Category: Corona Virus

A 1960s health poster from the National Tuberculosis Association indicates that TB was still a problem in the U.S. in that decade. Universal History Archive/Universal Images Group via Getty hide caption

A 1960s health poster from the National Tuberculosis Association indicates that TB was still a problem in the U.S. in that decade.

As the world battles the deadly coronavirus, there is a lot we can learn from one of the great pandemics of recent centuries: tuberculosis.

Like the bug that has caused the newest global outbreak, TB is spread through the air. Every exhaled breath by a person with the disease can spread the tuberculosis bacteria to new individuals. TB is thought to have killed 1 billion people between 1800 and 2000. It attacks the human body more slowly than viral diseases like flu or COVID-19, but exacts a great toll. Untreated TB is a death sentence for 80 percent of those who fall ill.

Although TB still kills 4,000 people every day in poor countries, it largely disappeared in wealthy countries after the 1950s through a set of tried and tested strategies which suggests important lessons for how to stop the newest plague.

Current efforts to battle COVID-19 focus largely on reducing transmission by quarantine and physical distancing and by providing hospital care for the severely ill. But as scientists discovered with TB, the secret is not to put the everyday life of the community on indefinite hold, but rather to make it progressively safer. The focus of stopping transmission and delivering care should not only be on hospitals, but also in the communities where people live and work: their homes, schools and workplaces. Using this approach, wealthy countries turned the airborne scourge of TB from the leading cause of death at the end of the 19th century to a tiny fraction of all infections only 60 years later.

How did public health agencies, municipalities and private partners do it? Aided by a flurry of diagnostic and treatment innovations in the early to mid-20th century, they stopped TB using a community-based strategy called "search, treat and prevent."

First they searched for contacts of known patients. In communities where TB was rampant, they went house-by-house looking for people who had the disease and were transmitting it to others. "Searching" meant giving thousands of people skin tests and chest X-rays, in many cases with mobile vans.

Then they treated the sick first with food, rest and basic nursing care, and later with medicines. This was done in combination with social and financial support for those who were ill with TB. This freed people from the need to keep working to support themselves and their families, spreading the illness in the process. Finally, starting in the early 1960s, they stopped further spread of the microbe by giving preventive therapy to exposed individuals before they became sick.

In the U.S., all this was made possible through an infusion of resources from national, state and local governments and by voluntary contributions from organizations like the National Tuberculosis Association, as well as employers and labor unions.

The results were stunning: "Search, treat and prevent" helped the U.S. and other wealthy countries stop TB in its tracks. A disease which had been a plague on mankind since the beginning of the modern era was brought to heel in the period from the 1950s to the 1970s fewer than 20 years.

The lesson for coronavirus? Community-focused mobilization using the "search, treat and prevent" approach could be transformative. Although physical distancing may indeed be necessary in the short term, its economic cost is devastating, particularly for those who cannot work from home or who work in industries that depend on social interaction. The dislocation caused by quarantines the destruction of social bonds and livelihoods may in the end be as harmful to health and well-being as the pandemic itself. Moreover, countries relaxing quarantines have seen transmission begin anew from carriers who are not showing symptoms.

So there is much reason to believe that physical distancing and quarantine alone will not stop the epidemic.

The announcement last Friday of a point-of-care test that can accurately diagnose the coronavirus in as little as five minutes is a game-changer. With such technology we can identify hot spots whose residents need to practice physical distancing, provide community-based care to those not sick enough to be in hospitals, and when preventive medicines, new treatments and vaccines become available deliver these tools to those who could benefit most.

After a few weeks of physical distancing, this approach would help to identify groups of individuals and even entire communities that could resume their regular economic and social life. Re-entry would require access to masks and other protective equipment for community members as these items become more available and more widespread application of tools like indirect UVC lamps in stores and closed work spaces. UVC light has been shown to kill tuberculosis, influenza, coronaviruses and other pathogens that linger in the air and on exposed surfaces in public spaces.

To implement this strategy we would need to give people access to free testing, treatment, medicines and the necessary resources to sustain themselves through any physical distancing. It would be carried out by neighborhood-based teams of professional and lay health workers trained to safely conduct screening, provide basic treatment at home, and give social and economic support to those in isolation. This is exactly what happened after 1963, when a wave of federal funding for the "approach to zero for TB" helped establish community-based health teams in every U.S. state and territory.

The organization and funding of these teams would vary in different national and local settings. In the U.S. during the 1960s and '70s, community-based TB interventions were overseen by municipal public health authorities with funding from federal, state and private sources.

Community-wide coronavirus teams would also, as health expert Dr. Joia Mukherjee has pointed out, employ thousands of people, helping to mitigate the economic impact of the pandemic.

A community-wide coronavirus strategy would require large-scale investment in manufacturing a variety of tests, personal protection equipment and UVC lighting, as well as rapid training and mobilization of community health teams. But given the potential contribution to restarting local economies put in limbo by the epidemic, the cost will be modest. We have entered a state of emergency that upends the logic of austerity that led to decades of public health cutbacks.

The federal coronavirus relief bill just signed by President Trump provides $500 million for patient tracking and data collection alone. States have also begun to open their coffers and are likely to make millions available to stop this epidemic. We have to ensure that these resources are spent on approaches that can help restore our daily lives and livelihoods.

The "search, treat and prevent" strategy that stopped TB in wealthy countries was never expanded to poor countries because of fear that it would be too difficult to do there. It would be a mistake to make this same decision with the coronavirus. This global pandemic has exposed the same truth as climate change: On an ecologically interconnected planet, piecemeal approaches are doomed. As soon as we have working models of this approach in the U.S., we should ensure that they are expanded to at-risk settings all over the world.

Using the full array of technological and programmatic tools at our disposal can help us bring the pandemic to a close with a minimum loss of life, while avoiding an economic crash that would throw millions of people around the world into poverty, with an equally devastating public health impact.

We need to lay a foundation that will ensure that when we leave our homes in weeks or months, we are better prepared and safer than when the outbreak began. The community-wide approach can ensure that we find the sick and begin the process of healing. And with the right resources, it can begin today.

Salmaan Keshavjee is a professor of global health and social medicine at Harvard Medical School and Director of the Harvard Medical School Center for Global Health Delivery. He is a physician at Boston's Brigham and Women's Hospital and senior TB specialist at the Boston-based nonprofit Partners In Health. He is a member of the Council on Foreign Relations. His twitter handle is @s_keshavjee.

