The first call in early April was from the testing center, informing the nurse she was positive for COVID-19 and should quarantine for two weeks.
The second call, less than 20 minutes later, was from her employer, as the hospital informed her she could return to her job within two days.
“I slept 20 hours a day,” said the nurse, who works at a hospital in New Jersey’s Hackensack Meridian Health system and spoke on the condition of anonymity because she is fearful of retaliation by her employer. Though she didn’t have a fever, “I was throwing up. I was coughing. I had all the G.I. symptoms you can get,” referring to gastrointestinal COVID symptoms like diarrhea and nausea.
“You’re telling me, because I don’t have a fever, that you think it’s safe for me to go take care of patients?” the nurse said. “And they told me yes.”
Guidance from public health experts has evolved as they have learned more about the coronavirus, but one message has remained consistent: If you feel sick, stay home.
Yet hospitals, clinics and other health care facilities have flouted that simple guidance, pressuring workers who contract COVID-19 to return to work sooner than public health standards suggest it’s safe for them, their colleagues or their patients. Some employers have failed to provide adequate paid leave, if any at all, so employees felt they had to return to work — even with coughs and possibly infectious — rather than forfeit the paycheck they need to feed their families.
Unprepared for the pandemic, many hospitals found themselves short-staffed, struggling to find enough caregivers to treat the onslaught of sick patients. That desperate need dovetailed with a deeply entrenched culture in medicine of “presenteeism.” Front-line health care workers, in particular, follow a brutal ethos of being tough enough to work even when ill under the notion that other “people are sicker,” said Andra Blomkalns, who chairs the emergency medicine department at Stanford University.
In a survey of nearly 1,200 health workers who are members of Health Professionals and Allied Employees Union, roughly a third of those who said they had gotten sick responded that they had to return to work while symptomatic.
That pressure not only stresses hospital employees as they are forced to choose between their paychecks and their health or that of their families. The consequences are starker still: An investigation by KHN and The Guardian has identified at least 875 front-line health workers who have died of COVID-19, likely exposed to the virus at work during the pandemic.
But the dilemma also strains health workers’ sense of professional responsibility, knowing they may become vectors spreading infectious diseases to the patients they’re meant to heal.
A database of COVID-related complaints made to the Occupational Safety and Health Administration this spring hints at the scope of the problem: a primary care facility in Illinois where symptomatic, COVID-positive employees were required to work; a respiratory clinic in North Carolina where COVID-positive employees were told they would be fired if they stayed home; a veterans hospital in Massachusetts where employees were returning to work sick because they weren’t getting paid otherwise.
“What we learned in this pandemic was employees felt disposable,” said Debbie White, a registered nurse and president of the Health Professionals and Allied Employees Union. “Employers didn’t protect them, and they felt like a commodity.”
Indeed, the pressure likely has been even worse than usual during the pandemic because hospitals have lacked backup staffing to deal with high rates of absenteeism caused by a highly infectious and serious virus. Hospitals do not staff for pandemics because in normal times “the cost of maintaining the personnel, the equipment, for something that may never happen” was hard to justify against more certain needs, said Dr. Marsha Rappley, who recently retired as chief executive of the Virginia Commonwealth University Health System in Richmond.
That has left many hospitals scrambling to find skilled staff to tend to waves of patients with COVID-19.
The nurse from Hackensack Meridian, the largest hospital chain in New Jersey, told the hospital’s occupational health and safety office that she could not return to work, citing a doctor’s instructions to isolate herself. No threat to fire her was made, she said.
But in daily calls from work, she was reminded her colleagues were short-staffed and “suffering.”
She also discovered her employer had revoked most of the paid time off she believed she had accumulated.
White said Hackensack Meridian had conducted what it described as a “payroll adjustment” in March and taken leave from many of its employees without explaining its calculations.
A statement provided by a Hackensack Meridian spokesperson, Mary Jo Layton, said the system’s occupational health office “has followed the CDC recommendations as it relates to the evaluation, testing and clearance of team members following infection with COVID-19.”
Hackensack Meridian adjusted some employees’ leave to correct a technical issue that prevented leave from being counted as it was taken, it said, adding workers were provided “an individual PTO reconciliation statement.”
“No team members were shorted any PTO that they rightfully earned,” Hackensack Meridian’s statement said.
Federal officials acknowledge that staffing shortages may require sick health care workers to return to work before they recover from COVID-19. The Centers for Disease Control and Prevention even has strategies for it.
