James Allen Smith was only supposed to be at a Texas prison for a matter of months, sentenced to a drug and alcohol rehabilitation program after he pled guilty to a repeat DWI offense in January.
But in May, while in a Huntsville prison where Texas Department of Criminal Justice officials halted almost all movement as inmates and employees fell ill with the new coronavirus, the 73-year-old retired teacher from Bastrop also contracted the virus that causes the COVID-19 disease. Instead of coming home to his family after completing a short program, Smith died in prison custody on June 11.
We never thought this would happen, Lani Davis, Smiths 26-year-old granddaughter, told The Texas Tribune last week, shock still evident in her voice. He was going to get out, he was being fine. He was only sentenced to six months.
At least 84 Texas state prisoners have died after catching the new coronavirus, according to TDCJ reports. The death toll, which the agencys leader called unprecedented, is the second highest among state prison systems. Those who have died include men serving life sentences, a man who was days away from his release date, and others, like Smith, who were only supposed to be locked up for a short time.
For months, advocates in Texas and across the country have pushed for the early release of some vulnerable prisoners such as those with underlying health problems as lockups became hotspots for the new coronavirus that has killed more than 2,600 people in the state. They argued that a smaller prison population would make it easier for inmates to socially distance and also better protect prison employees who can spread the virus to their families and communities.
But while some states have moved to release more parole-eligible prisoners or those nearing the end of their sentences, Texas practices have gone unchanged.
The spread of COVID in the prison system has shown that a period of incarceration for a number of people has turned into a death sentence, said Peter Steffensen, a staff attorney with the Texas Civil Rights Project. That doesnt change the fact that the parole board and the governor are both empowered to take a number of different steps that they could have and should have months ago.
Nearly 9,500 of about 131,000 people in Texas state prisons have tested positive for the coronavirus, according to TDCJ reports. Though the number of confirmed active cases went down in recent weeks, the agency continues to report more deaths.
At least 10 people who work in Texas prisons have also died after contracting the virus, the agency has reported. More than 1,700 TDCJ employees were confirmed to have the virus.
TDCJ has been criticized for its handling of the pandemic by prisoner rights advocates, family members, and inmates both in letters and a federal lawsuit. But early prison release decisions in Texas fall to the Texas Board of Pardons and Paroles, whose members are appointed by the governor. As the pandemic began taking hold in Texas earlier this year, both the board and Gov. Greg Abbott rejected the idea of early prison releases, with Abbott tweeting in March that releasing dangerous criminals in the streets is not the solution. A spokesperson did not respond to questions about whether the governor has changed his stance.
Abbotts decision was supported by some Texas law enforcement officials, who feared more prison and jail releases could lead to more crime while the state is already in a public health crisis. On Wednesday, the parole board reaffirmed that there have been no changes to the manner in which the [board] renders parole decisions.
The state prison population did drop, however, because intake of new inmates from county jails was halted in April. On Wednesday, TDCJ again began accepting newly sentenced inmates on a limited basis after significant consideration and planning, a spokesperson said. That includes people who, like Smith, have been waiting in a local jail to be sent to a TDCJ rehabilitation program.
After entering the state prison system, Smith landed at the Estelle Unit in Huntsville for his rehab program shortly before the coronavirus shut down prison visitation and intake from jails.
Even after the virus was confirmed on his unit and his movement was restricted, he still wrote frequent letters and called his family on Saturdays. But in early May, the letters abruptly stopped, and one of his three daughters, Jami Smith Hanchey, later noticed her letters to him were returned undelivered.
Neither she nor her sister, who was Smiths emergency contact, were told anything about his condition. But when she looked on the online inmate database in late May, Hanchey saw that her father had been transferred to the prison hospital in Galveston.
The sisters desperately and unsuccessfully tried to get information on their father. Finally, in early June, a prison supervisor called Hanchey to tell her Smith had a stroke but was OK and back at the Estelle Unit.
Within one week, hes died, Hanchey, 45, said. I dont even know what from yet. Maybe another stroke? Maybe COVID?
TDCJ spokesperson Jeremy Desel said Thursday that Smith first tested positive for the coronavirus on May 7 at Estelle and was moved to isolation. Desel said Smith was in the hospital from May 23 to June 5 for a non-COVID ailment, though he again tested positive for the virus while there. He was sent back to Estelle still actively infected with the virus, and six days later he was sent to a Huntsville hospital and died after going into cardiac arrest, Desel said.
TDCJ lists the deaths of 84 men who have died in its custody as presumed COVID-19 deaths. The presumptions are largely based on initial autopsy reports and medical investigations, and the cause of dozens of additional inmate deaths are still being investigated as potentially COVID-related. Desel said in some cases, though an inmate tested positive for the coronavirus, it is clear it had absolutely nothing to do with their death.
TDCJ notes on its list of presumed COVID-19 deaths that Smith had pre-existing conditions Hanchey said he was on medication for a heart condition. But the agency said Smiths preliminary autopsy results indicate COVID-19 was a contributing cause in his death.
Of the inmates with COVID-19 who died, Smith was supposed to spend the shortest amount of time in prison. But four others were serving sentences of five or fewer years.
Gerald Barragan, 62, was serving five years after being convicted of possessing two small bags of cocaine in Kendall County, according to court documents.
Another 62-year-old, Joe Channel, was given a three-year sentence in Nacogdoches County for jumping bail on a since-dismissed charge of drug possession.
David Uhrich, 60, had three years left on a five-year sentence out of Travis County on a drug dealing charge.
And 28-year-old Nicolas Andres Sanchez was sent to prison for three years after his probation was revoked for failing to report to his probation officer on a Dallas County domestic violence charge.
Of those serving longer sentences, 10 prisoners who had COVID-19 when they died had five years or fewer left to serve. One man, 54-year-old Alfredo De La Vega, died on May 5 with 12 days left on a 20-year sentence for aggravated sexual assault.
In late March, when only a handful of TDCJ prisoners were known to be infected with the virus, inmates at a geriatric unit sued the agency for its handling of the pandemic. They argued for more protective measures like face masks and hand sanitizer.