Aaron Shakow is director of the Initiative on Healing and Humanity at the Harvard Medical School Center for Global Health Delivery and a research associate in the department of global health and social medicine. A historian by training, he focuses his research on the social and political history of epidemics and quarantine.

Tom Nicholson is executive director of Advance Access and Delivery, a North Carolina-based nonprofit committed to improving access to high-quality health care. He is also a research associate at Duke University's Sanford School of Public Policy in the Duke Center for International Development. He is a member of the board of directors of the Global Health Council.

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The Fight Against Coronavirus Could Take A Lesson From The Fight Against TB : Goats and Soda - NPR

Is it safe to go outside?

Even if coronavirus particles can move through the air, they would still diffuse over distance. People envision these clouds of viruses roaming through the streets coming after them, but the risk of [infection] is higher if youre closer to the source, says Linsey Marr, who studies airborne disease transmission at Virginia Tech. The outside is great as long as youre not in a crowded park.

In February, scientists in Wuhan, Chinawhere the coronavirus outbreak originatedsampled the air in various public areas, and showed that the virus was either undetectable or found in extremely low concentrations. The only exceptions were two crowded sites, one in front of a department store and another next to a hospital. Even then, each cubic meter of air contained fewer than a dozen virus particles. (No one knows the infectious dose of SARS-CoV-2that is, the number of particles needed to start an infectionbut for the original SARS virus of 2003, one study estimated somewhere between 43 and 280.)

These particles might not even have been infectious. I think well find that like many other viruses, [SARS-CoV-2] isnt especially stable under outdoor conditions like sunlight or warm temperatures, Santarpia said. Dont congregate in groups outside, but going for a walk, or sitting on your porch on a sunny day, are still great ideas.

Read: This is how we can beat the coronavirus

You could tie yourself in knots gaming out the various scenarios that might pose a risk outdoors, but Marr recommends a simple technique. When I go out now, I imagine that everyone is smoking, and I pick my path to get the least exposure to that smoke, she told me. If thats the case, I asked her, is it irrational to hold your breath when another person walks past you and you dont have enough space to move away? Its not irrational; I do that myself, she said. I dont know if it makes a difference, but in theory it could. Its like when you walk through a cigarette plume.

Indoors, experts opinions start to diverge. Consider, for example, the grocery storeone of the last vestiges of public life. There, Santarpia is far more concerned about touching shared surfaces than breathing shared air, and he makes sure to sanitize his hands before he leaves. Marr said that she tries to go when its less crowded, although thats obviously harder in a big city. Bourouibas best advice is to always keep as much distance from other people as possible, and she adds that the onus is on stores to improve their ventilation or limit the number of concurrent customers. Stores must also devise ways of protecting the people at greatest risk: the cashiers and the workers stocking shelves.

Then there are shared spaces like hallways, stairwells, and elevators in apartment buildings. Elevators pose the highest risk, Bourouiba told me, since theyre enclosed boxes with limited airflow. For stairwells and hallways, she advocated a commonsense approach: If you hear neighbors going out, and there are 10 people in the corridor right now, maybe wait and go later.

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Everyone Thinks Theyre Right About Masks - The Atlantic

The initial guidance, issued by the I.R.S. on Monday, drew criticism from lawmakers in both parties. Representative Richard E. Neal, Democrat of Massachusetts and chairman of the House Ways and Means Committee, urged Treasury Secretary Steven Mnuchin and Social Security officials to find a solution that did not involve filing an additional return. Senator Tom Cotton, Republican of Arkansas, wrote on Twitter that he was extremely disappointed in the I.R.S.

The reversal should allow Social Security recipients to avoid filing an unexpected return, but the same cannot be said for many others who do not normally have to file.

The I.R.S. guidance acknowledged the potential complexity for low-income Americans, and the agency said it would soon offer instructions on its website for filing a 2019 tax return that contained simple, but necessary, information including their filing status, number of dependents and direct deposit bank account information.

Filing even the simplest of returns could pose challenges during a pandemic. The I.R.S. does have a free filing site, but those who lack internet access could be unable to use it because nonprofits, libraries and other places are closed. Low-income filers, however, will have until the end of the year to file and still get their stimulus payments.

The decision to require more people to file returns puzzled policy experts, who said the government had the ability to crosscheck various databases to make sure it reached everyone who was eligible, including those who would have the greatest need.

The matching part may take longer, and its legitimate for them to say that one group will get payments faster and one group will be slower, said Ms. Parrott, who worked in the federal Office of Management and Budget during the Obama administration. But to throw up their hands and say they cant do it? They have the capacity to do it, and I think they need the leadership to say that they are going to get this done.

There will be an extra layer of difficulty for people who dont normally file a return and lack a standard checking account.

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Needy Will Face Hurdles to Getting Coronavirus Stimulus - The New York Times

This dynamic has played out over the past few weeks, and was on full display again during the White House briefing on Tuesday. Trump said the drugs might be a "total game-changer" and implied that good news from clinical trials was just days away, only to be corrected by the nation's top infectious disease expert, who steered clear of glowing superlatives and said the research will take months, "at very best."

Trump went even further on Tuesday, falsely suggesting that the drugs have already been proven safe. "Very powerful drug, but it's been out there for a long time," he said at the daily White House coronavirus briefing. "So, it's tested in the sense that you know it doesn't kill you."

Doctors say he's wrong, and that comments like these could have deadly consequences.

"As the dose of chloroquine goes up, it goes from being safe and effective to highly toxic, quickly," said Dr. Christopher Plowe, a renowned malaria expert at the Duke Global Health Institute. "It's very easy to overdose on chloroquine. You get above the ceiling of safety pretty quickly. There are some very serious risks here. There's quite a bit to lose, including your life."

Experts like Plowe who study these drugs, and doctors who are prescribing them, agree with the public health officials that clinical trials will tell whether Trump's optimism is well-placed.

Testing is underway, including a large study in New York, the epicenter of the US outbreak with more than 75,000 cases, the most of any state in the country. New York public health authorities have obtained at least 1 million doses of hydroxychloroquine, which will be used for a large-scale clinical trial, an official at the New York State Department of Health told CNN.

Optimism versus science

Regardless, within 48 hours, Trump sprang into action and began touting the study and the drugs, and has done so at least a dozen times in two weeks, according to a CNN analysis.

Senior Trump administration officials and public health experts followed suit, partially walking back Trump's comments with their own tempered takes, often from the very same podium.

When a journalist asked Dr. Anthony Fauci, the nation's top infectious disease expert, if these medicines could prevent Covid-19, Fauci gave a crystal-clear response: "The answer is no."

