By February, as the disease crept across the U.S., Keeley said she found her calling: a career in public health. “This is something that’s going to be necessary,” Keeley remembered thinking. “This is something I can do. This is something I’m interested in.”
In August, Keeley began studying at the University of Illinois at Urbana-Champaign to become an epidemiologist.
Public health programs in the United States have seen a surge in enrollment as the coronavirus has swept through the country, killing more than 246,000 people. As state and local public health departments struggle with unprecedented challenges — slashed budgets, surging demand, staff departures and even threats to workers’ safety — a new generation is entering the field.
Among the more than 100 schools and public health programs that use the common application — a single admissions application form that students can send to multiple schools — there was a 20% increase in applications to master’s in public health programs for the current academic year, to nearly 40,000, according to the Association of Schools and Programs of Public Health.[khn_slabs slabs=”241884″ view=”inline” /]
Some programs are seeing even bigger jumps. Applications to Brown University’s small master’s in public health program rose 75%, according to Annie Gjelsvik, a professor and director of the program.
Demand was so high as the pandemic hit full force in the spring that Brown extended its application deadline by over a month. Seventy students ultimately matriculated this fall, up from 41 last year.
“People interested in public health are interested in solving complex problems,” Gjelsvik said. “The COVID pandemic is a complex issue that’s in the forefront every day.”
It’s too early to say whether the jump in interest in public health programs is specific to that field or reflects a broader surge of interest in graduate programs in general, according to those who track graduate school admissions. Factors such as pandemic-related deferrals and disruptions in international student admissions make it difficult to compare programs across the board.
Magnolia E. Hernández, an assistant dean at Florida International University’s Robert Stempel College of Public Health and Social Work, said new student enrollments in its master’s in public health program grew 63% from last year. The school has especially seen an uptick in interest among Black students, from 21% of newly admitted students last fall to 26.8% this year.
Kelsie Campbell is one of them. She’s part Jamaican and part British. When she heard in both the British and American media that Black and ethnic minorities were being disproportionately hurt by the pandemic, she wanted to focus on why.
“Why is the Black community being impacted disproportionately by the pandemic? Why is that happening?” Campbell asked. “I want to be able to come to you and say ‘This is happening. These are the numbers and this is what we’re going to do.’”
The biochemistry major at Florida International said she plans to explore that when she begins her MPH program at Stempel College in the spring. She said she hopes to eventually put her public health degree to work helping her own community.
“There’s power in having people from your community in high places, somebody to fight for you, somebody to be your voice,” she said.
Public health students are already working on the front lines of the nation’s pandemic response in many locations. Students at Brown’s public health program, for example, are crunching infection data and tracing the spread of the disease for the Rhode Island Department of Health.
Some students who had planned to work in public health shifted their focus as they watched the devastation of COVID-19 in their communities. In college, Emilie Saksvig, 23, double-majored in civil engineering and public health. She was supposed to start working this year as a Peace Corps volunteer to help with water infrastructure in Kenya. She had dreamed of working overseas on global public health.
The pandemic forced her to cancel those plans, and she decided instead to pursue a master’s degree in public health at Emory University.
“The pandemic has made it so that it is apparent that the United States needs a lot of help, too,” she said. “It changed the direction of where I wanted to go.”
These students are entering a field that faced serious challenges even before the pandemic exposed the strains on the underfunded patchwork of state and local public health departments. An analysis by AP and KHN found that since 2010, per capita spending for state public health departments has dropped by 16%, and for local health departments by 18%. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.
And the workforce is aging: Forty-two percent of governmental public health workers are over 50, according to the de Beaumont Foundation, and the field has high turnover. Before the pandemic, nearly half of public health workers said they planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons. Some public health workers are paid so little that they qualify for public aid.
Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, said government public health jobs need to be a “destination job” for top graduates of public health schools.
“If we aren’t going after the best and the brightest, it means that the best and the brightest aren’t protecting our nation from those threats that can, clearly, not only devastate from a human perspective, but from an economic perspective,” Castrucci said.
The pandemic put that already-stressed public health workforce in the middle of what became a pitched political battle over how to contain the disease. As public health officials recommended closing businesses and requiring people to wear masks, many, including Dr. Anthony Fauci, the U.S. government’s top virus expert, faced threats and political reprisals, AP and KHN found. Many were pushed out of their jobs. An ongoing count by AP/KHN has found that more than 100 public health leaders in dozens of states have retired, quit or been fired since April.
Those threats have had the effect of crystallizing for students the importance of their work, said Patricia Pittman, a professor of health policy and management at George Washington University’s Milken Institute School of Public Health.
“Our students have been both indignant and also energized by what it means to become a public health professional,” Pittman said. “Indignant because many of the local and the national leaders who are trying to make recommendations around public health practices were being mistreated. And proud because they know that they are going to be part of that front-line public health workforce that has not always gotten the respect that it deserves.”
Saksvig compared public health workers to law enforcement in the way they both have responsibility for enforcing rules that can alter people’s lives.
“I feel like before the coronavirus, a lot of people didn’t really pay attention to public health,” she said. “Especially now when something like a pandemic is happening, public health people are just on the forefront of everything.”
KHN Midwest correspondent Lauren Weber and KHN senior correspondent Anna Maria Barry-Jester contributed to this report.
This story is a collaboration between The Associated Press and KHN.]]>
The coronavirus pandemic has killed more than 246,000 people in the U.S., but it also has left hundreds of thousands of others grieving, and often feeling as if they have been robbed of the usual methods for dealing with the loss. For every person who dies of the virus, nine close family members are affected, researchers estimate. In addition to deep sadness, the ripple effects may linger for years as survivors deal with traumatic stress, anxiety, guilt and regret.
As the holidays approach, millions of people will be experiencing these losses afresh, as well as disruptions to comforting routines and beloved traditions.
Judith Graham, author of KHN’s Navigating Aging column, hosted a discussion on these unprecedented losses and dealing with the bereavement on Facebook Live on Monday. She was joined by Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City, and Diane Snyder-Cowan, leader of the bereavement professionals steering committee of the National Council of Hospice and Palliative Professionals.
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As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland. She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.
“All of those experiences actually made me really dislike physicians,” Asmerom said. “Particularly in my community, the saying is, ‘You only go to the doctor if you’re about to die.’”
But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too. Asmerom came to believe that as a doctor she could help turn things around.
Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.
Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.
This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests. But now, as with countless other U.S. institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action.
Debunking Race as a Diagnostic Tool
For many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more differences among people within each race. Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.
Dr. Brooke Cunningham, a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said. Some physicians claim it is useful to take race into account when treating patients; others argue it leads to bias and poor care.
Those views have led to a variety of false beliefs, including that Black people have thicker skin, their blood coagulates more quickly than white people’s or they feel less pain.
