of Care testing that allows for mass screening that could be distributed to a population via the health department – good luck. The FDA still strictly prohibits self administered tests. This is one of the major outstanding limitations preventing telemedicine from serving our most underserved and vulnerable populations in the United States during this pandemic.
Religious exemptions for medical care are a real thing. I know there are people reading this that are going to think, “but no one in their right mind is thinking that now!”
Oh honey, I wish I could say that was so. Let me first introduce you to What’s The Harm. Even without coronavirus, people are and will be dying due to lack of access to medical care in part because their families opt out via religious exemptions. When this is combined with alternative methods gone wrong and cultural factors, the vulnerability of this population is amplified by pre-existing public health issues.
When we care for the sick at home, a variety of other factors come into play that may delay or prevent access to medical intervention or reporting. Cultural norms around illness, including distrust of the medical system, preference for home care, and family caregiving will play their roles in the spread of COVID-19.
This means that children and older family members that do have symptoms may not have access to medical intervention, documentation, advice, or have sufficient care or separation from family members. While these deep-rooted beliefs come from a nurturing and caring place of love, it is important that cases at least be documented. These practices currently put families and communities at high risk of having the virus spread within them. While we do have recommendations for caregivers and home care instructions for coronavirus patients, they are not practical options, nor sufficient for the average family in America.
In Part 2 – Home Burials and Funeral Industry
Thank you to anyone reading these commentaries and predictions. Without you I would be shouting into a void.
Let’s talk about poverty and how it plays a role in pandemics (specifically covid-19 and the current state of things in the US).
First, to get this out of the way ,
Poverty does not mean someone is… dirty diseased uneducated deserving of their position being punished has made mistakes is suffering consequences or any of that B.S.
Now that that’s out of the way. Let’s move on.
Impoverished areas tend to have worse health care with low availability than areas of higher average income. And it has only gotten worse over the past 4 years. This means that in these areas everyone is of a much higher risk category when it comes to having community impact from covid-19. There are a couple factors playing into this, but let’s start with the accessibility question.
Closure of Rural Hospitals
Rural hospitals often serve impoverished areas. Because healthcare in the United States is privatized it is not secure. Based on whether or not a larger medical network parent hospital corporation thinks a hospital is profitable, a hospital can be closed down. This is not a new problem. It’s been going on for the past decade, quietly, while everyone else focused on all of the other aspects of healthcare. Except for rural communities where we banded together and started figuring out Ag worker clinics and other ways to cover vitals needs. But guess what: that can’t do crap against the coronavirus.
Since coronavirus entered the United States, West Virginia saw the closure of Fairmont Regional Medical Center at the hands of California owned Alecto Healthcare Services. Other hospitals across the United States are closing and laying off workers to reduce costs and shift resources within these greater hospital networks, like Alecto Healthcare Services. This reduces the resources available to impoverished or communities that might not make these networks as much money. Another example is Missoula, Montana where Western Montana Clinic laid employees ahead coronavirus in a similar way.
All of the areas where these hospitals once were are at much higher risk of having their remaining healthcare systems overwhelmed.
Under the Trump economy, hospitals have suffered immensely as measured by the Polsinelli TrBK Health Care Services Distress Index (tracks bankruptcy filings in health-care). Not only has this president set our healthcare system up to fail during his entire time in office, he is now trying to deny all responsibility. I don’t identify with a political party in the United States, but seriously.
Essential employees include delivery drivers, manufacturing employees, gas station workers, grocery store check out clerks, health care workers, government workers, and all of these low-paid minimum wage jobs. Who makes minimum wage?
Many of the essential employees that are still going to work are the same ones making minimum wage. They are also the ones living in low income areas where healthcare is suboptimal, easily overwhelmed, and is far away. Assuming they can afford it at all.
Notice something that will make your heart break? Where did all of the hospitals close?
