Hospital ratings often depend more on nice rooms than on health care

The study, “The Cost of Satisfaction,” appeared in JAMA Internal Medicine.

Oh, the irony. The most satisfied patients not only died in greater numbers but racked up higher costs along the way. Plus, health-care providers receiving the top satisfaction scores were rewarded with higher reimbursements by the Centers for Medicare and Medicaid Services (CMS), which administers the patient survey.

Lead author Joshua Fenton, a professor of family medicine at the University of California at Davis, had set out to measure the relationship between patient satisfaction and hospital resource use, drawing on the CMS Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Ultimately, his research raised questions about whether CMS is dangerously off target in collecting patient satisfaction data to drive health-care improvements.

That was 2012. More research published this year by two sociologists likewise found that a patient’s hospital recommendation had almost no correlation to the quality of medical care received or patient survival rate. The researchers looked at CMS hospital data and patient surveys at more than 3,000 U.S. hospitals over three years. The hospitals where fewer patients died had only a two percentage point edge in patient satisfaction over the others.

What’s going on? Cristobal Young, associate professor of sociology at Cornell University and lead author of the study, calls it “the halo effect of hospitality.” Young found that what mattered most to patients in ratings were the compassion of nurses and amenities like good food and quiet rooms. It’s why hospital managers are being recruited from the service industry and we’re seeing greeters in the lobby and premium TV channels in rooms, he says.

Patients tend to value what they see and understand, but that can be limited, Young continues. They give hospitals good cleanliness ratings when they observe waste baskets are emptied and sheets are changed. “They can’t see a virus or tell you how clean the room is in ways that matter,” he says.

Similarly, patients can tell you if a physician communicates well. But most people do not have the medical skills to assess whether a physician provided the appropriate diagnostic test or made suitable recommendations, Fenton says.

In his study, patients receiving more medical interventions, treatments and hospitalizations were more satisfied with their experience. Yet, after adjusting the 26 percent mortality rate of the satisfied patients with data about their baseline health and comorbidities, their death rate soared to 44 percent over the patients who weren’t as happy with their care.

One possible explanation is that every surgery, procedure or medication carries the potential to leave you worse off. While a patient may perceive that more aggressive treatment is better, “overtreatment” can hasten death, too.

There is a more insidious reason satisfied patients did not track with better medical outcomes, though. The majority of hospitals and medical practices today are rewarded with higher compensation, promotions, bonuses or increased CMS reimbursements for attaining high patient satisfaction scores. The twist is that the path to keeping patients happy can run counter to best medical practices.

A patient may give an unfavorable rating to a physician who refuses to write an unsafe opioid prescription or order an unwarranted CT scan. A doctor may not bring up a patient’s obesity or cognitive impairment to avoid the person’s ire on a survey later.

In a 2014 study of 155 physicians by the University of Wisconsin-Madison’s School of Medicine and Public Health, close to half said that pressure to please patients led to inappropriate care including unnecessary tests and procedures, hospital admissions, and opioid or antibiotic prescriptions.

“Time after time, studies show that physicians who accede to patient requests have higher patient satisfaction,” Terence Myckatyn and co-authors wrote in a 2017 article exploring how patient satisfaction scores affect medical practice. Keeping patients happy is not always the best strategy for patient wellness or physicians, however, says Myckatyn, a plastic and reconstructive surgeon at Washington University School of Medicine.

“Directly tying financials to surveys as a metric to evaluate physicians can be shortsighted and unfair. It’s a difficult calculus,” says Myckatyn, stressing that patient surveys should be only one measure in the toolbox for assessing health-care providers.

CMS posts patient satisfaction data on its Hospital Compare website along with medical statistics about surgery complications, infection rates and mortality. But it’s the hotel-like amenities that seem to drive ratings, so that’s where many hospitals have invested, Young says.

He points to the new $2 billion Stanford Hospital in Palo Alto that offers private patient rooms, each with a 55” television and iPad so patients can stream Net­flix, order a burger from the cafeteria, or video conference with family. This is how hospitals are competing with each other in a consumer market where medical quality indicators can take a back seat, he says.

Whether the 29-question HCAHPS survey has led to better medical care, Fenton credits public surveys for keeping hospitals and physicians accountable for treating patients with respect and dignity. What he objects to is the harm done by conflating patient satisfaction with the technical quality of medical care.

Likewise, Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association (AHA), sees patient satisfaction and medical outcomes as apples and oranges. They are each important and don’t have to correlate. In addition, whether a nurse responds quickly to a call button is not just about hospitality, Foster maintains in reference to Young’s study.

“If a patient needs to use the restroom and a nurse doesn’t arrive in a timely fashion, patients [who go on their own] can fall,” she says. “[The nurse’s responsiveness] becomes a crucial clinical outcome issue.”

Akin Demehin, AHA’s director of policy, also believes patient surveys have a place in improving medical care. “Patients have unique insights that only they are in a position to convey,” Demehin says.

Several hospitals were able to reduce their readmission rates after taking a close look at patient comments regarding problems in care coordination and hospital discharge, he says.

Collecting patient feedback began its ascent in 1985 when Press Ganey Associates introduced a survey to measure health-care provider performance. Ten thousand medical institutions today still use it. By 2006, CMS was distributing the HCAHPS survey to randomly selected patients around the country.

Once the Internet exploded, consumer-driven health care was out of the gate. Online ratings for restaurants, electronics, and the patient experience became “part of our modern day currency,” says physician Raina Merchant, director of the Center for Digital Health at the University of Pennsylvania Perelman School of Medicine and associate vice president at Penn Medicine.

Merchant studied the impact of patient ratings on Yelp and found they were strikingly parallel to HCAHPS results. The significant difference, she says, is that Yelp reviews cover a broader range of concerns than standard surveys. You’ll find more detailed patient-to-patient information about billing, comfort care, medical costs and the experience of family caregivers, for instance.

Health-care providers “miss an opportunity to learn about consumers if they don’t pay attention to social media,” says Merchant, who sees online reviews as “democratizing.”

Will covid-19 change how we rate physicians and hospitals? “Think about how much we spend on the health-care system in the U.S. Then when we need basic things like swabs [to test for coronavirus] we don’t have them,” says Young, “. . . or nurses and doctors straining to have [personal protective equipment].”

“It’s mind-boggling,” he says. “Maybe the coronavirus will help reprioritize everyone’s thinking about medical quality. Nobody is thinking about how nice their [hospital room] views are anymore.”

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Florida State University Child Care Policy Draws Backlash

Florida State University appears to be walking back an announcement that suggested it would not allow employees to care for children while working from home during the coronavirus outbreak.

“We want to be clear — our policy does allow employees to work from home while caring for children,” the university said in an email to staff members and in an announcement posted on its website on Thursday.

That message followed a barrage of questions and criticism that started last week, when the university, in Tallahassee, Fla., emailed its staff to say it would “no longer allow employees to care for children while working remotely” as of Aug. 7.

The move was an attempt to reinstate a policy that had existed before the outbreak. But the idea that employees might suddenly be required to make other arrangements for their children even as they continued to work from home led to an immediate backlash.