When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate). The eGFR can limit Black patients’ access to care because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.
In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.
Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.
“It was very personal,” Nkinsi said. “That’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”
Nkinsi helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.
Acknowledging Racism’s Adverse Effects on Health
The Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S. and Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.
This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities. But little data exists on how many schools teach students how to recognize and fight racism, he said.
An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.
“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.
Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.
Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.
“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.
Recognizing Racism in Medical Education’s Past and Present
Activists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements. Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.
Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. “It’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?” she said.
While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. “There needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.
Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.
“But I’m not going to hold my breath until I see actual changes,” she said.
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“I’ve always considered myself homeless because I don’t have a home,” he said on a recent crisp, fall day in the shelter’s sun-splashed courtyard. But he’s fortunate, said Barnes, 44. He’s never had to sleep outside when it was below zero or snowy. He always found a friend’s place, building or shelter to crash in. He knows others aren’t so lucky.
As winter approaches, hundreds — perhaps thousands — of people in this city of nearly 3 million are living on the streets: some in encampments, others hopping from corner to corner. And the numbers could grow without more federal aid and protections amid economic pressures from the pandemic.
This year, the coronavirus has forced homeless shelters to limit the number of beds they can offer. Pacific Garden Mission, for instance, is operating at roughly half its normal capacity of 740. And COVID-19 cases are rising as temperatures drop.
“What happens if we’re in the midst of a pandemic and a polar vortex happens?” said Doug Schenkelberg, executive director of the Chicago Coalition for the Homeless. “We’re trying to keep the contagion from spreading and keep people from dealing with hypothermia. Is there the infrastructure in place that can handle that type of dual crisis?”
Cold-weather cities across the nation are seeking creative ways to cautiously shelter homeless people this winter. Exposure to the elements kills individuals staying outside every year, so indoor refuges can be lifesaving. But fewer options exist nowadays, as coronavirus concerns limit access to libraries, public recreation facilities and restaurants. And in official shelters, safety precautions — spacing out beds and chairs, emphasizing masks and hand-washing, testing — are critical.
“The homeless check off most boxes in terms of being the most susceptible and most vulnerable to the COVID-19 pandemic, and most likely to spread and most likely to die from it,” said Neli Vazquez Rowland, founder of A Safe Haven Foundation, a Chicago nonprofit that has been operating a “medical respite” isolation facility for homeless individuals with the coronavirus.
Demand for shelter could grow. Stimulus checks helped stave off some of the pandemic’s initial economic pain, but Congress has stalled on additional relief packages. And though the Trump administration has ordered a moratorium on evictions for tenants who meet certain conditions through the end of the year, a group of landlords is suing to stop the ban. Some states have their own prohibitions on evictions, but only Illinois, Minnesota and Kansas do in the Midwest.
At the Guest House of Milwaukee, a publicly funded homeless shelter in Wisconsin, the pandemic complicates an already challenging situation.
“We’re like many communities. We never really have completely enough space for everybody who is in need of shelter,” said Cindy Krahenbuhl, its executive director. “The fact that we’ve had to reduce capacity, and all shelters have, has created even more of a burden on the system.”
She said outreach teams plan to connect individuals living outside with an open bed — whether at a shelter, a hotel or an emergency facility for homeless people at risk for COVID — and get them started with case management.
“The reality is we’ve got to make it happen. We’ve got to have space for folks because it’s a matter of life and death. You cannot be outside unsheltered in this environment too long,” said Rob Swiers, executive director of the New Life Center in Fargo, North Dakota, where the average high in January is 18 degrees.
His shelter, Fargo’s largest, plans to use an insulated, heated warehouse to provide roomy sanctuary for clients.
In Minnesota’s Ramsey County, home to St. Paul, an estimated 311 people are living on the streets, compared with “dozens” at this time in 2019, according to Max Holdhusen, the county’s interim manager of housing stability. The area just had a record snowfall for so early in the year.
The county has been using hotel rooms to make up for the reduction in shelter beds, and recently agreed to lease an old hospital to shelter an additional 100 homeless people.
The city of Chicago has set up emergency shelters in two unused public school buildings to replace beds lost to social distancing. As it does every winter, the city will also operate warming centers across Chicago, although this year with precautions such as spacing and masking.
In September, the city directed more than $35 million in funding — mostly from the federal CARES Act for coronavirus relief — to an “expedited housing” program aiming to get more than 2,500 people housed in the next few years. The initiative plans to financially incentivize landlords to take risks on renters they might normally avoid, such as those with criminal histories or poor credit. The nonprofit in charge, All Chicago, is also hosting “accelerated moving events,” in which its staffers descend on a shelter, encampment or drop-in center and work to house everyone in that facility.
“In the ideal world, we would have permanent housing for them,” said Dr. David Ansell, senior vice president of community health equity at Chicago’s Rush University Medical Center. “That is the only way we can protect people’s health. That’s the fundamental health issue. It’s a fundamental racial justice issue. It’s a fundamental social justice issue.”
Even though Black people make up only a third of Chicago’s population, they account for roughly three-fourths of those who are homeless, according to the city’s count.
Dr. Thomas Huggett, a family physician with Lawndale Christian Health Center on the city’s largely impoverished West Side, also called safely sheltering and housing people this winter a racial equity issue.
“We know that people who are African American have a higher prevalence of hypertension, of diabetes, of obesity, of smoking, of lung issues,” he said. “So they are hit harder with those predisposing conditions that make it more likely that if you get coronavirus, you’re going to have a serious case of it.”
Then add the cold. Dr. Stockton Mayer, an infectious disease specialist from the University of Illinois Hospital in Chicago, said hypothermia doesn’t increase the chances of contracting the virus but could aggravate symptoms.
As of Sept. 30, according to All Chicago, 778 people were unsheltered in the city. However, that number includes only people who are enrolled in homelessness services, and other estimates are even higher.
Some homeless people who plan to live outside this winter said they worry about staying warm, dry and healthy in the age of COVID-19. Efren Parderes, 48, has been on the streets of Chicago since he lost his restaurant job and rented room early in the pandemic. But he doesn’t want to go to a shelter. He’s concerned about catching the coronavirus and bedbugs, and doesn’t want to have to obey curfews.
He recently asked other unsheltered people what they do to keep warm during the winter. Their advice: Locate a spot that blocks the wind or snow, bundle up with many layers of clothing, sleep in a sleeping bag and use hand warmers.
“This is going to be the first time I’ll be out when it’s really cold,” he said after spending a largely sleepless night in the chilly October rain.
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“Please don’t leave me.”
“I need my family.”
Months of caring for older adults in a Rhode Island nursing home ravaged by COVID-19 have taken a steep toll on Silvestri, 37, a registered nurse.