Dr. Deborah Birx, the response coordinator for the White House's coronavirus task force, said, "We're trying to figure out how many anecdotal reports equal real scientific breakthrough," when asked about the drugs.

The FDA Commissioner, Dr. Stephen Hahn, said a "large, pragmatic clinical trial" is still needed to "actually gather that information and answer the question that needs to be answered," as to whether the drugs are effective and safe to use during the worsening coronavirus pandemic.

The report said more research is needed to corroborate the French study. If those early results are accurate, "this would be the first time chloroquine or hydroxychloroquine was found to be effective for the clinical management of a viral infection," the report said, because previous clinical trials determined that the drugs had no impact on other viruses like influenza and HIV.

Balancing benefits and risks

Senior public health officials like Fauci and Hahn have said Trump wants to strike an optimistic tone to keep hope alive among Americans who are worried about their health and their paycheck. But there are risks, both to public health and in the presidential campaign unfolding in the background, in over-promising when it comes to things like drug treatments during an epidemic.

"Medical history has so many examples of treatments that people had good experiences with, and people got better, and they had great confidence in the treatment, and years later when a randomized trial was done, it turned out no better than placebo," said Plowe, the Duke expert.

Even with that uncertainty, some doctors on the frontlines say there aren't many other options.

"The FDA made a difficult decision, but they were right," Colyer told CNN. "We won't have all the hard data we want for months. But at this point, this is one of the most promising treatments out there. We need to understand all these drugs better, but we're in a unique situation."

Regardless of Trump's glowing rhetoric about the medicines, Colyer said the FDA "made a finding after reviewing all the literature" that is available, even though the research is limited.

"They've seen the plusses and the minuses and made a professional decision," he added.

CNN's Elizabeth Cohen, Brynn Gingras and Tara Subramaniam contributed to this article.

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The dangerous disconnect between Trump's rhetoric and the reality for potential coronavirus treatments - CNN

The actress and wife of "Good Morning America anchor George Stephanopoulos, took to Instagram with the news on Wednesday, writing: "I have tested positive for the Corona Virus. I've never been sicker. High fever. Horrific body aches. Heavy chest. I'm quarantined from my family. This is pure misery. #stayhome"

Wentworth is home with Stephanopoulos and their two daughters, but is self-isolating in a separate room.

She called into "GMA" Thursday to say "First of all, thank you for all your well-wishes" and joked, "You know I'm feverish if I'm allowing myself to go on national television with no makeup on."

She explained how she started to feel ill while out walking her dog.

"What started was I had a real tightness in my chest. I was walking my dog Cooper, and I just felt very, very winded and I assumed, of course, it was because I never work out and I'm out of shape, but it was it was too heavy for that," she said via video from bed.

Wentworth said she wasn't feeling great, then she got a fever.

"And it wasn't until the fever started that I realized this can't be a common summer cold," she said. "I went and got tested ... which was three days ago, and now I've had high fevers, sort of 101, 103."

Suffering also from achy joints and flu-like symptoms, she advised that the "things that help are Tylenol, chicken soup. I took some hot baths when I had chills and I have two dogs that sleep on my bed with me."

She also warned people to stay home.

Stephanopoulos is the only one who is going in the room to help Wentworth, he said on "GMA."

"I have to get a little bit close sometimes to take her temperature and do the oxygen test and I bring her food," he said. "I'm definitely being careful in wiping down and wearing gloves. I have not been wearing a mask."

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Ali Wentworth shares coronavirus diagnosis and says she's 'never been sicker' - CNN

As the coronavirus spreads across the country, millions of Americans already struggling with health and finances especially those in minority communities could bear the brunt of it.

New data released Tuesday by the Centers for Disease Control and Prevention show that COVID-19 patients with underlying health issues in the United States are more likely to need treatment in a hospital or even in an intensive care unit. They are also at higher risk of dying, according to earlier epidemiological data from both China and the U.S.

Because health and wealth in the U.S. are so often linked, the coronavirus could hit low-income populations here much harder, experts say.

The elderly are the hardest hit by the disease, accounting for about 80% of fatal cases in China and the U.S., according to CDC data.

But studies have also shown that underlying health issues such as asthma, diabetes and heart disease can also make COVID-19 more dangerous, as the disease taxes already-burdened organs.

Whenever there is a disaster, people in low-income groups always tend to be the most impacted.

Pinar Keskinocak, Georgia Institute of Technology

More than a third of American adults 105 million people are at higher risk of serious illness if they get infected with the coronavirus, according to a Kaiser Family Foundation analysis of CDC data. For most of them, their age puts them in danger: More than 76 million Americans are 60 or older. The remaining 29 million people are younger but have underlying health issues.

Age and underlying health issues go hand in hand: COVID-19 has so far been most menacing to older people with underlying illnesses. But the disease has already killed younger Americans for example, a 34-year-old California man who had asthma and a 44-year-old Louisiana woman who had unspecified underlying illnesses.

Weakened already

More than three-quarters of the COVID-19 patients who required ICU treatment in the U.S. had underlying health issues, including heart disease, diabetes and chronic lung conditions, according to the new CDC data on 6,600 cases for which underlying conditions and hospitalization status were reported. Certain underlying conditions were more likely to lead to intensive care in the hospital for instance, of the COVID-19 patients who had underlying heart disease in that same CDC analysis, 21.5% landed in the ICU.

Don't see the graphic above? Click here.

Chinese scientists have also reported that heart disease, nearly as much as age, was a reliable indicator of whether a COVID-19 patient would require advanced medical treatment. And COVID-19 patients with underlying conditions in China were also more likely to die. About 10% of Chinese patients with cardiovascular problems died. For diabetes patients, the results were similar: More than 7% died. That's compared with 0.9% of patients with no underlying illness.

Don't see the graphic above? Click here.

Doctors around the world have also reported that some patients with severe COVID-19 were having heart attacks and other heart complications while hospitalized for the coronavirus, though those reports are still anecdotal.

Other viruses that attack the lungs, such as the flu, also affect the heart, says Dr. R. Scott Stephens, who runs an intensive care unit at Johns Hopkins Hospital in Baltimore. So it makes sense that underlying heart disease would make the coronavirus more dangerous.

"We're thinking about plans for 'How do we screen patients for this? What are interventions that we can use?'" Stephens says. "It's kind of like you're on the beach waiting for the wave to hit. You just don't know when it's going to hit and how big it's going to be."