“Initial responses over the weekend were of despair, shock and feeling disempowered,” said one professor, who spoke on the condition of anonymity because discussions with the administration were continuing.

“We’ve all been doing our jobs and performing our caregiving roles,” the professor said. “And it’s been really hard, but everybody has been pulling their weight, and that could have just carried on.”

The university’s announcement on June 26 attracted attention on social media and from news outlets over the weekend, turning one institution’s internal debate over its work-from-home policies into an example of the conflicts that can arise as schools, businesses and caregivers across the United States grapple with how to return to a sense of normalcy amid a pandemic. Those conflicts have been amplified in recent weeks in Florida, where the number of known infections has surged.

There have been more than 169,000 cases of coronavirus in Florida, according to a New York Times database. As of Thursday morning, more than 3,600 people had died. Over all, the state’s Covid-19 cases were up fivefold in the last two weeks.

The university shared the latest memo but otherwise declined to comment on Thursday.

In response to the objections that surfaced over the weekend, the university tried to clarify its email in a memo that was posted online Monday. That memo suggested that faculty members would not be affected by the change — and it elicited another backlash because it seemed to suggest that the policy would hurt lower-paid workers more. That memo was later taken down.

In its latest email on Thursday, the university sought to clarify the policy once again.

“We are requesting that employees coordinate with their supervisors on a schedule that allows them to meet their parental responsibilities in addition to work obligations,” it said. “This may be different for each employee based on the specifics of their situation.”

The school said it regretted that its initial communication “caused any unnecessary worry and concern or oversimplified a very nuanced issue.”

Matthew Lata, the F.S.U. chapter president of the United Faculty of Florida, a union representing faculty members there, was among those who criticized the university after its initial email announcing the policy change last week. In an interview on Thursday, he said the issue seemed to have been resolved.

“I’m glad that the university has taken a step back and looked at this situation and realized that the old normal cannot be the new normal,” he said.

It is not clear when schools and day care centers in the district that includes Tallahassee, Leon County Schools, will reopen. In a letter, the superintendent said he would ask the school board to make Aug. 19 the first day of classes for students. The superintendent also said he would be open to discussing the idea of delaying the start date until after Labor Day.

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How a Simple Phrase Can Strengthen Resolve

A well-said phrase can remind us how we’re not alone in our struggles — and, perhaps, more importantly, can also inspire us to push onward. Examples range from ancient Greek philosopher Aristotle’s “It is during our darkest moments that we must focus to see the light” to contemporary author and civil rights activist Maya Angelou’s “You will face many defeats in life, but never let yourself be defeated.” When facing tough times, difficult people, and challenging situations, a simple set of words such as these may keep hope alive, strengthen resolve — and help us to keep our cool.

In a Fast Company article titled “The Science Behind Why Inspirational Quotes Motivate Us” by author Gwen Moran, psychologist and motivation expert Jonathan Fader, PhD, explains that positive phrases can provide a powerful incentive to try harder and also build a “self-efficacy in that kind of dialogue that you’re having with yourself.” Also, the aspirational nature of certain quotes and phrases help us to see something in ourselves that we want to work on or overcome. 

I know that when I’m in a stressful situation, I often tell myself to “be like water,” as I picture myself gliding past the jagged rocks of anxiety and turbulent pockets of conflict. Since I started using this simple phrase (which I often have to silently repeat to myself), I’m far less reactive and am able to keep my cool while still maintaining my own sense of self-worth. And… when things get really bad, I’ll actually make swimming motions (but only when I’m on the phone and people can’t see me!). Interestingly, too, I’ve noticed that I don’t tense up as much as before, which I’m happy to say has (so far, at least!) decreased my chronic back pain. 

I was curious if other people I know also use quotes or phrases to help them deal with stress, so I asked a couple of friends about what they tell themselves to get through life, when they are most likely to use theses phrases, and how they help. I was pleasantly surprised that the first three people I contacted responded right away. Maybe more people use this technique than I thought (or I guessed at the most likely people who might do this). Regardless, I found their responses were not only insightful, but also resonated with some of their core strengths. 

Anna, a Senior Technology Officer, says that when she’s lonely or upset, she tells herself: “Like a wave is part of the ocean” to remind herself that she’s connected to everything. And like a wave, she feels as if she doesn’t just exist as an individual. Anna shared that this phrase helps her get out of her own head and see other people’s perspectives. It also reduces a reaction response and, instead, increases her capacity to understand other people’s perspectives.

From my personal experience with Anna, her mantra works, as she is one of the most accepting and friendly people I know. She adds that it’s particularly helpful when she finds that she’s frustrated with someone and her “thinking needs to be looked at.” 

Gabe, a restaurant manager and author, tells himself, “Where there’s a stupid person, there should not be two.” He says that he uses it every single day at work. And to quote Gabe: “People come and complain because, I don’t know, Santa didn’t come early this year, and I think of my mantra.” It helps him see how little is needed for some people to lose it, which only strengthens his resolve to stay stoic, calm, and rational while also maintaining his sense of humor.

Through the years, I have witnessed Gabe’s strength, wisdom, and fortitude — especially during the roughest of times. And in true Gabe fashion, even his own personal mantra is imbued with honesty and humor — just like him. 

K. Elaine, who is a Vice President of a large company, said that she tells herself: “We will get through this and this too shall pass.” She tells herself this when she loses an employee or one is crying on overload, threatening to quit. She also repeats it when clients are screaming at her — or, worse yet, when someone says that they want to sue the company.

This blended mantra helps K. Elaine remain professional while negotiating in a rational, caring tone with both clients and employees. And true to K. Elaine’s can-do, positive spirit, her mantra, which starts with the word “we,” encompasses her team-player style and personal warmth and charm. 

Whether people gravitate toward a certain mantra because it already highlights their natural strengths or because it helps them overcome something they want to work on, a simple set of words can increase one’s resolve — and may also serve as a handy reminder that may help lighten stressful situations and provide a deeper sense of calm, strength, and clarity. 

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Stroke Appears 8 Times More Likely With COVID Than With Flu

THURSDAY, July 2, 2020 (HealthDay News) — Both flu and COVID-19 can raise your risk for a stroke, but the odds appear to be eight times higher with the coronavirus, a new study finds.

Among more than 1,900 patients with COVID-19, 1.6% suffered a stroke, versus 0.2% of nearly 1,500 patients seriously ill with flu, researchers found.

“Doctors and practitioners taking care of patients with COVID-19 infection should remain vigilant for signs and symptoms of stroke, because prompt diagnosis may permit effective stroke treatment,” said researcher Dr. Neal Parikh, an assistant professor of neurology and neuroscience at Weill Cornell Medicine in New York City.

“Fundamentally, our results support the notion that COVID-19 infection is more severe than influenza infection,” Parikh added.

For the study, Parikh and colleagues compared the incidence of stroke among COVID patients and flu patients in two New York City hospitals. Patients with coronavirus were assessed March 4 through May 2, while researchers analyzed flu data from Jan. 1, 2016, through May 31, 2018.