She can’t sleep, as she replays memories of residents who became ill and died. She’s gained 45 pounds. “I have anxiety. Some days I don’t want to get out of bed,” she said.
Now, as the coronavirus surges around the country, Silvestri and hundreds of thousands of workers in nursing homes and assisted living centers are watching cases rise in long-term care facilities with a sense of dread.
Many of these workers struggle with grief over the suffering they’ve witnessed, both at work and in their communities. Some, like Silvestri, have been infected with the coronavirus and recovered physically — but not emotionally.
Since the start of the pandemic, more than 616,000 residents and employees at long-term care facilities have been struck by COVID-19, according to the latest data from KFF. Just over 91,000 have died as the coronavirus has invaded nearly 23,000 facilities. (KHN is an editorially independent program of KFF.)
At least 1,000 of those deaths represent certified nursing assistants, nurses and other people who work in institutions that care for older adults, according to a recent analysis of government data by Harold Pollack, a professor at the School of Social Service Administration at the University of Chicago. This is almost certainly an undercount, he said, because of incomplete data reporting.
How are long-term care workers affected by the losses they’re experiencing, including the deaths of colleagues and residents they’ve cared for, often for many years?
Edwina Gobewoe, a certified nursing assistant who has worked at Charlesgate Nursing Center in Providence, Rhode Island, for nearly 20 years, acknowledged “it’s been overwhelming for me, personally.”
At least 15 residents died of COVID-19 at Charlesgate from April to June, many of them suddenly. “One day, we hear our resident has breathing problems, needs oxygen, and then a few days later they pass,” she said. “Families couldn’t come in. We were the only people with them, holding their hands. It made me very, very sad.”
Every morning, Gobewoe would pray with a close friend at work. “We asked the Lord to give us strength so we could take care of these people who needed us so much.” When that colleague was struck by COVID-19 in the spring, Gobewoe prayed for her recovery and was glad when she returned to work several weeks later.
But sorrow followed in early September: Gobewoe’s friend collapsed and died at home while complaining of unusual chest pain. Gobewoe was told that her death was caused by blood clots, which can be a dangerous complication of COVID-19.
She would “do anything for any resident,” Gobewoe remembered, sobbing. “It’s too much, something you can’t even talk about,” describing her grief.
I first spoke to Kim Sangrey, 52, of Lancaster, Pennsylvania, in July. She was distraught over the deaths of 36 residents in March and April at the nursing home where she’s worked for several decades — most of them due to COVID-19 and related complications. Sangrey, a recreational therapist, asked me not to name the home, where she continues to be employed.
“You know residents like family — their likes and dislikes, the food they prefer, their families, their grandchildren,” she explained. “They depend on us for everything.”
When COVID-19 hit, “it was horrible,” she said. “You’d go into residents’ rooms and they couldn’t breathe. Their families wanted to see them, and we’d set up Zoom wearing full gear, head to toe. Tears are flowing under your mask as you watch this person that you loved dying — and the family mourning their death through a tablet.”
“It was completely devastating. It runs through your memory — you think about it all the time.”
Mostly, Sangrey said, she felt empty and exhausted. “You feel like this is never going to end — you feel defeated. But you have to continue moving forward,” she told me.
Three months later, when we spoke again, COVID-19 cases were rising in Pennsylvania but Sangrey sounded resolute. She’d had six sessions with a grief counselor and said it had become clear that “my purpose at this point is to take every ounce of strength I have and move through this second wave of COVID.”
“As human beings, it is our duty to be there for each other,” she continued. “You say to yourself, OK, I got through this last time, I can get through it again.”
That doesn’t mean that fear is absent. “All of us know COVID-19 is coming. Every day we say, ‘Is today the day it will come back? Is today the day I’ll find out I have it?’ It never leaves you.”
To this day, Silvestri feels horrified when she thinks about the end of March and early April at Greenville Center in Rhode Island, where up to 79 residents became ill with COVID-19 and at least 20 have died.
The coronavirus moved through the facility like wildfire. “You’re putting one patient on oxygen and the patient in the next room is on the floor but you can’t go to them yet,” Silvestri remembered. “And the patient down the hall has a fever of 103 and they’re screaming, ‘Help me, help me.’ But you can’t go to him either.”
“I left work every day crying. It was heartbreaking — and I felt I couldn’t do enough to save them.”
Then, there were the body bags. “You put this person who feels like family in a plastic body bag and wheel them out on a frame with wheels through the facility, by other residents’ rooms,” said Silvestri, who can’t smell certain kinds of plastic without reliving these memories. “Thinking back on it makes me feel physically ill.”
Silvestri, who has three children, developed a relatively mild case of COVID-19 in late April and returned to work several weeks later. Her husband, Michael, also became ill and lost his job as a truck driver. After several months of being unemployed, he’s now working at a construction site.
Since July 1, the family has gone without health insurance, “so I’m not able to get counseling to deal with the emotional side of what’s happened,” Silvestri said.
Although her nursing home set up a hotline number that employees could call, that doesn’t appeal to her. “Being on the phone with someone you don’t know, that doesn’t do it for me,” she said. “We definitely need more emotional support for health care workers.”
What does help is family. “I’ve leaned on my husband a lot and he’s been there for me,” Silvestri said. “And the children are OK. I’m grateful for what I have — but I’m really worried about what lies ahead.”
The Navigating Aging column last week focused on how nursing homes respond to grief sweeping through their facilities.
Join Judith Graham for a Facebook Live event on grief and bereavement during the coronavirus pandemic on Monday, Nov. 16, at 1 p.m. ET. You can watch the conversation here and submit questions in advance here.
We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.
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En su adolescencia, ayudó a sus padres, inmigrantes de Eritrea que hablaban poco inglés, a navegar el sistema de atención de salud en Oakland. Veía a médicos que eran irrespetuosos con su familia y que no se preocupaban por el tratamiento de la cirrosis, la hipertensión y la diabetes de su madre.
“Todas esas experiencias hicieron que no me gustaran los médicos”, dijo Asmerom.
“En mi comunidad siempre se decía: ‘Sólo ve al médico si estás a punto de morir’”.
Pero eso cambió cuando tomó un curso en la universidad sobre disparidades en salud. Se dio cuenta que otras comunidades de color sufrían lo mismo que su familia y amigos eritreos. Asmerom pensó que, como médica, podía ayudar a cambiar las cosas.
Hace tiempo que profesores y activistas estudiantiles de todo el país les piden a las escuelas de medicina que aumenten el número de estudiantes e instructores de comunidades poco representadas, para mejorar el tratamiento y fomentar la inclusión.
Pero para identificar las raíces del racismo y sus efectos en el sistema de salud, dicen, se deben hacer cambios fundamentales en los planes de estudio.