In the U.S., African Americans are far more likely to have fatal heart conditions than other groups, says Donna Spiegelman, a biostatistician and epidemiologist at the Yale School of Medicine. Researchers worry that this means the U.S. could end up with noticeable disparities in who dies from the coronavirus.

In 2017, the latest year for which data are available, African Americans died from heart disease at a rate of 208 per 100,000, while whites died at a rate of 169 per 100,000. Other racial and ethnic groups' rates were even lower.

"I would expect there would be racial and ethnic disparities simply based on the disease burden that is already present," says Leonard Friedman, a professor of health policy and management at George Washington University.

Don't see the graphic above? Click here.

The coronavirus could also exacerbate regional disparities, as heart disease takes a greater toll on some areas of the country than others. The map above shows that Appalachia, rural northwest Mississippi and eastern Michigan, including Detroit, are among areas with high percentages of Medicare recipients hospitalized for heart disease.

Low-income health struggles

In the U.S., people who struggle financially often struggle to stay healthy. The coronavirus could attack their lives at all angles, experts say: They are more likely to have underlying health issues, putting them at higher risk of serious complications and death. They are more likely to have jobs that do not allow them to work from home, increasing their likelihood of being exposed to the virus. And they are more likely to be underinsured, potentially keeping them from seeking treatment until it's too late.

"You start with those underlying conditions, and then each layer of this is just going to magnify that further," says Jon Zelner, a University of Michigan epidemiologist. "You may see disparities in who dies and who becomes ill."

During the 1918 Spanish flu pandemic, people who lived in Chicago neighborhoods with low literacy rates were more likely to die than people living in neighborhoods with high literacy rates, according to a 2016 study published by the National Academy of Sciences.

"Whenever there is a disaster," says Pinar Keskinocak, a professor at Georgia Institute of Technology who specializes in infectious disease modeling, "I think unfortunately people with low income and in low-income groups always tend to be the most impacted."

People in rural areas may have to travel farther to reach a doctor or a hospital with a ventilator if they find themselves short of breath with the coronavirus, but they aren't the only ones with barriers to accessing health care. Studies have shown that low-income people in urban areas also struggle to get to their doctor.

"Low-income populations are going to be hit regardless of where they live, rural or urban," says Julie Swann, an industrial engineering professor at North Carolina State University who has helped build models predicting how pandemics could spread. "If someone is not able to get in early enough to get appropriate care, then their situation could escalate, and they could end up in the hospital."

Don't see the graphic above? Click here.

But rural areas often do have weaker defenses against public health crises. The map above shows places the CDC says are more vulnerable to "stresses on human health" because of a combination of factors including poverty, education levels, housing quality and other issues like lack of access to transportation.

Counties along the border with Mexico, wide swaths of the South and sparsely populated areas in Alaska stand out as just a few of the places with few tools to fight the coronavirus.

Many rural hospitals have shuttered after years of financial hardship, and the ones that remain open often have small staffs without the layers of specialized doctors and critical care nurses found at urban hospitals.

"We can only imagine, but you can think about bringing your mother or grandmother to the emergency room and it being literally filled with people and having to wait outside for hours before you're even seen by somebody," says Spiegelman, the Yale epidemiologist. "And maybe even some people would even die while they're waiting."

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These Charts Show Who's Most Vulnerable To The Coronavirus : Shots - Health News - NPR

The 64-year-old patient arrived at a hospital in Brooklyn with symptoms looking like those seen in patients having a serious heart attack.

An electrocardiogram revealed an ominous heart rhythm. The patient had high blood levels of a protein called troponin, a sign of damaged heart muscle. Doctors rushed to open the patients blocked arteries but found that no arteries were blocked.

The patient was not having a heart attack. The culprit was the coronavirus.

The Brooklyn patient recovered after 12 days in the hospital and is now at home. But there have been reports of similar patients in the United States and abroad, and the cases have raised troubling questions for doctors.

What should doctors do these days when they see patients with apparent heart attacks? Should they first rule out coronavirus infection or is that a waste of valuable time for the majority of patients who are actually having heart attacks?

Should every coronavirus patient be tested for high blood levels of troponin to see if the virus has attacked the heart?

I dont know what the right answer is, said Dr. Nir Uriel, a cardiologist at Columbia University and Weill Cornell Medicine in New York.

The Brooklyn patient had myocarditis, an inflammation of the heart that has been seen in patients with other viral infections, such as MERS also caused by a coronavirus and the H1N1 swine flu.

But the new coronavirus, called SARS-CoV-2, mostly infects the lungs, causing pneumonia in severe cases. Believing it caused respiratory disease, many cardiologists thought the coronavirus was outside their specialty.

We were thinking lungs, lungs, lungs with us in a supportive role, said Dr. John Rumsfeld, chief science and quality officer at the American College of Cardiology. Then all of a sudden we began to hear about potential direct impact on the heart.

A report on heart problems among coronavirus patients in Wuhan, China, was published in JAMA Cardiology on Friday.

The study, led by Dr. Zhibing Lu at Zhongnan Hospital of Wuhan University, found that 20 percent of patients hospitalized with Covid-19, the illness caused by the coronavirus, had some evidence of heart damage.

Many were not known to have underlying heart disease. But they often had abnormal electrocardiograms, like the patient in Brooklyn, in addition to elevated troponin levels, which sometimes soared to levels seen in patients with heart attacks.

The risk of death was more than four times higher among these patients, compared with patients without heart complications.

The journal also published a report, by doctors in Italy, describing a previously healthy 53-year-old woman who developed myocarditis.

Like the patient in Brooklyn, her electrocardiogram was abnormal, and she had high levels of troponin in her blood. Because of the coronavirus outbreak in Italy, doctors thought to test her and found she was infected.

Dr. Enrico Ammirati, an expert in myocarditis at Niguarda Hospital in Milan who consulted on the case, said the patients heart problems were likely caused by her bodys immune response to the virus.

But so much about this new pathogen is unknown, and it is not yet clear what might cause heart damage following infection.

Myocarditis can likely be caused either by the virus itself, or the bodys immune and inflammatory response to the virus, said Dr. Scott Solomon, a cardiologist at Harvard Medical School.

Infected patients who get myocarditis do not necessarily have any more virus in their bodies than those who do not develop the condition, he said.

It is possible but not yet established that myocarditis results from an immune system that lurches out of control while trying to turn back the coronavirus, pumping out such excessive levels of chemicals called cytokines that cause inflammation that they damage the lungs and the heart alike.

The condition, called a cytokine storm, is more serious in older people and in people with underlying chronic diseases, Dr. Solomon said. It is the primary reason for the severe respiratory complications that can lead to death in patients with the coronavirus.