The CDC website lists mitigation options for short-staffed facilities, some of which have been implemented widely, such as canceling elective procedures and offering housing to workers who live with high-risk individuals.
But it acknowledges these strategies may not be enough. When all other options are exhausted, the CDC website says, workers who are suspected or confirmed to have COVID-19 (and “who are well enough to work”) can care for patients who are not severely immunocompromised — first for those who are also confirmed to have COVID-19, then those with suspected cases.
“As a last resort,” the website says, health care workers confirmed to have COVID-19 may provide care to patients who do not have the virus.
Like soldiers on the battlefield, Rappley said, front-line workers have been absorbing the consequences of that lack of preparedness on an institutional and societal level.
“This will leave scars for many generations to come,” she said.
Personal Choice or No Choice?
Shenetta White-Ballard carried an oxygen canister in a backpack at work. A nurse at Legacy Nursing and Rehabilitation of Port Allen in Louisiana, she needed the help to breathe after battling a serious respiratory infection two years earlier.
When COVID-19 began to spread, she showed up for work. Her husband, Eddie Ballard, said his paycheck from Walmart was not enough to support their family.
“She kept bringing up, she gotta pay the bills,” he said.
White-Ballard died May 1 at age 44.
Legacy Nursing and Rehabilitation did not respond to requests for comment.
Ballard said his wife’s employer offered no support for him and their 14-year-old son after her sudden death. “Only thing they said was, ‘Come pick up her last check,’” he said.
Liz Stokes, director of the American Nurses Association’s Center for Ethics and Human Rights, said immunocompromised workers, in particular, have faced difficult decisions during the pandemic — sometimes made more difficult by pressure from employers.
Stokes recounted the experience of a surgical nurse in Washington with Crohn’s disease who took a temporary leave at her doctor’s recommendation but was pressured by her bosses and co-workers to return.
“She really expressed severe guilt because she felt like she was abandoning her duties as a nurse,” she said. “She felt like she was abandoning her colleagues, her patients.”
The Right Thing to Do
Residents, or doctors in training, are among the most vulnerable, as they work on inflexible, tightly packed schedules often assisting in the front-line care of dozens of patients each day.
Not long after one of New York City’s first confirmed COVID-19 patients was admitted to NewYork-Presbyterian Hospital, Lauren Schleimer, a first-year surgical resident, reported she had developed a sore throat and a cough. Because she had not been exposed to that patient, she was told she could keep working and to wear a mask if she was coughing.
Her symptoms subsided. But a couple of weeks later, as cases surged and ventilators grew scarce, she was working in a COVID-only intensive care unit when her symptoms returned, worse than before.
The hospital instructed her to stay home for seven days, as health officials were recommending at the time. She was never tested.
A NewYork-Presbyterian Hospital spokesperson said of its front-line workers: “We have been constantly working to give them the support and resources they need to fight for every life while protecting their own health and safety, in accordance with New York State Department of Health and CDC guidelines.”
Schleimer returned to the ICU symptom-free at the end of her quarantine, caring for patients fighting the same virus she suspects she had. While she never felt that sick, she worried she could infect someone else — an immunocompromised nurse, a doctor whose age put him at risk, a colleague with a new baby at home.
“This was not the kind of thing I would stay home for,” Schleimer said. “But I definitely had some symptoms, and I was just trying to do the right thing.”
Doctors are seeing a rise in people reporting severe mental health difficulties, a group of NHS leaders says.
It follows a more than 30% drop in referrals to mental health services during the peak of the pandemic.
But there are predictions that the recent rise will mean demand actually outstrips pre-coronavirus levels – perhaps by as much as 20%.
The NHS Confederation said those who needed help should come forward.
But the group, which represents health and care leaders, said in a report that mental services required “intensive support and investment” in order to continue to be able to help those who needed it.
The NHS Confederation’s mental health lead, Sean Duggan, said that when coronavirus cases were at their highest, people stayed away from services, as they did from other parts of the NHS.
“A&E numbers were down, GP numbers were down. The same occurred in some of our mental health services,” he said, as people tried to ease the burden on the health service and sought to avoid catching the virus.
“The concern is, if you leave problems they can get worse.”
This may explain some of the rise in more severe cases coming forward.
As well as people whose conditions deteriorated during lockdown, NHS services also expect an increase in demand for mental health services as a direct result of the pandemic itself, the report said.
It flagged isolation, substance use, domestic violence and economic uncertainty as factors that might contribute to the need for extra support.
There are also “particular concerns that the stark inequalities in accessing services and recovery rates that black and minority ethnic communities face will be exacerbated”, the report said.