Asmerom es una de las muchas voces que piden una sólida educación antirracista. Exigen que las escuelas eliminen el uso de la raza como herramienta de diagnóstico, que reconozcan cómo el racismo sistémico perjudica a los pacientes, y que tengan en cuenta parte de la historia racista de la medicina.
Este activismo no es algo nuevo. White Coats for Black Lives (WC4BL), una organización dirigida por estudiantes que lucha contra el racismo en la medicina surgió a raíz de las protestas de Black Lives Matter en 2014.
Pero después del asesinato de George Floyd en Minneapolis, en mayo, las escuelas de medicina y las organizaciones médicas están bajo más presión para tomar medidas concretas.
Dejar de usar la raza como herramienta de diagnóstico
Durante muchos años, se ha enseñado a los estudiantes de medicina que las diferencias genéticas entre las razas tenían un efecto en la salud. Pero en los últimos años, estudios han encontrado que la raza no refleja eso de manera confiable.
El Instituto Nacional de Investigación del Genoma Humano observa muy poca variación genética entre las razas, y más diferencias entre las personas dentro de cada raza. Por eso, más médicos aceptan que la raza no es una diferencia biológica intrínseca, sino una construcción social.
Pero la doctora Brooke Cunningham, médica y socióloga en la Escuela de Medicina de la Universidad de Minnesota, señaló que en una idea difícil de abandonar. Forma parte de la manera en que los médicos diagnostican y miden las enfermedades, explicó.
Algunos médicos afirman que es útil tener en cuenta la raza cuando se trata a los pacientes; otros sostienen que conduce a prejuicios y a una atención deficiente.
Esas opiniones han llevado a una variedad de creencias falsas, como que los negros tienen la piel más gruesa, que su sangre se coagula más rápido que la de los blancos o que sienten menos dolor.
Cuando la raza interviene en los cálculos médicos, puede conducir a tratamientos menos eficaces y perpetuar las desigualdades basadas en la raza.
Uno de estos cálculos estima la función renal (eGFR, o la tasa estimada de filtración glomerular). El eGFR puede limitar el acceso de los pacientes negros a la atención médica porque el número utilizado para denotar la raza negra en la fórmula proporciona un resultado que sugiere que los riñones funcionan mejor de lo que lo hacen, según informaron recientemente los investigadores en el New England Journal of Medicine.
Entre otra docena de ejemplos que citan está una fórmula que los obstetras usan para determinar la probabilidad de un parto vaginal exitoso después de una cesárea, lo cual pone en desventaja a las pacientes negras no hispanas e hispanas, y un ajuste para medir la capacidad pulmonar usando un espirómetro, lo cual puede causar estimaciones inexactas de la función pulmonar para pacientes con asma o enfermedad pulmonar obstructiva crónica.
A la luz de estas investigaciones, los estudiantes de medicina piden a las escuelas que se replanteen los planes de estudio que tratan la raza como un factor de riesgo de enfermedad.
Briana Christophers, estudiante de segundo año en el Weill Cornell Medical College de Nueva York, dijo que no tiene sentido que la raza haga a alguien más propenso a las enfermedades, aunque los factores económicos y sociales jueguen un papel importante.
Naomi Nkinsi, estudiante de tercer año de la Escuela de Medicina de la Universidad de Washington en Seattle (UW Medicine), recordó haber asistido a una conferencia —junto a otras cuatro estudiantes negras en la sala— y haber oído que los negros son más propensos a enfermedades.
“Lo sentí muy personal”, expresó Nkinsi. “Ese es mi cuerpo, esos son mis padres, esos son mis hermanos. Ahora, cada vez que vaya a un consultorio, sentiré que no sólo no me consideran una persona completa, sino que soy físicamente diferente a todos los demás pacientes sólo porque tengo más melanina en la piel”.
Nkinsi ayudó en una exitosa campaña para excluir la raza del cálculo del eGFR en la UW Medicine, uniéndose a un pequeño número de otros sistemas de salud. Ella dijo que el logro, anunciado oficialmente a finales de mayo, se debió en gran parte a los incansables esfuerzos de los estudiantes negros.
Reconocer los efectos adversos del racismo en la salud
El Liaison Committee on Medical Education (LCME), órgano oficial de acreditación de las facultades de medicina de los Estados Unidos y Canadá, dice que se debe enseñar a los estudiantes a reconocer los prejuicios “en ellos mismos, en los demás y en el proceso de prestación de servicios de atención de la salud”.
Pero el LCME no exige explícitamente a las instituciones acreditadas que enseñen sobre el racismo sistémico en la medicina.
Esto es lo que los estudiantes y algunos profesores quieren cambiar.
El doctor David Acosta, jefe de diversidad e inclusión de la Asociación Americana de Escuelas de Medicina (AAMC, en inglés), reportó que cerca del 80% de las facultades ofrecen un curso obligatorio o electivo sobre disparidades en salud. Pero explicó que hay pocos datos sobre cuántas escuelas enseñan a los estudiantes a reconocer y combatir el racismo.
Un plan de estudios antirracista debería explorar formas de mitigar o eliminar el daño del racismo, indicó Rachel Hardeman, profesora de políticas de salud de la Universidad de Minnesota.
“Hay que pensar en cómo penetra esto en el aprendizaje de la educación médica”, dijo. Los cursos que profundizan en el racismo sistémico deben ser obligatorios, añadió Hardeman.
Edwin Lindo, profesor en la Escuela de Medicina de la Universidad de Washington, dijo que se debería adoptar un modelo interdisciplinario, permitiendo a sociólogos o historiadores dar conferencias sobre cómo el racismo perjudica la salud.
Acosta dijo que la AAMC ha organizado un comité de expertos para desarrollar un plan de estudios contra el racismo para cada nivel de la educación médica. Esperan hacer público su trabajo este mes y hablar con el LCME sobre el desarrollo e implementación de estándares.
“Nuestra próxima tarea es cómo persuadir e influenciar al LCME para que piense en añadir cursos de capacitación antirracista”, dijo Acosta.
Reconocer el racismo en el pasado y el presente de la educación médica
Los activistas quieren que sus instituciones reconozcan sus propios pasos en falso, así como el racismo que ha acompañado a los logros médicos del pasado.
Dereck Paul, estudiante de medicina en la Universidad de California-San Francisco, dijo que quiere que en todas las facultades se incluyan conferencias sobre personas como Henrietta Lacks, la mujer negra que se estaba muriendo de cáncer cuando le extrajeron células sin su consentimiento, que se utilizaron para desarrollar líneas celulares que han sido fundamentales en la investigación médica.
Asmerom puntualizó que quiere que la facultad reconozca el pasado racista de la medicina en las clases. Citó un curso introductorio de anatomía en su escuela que no señaló que en el pasado, cuando los científicos trataban de estudiar el cuerpo humano, los negros y otros grupos habían sido maltratados. “Es como, OK, ¿pero no vas a contar que sacaron de sus tumbas cuerpos de negros para usarlos en el laboratorio de anatomía?” preguntó.