Cytokines also promote blood coagulation and interfere with the bodys clot-busting system, said Dr. Peter Libby, a cardiologist at Harvard Medical School. Blood clots in coronary arteries can block blood flow and cause heart attacks.

Another possibility, Dr. Libby said, is that some coronavirus patients develop heart problems as a consequence of infections in their lungs.

The lungs are not working, so there is not enough oxygen, he said. That increases the risk for arrhythmias.

At the same time, fever caused by the virus increases the bodys metabolism and the hearts output of blood. The result is that the patients heart must struggle with an increased demand for oxygen but a reduced supply, an imbalance that may lead to heart damage.

But doctors cannot rule out the possibility that the coronavirus directly damages the heart, several experts said.

In Seattle, a patient infected with the virus recently died after experiencing so-called heart block: The electrical signals originating in the top of the organ, which sets the hearts normal rhythm, were not reaching the bottom of the heart.

When that happens, the heart goes into an emergency mode with so-called escape rhythm, which causes it to beat very slowly. The man had underlying lung disease, which worsened his prognosis.

Dr. April S. Stempien-Otero, a cardiologist at the University of Washington, hopes an autopsy will show whether the virus attacked the mans heart.

We thought it was older-person heart block, she said. Then all of a sudden Covid raises its head.

From now on, she said, we have to think, maybe that is what is going on.

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A Heart Attack? No, It Was the Coronavirus - The New York Times

New York Governor Andrew Cuomo has received the lions share of attention, as his informative and emotive press conferences have made him an overnight national political star, albeit halfway through his third term. But his record in responding to the crisis is more complicated than the sheen lets on: his coronavirus containment policies were not the most aggressive in the country, and did not prevent catastrophe. He hesitated to close all schools statewide even as other states began to do so, and resisted a statewide stay-at-home order for a few days before relenting.

So, if not Cuomo, then who? I see six governors who are poised to break out, and another six who risk serious damage to their political futures.

Perhaps no single governor has done more to put the nation on a war footing in the fight against coronavirus than DeWine, whose actions have contributed to Ohios relatively modest number of cases, with a per capita infection rate currently ranked 27th out of 50 states.

On March 12, even though Ohio had yet to suffer a major outbreak of Covid-19, DeWine called for the statewide closure of public schoolsthe first governor in the nation to do so, forcing most of his fellow governors to recognize they had to follow suit, and fast. Likewise, DeWine set the pace on delaying primary elections, even if his snubbing of an initial court order was constitutionally questionable.

The lifelong Republican public servant has been calm, sober and data-driven. He has not only been uninterested in emulating Donald Trumps style, he has been willing to defy Trumps edicts. When Trump tried to set a goal for reopening the economy by Easter, DeWine gently but firmly pushed back, When people are dying, when people don't feel safe, the economy is not gonna come back.

At 73 years old, DeWine is probably not going to ascend to higher office after this is all over. But if he has any interest in steering the post-Trump Republican Party away from Trumpism, he now has a much bigger national platform on which to do so.

Cuomos proximity to New York City the media capital of America has shifted much of the spotlight away from the other hungrily ambitious governor of a big blue state. But on March 19, Newsom was the first governor in America to issue a statewide order to shutter businesses and keep people at home. (Newsom had help when, three days earlier, public health officials in six Bay Area counties went first and issued a joint stay-at-home order.)

The strong action appears to be bending the curve. Californias number of Covid-19 confirmed cases and deaths is rising slower than in hard-hit states like New York, New Jersey, Louisiana and Michigan. (The death number may be a better indicator of spread than the confirmed cases number, because testing has been so poorly administered.)

National media outlets are starting to notice. Even Trump, who has repeatedly tangled with Newsom over the past three years, conceded this week that California has done a good job. But both Newsom and Trump acknowledge that California may still be facing a surge of cases, and that could strain its hospital system. Newsom is scrambling to fortify the system with additional hospital beds on ships and convention centers, and with an effort to enlist medical retirees and students in joining an expanded health care workforce.

Whether he succeeds may ultimately determine if Newsom is heralded as a skilled administrator who might warrant a promotion to the presidency someday.

Coming into 2020, Inslee had already burnished his national reputation by running for president as a visionary leader on climate change. Now, after his state identified the first American case of Covid-19, and suffered the first cluster of nursing home deaths, Inslee is adding crisis manager to his rsum.

After being shown data in early March that argued for severe social distancing, Inslee immediately moved to ban large gatherings and prepared the public for more stringent measures. The quick action has paid off: Washingtons curve of coronavirus deaths is flatter than any other state with more than 50 deaths.

At the same time, Inslee has been a public thorn in Trumps side. On February 27, Inslee provoked the president by recounting on Twitter a pointed exchange he had with Vice President Mike Pence: I told him our work would be more successful if the Trump administration stuck to the science and told the truth, Inslee said. Trump has responded with insults, calling Inslee a snake, and publicly encouraging Pence not to call him anymore.

Instigating a spat with the president during a national crisis can run the risk of making a governor look petty and political. But that risk is negated if you can still deliver results, which Inslee has done. Further, most Democrats dont mind seeing Inslee take Trump to task, and Inslee doesnt have to worry about swing voters right now. Either he is strengthening his ability to win a third gubernatorial term, or he is cannily positioning himself for a Cabinet post in a potential Biden administration.

Like DeWine, Hogan is a Republican governor who has acted aggressively to contain the virus. Unlike DeWine, Hogan is more willing to criticize the White House.

When asked on CNN last week if Marylands social distancing policies matched Trumps suggestion that it would soon be time to ease up, Hogan was pointed: They dont really match. Quite frankly, some of the messaging is pretty confusing. And I think its not just that it doesnt match with what were doing here in Maryland, some of the messaging coming out of the administration doesnt match.

On Monday, Hogan penned a bipartisan Washington Post op-ed with Michigan Governor Gretchen Whitmer, listing all the ways Washington and the federal government havent sufficiently helped the nations governors. And on Tuesday, when asked by NPR whether Trump was correct when he suggested recently that states have enough testing kits, Hogan was blunt: Thats just not true.

As governor of a deep blue state, Hogan has more political leeway than DeWine to complain about the presidents handling of the pandemic. But Hogan, who is term-limited, has flashed grand ambitions, flirting last year with a primary challenge to Trump. He concluded, accurately, he had no path to success and passed. But if, by 2024, some GOP-ers rediscover the value of managerial competence, and he continues to limit the spread of coronavirus in his state, Hogan will have distinguished himself as a different kind of Republican.