Two neurologists who reviewed the findings weren’t surprised that COVID was linked with stroke.

“Infections and other inflammatory conditions are established risk factors for stroke, so it is not surprising that patients with COVID-19 disease might have stroke as a complication of the infection,” said Dr. Larry Goldstein, professor and chairman of neurology at the University of Kentucky.

COVID-19 disease has also been associated with blood clots that could increase stroke risk, he said.

Dr. Salman Azhar is director of stroke at Lenox Hill Hospital in New York City. He said, “This virus has a predilection to cause some level of clotting, and we think that maybe it’s because of increases in inflammation in the body.”

Azhar explained that COVID-19 attacks the cells that line blood vessels, which is one reason for the increased risk for blood clots leading to stroke. Also, the virus increases the production of clotting factors, he said.

Antibodies also play a role in the development of stroke, Azhar said.

“There are antibodies that we’ve known for a long time, nothing to do with this virus, but we know increase people’s risk to have strokes and other blood vessel clots, and we are seeing them in a higher incidence in patients with COVID-19,” Azhar said.

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Models Project Face Masks Can Reduce Significant Amount Of Coronavirus Deaths : NPR

A face mask covers the mouth and nose of one of the iconic lion statues in front of the New York Public Library Main Branch on Wednesday, July 1, 2020, in New York, amid the coronavirus pandemic.

Ted Shaffrey/AP

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Ted Shaffrey/AP

A face mask covers the mouth and nose of one of the iconic lion statues in front of the New York Public Library Main Branch on Wednesday, July 1, 2020, in New York, amid the coronavirus pandemic.

Ted Shaffrey/AP

More widespread wearing of face masks could prevent tens of thousands of deaths by COVID-19, epidemiologists and mathematicians project.

A model from the University of Washington’s Institute for Health Metrics and Evaluation shows that near-universal wearing of cloth or homemade masks could prevent between 17,742 and 28,030 deaths across the US before Oct. 1.

The group, which advises the White House as well as state and local governments, is submitting the model for peer review, says Theo Vos, Professor of Health Metrics Sciences at IHME.

Another projection developed by researchers at Arizona State University in April showed that 24–65% of projected deaths could be prevented in Washington state in April and May if 80% of people wore cloth or homemade masks in public.

These projections shed light on the promises face masks might hold as COVID-19 cases surge in some states and more local authorities mandate the wearing of face masks.

Texas is now mandating face masks in public in most of the state; Jacksonville Fl, host city of the Republican National Convention in August, mandated wearing face masks in public and indoor locations where people cannot otherwise social distance on June 29.

Republican leaders including Vice President Mike Pence, Majority Leader Mitch McConnell, Tim Scott of South Carolina, Lamar Alexander of Tennessee and Marco Rubio of Florida, have joined public health officials urging the public to wear facemasks. Dr. Anthony Fauci and members of Congress appealed to the public to wear face masks in a congressional hearing Tuesday. And President Trump, in a change of tone, told Fox Business on Wednesday he’s ‘all for masks.’

But public health professionals lament that trust in face masks is hampered by the government’s earlier recommendation against them.

Fauci told TheStreet mid-June that he did not recommend face masks at the beginning of the outbreak to conserve supplies for healthcare workers. On Thursday Fauci told NPR that the administration’s initial ambivalence towards face masks was ‘detrimental in getting the message across.’

The World Health Organization gave NPR the same reasoning for not recommending masks to the general public in April. The organization has since updated its guidelines.

Benjamin Cowling, Professor and head of the Division of Epidemiology and Biostatistics in the School of Public Health at the University of Hong Kong, has studied effects of face masks for ten years and co-wrote a commentary in The Lancet advocating more face mask usage in March. He says while he understands the authorities’ desire to preserve supplies for medical workers, the messaging made the public distrust masks.

“Few months ago, medical experts were saying that they don’t work and you don’t need them. And now suddenly, without any change in the evidence base, they’re suddenly saying that they do work and you should wear them.” Cowling says, ‘I think that that’s unhelpful.

Mask adoption in the US has been uneven. A survey from the data collection firm Premise shows that the percentage of people who ‘always wear a mask when going out’ ranges from 15% in Tennessee to 62% in Massachusetts as of June 19.

For both ASU and IHME’s models, the proportion of deaths face masks could prevent differs from location to location and during different stages of the pandemic because transmission rates in the community at the time of projection affect outcomes.

In ASU’s model, widespread community transmission would call for more effective face masks – for example, the surgical masks used in hospitals – to significantly reduce the number of projected deaths. But in places where transmission is not as widespread, most people wearing simple cloth masks would be able to prevent a significant portion of deaths.

In IHME’s model, the more people each infected individual can spread the virus to, the more deaths masking can prevent. It also projects that the virus would follow seasonal patterns and pick up again in the fall. Vos says this means places that have relatively safe levels of the spread now could see more pressure to contain the virus later.

“The use of masks…in those places is going to become a lot more marked and beneficial.” Vos says.

Regardless of community transmission rates, both models show that the more universal face masks are worn, the more deaths can be prevented.

It’s difficult to know whether the projections are correct because it’s difficult to know how the public is actually wearing masks. But considering that research on face masks show that they can tamp down transmission, modellers agree that they should help save lives when worn by a large portion of the population.

“Clearly, clearly the data shows that every model and study that we have seen, every public health policy in the world has said exactly the same thing,” says Abba Gumel, who led the ASU project, ‘We have to wear a face mask.’

Andrea Hsu and Courtney Dorning produced and edited the audio version of this story.

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Coronavirus response at crossroads as U.S. marks Fourth of July

“We have perhaps one more chance to get this right,” said Aileen Marty, an infectious-disease specialist at Florida International University whose argument for meticulous asymptomatic testing went unheeded in April when a sampling site opened at the Miami school. Three months later, she is renewing her appeal as cases soar in Miami-Dade County, the center of the outbreak in Florida, which Friday reported 9,488 new infections.

This week, Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, warned the country could soon record 100,000 cases a day — more than half the total recorded by such peer democracies as France and Germany since the pandemic began. An outbreak on that scale could force whole swaths of the nation back into lockdown, depressing consumer activity, accelerating layoffs and further damaging the American economy as much of the developed world climbs back toward normalcy.

“This weekend, the next week-and-a-half, perhaps the next two weeks are make or break,” said Marty, a former Navy physician whose dire warnings were circulated in a letter this week among Miami-Dade commissioners. “If we don’t massively change our behavior right now, to stop facilitating the transmission of the virus, then we are facing either another lockdown or a massive number of hospitalizations and deaths.”

With the menace newly visible in Republican-controlled states, some in the party’s leadership have shifted their stance about masks. Vice President Pence has begun covering his face for public appearances, and President Trump said he liked the way he looked in one and would wear it when he saw fit.