Aunque a Asmerom le alegra ver que su facultad escucha las reivindicaciones estudiantiles, siente que los administradores deben reconocer sus errores del pasado reciente.
“Alguien tiene que admitir cómo se perpetuó el racismo anti-negro en esta institución”, dijo Asmerom.
Asmerom, una de las líderes de la Coalición Antirracista de la UCSD, aseguró que la administración ha respondido favorablemente hasta ahora a las demandas de la coalición de invertir tiempo y dinero en iniciativas antirracistas. Y se siente cautelosamente esperanzada.
“No me atrevo a aguantar la respiración hasta que vea cambios reales”, concluyó.
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This decision felt bigger than me, given all the weight that Black women’s hair carries. But after three months of wearing hats and scarves in a pandemic when trips to the hairdresser felt unsafe, I walked into a salon emotionally exhausted but ready to finally see my natural hair.
I thought a few tears would fall, but, as the last of my chemically straightened hair floated to the floor like rain, I felt cleansed. Free. I laughed hysterically as I drove away from the salon.
Friends and family cheered me on virtually, but my father quietly worried about my decision. My dad grew up in the Jim Crow South, where many women straightened their hair to land jobs, husbands and respect. Before my big chop, he never said much about my hair beyond the occasional compliment, which is why I was surprised when he issued a warning.
“Watch it out there. Your hair is cut now,” he blurted when he saw me walking out of the house.
My mother heard him but remained silent. She had her own set of concerns. She was worried about me looking less professional.
I also had to help my now 4-year-old daughter understand why I decided to go natural. We’ve watched the animated “Hair Love” a million times. We’ve read books like “Happy Hair” by Mechal Renee Roe, “I Love My Hair!” by Natasha Anastasia Tarpley and my personal favorite, “Don’t Touch My Hair!” by Sharee Miller.
Still, my daughter had a hard time adjusting to my new haircut, often asking when I planned to get my hair styled again. She preferred my extensions, saying she thought I looked more like a princess that way. I gently explained that my hair is a style — and the one I choose — even if it’s not long and straight.
My family’s emotions about my hair left me tangled.
Of course, the styling of Black hair has been fraught for centuries. The CROWN Act, which passed the U.S. House in September and is now pending in the Senate, is intended to protect Black people from discrimination in schools, housing and employment based on their hairstyle. But such a law, even if passed, cannot stop bigotry, bullets and the emotional battle that comes with being a Black woman in America as seen through something as simple as our hair.
I hadn’t considered talking to my daughter about how hair could affect her personal safety until my father broke his silence. A haircut shouldn’t influence your life expectancy.
On the night of my haircut, I drove to the store more aware of how others would perceive my new look. My father, however, was more worried about my safety because my silhouette could possibly be mistaken for a Black man’s frame.
We live in the Midwest, just outside St. Louis, where natural hair still makes a statement for Black women. If my buzz cut made me look more like a Black man, would the cops in our town treat me differently? In my dad’s eyes, my femininity increased my chances of making it home safely.
His comments also led to a conversation about the intersection between racism and sexism. Without reading the crucial work of scholar Kimberlé Crenshaw and other activists, my father intuitively understood that society has placed Black women in a blind spot, where our gender and our race make us invisible in many ways.
But that space isn’t safe, is it? A Eurocentric feminine hairstyle can’t protect Black women from the many deadly forms of racism.
Police officers can see us. Since 2015, at least 48 Black women have been killed by the police. I’m guessing the style of their hair didn’t matter to the officers pulling the triggers. In the past few years, the #SayHerName campaign has put a spotlight on their killings, but society still pays less attention to the police killings of Black women. While most people have heard of George Floyd, Michael Brown and Breonna Taylor, fewer know about Kathryn Johnston, Korryn Gaines and India Kager.
In death and life, our rights and our achievements don’t seem to hold as much weight compared with those of our male counterparts or our white ones. Yet, many Black women go to great lengths to be accepted in this country.
In the past few weeks, I’ve listened to other Black women in my life vent about their hair and navigating racism. We’ve shared our fears, hair horror stories and moments of victory. I’ve come to realize that my haircut wasn’t just about changing my style. It was also about reclaiming my crown after years of letting society control it.
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But there’s one question she still can’t answer: What makes some patients so much sicker than others?
Advancing age and underlying medical problems explain only part of the phenomenon, said Ranney, who has seen patients of similar age, background and health status follow wildly different trajectories.
“Why does one 40-year-old get really sick and another one not even need to be admitted?” asked Ranney, an associate professor of emergency medicine at Brown University.
In some cases, provocative new research shows, some people — men in particular — succumb because their immune systems are hit by friendly fire. Researchers hope the finding will help them develop targeted therapies for these patients.
In an international study in Science, 10% of nearly 1,000 COVID patients who developed life-threatening pneumonia had antibodies that disable key immune system proteins called interferons. These antibodies — known as autoantibodies because they attack the body itself — were not found at all in 663 people with mild or asymptomatic COVID infections. Only four of 1,227 healthy individuals had the autoantibodies. The study, published on Oct. 23, was led by the COVID Human Genetic Effort, which includes 200 research centers in 40 countries.
“This is one of the most important things we’ve learned about the immune system since the start of the pandemic,” said Dr. Eric Topol, executive vice president for research at Scripps Research in San Diego, who was not involved in the new study. “This is a breakthrough finding.”
In a second Science study by the same team, authors found that an additional 3.5% of critically ill patients had mutations in genes that control the interferons involved in fighting viruses. Given that the body has 500 to 600 of these genes, it’s possible researchers will find more mutations, said Qian Zhang, lead author of the second study.
Interferons serve as the body’s first line of defense against infection, sounding the alarm and activating an army of virus-fighting genes, said virologist Angela Rasmussen, an associate research scientist at the Center of Infection and Immunity at Columbia University’s Mailman School of Public Health.
“Interferons are like a fire alarm and a sprinkler system all in one,” said Rasmussen, who wasn’t involved in the new studies.
Lab studies show interferons are suppressed in some people with COVID-19, perhaps by the virus itself.
Interferons are particularly important for protecting the body against new viruses, such as the coronavirus, which the body has never encountered, said Zhang, a researcher at Rockefeller University’s St. Giles Laboratory of Human Genetics of Infectious Diseases.
When infected with the novel coronavirus, “your body should have alarms ringing everywhere,” said Zhang. “If you don’t get the alarm out, you could have viruses everywhere in large numbers.”
Significantly, patients didn’t make autoantibodies in response to the virus. Instead, they appeared to have had them before the pandemic even began, said Paul Bastard, the antibody study’s lead author, also a researcher at Rockefeller University.