But at hearings in early April, the federal judge overseeing the lawsuit kept coming back to a potentially simpler solution for the older, sick men that largely comprised the units population.
Would it be difficult for the prison authorities to make an early cut? To say, if people have all these characteristics: they are of compromised health, they are over the age of 65, they have served at least 75% of their sentence, and they have a habitat to go to, would it be hard to make that cut? U.S. District Judge Keith Ellison in Houston asked in the teleconference hearing.
After some silence and noncommittal answers, agency representatives eventually told the judge that its not possible for TDCJ to decide that. Release decisions come from the parole board, and though there are mechanisms in place for the board to release more people for medical reasons, it is not being used on a large scale, according to board reports.
The board can approve early parole review and release for prisoners who are mentally ill, disabled, terminally ill, or require long-term care under medically recommended intensive supervision. But the program is rarely used. Last year, 76 inmates fewer than 3% of those referred to the board were approved for such release, according to a board report.
This year, 22 people were approved for early medical release between March and June, according to the board spokesperson.
The only thing holding [the parole board] back is themselves, said Steffenson, the Texas Civil Rights Project attorney. Weve seen dozens of people die and the expectation is that there are many more to come, and thats a shame.
Prisoner rights advocates have also called on the board to quickly release men and women who the parole board have already approved for release. In May, thousands of inmates had been approved for parole pending completion of education or rehabilitation programs but because those programs had largely come to a standstill due to the virus, the inmates remained locked up.
Advocates and family members asked the governor and the board to let such inmates complete those programs outside prison walls, but those requests went unanswered.
Corrections departments, parole boards, judges and governors in numerous other states have released prisoners early during the pandemic. By May, Wisconsin released more than 1,400 people who were being held for probation or parole violations, while the governors of Kentucky and Oklahoma commuted hundreds of prisoners sentences. Multiple other states, including California and Ohio, approved the release of some inmates who had only months left on their sentences.
In Texas, Smiths family said the system failed him turning his six-month program into a death sentence. Since he wasnt sentenced to prison, only the in-prison program, Hanchey feels Bastrop County and TDCJ both let her father slip through the cracks.
He just felt like it was going to be like six months, get this over with, Hanchey said.
Seattle Mariners players are gearing up for the start of a shortened regular season. At their home ballpark, summer training is underway this week with strict coronavirus restrictions. Tom Goldman/NPR hide caption
Seattle Mariners players are gearing up for the start of a shortened regular season. At their home ballpark, summer training is underway this week with strict coronavirus restrictions.
Not long ago, a Major League Baseball season seemed improbable, with owners and players fighting about how to restart in the middle of a pandemic.
Now, the fighting is over, at least publicly.
And the Majors are a little more than two weeks away from playing ball. If all goes well.
Until then, teams are holding summer camps around the country, where players are quickly sharpening their baseball skills and adjusting to a slew of coronavirus safety measures.
Forget languid
When baseball shut down in March, it interrupted the languid days of spring training. Picture fans lounging on blankets, under the Florida and Arizona sun.
Now, with the summer version of spring training underway, forget languid.
There are no fans. And if you want to cover it as a reporter, you first have to get past people like Tyler King.
"In the past 72 hours, have you experienced any of the following symptoms?" King asked a journalist this week at a booth outside T-Mobile Park, home to Major League Baseball's Seattle Mariners. King was wearing a face shield and holding a clipboard. He works for Amphibious Medics, a company the Mariners contracted to do COVID-19 screening.
"Alright, we'll get your temperature here," King said as he reached for the visitor's forehead. "98.0 he's good for a wristband."
Then, after signing a waiver protecting the Mariners from COVID liability, it's time to head to the press box and a welcome sight.
Baseball.
The field's bright green grass is mowed to perfection. The massive video board flashes "Summer Camp 2020." Pitchers pitch. Batters bat. With the press box windows open as a precaution, you can clearly hear the crack of bat on ball, even pick up what players and coaches are saying, albeit muffled by face masks.
This view from above is as close as it gets reporters aren't allowed on the field, in the clubhouse, or anywhere else in the stadium. Player, coach and manager interviews, easily accessible during spring training, now are limited to Zoom sessions online.
"It is great to you see you all," Seattle manager Scott Servais told reporters in his first Zoom session of summer camp. "This is unprecedented times but I'm really, really happy we're getting a chance to get back together."
Servais was pressed for time, however. He had to get to a team meeting, in the stands along the first base line. Players at the meeting sat in every other row, several seats between them. They wore face masks. The clubhouse, a normal meeting site, now has limits to how many people can gather at a time.
At summer camp, as players shake the rust off their baseball skills, everyone players, coaches, staff, reporters is test driving baseball's 113-page health and safety plan.
At the Seattle Mariners summer training, the team is only conducting interviews using Zoom. Mariners manager Scott Servais answers reporters questions via computer. Tom Goldman/NPR hide caption
At the Seattle Mariners summer training, the team is only conducting interviews using Zoom. Mariners manager Scott Servais answers reporters questions via computer.
And Servais is determined to make sure the Mariners adhere.
"We don't want to be the team that goes down," he said, "or you don't want to be the player or coach that has brought [the virus] in."
Easy to forget
There are so many rules to follow. Every other day testing. No public transportation to or from the stadium. Physical distancing as much as possible. Players using their own personal equipment as much as possible. No fighting (not a bad idea under normal circumstances). Lots of hand washing.
And in a hurried-up version of spring training, it's sometimes easy to forget.
"It's very strange, still," said pitcher Justus Sheffield. "The main thing for me is remembering the mask. Just kind of before, free and easy walking around the [clubhouse], being able to hang out with friends, teammates. [Now] it's kind of in and out. Get your work in, make sure you have a mask on at all times. Hand sanitize."
The consensus is no spitting may be the hardest one to remember. Spitting, after all, is one of baseball's enduring, unconscious habits. It's also an easy way to transmit the coronavirus.
"I think today I was spitting and somebody got onto me," Sheffield laughs. "That's going to be tough. Especially pitching, you know. when you're out there and not thinking. It's a work in progress."
The Mariners say they are trying to help police each other's behavior. Team members say veterans like third baseman Kyle Seager are particularly outspoken.