Update: as of 31 March 2020
I’m not a religious person, but I ask if you read this to pray for those communities. This is where flattening the curve is both most important and least likely to happen. For further reading on how the US is doing with that check out this post here.
Happy to update this and answer questions, plus dress this up with additional research.
Thank you for reading – without you these would just be shouts into the ether.
How do you describe that feeling of watching numbers climb and realizing that you’re watching in real time the most global example of what you’ve studied and taught your entire adult life?
Dread? Excitement? Existence?
When teaching about pandemics we teach students to look retrospectively at the numbers of those that have recovered versus those that have died. We make estimates on the numbers of those that were actually infected based on documentation available (or more recently – on documented confirmation). At about 6:00PM on 27 March 2020 twice as many people had died of covid-19 in the United States as have recovered. Seeing those numbers broke my heart for a moment, so I had to talk it out to myself somewhere.
It’s too early to call what it will look like in the United States in terms of our final numbers with covid-19. At this time these numbers are skewed by post-mortem testing and testing criteria that limits test accessibility to those already in need of medical intervention over home care.
Things might look scary, but don’t give up hope. Update 30 March 2020: and reporting started coming in of recoveries! Part of why this reporting may have been delayed is due to stringent testing criteria.
The reason for this standard is that there is a very high false negative rate with the rt-PCR based test. If anything goes wrong along the way – say there’s a bad reagent, too low of a sample of viral particles, or something goes wrong that invalidates the test it will come back negative. This is the bane of every graduate student that has ever done rt-PCR. They will tell you their horror stories, especially if they were from poorly funded labs.
For some additional hope.
There’s this amazing power of graphs. We can look at growth of reported cases overtime to project the number of cumulative reported cases in the United States in the future.
Even as we have expanded albeit limited testing across the United States the overall rate of growth of total cumulative cases is slowing. While this hope is based on very limited data, could it be that we may actually be flattening the curve?
We’re able to see the slope change as the day to day numbers change. Thus, we can see when our efforts are working. (See below)
This is part of why we need accurate reporting above anything else. The numbers that only require home care matter. In order to accurately understanding the danger of a disease we have to know how many people have it and are acting as asymptomatic or low symptomatic carriers. This influences anticipatory healthcare planning decisions for patients and facilities. I will address this a bit more later in regards to the limitations of cultural understanding around death, dying, and disease.
We can be hopeful. As of 30 March 2020 we were set to diagnose our 500,000th case on 4 April, 2020. Flattening the curve is succeeding in different parts of the country. I will be addressing this in a new post. As a brief update as of 12:01AM 1 April, 2020, we have moved that projection out to 5 April, 2020. My model is limited by not knowing what the current daily max testing capacity of the United States is yet.
Update 5 April 2020:
Hey, look! We didn’t hit 500,000 cases. That’s incredibly comforting and is a fantastic sign. That said, we still have a backlog of COVID-19 tests, an untested positive population acting as a reservoir to continue infecting our healthy population, and we have no control over this. At this point, it is believed that SARS-CoV-2 will become a seasonal illness in the United States.
Remember how I said before that the 500,000th case had been pushed out to 5th April? Now, that’s 6th April, 2020 if only looking at the cumulative cases since the 15,000th case in the United States. What if we look at since 23 March? On this day we had approximately 46,000 confirmed cases, with the next day climbing to 55,000 confirmed cases. This is the date we should look at to consider since 50,000 cases reported.
It’s not changing. There’s enough growth in of confirmed cases in parts of the country that any flattening is being overwhelmed right now. America’s current check up isn’t doing so hot.
It’s not the fault of our healthcare workers and everyone needs to show gratitude. The United States is facing extreme PPE shortages, resulting in healthcare workers being put at risk for infection and at risk for being vectors of covid-19. Hospital acquired infections have long been a problem in the US due to poor hygiene practices among staff and invasive devices used in hospital settings such as catheters, PICC lines, and IVs. While this has been combatted over recent years by the installation of improved educational programs and the implementation of disease control specialist positions in hospitals and clinics, these measures are useless without sufficient PPE. Washing hands and hand sanitization does only so much. We dedicate a lot of research time and money to this topic.