Mental health providers report that as well as seeing patients with “more significant needs”, a higher proportion of their referrals are patients who are accessing services for the first time.
Meanwhile, providers predict infection control and social-distancing measures will mean they have an estimated 10-30% less capacity than normal.
Mr Duggan said he did not want to “medicalise everything… It’s perfectly normal to feel uneasy and anxious” at such an uncertain time.
But nevertheless, there was a “real” increase in people needing mental health services, he added.
NHS England last week published the next phase of its response to Covid-19, acknowledging that “mental health needs may increase significantly”.
Its plan includes expanding Improving Access to Psychological Therapies (IAPT) services – the route for treating the most common, mild to moderate conditions, into which people can refer themselves.
It also said people being looked after by community mental health teams – generally those with greater needs – should have their care reviewed. People with severe mental illness should receive more therapy and support, it said.
NHS England also pointed to its mental health and wellbeing service launched for all health staff.
Healthcare organizations must become more collaborative with patients, employees, partners and the public when creating digital innovations to have success in the future, according to research from Accenture.
The professional services company released its “Digital Health Technology Vision 2020” report that identified five trends that emerged before the COVID-19 pandemic, but that have only accelerated because of it.
The trends relate to digital patient experience, artificial intelligence, smart devices, robots and innovation.
The pandemic has turned digital technology into a lifeline for many. It has become the way people receive healthcare, get information about the virus, and stay in touch with family and friends. It’s also become the way people entertain themselves during the lockdown.
The survey found that 85% of health executives believe that technology has become an inextricable part of life, and 70% of global consumers expect it to become an even bigger part of their lives in the next three years.
When it comes to the future of patient engagement, 90% of health executives believe organizations need to elevate their relationships with customers and partners if they hope to compete.
“People today expect more from their digital experiences,” the authors wrote in the report. “They want to feel important and as if the healthcare organization recognizes and takes notice of them. Gone are the days of mass services and black box personalization.”
The report says that organizations can set themselves up for future success by customizing the consumer experience and by giving consumers agency over their health decisions.
The future of AI is already in the works, with 69% of healthcare organizations saying they are piloting or adopting it. They can use AI by plugging it into existing workflows to automate processes, to screen and triage patients using chatbots, and to reconfigure supply chains, among other things.
To be successful when it comes to AI, healthcare organizations must work with AI, instead of simply automating the workflow, according to the report. This collaboration can be done through advancements in natural language processing to help people and machines better work together.
“Providers and payers that facilitate human-machine collaboration today will be able to reimagine every aspect of their organization, from the way they care for patients to the way they hire and train employees,” the report says. “True pioneers will use these capabilities to reinvent care delivery.”
Smart devices have become a more prominent presence as people invite them into their lives to help fight the COVID-19 virus and to share health data with their doctors. However, the study argues, while people do benefit from technology, people are concerned about how their data is used. Seventy percent of healthcare consumers surveyed said they are concerned about data privacy and commercial tracking associated with their online activities, behaviors, location and interests.
To combat that concern, the report suggests that healthcare organizations must ensure that their operating models are equipped to handle the ownership of consumer data. It also says that innovators must get comfortable releasing products that may seem unfinished at the time with the intention of transforming over time.
COVID-19 has moved robots out of the warehouse and into the healthcare system, according to the report. More than 70% of health executives said that robotics will enable the next generation of services in the physical world.
With the growing number of robots in the health sector, the report says that organizations must integrate them into the workforce in a way that produces trust with existing staff. The report found that 54% of health executives say their employees will be challenged to figure out how to work with robots.
“A proper introduction matters when it comes to bringing robots into healthcare settings,” the report says. “Gauge the sentiment, attitudes and fears of employees and consumers alike – and adapt accordingly.”
With 78% of the healthcare executives saying they believe that the stakes for innovation have never been higher, the report notes that “getting it right” will require new ways of innovating with ecosystem partners and third-party organizations.
“COVID-19 has not slowed digital technology innovation; rather, it’s amplifying it to historic levels,” said Dr. Kaveh Safavi, a senior managing director in Accenture’s Health practice and an author of the report, in a statement. “Given the current environment, healthcare organizations must elevate their technology agenda to explore emerging digital technologies that provide the right infrastructure to help people feel safer about using technology tools for their healthcare experience.”
HOW IT WAS DONE
This report was derived from Accenture’s annual Tech Vision 2020 report, which predicts trends likely to disrupt business in the near future.