Scarred by surging cases after Memorial Day, state and local leaders from Los Angeles to Miami Beach prepared for the Fourth of July holiday by closing businesses and imposing curfews. In California, which took some of the earliest and most aggressive actions to contain the virus but saw cases explode after easing restrictions, Gov. Gavin Newsom (D) shut down bars and suspended indoor dining in much of the state.

On Thursday, the mayor of Miami-Dade County took the extraordinary step of imposing a 10 p.m. to 6 a.m. curfew.

“This curfew is meant to stop people from venturing out and hanging out with friends in groups, which has shown to be spreading the virus rapidly,” Mayor Carlos A. Giménez wrote in a statement, which cited the death of an 11-year-old in the county from covid-19, the disease caused by the coronavirus.

Leaders who once ordered residents indoors reached instead for ultimatums, signaling that more painful measures were on the horizon. Oregon Gov. Kate Brown (D) cautioned students and parents this week that their “actions will determine, frankly, whether we can open schools in the fall.” She joined governors of both parties, many of them reluctant to take more sweeping actions, in “urging” and “asking” residents to stay home and to practice social distancing.

In Georgia, Gov. Brian Kemp (R) embarked on a “wear a mask” tour of his state. Gov. Ron DeSantis (R) encouraged Floridians to be “diligent.”

“It’s a small sacrifice to make if we know we’re protecting others,” said Cara Conlogue, a first-grade teacher in Palm Beach, Fla.

Nearby, Jason Higgins was loading $500 worth of fireworks into his SUV. He planned to set them off in his backyard, observing, “We need to get on with life, but we need to be cautious.”

Few, however, can agree on how to strike that balance. Ron Ayala, a sales manager in Phoenix, said the precautions taken by some do not compensate for the disregard of others.

“The problem is that you’ve got some people that they’ll go all in — they’re wearing gloves and masks, they’ve got the eye protection, they don’t leave the house unless it’s absolutely necessary,” Ayala said. “And then there’s others that they don’t care. They’ll do whatever they want.”

That divide is on vivid display for nurses and emergency physicians, who finish 12-hour shifts in coronavirus wards and then walk the aisles of grocery stores, sometimes the only shoppers in masks.

“It’s very discouraging,” said Serena Bumpus, the Austin-based director of practice for the Texas Nurses Association. “We’re still waiting to see if the public will change their behavior.”

A turning point was marked Thursday, as Texas Gov. Greg Abbott (R) stopped waiting and imposed a statewide mask mandate requiring face coverings in counties with more than 20 cases. Mark McClellan, a former commissioner of the Food and Drug Administration who has been advising Abbott on his response, said the governor became concerned by how quickly the rate of hospitalizations was intensifying, with the state’s average of daily covid-19 hospitalizations 60 percent higher than it was a week ago, according to Washington Post data.

Abbott, who once blocked efforts by local officials to require masks, said of his decision, “Covid-19 is not going away. In fact, it’s getting worse.”

That much is true nationally, as the country Friday reached a new high in its seven-day average of cases, as it has done consecutively for the past 25 days. At least 35 states this week reported single-day increases that eclipsed new cases in all of Italy, the center of the European outbreak.

“We’ve all been looking at these charts of Europe and the U.S.,” said David O’Sullivan, a former Irish civil servant who served as ambassador from the European Union to the United States from 2014 to 2019. “At one point, we were more or less at the same point on the graph, but then we’ve gone down and down, even with opening back up, and in the U.S., the numbers are soaring.”

Americans submitted to stay-at-home orders in March and April in a bid to preserve medical resources and buy the country’s leaders time to develop an effective regime of testing, contact tracing and isolation. But they emerged this summer to conflicting messages about the scale of sacrifice still required; squabbles over the partisan signals sent by wearing masks; and inadequate resources, from testing reagents to hospital beds, to keep them safe.

Universities that once entertained the prospect of resuming ordinary operations in the fall are increasingly committing to alternative plans. From the White House to governor’s offices, trade-offs are crystallizing.

Kellyanne Conway, Trump’s senior counselor, defined the decision this way in a recent appearance on Fox News: “Do you want to open the bars now, or do you want to open the schools and the day-care centers in a few short weeks? I vote for the latter.”

In Georgia, Kemp threatened to take away college football, saying this year’s season would be a “tall task” if the state’s numbers kept rising.

South Carolina Gov. Henry McMaster (R) invoked the favorite pastime as an incentive. “Let me make it very clear,” he tweeted Wednesday. “Wear a mask and social distance now so we can enjoy high school and college football in South Carolina this fall.”

Congressional Republicans were at pains to dispel the stigma of masks for some in their party as even Trump seemed to shift his stance this week. “I’m all for masks,” he said in an interview on Fox Business Network.

At the same time, the president renewed his notion, which defies evidence, that the virus would simply fade away.

“I think we’re going to be very good with the coronavirus,” Trump said. “I think that at some point, that’s going to sort of just disappear, I hope.”

Similar confidence seemed to animate the approach of some leaders even in regions buffeted by the virus. In Texas, the Republican lieutenant governor, Dan Patrick, assailed Fauci for suggesting that some states “skipped over” key benchmarks for reopening.

“The only thing I’m skipping over is listening to him,” Patrick told Fox anchor Laura Ingraham, referring to the nation’s top infectious diseases expert.

The inconsistent messaging is causing Americans to throw up their hands, said Umair A. Shah, the medical director in hard-hit Harris County, which includes Houston and is leading Texas in confirmed cases. Some people, he said, are concluding, “Well, gosh, I’m just going to risk it.”

“This is where the federal government, and the [Centers for Disease Control and Prevention] in particular, comes in,” Shah said. “In the past it’s been a convener, bringing communities and health departments together, saying, ‘Here’s what we’re doing across the system.’ I have not seen that as much now.”

The CDC had 47 teams activated as of this week to assist local health officials, including 36 working directly in the field. A number were tackling outbreaks in communities of color and among younger age groups, according to a spreadsheet obtained by The Post.

While new infections have been most prevalent among young people, and while deaths have not risen as sharply as caseloads, the death toll is only just coming into view. Arizona on Wednesday reported 88 deaths, a one-day high, and CDC analysis of incidence and mortality — collected in a slide deck obtained by The Post — also shows sharp increases in daily deaths from covid-19 in Texas and Florida.

Meanwhile, scenes of besieged intensive care units that shocked the country when they emerged from New York in the spring are now being envisioned across the Sun Belt. Don Williamson, president of the Alabama Hospital Association, said he worries some hospitals could run out of ICU beds by the end of July — the entire state by the end of August.

The holiday weekend, he said, “is probably our last chance to avoid at least some of our hospitals simply being overwhelmed.”

But health officials across the country are drained, and some are using the holiday weekend as the first opportunity to take time off since the pandemic’s onset. Testing sites administered by the public health district that covers 13 counties in central Georgia are closed Friday and Saturday. “We have been working six to seven days a week since March,” said the health district’s spokesman, Michael Hokanson.

Others preparing to work over the holiday weekend wondered if they would come to regret it. Geoconda Argüello-Kline, secretary-treasurer of the Culinary Workers Union in Las Vegas, welcomed a new statewide mask mandate but noted it came 24 days after casinos opened. The union is suing three casino companies, alleging they failed to adequately protect workers from exposure to the virus among unmasked crowds, while the companies say they followed proper procedure.