"I think Seag is probably the biggest one," Mariners outfielder Braden Bishop said. "He's got family here with [him]. He talked to us yesterday about, we were put in this position, we have this opportunity to play. We can only control so much, but what we need to control is extremely important, like more so than any other year. So while [we] need to focus on baseball, to be ready to play, [we] also have to take into account, okay, I'm going back to the hotel. Like, I can't do these certain things I could in the past because it can affect 50, 60 people."
"I think the biggest problem is you could put in the greatest protocols ever, but if you don't have full compliance by every single guy and every single employee, it puts everyone at risk. While the percentage is small, you don't want one of those serious cases [of COVID-19] to be part of our group."
According to Servais, the Mariners have had "a few players" test positive.
"We'll wait and see," Servais said this week. "Certainly there's a protocol they have to go through before they can come back inside the bubble, so to speak. T-Mobile is our bubble. We'll follow the guidelines MLB's set up. They're very strict. Rightly so."
Elsewhere a rough start
While camp seems to be working in Seattle, other teams around the league are having a rough start as they prepare for the regular season.
Last season's World Series competitors, the Washington Nationals and Houston Astros, were among several teams to cancel workouts this week after a delay in getting coronavirus test results.
MLB acknowledged the delays were due to delivery and shipping service problems during the Fourth of July holiday weekend. Baseball officials say it's "addressed the delays and does not expect a recurrence."
With so many fragile and moving parts in the baseball restart, avoidable holiday shipping delays fueled critics belief that, with the pandemic surging again in this country, an MLB 2020 season, even one shrunk from a 162 game marathon to a 60-game sprint, is a fool's errand.
For this and other reasons, some players have opted not to play.
Asked about them, several Mariners said they have no problem.
"For each guy, it's a personal, family decision," Seattle pitcher Marco Gonzales said. "One that shouldn't be taken lightly. For the guys who've opted out, I don't think they owe anyone a reason. I think there are plenty of reasons to opt out of this season, whether family, personal reasons or whatever."
Braden Bishop says he debated what to do after his brother tested positive for COVID-19.
"[He was] a good example for me that the virus doesn't take time off," Bishop said. "He's healthy, athletic and he got it. While he doesn't have extreme symptoms, we don't know the possible adverse effects down the line. That's the thing we're both worried about. It was definitely scary."
Despite his fears, despite the strangeness of this season, Bishop chose to play.
"My window in the Major Leagues, whether it be two years, whether it be ten years," Bishop said, "[it's] going to be such a short time and I don't want to let this crazy 60 game season be the reason that, y'know, I wasn't ready and I played poorly and then my career was over because of that."
Bishop, and his teammates, will try to be as ready, and healthy, as they can be, for their opening night game. It's scheduled for July 24th, in Houston.
Of course, pandemic permitting.
In early March, most doctors in the United States had never seen a person sick with COVID-19. Four months later, nearly every emergency room and intensive care physician in the country is intimately familiar with the disease. In that time, theyve learned a lot about how best to treat patients. But in some cases, theyre still taking the same approach they did in the spring.
Theres so much thats different, and so much thats the same, says Megan Ranney, an emergency physician and associate professor at the Brown University Department of Emergency Medicine.
For the first few months of the pandemic, recommendations for every incremental decision made in a hospital were changing faster than they ever have before. You almost couldnt keep up from one day to the next, your practice would change and your protocols would change. It was really disorienting for doctors and nurses, Ranney says.
Information spread between colleagues, through medical education blogs and podcasts, and on social media. Doctors talked about new research on Twitter and shared new strategies in Facebook groups and on WhatsApp. If a suggestion that floated by a doctor in a Facebook group was low-risk and seemed like it might be helpful, it could be put into practice immediately. If its a small change, they could start using it the next day, she says.
Thats how the now-common practice of asking patients with COVID-19 to flip onto their stomachs spread: through word-of-mouth and on social media. When someone is on their back, their organs squish their lungs and make it harder for their airways to fully expand. When someone is on their stomach, their lungs have more room to fill up with air. The advice started circulating through the medical community before there was a formal, published study on the practice.
Testing it out wouldnt have many downsides (it wasnt dangerous to patients), and it was easy to do. Theres this possibility that it could be positive, and there were a lot of stories about it having a positive effect, Ranney says. So, it spread in a much more organic and quick way, because it was something that we could do, but we werent worried it would hurt patients.
Doctors like Seth Trueger, an assistant professor of emergency medicine at Northwestern University, saw the position help patients get enough oxygen to avoid needing a ventilator. I started jokingly call it tummy time, he says. Studies are starting to validate those observations, finding that patients who spent time on their stomachs were, in fact, better off.
Since March, physicians have also figured out other ways to help severely ill patients avoid ventilation. We appreciate that its probably not a great thing for these patients, and weve developed other ways to get people high levels of oxygen, says James Hudspeth, the COVID response inpatient floor lead at Boston Medical Center. For example, doctors are turning to nasal cannulas, which are noninvasive prongs that blow oxygen into the nose, before a ventilator.
They have better medications for hospitalized patients now, too. Since March, doctors have cycled through a few different options like hydroxychloroquine, which turned out not to be effective. Now, theyre primarily using remdesivir, and antiviral drug that appears to help COVID-19 patients recover more quickly, and the steroid dexamethasone, which helps improve the survival rate for patients on ventilators. Many intensive care units and many hospitals have created their own standard order sets, or standard therapies, for people with COVID-19, Ranney says. Those shift as new evidence comes out around different medications.
Thats not unusual, Ranney says. Hospitals regularly change the drugs they use for conditions like flu and pneumonia as new data comes out. Whats unusual is to change practice so quickly, she says. Thats just the reality of a global pandemic, with a disease weve never seen before.
Most of the changes in doctors strategies over the past few months have been in patients who are severely ill. If someone is sick enough to be hospitalized with COVID-19 but doesnt need to be in intensive care, there still isnt much doctors can do for them. Theyll get fluids to make sure they stay hydrated and are given oxygen if they need it. Doctors will try to keep their fever down and monitor them to see if they get sicker, but thats about it.