For reasons that researchers don’t understand, the autoantibodies never caused a problem until patients were infected with COVID-19, Bastard said. Somehow, the novel coronavirus, or the immune response it triggered, appears to have set them in motion.
“Before COVID, their condition was silent,” Bastard said. “Most of them hadn’t gotten sick before.”
Bastard said he now wonders whether autoantibodies against interferon also increase the risk from other viruses, such as influenza. Among patients in his study, “some of them had gotten flu in the past, and we’re looking to see if the autoantibodies could have had an effect on flu.”
Scientists have long known that viruses and the immune system compete in a sort of arms race, with viruses evolving ways to evade the immune system and even suppress its response, said Sabra Klein, a professor of molecular microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health.
Antibodies are usually the heroes of the immune system, defending the body against viruses and other threats. But sometimes, in a phenomenon known as autoimmune disease, the immune system appears confused and creates autoantibodies. This occurs in diseases such as rheumatoid arthritis, when antibodies attack the joints, and Type 1 diabetes, in which the immune system attacks insulin-producing cells in the pancreas.
Although doctors don’t know the exact causes of autoimmune disease, they’ve observed that the conditions often occur after a viral infection. Autoimmune diseases are more common as people age.
In yet another unexpected finding, 94% of patients in the study with these autoantibodies were men. About 12.5% of men with life-threatening COVID pneumonia had autoantibodies against interferon, compared with 2.6% of women.
That was unexpected, given that autoimmune disease is far more common in women, Klein said.
“I’ve been studying sex differences in viral infections for 22 years, and I don’t think anybody who studies autoantibodies thought this would be a risk factor for COVID-19,” Klein said.
The study might help explain why men are more likely than women to become critically ill with COVID-19 and die, Klein said.
“You see significantly more men dying in their 30s, not just in their 80s,” she said.
Akiko Iwasaki, a professor of immunobiology at the Yale School of Medicine, noted that several genes involved in the immune system’s response to viruses are on the X chromosome.
Women have two copies of this chromosome — along with two copies of each gene. That gives women a backup in case one copy of a gene becomes defective, Iwasaki said.
Men, however, have only one copy of the X chromosome. So if there is a defect or harmful gene on the X chromosome, they have no other copy of that gene to correct the problem, Iwasaki said.
Bastard noted that one woman in the study who developed autoantibodies has a rare genetic condition in which she has only one X chromosome.
Scientists have struggled to explain why men have a higher risk of hospitalization and death from COVID-19. When the disease first appeared in China, experts speculated that men suffered more from the virus because they are much more likely to smoke than Chinese women.
Researchers quickly noticed that men in Spain were also more likely to die of COVID-19, however, even though men and women there smoke at about the same rate, Klein said.
Experts have hypothesized that men might be put at higher risk by being less likely to wear masks in public than women and more likely to delay seeking medical care, Klein said.
But behavioral differences between men and women provide only part of the answer. Scientists say it’s possible that the hormone estrogen may somehow protect women, while testosterone may put men at greater risk. Interestingly, recent studies have found that obesity poses a much greater risk to men with COVID-19 than to women, Klein said.
Yet women have their own form of suffering from COVID-19.
Studies show women are four times more likely to experience long-term COVID symptoms, lasting weeks or months, including fatigue, weakness and a kind of mental confusion known as “brain fog,” Klein noted.
As women, “maybe we survive it and are less likely to die, but then we have all these long-term complications,” she said.
After reading the studies, Klein said, she would like to learn whether patients who become severely ill from other viruses, such as influenza, also harbor genes or antibodies that disable interferon.
“There’s no evidence for this in flu,” Klein said. “But we haven’t looked. Through COVID-19, we may have uncovered a very novel mechanism of disease, which we could find is present in a number of diseases.”
To be sure, scientists say that the new study solves only part of the mystery of why patient outcomes can vary so greatly.
Researchers say it’s possible that some patients are protected by past exposure to other coronaviruses. Patients who get very sick also may have inhaled higher doses of the virus, such as from repeated exposure to infected co-workers.
Although doctors have looked for links between disease outcomes and blood type, studies have produced conflicting results.
Screening patients for autoantibodies against interferons could help predict which patients are more likely to become very sick, said Bastard, who is also affiliated with the Necker Hospital for Sick Children in Paris. Testing takes about two days. Hospitals in Paris can now screen patients on request from a doctor, he said.
Although only 10% of patients with life-threatening COVID-19 have autoantibodies, “I think we should give the test to everyone who is admitted,” Bastard said. Otherwise, “we wouldn’t know who is at risk for a severe form of the disease.”
Bastard said he hopes his findings will lead to new therapies that save lives. He notes that the body manufactures many types of interferons. Giving these patients a different type of interferon — one not disabled by their genes or autoantibodies — might help them fight off the virus.
In fact, a pilot study of 98 patients published Thursday in the Lancet Respiratory Medicine journal found benefits from an inhaled form of interferon. In the industry-funded British study, hospitalized COVID patients randomly assigned to receive interferon beta-1a were more than twice as likely as others to recover enough to resume their regular activities.
Researchers need to confirm these findings in a much larger study, said Dr. Nathan Peiffer-Smadja, a researcher at Imperial College London who was not involved in the study but wrote an accompanying editorial. Future studies should test patients’ blood for genetic mutations and autoantibodies against interferon, to see if they respond differently than others.
Peiffer-Smadja notes that inhaled interferon may work better than an injected form of the drug because it’s delivered directly to the lungs. While injected versions of interferon have been used for years to treat other diseases, the inhaled version is still experimental and not commercially available.
And doctors should be cautious about interferon for now, because a study led by the World Health Organization found no benefit to an injected form of the drug in COVID patients, Peiffer-Smadja said. In fact, there was a trend toward higher mortality rates in patients given interferon, although this finding could have been due to chance. Giving interferon later in the course of disease could encourage a destructive immune overreaction called a cytokine storm, in which the immune system does more damage than the virus.
Around the world, scientists have launched more than 100 clinical trials of interferons, according to clinicaltrials.gov, a database of research studies from the National Institutes of Health.
Until larger studies are completed, doctors say, Bastard’s findings are unlikely to change how they treat COVID-19.
Dr. Lewis Kaplan, president of the Society of Critical Care Medicine, said he treats patients according to their symptoms, not their risk factors.
“If you are a little sick, you get treated with a little bit of care,” Kaplan said. “You are really sick, you get a lot of care. But if a COVID patient comes in with hypertension, diabetes and obesity, we don’t say, ‘They have risk factors. Let’s put them in the ICU.’”
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“They were breaking up picnics. They were breaking up yoga groups,” said one graduate student, who asked not to be identified so as to avoid social media blowback. “Sometimes they’d ask you whether you actually lived in the dorm you were about to go into.”