Elsewhere, there was hope a silver lining might emerge from an increasingly visible crisis. Arizona health officials this week authorized hospitals to implement “crisis care” standards dictating how to ration medical resources, a move that public health experts said may finally make clear to residents the consequences of unchecked viral spread.

“People are just in denial,” said Joanna Bivens, a hairstylist in Gilbert, Ariz.

Cara Christ, director of the Arizona Department of Health Services, said new guidelines issued by the governor, combined with “public messaging and education,” would help stem the tide.

Others said the emphasis on coaxing the public to behave was misplaced. In Miami-Dade, a county commissioner who disseminated Marty’s proposal for more robust testing and contact tracing, said the government’s response must go beyond beseeching people to be safe.

“To blame it on people not wearing masks is to mask the truth,” said the commissioner, Daniella Levine Cava, a Democrat running to be the county’s mayor.

She said contact tracing, which is overseen by the state, is perfunctory and highly limited, despite plans to contract with a third-party call center, Maximus, to bolster Florida’s workforce.

Neither the state health department nor the county mayor, Giménez, responded to requests for comment. And it remained unclear how the plan laid out by Marty, though it met a positive reception among county officials, would be put into practice.

At a commission meeting this week convened to address the county’s rising caseload, Giménez, a Republican running for Congress, stressed the importance of social distancing and wearing masks. “Unfortunately, we think — we know — that a number of our citizens did not do the things that we asked them to do,” he said

The mayor made the right call by closing the beaches for the Fourth of July, Marty said. Now, there needs to be a broader reset, said the infectious diseases expert.

“We have to give this piece of genetic material its due, or it’s going to continue to wreak havoc,” she said.

Jacqueline Dupree in Washington, Jeremy Duda in Phoenix and Lori Rozsa in Palm Beach and West Palm Beach contributed to this report.

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Coronavirus Live Updates: U.S. Leaders Change Course

As daily cases in the U.S. pass 50,000, officials stress precautions.

In Columbia, Mo., where coronavirus case numbers are as high as they’ve ever been, contact tracers are overwhelmed. Around Seattle, where a surge is underway, officials warned that social distancing was waning. And in Flint, Mich., where there are worrisome signs after weeks of improvement, the mayor said the city would crack down on late-night parties that have drawn hundreds of young people.

“Someday we will welcome these crowds to our great city,” Flint’s mayor, Sheldon Neeley, said. “Now is not the time.”

As the pandemic spirals further out of control in the United States, politicians and public health officials have become noticeably more stern. New cases reported have increased 90 percent in the United States in the last two weeks. On Thursday, the U.S. also set a single-day case record for the sixth time in nine days, with more than 55,000 new cases announced, and single-day highs in eight states.

In many places, face coverings have gone from suggestions to mandates. Bars have been reopened — and closed again. Domestic travel restrictions have re-emerged. And mayors have told people to shape up and follow the rules.

“I know that wearing a mask is uncomfortable,” said Mayor Nan Whaley of Dayton, Ohio, where case numbers are spiking and face coverings are now required. “I know that, unfortunately, wearing a mask has become a political flash point. But I also know that masks save lives.”

In a reversal, Gov. Greg Abbott of Texas, one of the worst-hit states in the past week, on Thursday ordered residents in counties with 20 or more virus cases to wear masks in public.

Mr. Abbott, a Republican, had previously opposed attempts by Democratic mayors and other local officials to require everyone in their cities to wear masks in public.

In Chicago, Mayor Lori Lightfoot said Thursday that travelers from 15 states with large outbreaks would have to quarantine for two weeks or face up to $7,000 in fines. In Los Angeles County, Calif., where there are more than 2,000 new cases most days, the top public health official said “we urgently need to make a change in the trajectory.” And in Northern California, where the outlook is also bad, leaders in several counties urged residents to celebrate the Fourth of July at home and not test the limits of the law.

“Just because you can does not mean it is safe or that you should rush to do it,” said Dr. Matt Willis, the Marin County public health officer.

President Trump plans to celebrate the Independence Day holiday with a fireworks display on Friday at the Mount Rushmore National Memorial in South Dakota. About 7,500 people are expected to attend the outdoor event, where masks will be available but not required.

Boris Johnson, Britain’s prime minister, who said earlier this week that it was Britons’ “patriotic duty” to go to the pub when they reopen on Saturday, has now urged people not to “overdo it.” His warning came after tens of thousands have flocked to beaches, organized illegal music parties and violated social-distancing rules in recent weeks.

Britain has reported the world’s third-highest pandemic death toll, with triple-digit death counts still coming most days.

“Let’s not blow it now, folks,” Mr. Johnson told LBC radio on Friday, weeks after he announced that the country’s “long hibernation” was over and that the virus was under control. Restaurant industry workers have said in British news outlets that they were afraid of going back to work, and concerns are high that pub customers could flout basic rules and trigger new waves of infections.

A spokesman for Mr. Johnson said that pubs could reopen starting at 6 a.m. on Saturday, “in the event anybody would attempt to try to open at midnight.”

On Wednesday, the Treasury tweeted that people should “grab a drink and raise a glass” when pubs reopen. The tweet was later deleted. A pub in south London has promised “endless supply” of drinks to “fuel your shenanigans,” after more than three months of closure, which was a first in the history of the country’s pubs.

Pubs — like restaurants, hair salons and other businesses welcoming visitors again on Saturday — will have to maintain a 21-day record of their customers, the government has said, to trace contacts in case of new outbreaks.

In Leicester, 100 miles north of London, pubs and other nonessential businesses will remain closed because of a regional outbreak of virus cases.

The British authorities also announced on Friday that, starting July 10, travelers from countries in Europe including France, Italy and Spain will no longer have to self-quarantine for 14 days. The change will currently only apply to England, with Scotland, Wales and Northern Ireland expected to set up their own rules.

In other news:

  • Brazil, which has been experiencing a surge in virus cases, allowed restaurants and bars to reopen with conditions on Thursday, according to The Associated Press. Gyms, dance, fighting and swimming classes were also authorized to restart, The A.P. said, as long as there is no physical contact, a third of capacity and a time-slot schedule.

  • Starting July 10, England will drop its mandatory 14-day quarantine for visitors from more than 50 countries but leave the restrictions in place for travelers coming from the United States, deepening the isolation of America. Scotland, Wales and Northern Ireland apply their own travel policies and may not follow England’s lead in easing restrictions.

  • Residents in nursing homes in Britain will be tested for the virus monthly, while staff members will receive tests weekly, officials announced. According to a survey published on Friday by the Office for National Statistics, 56 percent of the country’s nursing homes have had at least one case since March, with 20 percent of residents in such facilities known to have been infected. Out of the nearly 44,000 reported deaths in Britain, at least 15,500 people have died in nursing homes.