Its just those basic things, Ranney says. Doctors now are more vigilant to the threat from blood clots, which have appeared in many COVID-19 patients over the past months. Because testing is more available in hospitals than it was earlier this year, theyll also confirm that a moderately ill patient actually does have COVID-19 and avoid giving them unnecessary treatments. But active interventions for patients with less severe symptoms are still around the same as they were back in March. Were still kind of in this watchful waiting, she says.
One lingering question, Hudspeth says, is figuring out how to keep those moderately ill patients from becoming severely ill. Steroids may be helpful earlier on, he says, as could artificial antibody treatments that block the virus, though those strategies are still under investigation. Part the challenge we face at the present moment is that the moderate patients are often where we would want to intervene, he says.
Changes to treatment strategies for patients who are not severely sick have been harder to come by in part because its riskier to try something new in that group. If someone isnt dangerously sick, there isnt as much to gain from using an experimental treatment that may have a chance of causing harm, so doctors are less likely to take risks. Were more likely to try stuff with sicker patients, Ranney says. And their families are more likely to consent to a clinical trial.
Despite the open issues around COVID-19 treatments, the rate of new information is slowing down. Doctors arent shifting their practices as quickly as they were back in March and April, and Trueger says he thinks the next few months may be relatively stable. Doctors might get new information about which medications are more or less helpful, but other common best practices might be more entrenched. I dont think things are going to change as rapidly as the changes we had up front, when we were really flying half blind, he says.
UPCOMING FREE COMMUNITY TESTING: MARSHALL, MERCER, MONONGALIA, PRESTON, UPSHUR, AND WAYNE COUNTIES Additionally during his briefing, Gov. Justice offered a reminder that the next round offree community COVID-19 testingwill be provided later this week Friday, July 10 and Saturday, July 11 in Marshall, Mercer, Monongalia, Preston, Upshur, and Wayne counties.
The effort is part of a plan to provide free optional testing to all residents in several counties that are experiencing higher rates of COVID-19 transmission. It targets residents who have struggled to be seen by a physician or do not have insurance to pay for testing. However, other residents, including those who are asymptomatic are welcome to be tested.
Testing is scheduled as follows:
Marshall County Friday, July 10 9 a.m. 4 p.m. McMechen City Hall: 325 Logan Street, McMechen, WV 26040 Saturday, July 11 9 a.m. 4 p.m. Marshall County Health Department: 513 6th Street, Moundsville, WV 26041
Mercer County Saturday, July 11 9:30 a.m. 4 p.m. Mercer County Health Department: 978 Blue Prince Road, Bluefield, WV 24701
Monongalia County Friday, July 10 9 a.m. 4 p.m. Morgantown Farmers Market (Downtown): 400 Spruce Street, Morgantown, WV 26505 Saturday, July 11 9 a.m. 4 p.m. Mountainview Elementary School: 661 Green Bag Road, Morgantown, WV 26508
Preston County Friday, July 10 & Saturday, July 11 9 a.m. 4 p.m. Kingwood Elementary School: 207 South Price Street, Kingwood, WV 26537
Upshur County Friday, July 10 & Saturday, July 11 10 a.m. 7 p.m. Buckhannon-Upshur High School: 270 B-U Drive, Buckhannon, WV 26201 Friday, July 10 & Saturday, July 11 10 a.m. 4 p.m. 78 Queens Alley, Rock Cave, WV 26234
Wayne County Friday, July 10 10 a.m. 4 p.m. Dunlow Community Center: 1475 Left Fork Dunlow Bypass Road, Dunlow, WV 25511 Saturday, July 11 10 a.m. 4 p.m. Wayne Elementary School: 80 McGinnis Drive, Wayne, WV 25570
The US is struggling with a resurgence of the coronavirus in the South and West. But the severity of Arizonas Covid-19 outbreak is in a league of its own.
Over the week of June 30, Arizona reported 55 new coronavirus cases per 100,000 people per day. Thats 34 percent more than the second-worst state, Florida. Its more than double Texas, another hard-hit state. Its more than triple the US average.
Arizona also maintained the highest rate of positive tests of any state at more than 25 percent over the week of June 30 meaning more than a quarter of people who were tested for the coronavirus ultimately had it. Thats more than five times the recommended maximum of 5 percent. Such a high positive rate indicates Arizona doesnt have enough testing to match its big Covid-19 outbreak.
To put it another way: As bad as Arizonas coronavirus outbreak seems right now, the state is very likely still undercounting a lot of cases since it doesnt have enough testing to pick up all the new infections.
The state also leads the country in coronavirus-related hospitalizations. According to the Centers for Disease Control and Prevention, more than one in five inpatient beds in Arizona are occupied by Covid-19 patients about 42 percent more than Texas and 65 percent more than Florida, the states with the next-highest share of Covid-19 patient-occupied beds. With hospitalizations rapidly climbing, Arizona became the first in the country to trigger crisis care standards to help doctors and nurses decide who gets treatment as the system deals with a surge of patients. Around 90 percent of the states intensive care unit beds are occupied, based on Arizona Department of Health Services data.
While reported deaths typically lag new coronavirus cases, the state has also seen its Covid-19 death toll increase over the past several weeks.
This is the result, experts say, of Arizonas missteps at three crucial points in the pandemic. The state reacted too slowly to the coronavirus pandemic in March. As cases began to level off nationwide, officials moved too quickly to reopen in early and mid-May. As cases rose in the state in late May and then June, its leaders once again moved too slowly.
What youre seeing is not only a premature opening, but one done so rapidly there was no way to ensure the health care and public health systems didnt get stressed in this process, Saskia Popescu, an infectious disease epidemiologist based in Arizona, told me.
At the same time, recommended precautions against the coronavirus werent always taken seriously by the general public with experts saying that, anecdotally, mask use in the state can be spotty. That could be partly a result of Republican Gov. Doug Ducey downplaying the threat of the virus: While he eventually told people to wear masks in mid-June, as of late May he claimed that its safe out there, adding, I want to encourage people to get out and about, to take a loved one to dinner, to go retail shopping.