Diagnostic Testing Has Barriers
Point of Care rapid testing is a luxury afforded us over the past ten years (and toward the end of the 20th century) for strep throat, influenza, drug screenings, and other common “ailments” that bring you in to say hello to someone like me (only using quotes because I included drug screenings). The fact that we have this soon to be available for the coronavirus at all is incredible. Not only will this help with disease surveillance, but we have the ability to accurately study a pandemic in real time on a scale like never before. We could have the ability to intervene and institute true quarantine measures assuming we roll out extensive Point of Care screening for everyone.
But until then, can I even trust this data?
Rituals Around Disease, Death & Dying Complicate Things
How many people are dying at home untested? Remember that across America we have incredibly diverse customs about death and dying.
I recently spoke with friends in New York City and she mentioned that she knew members of certain cultural communities that though they were symptomatic were not getting tested. Part of why this happens is because of cultural beliefs around illness and dying. It’s going to be scary and everyone is reacting in ways that may deter them from getting tested. This will limit our surveillance and will also result in transmission within communities.
In the American South (where I’m from) families conduct home hospice even during severe illness out of pride and the cost of healthcare. Once the family member has died they will contact the local mortician. While it might no longer be legal to do home embalming and many states have prevented home burials, this has never stopped families from caring for the dead. Caring for the ones we love as a final act is one of the most essential acts as a family member that is often robbed of Americans elsewhere across the United States. In twenty to fifty years will we need to do go all paleovirology/anthrovirology (actual fields!) on disinterred bodies to get the actual numbers? Or will we go the route of China with incinerating covid-19 presumed bodies without testing? Will we go the route of the US during 1918? Will we burn it all?
Another thing to consider with any pandemic is how the rituals around death in the home contribute to the spread of a disease. This paper regarding the Ebola pandemic addresses why it is important to understand how we culturally handle death in times of pandemic in order to appropriately control spread.
Future Questions We Will Hopefully Answer:
As we look into ways to protect our healthcare workers with limited PPE we should be reminded that there are other ways we control the spread of disease.
Are healthcare workers on PReP faring better?
Many of the antivirals in PReP and PeP are being tested in the treatment of covid-19. Healthcare workers in Emergency Medicine have recently started turning to PReP and PeP to prevent the spread of HIV as a result of blood born pathogen exposure. Are these healthcare workers faring better than those not on PReP? Only time will tell since the number of workers on PReP reporting is still rather low.
What percent of the population needs to participate in social distancing in order to flatten the curve?
There’s isn’t actually an exact percent. What’s critical is that those at highest risk of being effective vectors for covid-19 during the transmission period of infection while shedding virus are able to infect as few other people as possible. This is a complicated question I’ve broken down into a couple parts.
Who actually needs to be on a stay-at-home order / essential workers only order for us to flatten the curve?
On the U.S. Census map above population density is shown in dark areas.Are you in that darker half? Stay. The 🦆 Home unless you are an essential worker.
Are you NOT in the darker half?Then you should be worried if you hear that there’s community transmission in your county. At that point practice social-distancing.
But you’re not out of the woods yet my friends. I have some more criteria for you:
How far away does your closest neighbor live? If you live in an apartment building – you should stay home. Live out in the country? Congratulations you lucky son of a gun! We’ve shown those city slickers that living in the underserved parts of America with crappy, dying economies that have been sputtering out and suffering at the hands of a global economy and evil corporations ain’t so bad, now is it? Or is it.
How far away is the closest interstate, highway, airport, train station, and other means of connection?Ever go to the gas station close to those things? May want to rethink that. Those are going to be your highest risk areas.