  • Seeking to give his government a fresh start after the pandemic battered the nation, President Emmanuel Macron of France shuffled prime ministers on Friday, trading in the popular incumbent, Édouard Philippe, for a relatively unknown functionary who helped guide the country out of the health emergency, Jean Castex.

  • Spain said on Friday that it would not reopen its borders with Morocco after Morocco’s decision to keep entry points closed that are used by millions of people every summer. The dispute also affects Ceuta and Melilla, two Spanish enclaves in North Africa. Spain also said that it would bar arrivals from Algeria and China. The European Union reopened its borders this week to travelers from 15 countries, including Algeria, while travelers from China would be permitted if China reciprocates.

  • Austria recorded more than 100 new cases of the virus on a single day this week, its highest such total in more than two months. Many of the confirmed infections are connected to a religious community in Linz, a city in the northern part of the country, and officials closed schools and day care centers in the area for a week. Austria’s health ministry has registered 17,959 cases and 705 deaths.

Vice President Mike Pence changed his travel plans in Arizona after Secret Service agents set to accompany with him tested positive or showed symptoms, two administration officials said on Thursday.

Mr. Pence had been scheduled to visit Arizona on Tuesday, but multiple factors related to the spread of the virus foiled those plans, according to a person familiar with Mr. Pence’s travel.

A swift rise in new cases in the state has overwhelmed testing centers in recent days, and Gov. Doug Ducey, a Republican, ordered bars, gyms and movie theaters closed this week. In an apparent acknowledgment of outbreaks erupting across the South and the West, the vice president canceled his plan to headline a “Faith in America” campaign rally in Tucson on Tuesday and then tour Yuma with Mr. Ducey.

Instead, Mr. Pence opted for a shorter visit to Phoenix on Wednesday, where he participated in a public health briefing at Sky Harbor International Airport.

“Help is on the way,” Mr. Pence said at a news conference with Mr. Ducey at the airport, after descending the steps of Air Force Two wearing a mask, the latest sign of the administration’s evolving stance on face coverings.

But the positive tests and symptoms of Secret Service agents expected to be in proximity to the man who is second in line for the presidency were some of the factors that prompted his change of schedule, the officials said. The news of the agents who showed symptoms, or tested positive, was first reported by The Washington Post.

A spokeswoman for Mr. Pence did not respond to a request for comment.

The latest illnesses among the small circle of individuals who interact directly with the vice president were a reminder of the dangers of carrying on with campaign and official government travel as the pandemic rages on.

New York, transformed by the virus and protests for racial justice, has been cooped up, and a good, old-fashioned swim “takes the edge off,” said Rachel Thompson, a schoolteacher. She was at Rockaway Beach in Queens on Wednesday as New York City opened its beaches for swimming — just in time for the Fourth of July weekend, when even more people are expected to pack the sand.

Still, several beachgoers that morning, Ms. Thompson included, were feeling a bit jittery about the city’s gradual reopening. An hour after the ban on swimming was lifted, the mayor announced that indoor dining at restaurants would not resume on Monday as anticipated, citing the virus’s rapid spread in other large states.

Mayor Bill de Blasio, worried that large crowds might risk virus transmission, had kept the city’s 14 miles of beaches closed even as temperatures rose — along with frustration from long-quarantined New Yorkers. With an estimated million visitors total on a hot day, they are some of the country’s most crowded shorelines, and people largely access them via subways and buses.

Safety measures include lifeguards in masks carrying waist packs with a face mask, gloves and hand sanitizer. Beachgoers must keep at least six feet apart and wear face coverings when on the sand or the boardwalk. Restrooms will operate at half-capacity, and boardwalk concessions must offer to-go service only.

Hundreds of city workers, deployed as social distancing ambassadors, will hand out masks, keep space between beachgoers, tally beachgoers to prevent overcrowding, tend beach entrances to limit capacity and, if necessary, direct people to less crowded sections.

Worries have lingered about a possible backslide in the state, where, after reining in the virus, there have been a few alarming outbreaks, such those at a house party and graduation party in the suburbs just north of the city.

College students across the country have been warned that campus life will look dramatically different in the fall, with temperature checks at academic buildings, masks in half-empty lecture halls and maybe no football games.

What they might not expect: a lack of professors in the classroom.

Thousands of instructors at American colleges and universities have told administrators in recent days that they are unwilling to resume in-person classes because of the pandemic.

More than three-quarters of colleges and universities have decided students can return to campus this fall. But they face a growing faculty revolt.

“Until there’s a vaccine, I’m not setting foot on campus,” said Dana Ward, 70, an emeritus professor of political studies at Pitzer College in Claremont, Calif., who teaches a class in anarchist history and thought. “Going into the classroom is like playing Russian roulette.”

This comes as major outbreaks have hit college towns this summer, spread by partying students and practicing athletes.

In an indication of how fluid the situation is, the University of Southern California said on Wednesday that an “alarming spike” in coronavirus cases had prompted it to reverse an earlier decision to encourage attending classes in person.

With more than a month before campuses start reopening, it is hard to predict how many professors will refuse to teach face-to-face classes in the fall. But colleges and professors are planning ahead.

Elsewhere in the U.S.:

  • In Miami-Dade County, Fla., the mayor imposed a countywide curfew from 10 p.m. to 6 a.m., starting Friday; he also rolled back the opening of movie theaters, arcades, casinos, concert halls, bowling halls and adult entertainment venues that recently had their reopening plans approved by the county. Miami-Dade and Broward counties had already announced they were closing beaches for the Fourth of July weekend.

  • Critics of Amtrak’s newly announced cutbacks worry that the rail agency will not bring back service to the long-distance routes it has long sought to end. With ridership down 95 percent and revenue plummeting, Amtrak plans to cut up to 20 percent of its work force by October and suspend daily service on routes that service over 220 communities. Amtrak has received letters from 16 senators asking why it needed to enact such steep cuts since it had already received $1 billion in emergency aid.

China appears to be downplaying expectations ahead of a planned trip next week by a World Health Organization team to the country to investigate the origins of the outbreak.

Since the head of the W.H.O., Tedros Adhanom Ghebreyesus, announced the trip on Monday, several Chinese officials and experts have said that any investigation into the origins of the virus should not focus only on China.

“It does not matter which country the scientific identification work starts with, as long as it involves all related countries and is fairly conducted,” Zeng Guang, the chief epidemiologist for the Chinese Center for Disease Control and Prevention, told the state-run nationalist newspaper Global Times on Tuesday.

Wang Guangfa, a top government health adviser, told Global Times this week that the W.H.O. should also go to Spain. He cited a not-yet-published study by researchers at the University of Barcelona that suggests the virus was present in Spain’s wastewater as early as March 2019.

Independent experts have said the study was flawed, and that other lines of evidence strongly suggest the virus emerged in China late last year.

The virus most likely originated in bats, but the path of transmission is still unknown. Experts say establishing that will be a crucial step in preventing future outbreaks.

The hunt for information has focused on Wuhan, the central Chinese city where the virus is believed to have first emerged, and specifically the Huanan Seafood Wholesale Market, which was said to have sold wildlife and had links to many of the country’s first reported cases.