Duceys actions and comments gave the impression we were past Covid-19 and it was no longer an issue, Popescu said, which I believe encouraged people to become lax in their masking [and] social distancing.
After weeks of increases in coronavirus cases and hospitalizations, Ducey pulled back Arizonas reopening on June 29, closing downs bars, theaters, and gyms.
Experts say the move is a positive step forward, but also one that came too late: With coronavirus symptoms taking up to two weeks to develop, there are already infections out there that arent yet showing up in the data. The state can expect cases, hospitalizations, and, probably, deaths to continue to climb over the next few weeks.
Ducey acknowledged the sad reality: It will take several weeks for the mitigations that we have put in place and are putting in place to take effect, he said. But they will take effect.
Duceys office argued it took the action as was necessary at the time, based on the data it collected and its experts recommendations. Our steps are in line with our facts on the ground that weve been tracking closely, Patrick Ptak, a spokesperson for the governors office, told me.
Arizona now offers a warning to the rest of the world. The states caseload was for months far below the totals in New York, Michigan, and Louisiana, among the states that suffered the brunt of the virus in the US in the early months. But by letting its guard down, Arizona became a global hot spot for Covid-19 a testament to the need for continued vigilance against the coronavirus until a vaccine or similarly effective treatment is developed.
Arizona was initially slow to close down. While neighboring California instituted a stay-at-home order on March 19, Ducey didnt issue a similar order for Arizona until March 31 12 days later.
That might not seem like too much time, but experts say it really is: When the number of Covid-19 cases statewide can double within just 24 to 72 hours, days and weeks matter.
Arizona was also quick to reopen its economy. After states started to close down, experts and the White House recommended that states see a decline in coronavirus cases for two weeks before they reopen. Arizona never saw such a decline. In fact, it arguably never even saw a real plateau. The number of daily new cases rose slowly and steadily through April and into May, and then the exponential spike took off.
So its not quite right to say that Arizona is experiencing a second wave of the coronavirus. It arguably never controlled the first wave, and the current rise of cases is a result of continued inaction as the initial wave of the virus continued spreading across the state. (The Navajo Nation, which is partly in Arizona, was an initial coronavirus hot spot. But its case count has declined since May, in part because it took strong measures against the virus.)
Arizona and other states experiencing a surge in Covid-19 now never got to flat, Pia MacDonald, an epidemiologist at the research institute RTI International, told me. That means the states didnt get to very good compliance with the public health interventions that we all need to take to make sure the outbreak doesnt continue to grow.
Despite no sustained decline in Covid-19 cases, Arizona moved forward with reopening anyway. Ptak, the governors spokesperson, acknowledged that the state didnt meet the two-week decline in cases, but he said the state had met another federal gating criteria for reopening by seeing a decline in the test positivity rate week after week throughout May.
Once the state started to reopen, it moved quickly. Within weeks, Arizona not only let hospitals do elective surgeries but started to allow dining-in at restaurants and bars, and gyms and salons, among other high-risk indoor spaces, to reopen. The short time frame prevented the state from seeing the full impact of each step of its reopening, even as it moved forward with additional steps.
Will Humble, executive director of the Arizona Public Health Association, argued it was this rate of reopening that really caused problems for the state. It was a free-for-all by May 15, Humble told me. Referencing federal guidelines for reopening in phases, he added, Arizona effectively went from phase 0 to phase 3.
Its not just that Ducey aggressively reopened the state, but that he also prevented local governments from imposing their own stricter measures. That included requirements for masks, which Ducey didnt allow municipalities to impose until mid-June weeks after Covid-19 cases started to rapidly rise. (Ptak claimed the governor acted once he received requests from mayors along the southern border to do so.)
Some of that is likely political. As recommendations and requirements for masks have expanded, some conservatives have suggested wearing a mask is emblematic of an overreaction to the coronavirus pandemic that has eroded civil liberties. President Donald Trump has by and large refused to wear a mask in public, even saying that people wear masks to spite him and suggesting, contrary to the evidence, that masks do more harm than good. While some Republicans are breaking from Trump on this issue, his comments and actions have helped politicize mask-wearing and other measures.
For example, there was an anti-mask rally in Scottsdale, Arizona, on June 24. There, a local council member, Republican Guy Phillips, shouted George Floyds dying words I cant breathe! before ripping his own mask off, according to the Washington Post. (Phillips later apologized to anyone who became offended.)
Evidence supports the use of masks: Several recent studies found masks reduce transmission. Some experts hypothesize and early research suggests that masks played a significant role in containing outbreaks in several Asian countries where their use is widespread, like South Korea and Japan.
But for a Republican governor like Ducey, the politicization of the issue means a large chunk of his political base is resistant to the kind of measures needed to get the coronavirus under control. And those same constituents are likelier to reject taking precautions against the coronavirus, even if theyre recommended by government officials or experts.
Ducey himself seemed to play into the politics: One day before Trump visited a plant in the state, and as the president urged states to reopen, Ducey announced an acceleration of the states reopening plans.
Other factors, beyond policy, likely played a role as well in the rise in cases. While summer in other parts of the country lets people go outside more often where the coronavirus is less likely to spread triple-digit temperatures in Arizona can actually push people inside, where poor ventilation and close contact is more likely to lead to transmission.
Some officials have argued Black Lives Matter protests played a role in the new outbreak. But the research and data so far suggest the demonstrations didnt lead to a significant increase in Covid-19 cases, thanks to protests mostly taking place outside and participants embracing steps, such as wearing masks, that mitigate the risk of transmission. In Arizona, the surge in coronavirus cases also began before the protests took off in the state.
Arizona saw its coronavirus cases start to increase by Memorial Day on May 25. The increase came hard with the test positivity rate rising too, indicating early on that the increase was not merely the result of more testing in Arizona. Hospitalizations and deaths soon followed.
Yet Ducey didnt begin to scale back the states reopening until more than a month later on June 29. This left weeks for the coronavirus to spread throughout the community.
The sad reality is Arizona will suffer the consequences of the governors slow action for weeks. Because people can spread the virus without showing symptoms, can take up to weeks to show symptoms or get seriously ill, and theres a delay in when new cases and deaths are reported, Arizona is bound to see weeks of new infections and deaths even after Duceys renewed restrictions.