Across the country in Boston, students at the Harvard Business School gathered for the new semester after being gently advised by the school’s top administrators, via email, that they were part of “a delicate experiment.” The students were given the ground rules for the term, then received updates every few days about how things were going. And that, basically, was that.
In the time of COVID-19, it’s fair to say that no two institutions have come to quite the same conclusions about how to proceed safely. But as Harvard’s and Stanford’s elite MBA-granting programs have proved, those paths can diverge radically, even as they may eventually lead toward the same place.
For months, college and university administrators nationwide have huddled with their own medical experts and with local and county health authorities, trying to determine how best to operate in the midst of the novel coronavirus. Could classes be offered in person? Would students be allowed to live on campus — and, if so, how many? Could they hang out together?
“The complexity of the task and the enormity of the task really can’t be overstated,” said Dr. Sarah Van Orman, head of student health services at the University of Southern California and a past president of the American College Health Association. “Our first concern is making sure our campuses are safe and that we can maintain the health of our students, and each institution goes through that analysis to determine what it can deliver.”
With a campus spread over more than 8,000 acres on the San Francisco Peninsula, Stanford might have seemed like a great candidate to host large numbers of students in the fall. But after sounding hopeful tones earlier in the summer, university officials reversed course as the pandemic worsened, discussing several possibilities before finally deciding to limit on-campus residential status to graduate students and certain undergrads with special circumstances.
The Graduate School of Business sits in the middle of that vast and now mostly deserted campus, so the thought was that Stanford’s MBA hopefuls would have all the physical distance they needed to stay safe. Almost from the students’ arrival in late August, though, Stanford’s approach was wracked by missteps, policy reversals and general confusion over what the COVID rules were and how they were to be applied.
Stanford’s business grad students were asked to sign a campus compact that specified strict safety measures for residents. Students at Harvard Business School signed a similar agreement. In both cases, state and local regulations weighed heavily, especially in limiting the size of gatherings. But Harvard’s compact emerged fully formed and relied largely on the trustworthiness of its students. The process at Stanford was unexpectedly torturous, with serial adjustments and enforcers who sometimes went above and beyond the stated restrictions.
Graduate students there, mobilized by their frustration over not being consulted when the policy was conceived, urged colleagues not to sign the compact even though they wouldn’t be allowed to enroll in classes, receive pay for teaching or live in campus housing until they did. Among their objections: Stanford’s original policy had no clear appeals process, and it did not guarantee amnesty from COVID violation punishments to those who reported a sexual assault “at a party/gathering of multiple individuals” if the gathering broke COVID protocols.
Under heavy pressure, university administrators ultimately altered course, solicited input from the grad student population and produced a revised compact addressing the students’ concerns in early September, including the amnesty they sought for reporting sexual assault. But the Stanford business students were already unsettled by the manners of enforcement, including the specter of vest-wearing staffers roaming campus.
According to the Stanford Daily, nine graduate students were approached in late August by armed campus police officers who said they’d received a call about the group’s outdoor picnic and who — according to the students — threatened eviction from campus housing as an ultimate penalty for flouting safety rules. “For international students, [losing] housing is really threatening,” one of the students told the newspaper.
The people in the vests were Event Services staff working as “Safety Ambassadors,” Stanford spokesperson E.J. Miranda wrote in an email. The staffers were not on campus to enforce the compact, but rather were “emphasizing educational and restorative interventions,” he said. Still, when the university announced the division of its campus into five zones in September, it told students in a health alert email that the program “will be enforced by civilian Stanford representatives” — the safety ambassadors.
The Harvard Business School’s approach was certainly different in style. In July, an email from top administrators reaffirmed the school’s commitment to students living on campus and taking business classes in person in a hybrid learning model. As for COVID protocols, the officials adopted “a parental tone,” as the graduate business education site Poets & Quants put it. “All eyes are on us,” the administrators wrote in an August email.
But the guts of the school’s instructions were similar to those at Stanford. Both Harvard and Stanford severely restricted who could be on campus at any given time, limiting access to students, staff members and preapproved visitors. Both required that anyone living on campus report their health daily through an online portal, checking for any symptoms that could be caused by COVID-19. Both required face coverings when outside on campus — even, a Harvard missive said, in situations “when physical distancing from others can be maintained.”
So far, both Harvard and Stanford have posted low positive test rates overall, and the business schools are part of those reporting totals, with no significant outbreaks reported. Despite their distinct delivery methods, the schools ultimately relied on science to guide their COVID-related decisions.
“I feel like we’ve been treated as adults who know how to stay safe,” said a Harvard second-year MBA candidate who requested anonymity. “It’s worked — at least here.”
But as the experiences at the two campuses show, policies are being written and enforced on the fly, in the midst of a pandemic that has brought challenge after challenge. While the gentler approach at Harvard Business School largely worked, it did so within a larger framework of the health regulations put forth by local and county officials. As skyrocketing COVID-19 rates across the nation suggest, merely writing recommendations does little to slow the spread of disease.
Universities have struggled to strike a balance between the desire to deliver a meaningful college experience and the discipline needed to keep the campus caseload low in hopes of further reopening in 2021. In Stanford’s case, that struggle led to overreach and grad-student blowback that Harvard was able to avoid.
The fall term has seen colleges across the country cycling through a series of fits and stops. Some schools welcomed students for in-person classes but quickly reverted to distance learning only. And large campuses, with little ability to maintain the kind of control of a grad school, have been hit tremendously hard. Major outbreaks have been recorded at Clemson, Arizona State, Wisconsin, Penn State, Texas Tech — locations all over the map that opened their doors with more students and less stringent guidelines.
In May, as campuses mostly shut down to consider their future plans, USC’s Van Orman expressed hope that universities’ past experiences with international students and global outbreaks, such as SARS, would put them in a position to better plan for COVID-19. “In many ways, we’re one of the best-prepared sectors for this test,” she said.
Six months later, colleges are still being tested.
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As scientists have come to know the disease better, they have homed in on the vascular system — the body’s network of arteries, veins and capillaries, stretching more than 60,000 miles — to understand this wide-ranging disease and to find treatments that can stymie its most pernicious effects.
Some of the earliest insights into how COVID-19 can act like a vascular disease came from studying the aftermath of the most serious infections. Those reveal that the virus warps a critical piece of our vascular infrastructure: the single layer of cells lining the inside of every blood vessel, known as the endothelial cells or simply the endothelium.
Dr. William Li, a vascular biologist, compares this lining to a freshly resurfaced ice rink before a hockey game on which the players and pucks glide smoothly along.
“When the virus damages the inside of the blood vessel and shreds the lining, that’s like the ice after a hockey game,” said Li, a researcher and founder of the Angiogenesis Foundation. “You wind up with a situation that is really untenable for blood flow.”