Perhaps no governor has gotten under Trumps skin more than Whitmer, who has repeatedly criticized the administrations handling of the pandemic. He has snidely referred to her as the woman in Michigan and Gretchen Half Whitmer, and like Inslee, suggested Pence should not call her. She has responded in kind on her Twitter feed and in TV interviews.

For the moment, Whitmer has gotten the better out of their tussle. A poll taken in mid-March, in the midst of the initial clash between the governor and the president, showed Whitmer with a 60 percent approval rating, and Trump at only 45 percent. Michigan Republicans have been warning Trump to tone it down.

But Whitmer also appears aware she should go only so far. In recent days, as Detroit hospitals are suffering from strain, she has toned it down. She praised the White House and the Federal Emergency Management Agency for shipments of masks and ventilators. She had civil phone calls with Trump and Pence. As New York Times reporter Annie Karni suggested, Whitmers gender might have something to do with Trumps particularly harsh tone. But perhaps another major factor is that Michigan is a major Electoral College prize one Trump barely won in 2016. As Covid-19 cases explode in Detroit, if Whitmer successfully pins the blame on Trump, that could help flip the state back to blue in November. But if Trump can successfully tag her for blame-shifting while the pandemic raged, that could cripple Whitmers ability to deliver the state to Joe Biden.

In the meantime, Whitmer has been getting more buzz as Bidens potential running mate (which Biden stirred himself Tuesday night on MSNBC). After lowering the temperature of her presidential fight, but with the states caseload rising quickly, she now has to assure her constituents she is doing the best she can with what resources are available.

On the mainland, California was the first state to shut down nonessential businesses and largely keep people in their homes. But in Puerto Rico, Vazquez moved four days earlier, shutting down businesses, schools and beaches; ordering people inside and installing a nighttime curfew.

With Puerto Ricos health care infrastructure still fragile in the aftermath of Hurricane Maria, the territory is acutely vulnerable to a pandemic. (In early January, a 13-year-old in Vieques with flu-like symptoms died in part because the lone hospital on the island has been shuttered since Maria.) So Vazquez had every incentive to move quickly and boldly.

Shes also in a fragile political state. She ascended to her position after evidence of corruption forced out Ricardo Rossell, the last elected governor. But some accused her, while serving as secretary of justice, of failing to properly investigate Rossell. In January, she suffered another scandal when, after a series of earthquakes, unused emergency supplies were discovered in a warehouse. She now faces a close race in her partys primary to earn a nomination for a full term later this year.

According to the most recent data, Puerto Rico has a lower rate of infection than any of the 50 states. That may be partly because Puerto Rico has a lower rate of testing than almost every state. But Vazquezs swift and sweeping action on social distancing likely is helping to prevent a worst-case scenario and could well help her keep her job.

DeSantis is one of Trumps favorite governors and a potential 2024 presidential prospect. But he has made a bad first impression on the rest of the country by failing to fully shut down Floridas beaches before or after they were overrun with partiers on spring break, many of whom then traveled home to locations throughout the United States.

He also resisted making a statewide stay-at-home order until finally relenting on Wednesday in the wake of intense pressure from Florida Democrats, and televised comments Wednesday morning by the surgeon general urging all governors to get their residents to stay at home. Before that point, his seemingly toughest measure was issuing a quarantine for travelers coming from the New York City tri-state area or Louisiana, but the focus on hot spots ignores all the community spread inside Florida and in other states. Florida already has nearly 7,000 confirmed cases, ranking it 17th among the states on a per capita basis.

Earlier, DeSantis justified eschewing broader measures. Were also in a situation where we have counties who have no community spread, he said on March 19. We have some counties that dont have a single positive test yet. But everything we have experienced strongly suggests you don't want to wait until you have community spread before taking strong action.

DeSantis may still be helped by Trump, who may be giving Florida preferential treatment. According to the Washington Post, other governors have had difficulty getting supplies from the Strategic National Stockpile, but not DeSantis. And Trump has been influenced by DeSantis argument that some social distancing measures are too harmful to the economy. The Post quoted an anonymous White House official, who explained, The president knows Florida is so important for his reelection, so when DeSantis says that, it means a lot. He pays close attention to what Florida wants.

For now, DeSantis remains on the GOPs 2024 shortlist. But if DeSantis encourages Trump to make bad decisions, and if Florida is getting supplies while other states scrounge, the governors ties to the president may become a serious liability for his own future prospects.

Aside from its next-door neighbor Louisiana, Mississippi is the Southern state with the most confirmed Covid-19 cases on a per capita basis. Yet Reeves has made a hash out of the response.

As Mississippis localities began issuing stay-at-home edicts, Reeves issued his own order on March 24, broadly defining what business and social activity is essential including religious services and declared any order from any other governing body which conflicts with the state order to be suspended and unenforceable. Two days later, under pressure, he tried to clarify that the state order provided only a floor, which counties and cities could surpass, but confusingly added that no order can keep those essential services from going on. Mississippi mayors have been confused and have interpreted the governor differently.

Reeves had resisted a statewide stay-at-home order on ideological grounds, insisting that Mississippi's never going to be China. Mississippi's never going to be North Korea. Yet as the virus spreads, Reeves may find himself dragged into a more expansive response.

On Tuesday, Reeves issued his first stay-at-home order, but in just one county, Lauderdale, where a nursing home has suffered an outbreak. The businesses in Lauderdale County are simply losing customers to surrounding counties and BTW covid doesnt stop at the county line, tweeted the mayor of Tupelo, which is in Lee County.

On Wednesday, Reeves issued a stay-at-home order that encompasses the whole state but which doesn't take effect for another two days. If Mississippis spread becomes severe, Reeves haphazard response will come back to haunt him.

On March 14, Stitt tweeted a picture of his family eating at a restaurant, as if he deserved an award for defying the coronavirus panic. Its packed tonight! he enthusiastically shared, but facing blowback, later deleted the post.

The next day, Stitt declared a state of emergency. Then, the day after that, the governors spokesman said, the governor will continue to take his family out to dinner and to the grocery store without living in fear, and encourages Oklahomans to do the same. Stitt still has not issued a statewide stay-at-home order. In the absence of one, major Oklahoma cities have imposed their own over the past few days.

Two weeks later, Oklahomas rate of infection is intensifying, and testing is minimal. Stitt is not the only governor who has hesitated to implement stiff restrictions, but he may become a case study of the pitfalls of glib social media use in a time of crisis.