Even if I put in 100 percent face mask use and everybody complied with it in Arizona right now, there would still be weeks of pain, Cyrus Shahpar, a director at the global health advocacy group Resolve to Save Lives, told me. There are people out there spreading disease, and it takes time [to pick them up as cases], from exposure to symptom onset to testing to getting the testing results.
Experts argue the state still needs to go even further. Humble advocated for more hospital staffing, a statewide mask requirement, more rigorous rules and better enforcement of the rules for reopening businesses, and improved testing capacity and contact tracing. He also pointed to the lack of timely testing in prisons as one area that hasnt gotten enough attention and could lead to a blind spot for future Covid-19 outbreaks.
One potentially mitigating factor is the states infected have trended younger than they did in initial bouts of the USs coronavirus outbreak, with people aged 20 to 44 making up roughly half of cases. That could keep the death toll down a bit though Covid-19 deaths in Arizona have already risen, and experts warn of the risks of long-term complications from the coronavirus, including severe lung scarring, among young people as well.
Above all, experts say that the rise in cases was preventable and predictable.
The research suggests the lockdowns worked. One study in Health Affairs concluded:
Adoption of government-imposed social distancing measures reduced the daily growth rate by 5.4 percentage points after 15 days, 6.8 after 610 days, 8.2 after 1115 days, and 9.1 after 1620 days. Holding the amount of voluntary social distancing constant, these results imply 10 times greater spread by April 27 without SIPOs (10 million cases) and more than 35 times greater spread without any of the four measures (35 million).
The flipside, then, is likely true: Easing lockdowns likely led to more virus transmission.
This is what researchers saw in previous disease outbreaks.
Several studies of the 1918 flu pandemic found that quicker and more aggressive steps to enforce social distancing saved lives in those areas. But this research also shows the consequences of pulling back restrictions too early: A 2007 study in JAMA found that when St. Louis widely praised for its response to the 1918 pandemic eased its school closures, bans on public gatherings, and other restrictions, it saw a rise in deaths.
Heres how that looks in chart form, with the dotted line representing excess flu deaths and the black and gray bars showing when social distancing measures were in place. The peak came after those measures were lifted, and the death rate fell only after they were reinstated.
This did not happen only in St. Louis. Analyzing data from 43 cities, the JAMA study found this pattern repeatedly across the country. Howard Markel, a co-author of the study and the director of the University of Michigans Center for the History of Medicine, described the results as a bunch of double-humped epi curves officials instituted social distancing measures, saw flu cases fall, then pulled back the measures and saw flu cases rise again.
Arizona is now seeing that in real time: Social distancing worked at first. But as the state relaxed social distancing, it saw cases quickly rise.
This is why experts consistently cautioned not just Arizona but other states against reopening too quickly. Its why they asked for some time two weeks of falling cases before states could start to reopen. Its why they asked for states to take the reopening process slowly, ensuring that each relaxation didnt lead to a surge in new Covid-19 cases.
Because Arizona and its leaders didnt heed such warnings, its now suffering a predictable, preventable crisis making it the state with the worst coronavirus epidemic in the country thats suffered the most widespread coronavirus outbreak in the world.
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The news: A group of 239 scientists from 32 countries have written an open letter to the World Health Organization arguing that covid-19 can be transmitted through the air. You might think we know that already, but most current guidance is based on the idea that covid-19 is transmitted via droplets expelled from an infected persons nose or mouth. The thought is that these larger respiratory droplets quickly fall to the floor. That's the position the WHO has taken from early on in the pandemic, and thats why we have been keeping at a distance from one other. However, the signatories of the open letter say the organization is underestimating the role of airborne transmission, where much smaller droplets (called aerosols) stay suspended in the air. These aerosols can travel farther than droplets and linger in an area even when an infected person has left.
Whats the evidence? The letter says multiple studies have demonstrated beyond any reasonable doubt that viruses are released during exhalation, talking, and coughing in microdroplets small enough to remain aloft in air. It says these microdroplets pose a risk of exposure at distances beyond 1 to 2 m from an infected individual. An early laboratory study carried out by the US National Institutes of Healthfound that the coronavirus can linger in the air for up to four hours in aerosol form. The coronavirus was also detected in aerosols collected at two hospitals in Wuhan, China, according to a study published in Nature in April. And superspreading events add to the weight of evidence: for example, after a choir practice in the US nearly 50 people were infected even though they kept a safe distance apart.
The implications: If airborne transmission is a route for the spread of the virus, it could lead to changes in the current advice. It would suggest that social distancing may be insufficient, especially indoors. This may place yet more importance on mask-wearing around people who are not part of your household if you meet them indoors, even if you are distancing, and increasing ventilation in enclosed areas. It could make air-filtering systems more important to try to cut down on the recirculation of air. And it might mean health-care workers caring for coronavirus patients need the highest grade of maskN95to filter out the smallest droplets.
Now, as nurses are hailed as health care heroes during the pandemic, we're faced with what to do about these psychological injuries, not only for the 4 million nurses in the US the largest health care workforce in America but for the rest of us who depend on them.For the past five years, I've examined the types of psychological trauma that nurses experience. Along with Dr. John Thompson, my co-author, I've described them in our 2019 book, prophetic as it was published six months before Covid-19 first appeared in China.
Prior to the pandemic, nurses faced ethical and personal safety dilemmas during disasters and other emergencies. They saw patients suffer, not only from illness itself, but because of health care interventions, otherwise known as medically induced trauma (think of a patient on a ventilator).
Demands for resources largely ignored for decades
More recently, there has been a shortage of PPE (personal protective equipment) throughout US hospitals. But I know nurses who were told by employers to take care of Covid-19 patients regardless of whether or not adequate PPE was available. Clearly this was a danger to both nurses and patients; surely this qualifies as a traumatizing experience.
Other nurses some new, some working previously in non-acute care have been deployed to critical care units. Understanding the technology of these complex environments requires a steep learning curve. The knowledge, then, to competently care for these patients may be considered an insufficient resource.