Mike Ryan, head of the W.H.O.’s emergencies program, said on Wednesday that the agency would be sending two experts from Geneva to join its China team on next week’s trip. He said one would likely be an epidemiologist and the other an expert in animal health.

Dr. Ryan did not reveal which cities the team was planning to visit. He described it as a “scoping mission.”

Getting answers on the origins of the virus has become more difficult as the issue has become increasingly politicized. China has been on the defensive for months in response to growing criticism from the United States and other countries for its initial mishandling of the outbreak. Officials from both the United States and China have, without providing evidence, accused each other of intentionally releasing the virus.

But at a news briefing this week, a Chinese foreign ministry spokesman sounded a less-aggressive note.

“China has always believed that virus tracing is a scientific issue, and relevant research should be carried out by scientists and medical experts,” said Zhao Lijian, the spokesman, who in March promoted a theory that the U.S. Army purposely introduced the virus to China.

“China continues to support scientists from all over the world in conducting global scientific research on the source and spread of viruses,” he added.

In an essay for The Times, Deb Perelman, a New York writer and the creator of the food blog, discussed the dilemma facing working parents:

Last week, I received an email from my children’s principal, sharing some of the first details about plans to reopen New York City schools this fall. The message explained that the city’s Department of Education, following federal guidelines, will require each student to have 65 square feet of classroom space. Not everyone will be allowed in the building at once. The upshot is that my children will be able to physically attend school one out of every three weeks.

At the same time, many adults — at least the lucky ones that have held onto their jobs — are supposed to be back at work as the economy reopens. What is confusing to me is that these two plans are moving forward apace without any consideration of the working parents who will be ground up in the gears when they collide.

Let me say the quiet part loud: In the Covid-19 economy, you’re allowed only a kid or a job.

Here are some tips on how to have some socially distanced fun this weekend.

Leaders in many states are urging people to stay at home this holiday weekend. Here are some safe ideas for enjoying the Fourth of July holiday.

Identifying likely voters is a challenge for pollsters in every election. This year, the coronavirus, mail voting and a surge in political engagement may make it even harder than usual.

For now, former Vice President Joseph R. Biden Jr.’s nine-point lead across the critical battleground states is so significant that it is essentially invulnerable to assumptions about turnout, according to New York Times/Siena College surveys of the states likeliest to decide the election. But supporters of Mr. Biden, the presumptive Democratic nominee, are far more likely to be concerned about in-person voting during the pandemic, and his wide polling lead among registered voters could narrow if their concerns persist to the election.

Over all, one-quarter of registered voters in the battleground states said they would feel uncomfortable voting in person.

People were asked if they would feel uncomfortable voting in person if the election were held during the week they were interviewed in June. About 40 percent of Mr. Biden’s supporters said they would feel uncomfortable, compared with just 6 percent of President Trump’s supporters.

This political divide transcends demographics. A young Biden supporter in a rural area, for instance, would be likelier to feel uncomfortable voting than an older Trump supporter in a city, even though the health risk is probably quite low for the Biden voter and potentially quite significant for the Trump supporter.

Most of these voters would go to the polls anyway. But about one-quarter of the uncomfortable voters — or about 6 percent of the overall electorate — said they would feel too uncomfortable to vote in person if the election were held during the week they were interviewed. This includes 8 percent of all of Mr. Biden’s supporters in the battleground states, compared with fewer than 2 percent of Mr. Trump’s supporters.

It is important to emphasize that no-excuse absentee voting, in which any voter can request a mail ballot, is available in all six of the battleground states included in the Times/Siena data.

On Thursday, the Supreme Court blocked a trial judge’s order that would have made it easier for voters in three Alabama counties to use absentee ballots in this month’s primary runoff election.

The court’s brief, unsigned order gave no reasons, which is typical when it rules on emergency applications, and it said the order would remain in effect while appeals moved forward.

The court’s four more liberal members — Justices Ruth Bader Ginsburg, Stephen G. Breyer, Sonia Sotomayor and Elena Kagan — said they would have rejected Alabama’s request.

Reporting was contributed by Aurelien Breeden, Benedict Carey, Nate Cohn, Richard Fausset, J. David Goodman, Anemona Hartocollis, Annie Karni, Adam Liptak, Raphael Minder, David Montgomery, Adam Nossiter, Elian Peltier, Amy Qin, Christopher F. Schuetze, Mitch Smith, Sabrina Tavernise and Derrick Bryson Taylor.

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Trials and Tribulations of an Undocumented Immigrant

This is not a love story. This is a story that talks about sensitivity, vulnerability and understanding of being with someone who is or was once undocumented. The life of undocumented immigrants who grew up in the United States, also known as the 1.5 generation, can be very difficult and confusing. 

As a mental health practitioner and researcher, I was invited to join a panel to address mental health issues for this specific undocumented immigrant college student’s community. I formulated a support group, where the students shared their stories about love and vulnerability. I would like to share the story of a girl who immigrated from Nigeria when she was seven years old and her life trajectory as influenced by her undocumented status. 

As an undocumented child, she was told to never reveal her immigration status to anyone, including her teachers and peers. At the playgrounds, she remained cautious when forming new bonds with peers. She learned to manipulate and deflect conversations away from topics that might reveal this vulnerable identity. The only time she could talk about this topic, was at home, with her mother and her brother. They were her only protection, but also her deepest fear of abandonment — as she knew that she can be separated from them at any time.

Shame and Guilt

She related an incident in her senior year of high school, when she asked a boy, a friend who she liked and built a relationship with through her freshman and sophomore year of high school, to help her with her financial aid application for college. He jokingly questioned her immigration status, “You don’t have papers?” All her fears immediately came to light. Triggered, she abruptly left the room to go home and cry in her mother’s lap.

Upon her return, her friend had apologized, but she kept him at bay, choosing not to give him any opportunity to exploit her fear of feeling powerless, deceived and abandoned by him. She did not give this relationship another chance and denigrated all her relationships whenever she felt the same comfort as she did with this one friend. A pattern started to emerge, where she could not maintain friendships as simple interpersonal conflicts resulted in an intense provocation of anxiety and rage. Understand her struggle.


After she graduated high school, she started community college. As the semester wrapped up, one of her classmates, who she liked, invited her to come drinking at a local jazz bar, as it was the last day of class for the semester. As she stood in line with the rest of the people to enter the bar, she was denied entry because she did not have a legal form of state ID. This minor rejection evoked the past experience of feeling abandoned and ashamed. She remained frozen, while her classmate nudged her to capture her attention. As she looked around, she could not hear what her classmate was saying, she pushed him aside and left for home. Recalling the incident, she reflected, “I felt like there was a ball stuck in my throat, I couldn’t speak… as soon as I snapped out of it, I left and walked home, which is 5 miles away… I didn’t even have the capacity to think of taking the train.”

When she went home, she told her family what happened. They listened to her and poured her a glass of wine, to recreate this celebration at home, for the end of the semester. Helpless yet safe, she wondered if anyone would understand her struggle.