You may remember Ige as the governor who, for 17 minutes in 2018, couldnt correct a false warning of an incoming ballistic missile because he didnt know his Twitter password.

Earlier this month, Ige tapped his Lieutenant Governor Josh Green to play a key role in the states response to coronavirus. Green is an emergency room doctor, so his calls for strict travel restrictions and quarantines on arrivals carried great weight. But once Green publicly pushed for strong measures, Ige cut him out of the loop, instructing Cabinet officials not to consult with Green, and keeping Green out of his press conferences.

Hawaii faced an influx of crisis tourists looking to ride out the pandemic in paradise. But as the governor of a tourism-dependent state, Ige hesitated to act. On March 19, the state House speaker, fellow Democrat Scott Saiki, upbraided Ige in a letter, describing the administrations response as utterly chaotic, causing mass confusion among the public.

Ige has now made peace with Green, and recently ordered a 14-day quarantine for arrivals though there was a five-day gap between the announcement and the implementation. A stay-at-home order has been issued, though with exceptions for swimming and surfing. Ige better hope those steps are enough.

Ige isnt the only governor taking heat from his No. 2. Ivey is being shown up by her lieutenant governor, Will Ainsworth.

On March 25, Ainsworth, who serves on Iveys coronavirus task force, wrote a letter to the panels other members. After some perfunctory pleasantries, he lit into them: A tsunami of hospital patients is likely to fall upon Alabama in the not too distant future, and it is my opinion that this task force and the state are not taking a realistic view of the numbers or adequately preparing for what awaits us.

The day after, Ivey sounded a completely different note at a press conference, when she dismissed the idea of a statewide stay-at-home order. Yall, we are not Louisiana, we are not New York sate, we are not California, she said. (Washington Post data journalist Philip Bump warned Ivey that Alabamas caseload was growing faster than Californias.)

Then, at a press conference one day after that, Ivey dumped on Ainsworth, saying he was not helpful in raising challenges and criticism and issues we are aware of, and offering no solutions and showing no willingness to work with the task force and the team willing to fix it. (Ainsworths letter did, in fact, offer solutions regarding health care capacity.)

Ivey, who is not yet term-limited, would turn 78 before the 2022 election. By that time, Ainsworth, who won a separate election for lieutenant governor and did not run with Ivey on a ticket, would be 41, and well-positioned to move into the governors mansion. Perhaps Ivey will just want to retire by 2022. But if she does plan on seeking reelection, she now has to worry about a possible primary challenger who has successfully separated himself from her questionable pandemic response.

Justice is a billionaire political neophyte who won the 2016 gubernatorial election as a Democrat, then, in 2017, switched to become a Republican and a Trump ally. His lack of experience in crisis management has been glaringly obvious from his discordant statements and actions.

On March 16, he was preaching defiance. For crying out loud, go to the grocery stores, Jutice said. If you want to go to Bob Evans and eat, go to Bob Evans and eat. Then, the very next day, he shut down dine-in eating at the states restaurants.

The following Saturday, Justice gave a disjointed address which, according to the Associated Press, featured jumbled sets of numbers that puzzled viewers in their randomness. He warned of dire consequences, but neglected to issue a stay-at-home order. Governor Urges Action, Takes None, read a headline in the Charleston Gazette-Mail the next day. Later that week, Justice finally announced a stay-at-home order.

This wobbly performance is coming at the worst possible time for Justice politically, because he faces a contested party primary for the gubernatorial nomination this spring. (Justice just pushed back the primary from May 12 to June 9.) Justice faces six primary opponents, with the most spirited challenge coming from Justices former Commerce secretary, Woody Thrasher. Justice has been a heavy favorite to date, but a mismanaged crisis can change poll numbers very fast.

CLARIFICATION: An earlier version of this article said Mississippi Gov. Tate Reeves had issued a stay-at-home order only covering one county. As this piece was being edited and produced, he announced a new stay-at-home order covering the whole state. The piece has been updated accordingly.

Read the rest here:

Opinion | Coronavirus vs. Governors: Ranking the Best and Worst State Leaders - POLITICO

The coronavirus has ravaged all of New York City, closing schools, emptying streets and turning stadiums into makeshift hospitals. And data made public by city health officials on Wednesday suggests it is hitting low-income neighborhoods the hardest.

Coronavirus cases by ZIP code

Coronavirus cases by ZIP code

Coronavirus cases by ZIP code

By The New York TimesNote: The map shows total number of cases as of April 1. Source: New York City Department of Health and Mental Hygiene

During the first month of the outbreak in the city the epicenter of Americas coronavirus crisis many of the neighborhoods with the most confirmed virus cases were in areas with the lowest median incomes, the data shows. The biggest hot spots included communities in the South Bronx and western Queens.

The data, collected by the New York City Department of Health and Mental Hygiene, offers the first snapshot of an outbreak that infected more than 40,000 and killed more than 1,000 in the city in its first month.

[Read the latest coverage of the coronavirus outbreak in the New York area.]

The coronavirus has spread into virtually every corner of the city, and some wealthier neighborhoods have been overrun with cases, including some parts of Manhattan and Staten Island. But that may be because of the availability of testing in those areas. Nineteen of the 20 neighborhoods with the lowest percentage of positive tests have been in wealthy ZIP codes.

The patterns are even more striking when analyzing the data on people who visited the citys 53 emergency rooms with the flulike symptoms that are a hallmark of the coronavirus.

Over all, nearly three times as many people with flulike symptoms like fever, cough or sore throat visited city emergency rooms this March when compared with the same month in previous years.

In the last four years, there were on average 9,250 flu-related visits to emergency rooms in March; this March, the number tripled to about 30,000.

Average of March

visits in 2016-19

Average of March

visits in 2016-19

Average of March

visits in 2016-19

By The New York TimesNote: E.R. visits are calculated to show the rate per 1,000 people. Source: New York City Department of Health and Mental Hygiene

The increases in flu-related emergency room visits varied widely by neighborhood, with many of the surges occurring among residents of neighborhoods where the typical household income is less than the city median of about $60,000, the data shows.

In Corona, Queens, for example, the median household income is about $48,000, according to the U.S. Census Bureau. That neighborhood is near the Elmhurst Hospital Center, which Mayor Bill de Blasio has cited as the hardest-hit hospital in the city. Doctors in the overwhelmed emergency room there have described the conditions as apocalyptic.

Visits in Central Harlem were up 220 percent.

Corona saw nearly 1,000 more flu-related visits than average.