The toll on patients and nurses
Nurses, more than anything, strive to deliver high-quality care and connect with patients during their most vulnerable times. But often there isn't the time. The inability to achieve that goal causes stress. Imagine being forced to choose between giving morning meds and sitting down with a patient newly diagnosed with cancer or spending time with the family of a patient with Covid-19. Choices like that leave nurses focused on tasks and morally injured.
Some traumas may be unavoidable. That happens when the nurse fully engages with the patient and co-experiences suffering. This is called secondary or vicarious trauma. That's why we need to offer trauma-informed care to both nurse and patient. Meaningful connections with others is critical, but so is psychological safety.
Compassion helps to heal
While I haven't been at the bedside for a number of years, I still remember how it felt to report to the acute care center at the hospital, hoping no one had called in sick. When that happened, I was assigned an extra patient or two. I knew I couldn't give the care I wanted to the paraplegic young man. I knew I couldn't spend more time communicating with the older adult who had a sudden right-sided stroke. I couldn't give them the things so important to healing -- the physical care, the nursing presence and the compassion they needed and deserved.
Those experiences stay with you. It's a heck of a feeling.
Nursing care is both an art and a science; it is a distinct profession that wields enormous influence on those who need the most help. They do not merely follow instructions from other providers. It's a beautiful profession, unlike any other, founded on intellect, judgment and a caring spirit. It pushes a person to examine values such as social justice and the ethics of life, and it becomes a part of who a nurse is.
Until all of us see nursing this way and until organizations provide sufficient resources to prevent avoidable trauma, which will allow nurses to provide safe, quality care nurses will continue to suffer. More will choose to leave the profession. Particularly now, that's a loss society can't afford.
Karen J. Foli is an associate professor at the School of Nursing, Purdue University. Disclosure: Foli received funding for her research from the National Council of State Boards of Nursing: Center for Regulatory Excellence. She receives royalties from her book, "The Influence of Psychological Trauma in Nursing."
As thepandemic slammed Michigan, workers inside some of the state's hardest-hit nursing homes rationed protective gear, went without COVID-19 tests and struggled to care for seniors who carried a deadly virus.
At one Lapeer County facility, an occupational therapist and a nursing assistant said they had been ordered in late March not to wear masks by a supervisor, according to an inspection report.
On March 29 19 days after Michigan confirmed its first COVID-19 cases a nurse at a Macomb County facility told a government inspectorthat a resident there was "actively dying right now" and there were no tests for the virus available.
Out of the 45 nursing homes in Michigan that have reported the most deaths linked to COVID-19, nearly half 22 have been cited by state inspectors in the last four months for failing to follow infection control, isolation or staffing policies, according to a Detroit News review of hundreds of pages of state records.
The News' review of the documents provides the most comprehensive examinationyet ofconditions inside Michigan's nursing homes as the coronavirus began infecting vulnerable seniors in March and as hospitals were struggling to provide care for COVID-19 patients.They could also play into an ongoing policy debate over Gov. Gretchen Whitmer's decision to have facilities set up isolated areas for caring for residents with the virus.
As of Sunday, the Michigan Department of Health and Human Services had tracked 1,988 COVID-19 deaths linked to the facilities, accounting for 33% of the statewide death toll.
Nursing homes were caught off guard by the virus initially and haven't been able to catch up, said Tamara Blue, who worked for a facility in Detroit as a certified nursing assistant and is a representative for the Service Employees International Union. Blue was making $13 an hour at her job where she cared for residents with COVID-19 before she stepped away because she contracted it, she said.
"Its overwhelming," Blue said of working in nursing homes during the pandemic. Its heartbreaking because you are literally watching someone take their last breath over and over and over again. And theres nothing you can do about it."
But the situation varies from facility to facility, said Melissa Samuel, president and CEO of the Health Care Association of Michigan, which represents nursing homes. Likewise, she said, the severity of citations from inspectors varies.
"At the beginning of this battle, there were more unknowns than knowns," Samuel added. "New protocols and procedures were being written and implemented on a daily basis. The state and federal government changed our operations overnight.
"Facilities were working to comply and make those changes as quickly as possible. The primary reasons for the COVID-19 outbreaks in nursing facilities is the prevalence in the community and the lack of prioritizing these settings for testing and PPE (personal protective equipment)."
The 45 facilities reviewed by The Detroit News represent about 10% of the nursing homes statewide.
Of the 45, five didn't have COVID-19 inspection or survey reports available online through a website of the state Department of Licensing and Regulatory Affairs. For 18 others, government inspectors listed them in "substantial compliance" with safety policies after COVID-19-related surveys or didn't list any violations in documents available Wednesday.
The Bureau of Community and Health Systems within the Department of Licensing and Regulatory Affairs serves as an agent of the federal Centers for Medicare and Medicaid Services and provides regulatory oversight of the states nursing homes.
According to the available reports, 22 facilities failed to meet at least one standard directly related to stemming the spread of a virus that hasdevastated the elderly. Nearly 69% of Michigan's COVID-19 deaths have been individuals who were at least 70 years old, according to state data.
For every citation, a facility must write a plan of correction, and the state must then confirm that those corrections have been implemented, Samuel noted.
AARP Michigan, which advocates on behalf of the elderly, is "greatly concerned about differences in quality from one nursing home to another across the state," said Mark Hornbeck, the organization's spokesman.
"We know some long-term care facilities are doing a great job and others are struggling," Hornbeck added. "We are hearing firsthand accounts every day that reflect these differences."
Some Michigan nursing homes' violations have been relatively minor, such as masks found lying on the ground or a mystery oxygen tank left leaning on a chair in a common area inside the COVID-19 unit.
For others, state inspectors found a laundry list of missteps and specifically said in their reports the facilities' actions increased the potential for spread of COVID-19, hospitalizations and death.
An inspector required The Villages of Lapeer Nursing & Rehabilitation to seek "immediate" action to correct problems in April after workers revealed that the facility's then-director of nursing had ordered them not to wear masks inside the facility.
This is a section of an April 2020 state survey report examining the practices of The Villages of Lapeer Nursing & Rehabilitation.(Photo: Screenshot)
On March 24 14 days after Michigan confirmed its first cases of the virus the director of nursing, who isnot identified by name, entered the facility's therapy room and told an occupational therapist to remove "her own personal protective face mask," according to an inspector's report.