The research team gathered input from Technology Vision External Advisory Board and conducted interviews with industry experts. It also conducted an online survey of over 6,000 business and IT executives from 25 different countries. The survey took responses from November 2019 to January 2020.
At the same time, the company surveyed 2,000 people in the U.S., U.K., China and India, with respondents representing different age and demographic groups, to understand the use and role of technology in people’s lives.
THE LARGER TREND
The idea that the technological innovations that came out of the COVID-19 pandemic are here to stay is not new.
Over the course of the pandemic, technology has been adapted to track, test and treat the virus. New advancements in digital therapeutics, online training, at-home testing and more have come onto the market recently.
ON THE RECORD
“The intersection between digital technology and healthcare experiences has certainly accelerated with the COVID-19 pandemic, and leading the future of care will demand rethinking core assumptions about the intersection of people and technology,” Safavi said. “People’s perceptions of and relationships with technology are changing, and to adapt, healthcare payers and providers need to redesign digital experiences.”
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The top doctor advising Starr County on local health policy resigned abruptly Monday, leaving a key position temporarily vacant in a rural border community already battered by the coronavirus.
Dr. Jose Vazquez resigned from his position as health authority after members of the commissioners court rejected increasing his pay from $500 a month to $10,000, according to a press release from the county and County Judge Eloy Vera.
Vera, who brought the pay increase to the commissioners, said the contract would last only as long as Vazquez’s services were needed and had a termination clause that let either party cancel it. It also would have been paid with federal CARES Act funding.
Vazquez has “been working tirelessly for the county for the last six, seven months getting just a token amount for the last six, seven years,” Vera said. “Since COVID started, he has been putting in at least 60 to 70 hours a week… It was only fair that he be compensated for that.”
Vazquez, who is also board president of the county’s only hospital, could not be immediately reached for comment.
Local health authorities provide guidance to city and county officials on how to manage the coronavirus, often play a role in addressing the public at press conferences or hearings and can make recommendations about school closures, in the event of an outbreak.
A press release from the county thanked Vazquez for his “outstanding service” and said the appointment of a new health authority “should be forthcoming.”
County Commissioner Eloy Garza rejected the proposal because he thought it cost too much. He said another doctor, Antonio Falcon, had agreed to serve in the position for free and that the commissioners court was expected to formalize the arrangement Friday.
“I got a call from Dr. Falcon and he told me he was willing to do it free of charge,” he said.
Vera said he asked Falcon to start immediately providing him with guidance on medical decisions in an informal capacity.
“I cannot wait until Friday,” he said. “I’m an engineer by trade, know nothing about medicine. So I need a doctor to help me with that sort of thing.”
The other three commissioners could not be immediately reached for comment.
Starr County, population 65,000, is one of the poorest counties in the country. Its residents are more than 95% Hispanic, a demographic that’s been disproportionately affected by the virus. About a third of the county’s population under age 65 lack health insurance.
As the virus has hammered south Texas, workers at the county’s small hospital, which had no intensive care unit, have flown patients hundreds of miles away for treatment. Hospital leaders discussed forming an ethics committee to wrestle with decisions about which patients should go home to die with family and which should be transported elsewhere for care.
Vazquez said in July that “the time of rationing medical care is a time that we all have feared from the beginning but it looks like we are getting to that point now.”
Officials in Starr and other South Texas counties were initially successful in forestalling the spread of the virus. But infections surged in June about a month after Gov. Greg Abbott allowed businesses to begin reopening and overrode local authorities’ ability to take a more cautious approach. Graduations and summer holidays that brought a series of occasions to gather likely exacerbated the spread.
Starr County has had 68 confirmed coronavirus deaths and 2,213 cases as of Monday, according to state data.
Vazquez is not the first health official to leave during the pandemic. The leader of San Antonio’s health department stepped down over the summer saying it was time for a “person of color to lead.” The San Antonio Express-News reported her boss sent an internal memo harshly criticizing her abilities the day before.
Across the country, dozens of state and local public health leaders have resigned or been fired since April, reflecting burnout, hostility toward public health experts and the politics of the moment, according to a review by the Kaiser Health News service and The Associated Press.
California’s public health chief resigned late Sunday, days after officials revealed a backlog of hundreds of thousands of coronavirus records that Gov. Gavin Newsom said Monday were never reported to his administration.
Pressed during a news conference about the abrupt resignation of Dr. Sonia Angell, the former director of the state Department of Public Health, Newsom declined to say if he asked her to quit.
“We’re all accountable in our respective roles for what happens underneath us,” he said. “I don’t want to air any more than that. But if it’s not obvious then, well, I encourage you to consider the fact that we accepted the resignation.”