There’s a certain percentage of the population that can’t participate in the Stay at Home orders. It’s not their faults and they should be treated with the utmost kindness. They are taking huge risks. If you are a member of this population there are ways to assess how high risk your workplace is (if you’re interested). The actions of everyone else helps to make up for that by creating distance and reducing the number of people available for transmission at all. I know that’s a little messed up, but that is part of the theory behind it.
What is the median age of your area? Serious question though. Also, how old are you? Yes, this disease is affecting young people and those with conditions that make them more vulnerable. But I want you think about what kind of threat you are posing to the other people in your area by being a vector. If you live in a dark blue area, even if there hasn’t been a reported case in your county yet – staying home or social distancing is protecting this vulnerable population. You don’t want to have helped transmit the first.
(Update 5 April 2020) What Is Your Social Distancing Score?
You have thought about population density. You have thought about your median age group and how that plays into susceptibility of your area. The actions of those around you also put you at risk. In the flattening the curve check ups on New York, Pennsylvania, and New Jersey I talk about how important social distancing is right now and how big of an impact it is going to have on what we see in the future, such as the one vs. two peaks in New Jersey. But remember that not everywhere can social distance. Pay attention to the areas graded “F” as we address poverty below and in this post here.
Do you live in a multigenerational household or live close by to family? Do you see them often?
You absolutely need to be trying to stay home. These stay at home orders are critical to you. Illnesses like this can spread through families like wildfire. We love our families, right? Keep our families safe. If you are an essential business employee, it is even more important that you protect your family and isolate from them if possible. In many cases there is caregiving. This is addressed more in this post.
Do you live in an area that is severely impoverished?
Disease outbreaks are worse in areas where poverty is not appropriately addressed. If you live in an area like this, you need to take stay at home orders seriously and the problem is, you can’t. And it’s not your fault. Our government and humanity are failing you.
What is determined to be essential and how do they determine whatpercentage of the workforce can be considered essential?
Oh. See, here’s the fun part. They don’t. They think of essential services, not the total number of employees this prevents from participating in social distancing. The state governments will figure out why this is really really dumb pretty fast, especially since many are now seeing hiring booms in those fields (like gas stations and weed delivery). I’m not an economist or a business person. People need to eat. This will be a strain on efforts that has to be monitored.
If people are interested in hearing me rant about the topics I’m actually an “expert” (by degrees and academic research/teaching background only) in let me know. If you are I’ll actually go back and edit this rant and dress it up a bit.
Thank you to anyone reading this. Without you this is just a shout into the ether.
I didn’t mean to time the release of a story related to waking up in a hospital with a pandemic. Today is Day 17 of a fever of ~100-101 F (37.7 – 38.3 C). I have ice on the back of my neck as I write this. There will be a delay in the release of part 2.
It’s all surreal, right?
I grew up among hardy people that believed in staying put when the hurricane came and destroyed the town (this literally happened and I was out of school for 2-3 months in high school while we rebuilt the town). One of the places I lived was almost wiped off the map by the 1918 Influenza pandemic. Entire families died – their bodies buried in mass graves next to their homes by the brave neighbors who ventured into the houses later. The houses and all of their belongings were either burned or were left to rot until us, curious, mischievous rural kids with nothing better to do broke in and wandered around those unwired houses like the generations and generations of kids before us. Look but don’t touch. The objects are cursed and haunted by the disease. Even then the belief was that the ghost of the disease persisted and could kill.
On that note, stay tuned for a short story exclusively posted here since I’m taking a week off. Don’t expect it to be edited well because, frankly, I feel like s***.
Take care and I hope everyone is staying well. As always, thank you for reading. Without you I’m writing words into a void.
Check out this thing called the Waffle House Index – it’s used by FEMA to determine how bad a natural disaster is in the United States based on the number of Waffle Houses still open in an area. I’m not joking. It’s a real thing. Waffle House is historically known for being open 24/7/365 and has called itself a “trucker shelter” during inclement weather.