The occupational therapist "was not going to wear the mask in 'her building,'" the director of nursing said, according to the report.
"This was during a worldwide pandemic of the COVID-19 virus," the inspector wrote.
A nursing assistant at the facility told an inspector that the same director of nursing ordered her to take her mask off or "go home."
The director of nursing later resigned, and her successor said all personal protective equipment was welcomed at the facility. According to an inspector's report, the former director of nursing was concerned masks would cause "a panic." By April 7, an inspector found staff to be wearing proper protective equipment.
The Villages of Lapeer has reported 47 COVID-19 cases among residents, 16 cases among staff and 19 deaths linked to the virus among residents, according to state data. An official didn't respond to a request for comment for this story.
Medilodge of Southfield located at 26715 Greenfield Road(Photo: Max Ortiz, The Detroit News)
Many of the 22 facilities cited for failing to meet safety standards faced shortages in personal protective equipment, staffing or COVID-19 tests, according to the inspection reports.
At Medilodge of Southfield, a handful of employees told an inspector that they had to use the same isolation gown "all day for residents with COVID-19 and those without it," according to a state report on that facility.
A nursing assistant told an inspector that the assistant was not provided a face shield to use when caring for residents with the coronavirus before April 28, 49 days after Michigan confirmed its first cases of the virus.
"CNA I (the abbreviation used to keep the employee's name secret) indicated that residents would cough all over them and the staff were getting sick," an inspector wrote.
Medilodge of Southfield has reported 51 cases among residents, 16 cases among staff and 20 deaths linked to the virus among residents, according to the state's tracking.
Medilodge didn't respond to a request for comment. But according to the inspection report, staff members were re-educated on the use of personal protective equipment and walking rounds were made by management staff each shift to conduct observations of staff and the use of the equipment.
Advantage Living Center in Roseville.(Photo: Max Ortiz, The Detroit News)
Multiple facilities faced staffing shortages as employees called off work or contracted the virus and had to take time off, according to inspectors' findings.
At Advantage Living Center Roseville, a nursing assistant told a state inspector on March 29 that the nursing assistant wasthe only oneworking on the facility's isolation unit, which had 23 residents. Of those 23 residents, 98% required assistance or were incontinent, the nursing assistant said, according to the inspection report.
Asked how the nursing assistant providedregular care for each of the residents, the nursing assistant responded, "I can't."
On the same day in the same facility, an inspector reported questioning whether a nurse was aware their mask was not positioned properly.
'"No," the nurse replied before adding, ''I have one (resident) who is actively dying right now,'" according to the survey report.
This is a section of a state COVID-19 survey report on Advantage Living Center Roseville from March 2020.(Photo: Screenshot)
The nurse told the inspector she didn't have time to take a break, the facility wasn't able to obtain COVID-19 tests to determine whohad the virus and there were "no tests" available on March 29.
As of Tuesday, Advantage Living Center Roseville reported 66 COVID-19 cases among residents and eight among staff, according to state tracking data. The facility reported 20 COVID-19 deaths among residents and one death among staff.
Advantage Living Centers didn't respond to a request for comment. However, it instituted a plan to resolve issues identified in the state's inspection, according to the report. The plan included re-educating staff on personal protective equipment procedures.
Testing was also an issue at Medilodge of Kalamazoo, according to an inspection report.
This is a section of a state COVID-19 survey of Medilodge of Kalamzoo from April 2020.(Photo: Screenshot)
There, an unnamed nursing home administrator told an inspector on April 23 that four staff members had tested positive for COVID-19 and the administrator said "they would not test anymore of their staff members for COVID-19," according to a report.
A spokesman for Medilodge didn't respond to a request for comment. On June 15, Gov. Gretchen Whitmer's administration unveiled new testing policies, requiring nursing homes to test all residents and staff initially and to test residents and staff with symptoms of the virus.
Michigan's nursing home policies have been in the spotlight for months now as Republican lawmakers and some Democratic legislators have disagreed with the Democratic governor's decision to have elderly individuals with the virus cared for in isolated areas of existing facilities.
Republicans have argued individuals with COVID-19 should be cared for in other facilities like hospitals or separate quarantine centers to prevent the spread of the virus to other vulnerable nursing home residents. But Whitmer's administration has been worried about overwhelming hospital capacity during the pandemic and has voiced concerns about the ability to properly care for nursing home residents in a makeshift field hospital.
The debate has largely focused on buildings and not the safety of nursing home employees, said Sen. Jeff Irwin, D-Ann Arbor, who serves on the Senate Oversight Committee, which has been investigating nursing home policies.
"They cant afford to miss work if theyre sick," Irwin said of nursing home workers Wednesday. "They cant afford to contract a cold, much less COVID-19."
Samuel, who leads the Health Care Association of Michigan, said state and federal government need to prioritize nursing facilities for personal protective equipment, testing and support for staff.
"The collective goal of local, state, federal agencies as well as other stakeholders should be to build up nursing facilities to enable them to meet and overcome the challenges inherent with the presence of COVID-19," Samuel said. "Nursing facilities are taking extraordinary measures to meet the new expectations of how care is provided based on regulatory and operational changes required by the state and federal governments."
Whitmer established the Michigan Nursing Homes COVID-19 Preparedness Task Force in June to help the state ready facilities for a potential second wave of the virus. On Tuesday, the governor announced the task force's 20 members.
The panel includes four state lawmakers, two members of Whitmer's administration, the leaders of a handful of health care interest groups and TreceAndrews ofDetroit, who isa caregiver at the nursing home Regencyat St. Clair Shores.
"Im excited and proud to be a voice who can speak with first-hand experience on conditions in nursing homes," Andrews said in a press release. A lot of attention has been paid to resident safety, but not enough to worker safety."
On Monday, Michigan's Bureau of Community and Health Systems saidit had completed 100% of federally required infection control surveys of nursing homes. All of the state's 442 federally certified nursing homeswent through an infection control survey from March 26 through June 19, according to the press release.
cmauger@detroitnews.com
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