Where Flu-Related E.R. Visits Have Increased

Circles are sized by the increase in the number of flu-related E.R. visits by residents in each ZIP code for the month of March in 2020, compared with 2016-19.

Yellow circles indicate ZIP codes in which the median household income is less than the city median, which is about $60,000.

Blue circles indicate areas with higher median incomes.

On the north shore of Staten Island, flu-related E.R. visits doubled.

Visits in Central Harlem were up 220 percent.

Corona saw nearly 1,000 more flu-related visits than average.

Where Flu-Related E.R. Visits Have Increased

Circles are sized by the increase in the number of flu-related E.R. visits by residents in each ZIP code for the month of March in 2020, compared with 2016-19.

Yellow circles indicate ZIP codes in which the median household income is less than the city median, which is about $60,000.

Blue circles indicate areas with higher median incomes.

On the north shore of Staten Island, flu-related E.R. visits doubled.

Where Flu-Related E.R. Visits Have Increased

Circles are sized by the increase in the number of flu-related E.R. visits by residents in each ZIP code for the month of March in 2020, compared with 2016-19.

Yellow circles indicate ZIP codes in which the median household income is less than the city median, which is about $60,000.

Blue circles indicate areas with higher median incomes.

Visits in Central Harlem were up 220 percent.

Corona saw nearly 1,000 more flu-related visits than average.

On the north shore of Staten Island, flu-related E.R. visits doubled.

Where Flu-Related E.R. Visits Have Increased

Circles are sized by the increase in the number of flu-related E.R. visits by residents in each ZIP code for the month of March in 2020, compared with 2016-19.

Yellow circles indicate ZIP codes in which the median household income is less than the city median, which is about $60,000.

Blue circles indicate areas with higher median incomes.

Visits in Central Harlem were up 220 percent.

Corona saw nearly 1,000 more flu-related visits than average.

On the north shore of Staten Island, flu-related E.R. visits doubled.

Where Flu-Related E.R. Visits Have Increased

Circles are sized by the increase in the number of flu-related E.R. visits by residents in each ZIP code for the month of March in 2020, compared with 2016-19.

Yellow circles indicate ZIP codes in which the median household income is less than the city median, which is about $60,000.

Blue circles indicate areas with higher median incomes.

Visits in Central Harlem were up 220 percent.

Corona saw

nearly

1,000 more

flu-related

visits than

average.

On the north shore of Staten Island, flu-related E.R. visits doubled.

By The New York TimesE.R. visits are calculated to show the rate per 1,000 people. Sources: New York City Department of Health and Mental Hygiene; 2014-18 American Community Survey

Dr. Jessica Justman, an epidemiologist at Columbia University in Manhattan, said the numbers were most likely because many immigrants and low-income residents live with large families in small apartments and cannot isolate at home.

I think unfortunately this is showing how devastating that can be, Dr. Justman said.

In New York, experts said, a vast majority of people visiting emergency rooms with flu-like symptoms probably have the coronavirus.

Weve actually stopped testing for the flu because its all coronavirus, said Bruce Farber, chief of infectious disease at North Shore University Hospital, part of Northwell Health, a network of 23 hospitals throughout the state. Almost anybody who has an influenza illness right now almost certainly has coronavirus.

Many of the emergency rooms with the biggest increases in patients who have flulike symptoms are in Queens, the borough that has the highest number of confirmed coronavirus cases. There are about 616 confirmed cases for every 100,000 residents in Queens, and 584 confirmed cases for every 100,000 residents in the Bronx. Thats far more per 100,000 than the 376 in Manhattan and 453 in Brooklyn.

With infections across all five boroughs, New York has far more confirmed cases than any other city in the United States.

The emergency room data also tracks admissions the number of E.R. visitors who end up treated at a hospital. On that metric, the data shows that older visitors are far more likely to be admitted than younger visitors.

There is a simple reason for that difference, according to the hospital officials and experts: The coronavirus seems to take a bigger toll on older people, as well as those with compromised immune systems.

I dont think that infection rates are necessarily different between older and younger people, said Dr. Isaac Weisfuse, the former deputy head for disease control at the citys Department of Health. Elderly have worse clinical outcomes than younger patients, and may have more pre-existing conditions.

By The New York TimesNote: The chart shows E.R. admissions as of March 31. Source: New York City Department of Health and Mental Hygiene

Over all, more than 8,500 people have been hospitalized with the coronavirus in New York City. That number is expected to soar in the coming weeks.

But officials are hopeful that the social distancing restrictions put in place by the state may have finally started to at least slow the spread of the coronavirus. They have noted that the number of hospitalizations is now doubling every six days, instead of every two or three days.

The citys data shows a slight decline in emergency room admissions over last weekend, and then continuing increases this week.

Dr. Denis Nash, an epidemiologist at the City University of New Yorks School of Public Health, said it was still too soon to tell whether the social distancing restrictions were working.

It may be too soon to say whats really going on here, he said. I just hope it means something good.

ZIP code

Borough

Total cases

Cases per 1,000 people

11368

Queens

947

9

11373

Queens

831

9

11219

Brooklyn

771

9

10467

Bronx

638

7

11230

Brooklyn

631

More here:

A Month of Coronavirus in New York City: See the Hardest-Hit Areas - The New York Times

Spotty health insurance coverage has been the deciding factor for some expats. Anna Inglis, a 38-year-old freelance photo producer based in Brooklyn, said she had decided last month to return home to New Zealand in part because she did not have health coverage through her job.

The American system of private health insurance, with varying coverage and sometimes high premiums, deductibles or co-payments, is a stark contrast to the public systems in places like New Zealand, Australia and Britain, where government-subsidized access to doctors and many services is universal.

Some expats say their health insurance options in the United States are so poor that they have instead used travel insurance as their primary coverage. Others, like Ms. Inglis, have only the most basic level of health coverage in New York, but back home, that is not a consideration.

I feel reassured by the New Zealand political system, she said. Hopefully, the system can cope better than the New York system is currently.

This intuition to flee the United States, and its health care system, during a pandemic may be a good one.

The U.S. has been a leader in so many other areas, but when it comes to the health care system, it is behind, said Adam Kamradt-Scott, a global health security expert at the Center for International Security Studies at the University of Sydney.

Professor Kamradt-Scott said that as pressure mounted on the American system, it was possible that citizens would be prioritized over foreigners. Some hospitals in the United States, especially in New York, are literally so overwhelmed that people are only presenting when they are very, very sick.

Read more:

They Made New Lives in the U.S. The Coronavirus Sent Them Fleeing. - The New York Times