In a study published this summer, Li and an international team of researchers compared the lung tissues of people who died of COVID-19 with those of people who died of influenza. They found stark differences: The lung tissues of the COVID victims had nine times as many tiny blood clots (“microthrombi”) as those of the influenza victims, and the coronavirus-infected lungs also exhibited “severe endothelial injury.”
“The surprise was that this respiratory virus makes a beeline for the cells lining blood vessels, filling them up like a gumball machine and shredding the cell from the inside out,” Li said. “We found blood vessels are blocked and blood clots are forming because of that lining damage.”
It’s already known that the coronavirus breaks into cells by way of a specific receptor, called ACE2, which is found all over the body. But scientists are still trying to understand how the virus sets off a cascade of events that cause so much destruction to blood vessels. Li said one theory is that the virus directly attacks endothelial cells. Lab experiments have shown that the coronavirus can infect engineered human endothelial cells.
It’s also possible the problems begin elsewhere, and the endothelial cells sustain collateral damage along the way as the immune system reacts — and sometimes overreacts — to the invading virus.
Endothelial cells have a slew of important jobs; these include preventing clotting, controlling blood pressure, regulating oxidative stress and fending off pathogens. And Li said uncovering how the virus jeopardizes the endothelium may link many of COVID-19’s complications: “the effects in the brain, the blood clots in the lung and elsewhere in the legs, the COVID toe, the problem with the kidneys and even the heart.”
In Spain, skin biopsies of distinctive red lesions on toes, known as chilblains, found viral particles in the endothelial cells, leading the authors to conclude that “endothelial damage induced by the virus could be the key mechanism.”
Is Blood Vessel Damage Behind COVID Complications?
“The endothelium has developed a distant early warning system to alert the body to get ready for an invasion if there’s trouble brewing,” said Dr. Peter Libby, a cardiologist and research scientist at Harvard Medical School. When that happens, endothelial cells change the way they function, he said. But that process can go too far.
“The very functions that help us maintain health and fight off invaders, when they run out of control, then it can actually make the disease worse,” Libby said.
In that case, the endothelial cells turn against their host and start to promote clotting and high blood pressure.
“In COVID-19 patients, we have both of these markers of dysfunction,” said Dr. Gaetano Santulli, a cardiologist and researcher at the Albert Einstein College of Medicine in New York City.
The novel coronavirus triggers a condition seen in other cardiovascular diseases called endothelial dysfunction. Santulli, who wrote about this idea in the spring, said that may be the “cornerstone” of organ dysfunction in COVID patients.
“The common denominator in all of these COVID-19 patients is endothelial dysfunction,” he said. “It’s like the virus knows where to go and knows how to attack these cells.”
Runaway Immune Response Adds a Plot Twist
A major source of damage to the vascular system likely also comes from the body’s own runaway immune response to the coronavirus.
“What we see with the SARS-CoV-2 is really an unprecedented level of inflammation in the bloodstream,” said Dr. Yogen Kanthi, a cardiologist and vascular medicine specialist at the National Institutes of Health who’s researching this phase of the illness. “This virus is leveraging its ability to create inflammation, and that has these deleterious, nefarious effects downstream.”
When inflammation spreads through the inner lining of the blood vessels — a condition called endothelialitis — blood clots can form throughout the body, starving tissues of oxygen and promoting even more inflammation.
“We start to get this relentless, self-amplifying cycle of inflammation in the body, which can then lead to more clotting and more inflammation,” Kanthi said.
Another sign of endothelial damage comes from analyzing the blood of COVID patients. A recent study found elevated levels of a protein produced by endothelial cells, called von Willebrand factor, that is involved in clotting.
“They are through the roof in those who are critically ill,” said Dr. Alfred Lee, a hematologist at the Yale Cancer Center who coauthored the study with Hyung Chun, a cardiologist and vascular biologist at Yale.
Lee pointed out that some autoimmune diseases can lead to a similar interplay of clotting and inflammation called immunothrombosis.
Chun said the elevated levels of von Willebrand factor show that vascular injury can be detected in patients while in the hospital — and perhaps even before, which could help predict their likelihood of developing more serious complications.
But he said it’s not yet clear what is the driving force behind the blood vessel damage: “It does seem to be a progression of disease that really brings out this endothelial injury. The key question is, what’s the root cause of this?”
After they presented their data, Lee said, Yale’s hospital system started putting patients who were critically ill with COVID-19 on aspirin, which can prevent clotting. While the best combinations and dosages are still being studied, research indicates blood thinners may improve outcomes in COVID patients.
Chun said treatments are also being studied that may more directly protect endothelial cells from the coronavirus.
“Is that the end-all-be-all to treating COVID-19? I absolutely don’t think so. There’s so many aspects of the disease that we still don’t understand,” he said.
COVID Is Often a Vascular ‘Stress Test’
Early in the pandemic, Dr. Roger Seheult, a critical care and pulmonary physician in Southern California, realized the patients he expected to be most vulnerable to a respiratory virus, those with underlying lung conditions such as chronic obstructive pulmonary disease and asthma, were not the ones ending up disproportionately in his intensive care unit. Seheult, who runs the popular medical education website MedCram, said, “Instead, what we are seeing are patients who are obese, people who have large BMIs, people who have Type 2 diabetes and with high blood pressure.”
Over time, all those conditions can cause inflammation and damage to the lining of blood vessels, he said, including a harmful chemical imbalance known as oxidative stress. Seheult said infection with the coronavirus becomes an added stress for people with those conditions that already tax the blood vessels: “If you’re right on the edge and you get the wind blown from this coronavirus, now you’ve gone over the edge.”
He said the extensive damage to blood vessels could explain why COVID patients with severe respiratory problems don’t necessarily resemble patients who get sick from the flu.
“They are having shortness of breath, but we have to realize the lungs are more than just the airways,” he said. “It’s an issue with the blood vessels themselves.”
This is why COVID patients struggle to fill their blood supply with oxygen, even when air is being pumped into their lungs.
“The endothelial cells get leaky, so instead of being like saran wrap, it turns into a sieve and then it allows fluid from the bloodstream to accumulate in the air spaces,” Harvard’s Libby said.
Doctors who treat COVID-19 are now keenly aware that complications such as strokes and heart problems can appear even after a patient gets better and their breathing improves.
“They are off oxygen, they can be discharged home, but their vasculature is not completely resolved. They still have inflammation,” he said. “What can happen is they develop a blood clot, and they have a massive pulmonary embolism.”
Patients can be closely monitored for these problems, but one of the big unknowns for doctors and patients is the long-term effects of COVID-19 on the circulatory system. The Angiogenesis Foundation’s Li puts it this way: “The virus enters your body and it leaves your body. You might or might not have gotten sick. But is that leaving behind a trashed vascular system?”
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