In her letter, Angell, who was hired less than a year ago, did not say why she was resigning effective immediately, according to NBC Bay Area, which obtained the letter.
But last week, California Health and Human Services Secretary Dr. Mark Ghaly disclosed that as many 300,000 records hadn’t been processed, leaving county health officials without data on the virus’ transmission.
The revelations came as Newsom said that coronavirus cases in the state appeared to be trending down. California, the most populous state in the country, topped New York last month with the highest number of reported cases in the United States.
Ghaly attributed the problem to a computer server outage late last month and a failure to renew a certificate for Quest Diagnostics, a commercial lab that tests for coronavirus. He said that Newsom had a ordered a full investigation into the incident.
Ghaly said Monday that the backlog was processed over the weekend and would be available to counties in the coming days.
Newsom said he was confident those cases wouldn’t alter the virus’ downward trajectory statewide. Hospitalizations were down 19 percent over a two-week period, while intensive care unit admissions were down five percent, he said.
Sixty-six people died Sunday, he said. The average daily death count remained at 137.
Angell’s resignation comes amid resignations and terminations of public health officials across the United States. A review by the Associated Press and Kaiser Health News found that 49 officials in 23 states have been fired or quit since April.
The review attributed many departures to conflicts over mask orders and shutdowns. Others quit for family reasons or because they said they were overworked and underpaid.
Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials, told the AP that state and city officials could scarcely “afford to hit the pause button and say, ‘We’re going to change the leadership around here and we’ll get back to you after we hire somebody.’”
Among the officials to step down was New York City health commissioner Dr. Oxiris Barbot, who resigned last week after her department’s role was diminished in the administration of Mayor Bill de Blasio, according to NBC New York. Earlier this year, she had a much-publicized “argument” with a top New York Police Department official over personal protective equipment, according to the station.
In a resignation letter, Barbot did not say why she quit, but the chairman of the city council’s health committee, Mark Levine, called her departure a “grave blow to the fight for public health here.”
Associated Press contributed.
The NHS test and trace system in England is cutting 6,000 staff by the end of August, the government has announced.
The remaining contact tracers will work alongside local public health teams to reach more infected people and their contacts in communities.
It comes after criticism that the national system was not tapping into local knowledge.
The approach has been used in virus hotspots like Blackburn and Luton.
And it’s now being offered to all councils that are responsible for public health in their area.
Test and trace is staffed by NHS clinicians and people who were trained to become contact tracers during the pandemic.
NHS staff who offer advice to people who have tested positive for coronavirus will not be laid off.
But the national service will shrink from 18,000 contact tracers to 12,000 with the remaining non-NHS call handlers redeployed as part of dedicated local test and trace teams, the Department of Health says.
This means local areas will have “ring-fenced teams” from the national test and trace service.
Another 200 walk-in testing centres will also open by October.
As part of NHS Test and Trace, public health teams dealing with outbreaks in factories or care homes have consistently reached more than 90% of the contacts on their lists.
Outside of those very localised outbreaks, it is call centres who trace contacts.
But they don’t reach as many contacts – their success rate for reaching contacts who don’t live together peaked at just over 70% in the middle of July, but has fallen since then.
A return to old-fashioned contact tracing?
In May, the Health Secretary, Matt Hancock, announced that an “army” of contact tracers would be recruited for the NHS Test and Trace service.
Early on, there were reports that new recruits were sitting idle – with one telling the BBC that she spent her time watching Netflix.
Thousands are now being stood down in England with more of their work conducted by local staff with knowledge of their area. The Department of Health has said that this is to provide a “more tailored approach”.
But critics will see it as the latest example of the government departing from its centralised approach to tackling the outbreak. In June the government had to postpone its idea of using a national app to identify potentially infected people – because it didn’t work.
Now, the top-down, high-tech strategy for contact tracing is making way for what seasoned local public health officials describe as old-fashioned “shoe leather epidemiology”.
This relies on people with local knowledge collecting information by going door-to-door on foot.
Dido Harding, the head of NHS Test and Trace, said: “We have always been clear that NHS Test and Trace must be local by default and that we do not operate alone – we work with and through partners across the country.
“As we learn more about the spread of the disease, we are able to move to our planned next step and become even more effective in tackling the virus.
“After successful trials in a small number of local areas, I am very pleased to announce that we are now offering this integrated localised approach to all local authorities to ensure we can reach more people in their communities and stop the spread of Covid-19,” she said.