For her, family was always safe. Until her mother married a man with legal status — for love and to possibly legalize their immigration status in the future. Not realizing that this person was an outsider, she showed similar attachment to him as she did for her brother and mother. She said, “I was so happy to know there is one more person in my life who would understand me, I took my safety at home for granted and dropped my guard as I though he was a part of the family.”

Her mother was the authority figure and now there was a new authority figure, a caretaker who she could idealize and hope to share her struggle with. However, as she vented to him, he would make sexual advances. She would again dissociate, not fully conscious of her surroundings and unable to fathom the severity of the situation, she was molested. When she told her mother and brother about the incident, the stepfather threatened them with deportation by calling Immigration and Custom Enforcement on them. The very next day, in the midst of night, the family ran away from home, leaving everything behind to take shelter at a church, later settling in a smaller town, away from this dangerous person.

After sharing this story, she added, “I wondered if this would keep happening to me, will I always end up putting myself in similar humiliating situations?” She seemed to have blamed herself for the abuse she experienced, rather than seeing herself as the innocent victim.

“No one understand me,” she told me. “You will never understand me.”

“It’s true,” I said. “I will never understand your pain… no one will understand your pain.”

She interrupted me and said, “Thank you for saying that… it feels so good to hear that… everyone always acted like they understood me… even when they didn’t and that hurts so much!”


Eventually, she returned to her college, taking a semester off to recuperate. She wanted to reconnect with her old friends and make ones. Except, she had difficulty with intimacy and the relationships became fragmented. One mistake and she would accuse her friends of neglect and abandonment.

After talking about several broken friendship incidents, she would say, “I don’t even know what trust is anymore… I don’t know who to trust.”

I would respond, “It takes time to build trust, especially after everything you have been through… you will know when you feel safe in a friendship.”

From a clinical lens, I knew she was showing symptoms of hyperarousal, flashback and dissociation, that prevented her from forming healthy intimate relationships.


Over time, she knew her current maladaptive reactions to her friendships were preventing her from establishing healthy and secure relationships. She started journaling and reflecting on her relationships, only to realize the importance of forming new experiences without prematurely sabotaging them in order to prevent the possibility of any emotional hurt. As a result, she only engaged in some casual relationships, only to find a pattern of entering relationships that she knows will never turn into anything serious or long term. Upon further reflection, she recognized her vulnerability to exposing herself to risk of repeated victimization, especially in intimate relationships.


After attaining her associated degree, she gave another shot to a serious relationship. Six months into the relationship, her partner wanted to go on vacation to Cancun together. He invited her to come with him, only to be reminded that she was undocumented, and she cannot travel out of the country. So they decide to go local and take a trip to Florida.

Over time, however, the limitations turned into resentment and the relationship fell apart. Instead of seeing this as a failure, she recognized it as a renewed sense of control. In other words, at least, she knew to end the relationship as her partner did not have the capacity to support her in her survival of her marginalized identity. There was a new sense of autonomy and empowerment. She would define this as the ability to form relationships that were based on her wants and not her needs.


In 2015, she became eligible for Deferred Action for Childhood Arrivals (DACA), which prevented her from being deported and gave her accessibility to health insurance. With psychotherapy and psychiatric support, she discovered that her symptoms were like symptoms of complex post-traumatic stress disorder. When she was alone, intrusive thoughts of physical and emotional abuse came flooding in, limiting her ability to be present in the moment and causing her to dissociate. And, when she was questioned about anything associated with her immigration status, she became defensive and everything was perceived as a threat or her enemy. 

Even as a temporarily documented person, she had difficulty letting go of these various survival traits. If she felt like she was not in control of something, she ran away from those scenarios, including friendships and intimate relationships. The outcome was isolation and alienation, which manifested as depression and anxiety.


She is one of the fortunate survivors of such severe hardship that comes along with the identity of being a 1.5 generation undocumented immigrant. Her story bears one conclusion: being undocumented and the hardship associated with such status, can manifest as a form of complex post-traumatic stress disorder.

She is your co-worker, neighbor and classmate. This article is a reminder to be compassionate towards your peers, even if you do not know about their immigration status. Be sensitive and understanding of the hardships associated with immigration status. More importantly, advocate for the undocumented immigrants to have access to mental health care.

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How Safe Is it to Use A Public Bathroom?

July 2, 2020 — With dirty door handles, heavily trafficked toilet bowls, and proximity to strangers, public restrooms can be a germophobe’s worst nightmare. But the COVID-19 pandemic adds a new layer of risk, and infectious disease doctors are urging people to be cautious ahead of the holiday weekend.

A recent study published in Physics of Fluids outlines the potential dangers of toilet plumes — clouds of droplets that can rise 3 feet from a flushing toilet and be inhaled by an unsuspecting user. Aside from the obvious ick factor, simulations found that coronavirus remnants in a person’s stool can make their way onto other surfaces or linger in the air nearby.

But there are things people can do to avoid the dangers of restrooms.

“What’s the most hazardous part of using a public restroom? It’s the people in it,” says William Schaffner, MD, a professor of medicine in the Division of Infectious Diseases at the Vanderbilt University School of Medicine. “It’s not necessarily the inanimate environment.”

Wear a mask, of course. Scope out the bathroom ahead of time to see how congested it is, Schaffner says, and wait to use it until it has cleared out a bit. If it is urgent, try to keep your distance from people — for men, stay a couple of urinals away from the nearest person. Aim to use larger restrooms to avoid close contact with people and toilet sprays.

Though it may be tempting to use seat covers, it is not recommended — they could be covered with their own germs, and it is smart to keep contact with objects to a minimum.

“If you want, you can carry wipes into the bathroom with you and wipe off the toilet seat before sitting down,” Schaffner says.

Toilets with lids can be closed before flushing to avoid the plume. If they don’t have lids, back away and exit the stall as quickly as possible. And when approaching the sink for hand-washing, Schaffner says, pay attention to the number of people already using the space. If you can, wait until the area is clear.

Although studies have shown that high-powered air dryers can blow harmful particles around, infectious disease experts say those machines and paper towels have similar risks. In fact, Schaffner says, the air dryers might be safer.

“I think air dryers help rather than hurt — they move air around,” he says. “If there happens to be a person next to you that’s infected, the air dryer will disperse the air, and you’re much less likely to get an infectious dose of the virus.”

According to Aaron E. Glatt, MD, chairman of medicine at Mount Sinai South Nassau, the risk of contact with bodily fluids pales in comparison to the dangers of close gatherings. After all, there is always a chance of plume contamination with viruses and bacteria like E. coli.

“Bodily fluids are always a concern, regardless of COVID,” he says.

Glatt’s main advice? Be smart and use common sense. If you are going on a trip, try to avoid using a public restroom altogether and go before you leave the house.

The bigger concern, Glatt says, is the potential spike of COVID-19 cases after fireworks displays and barbeques bring large groups of people together.

“People aren’t being careful. We’re seeing it across the country right now,” he says. “This is a formula for disaster.”

As long as people are mindful of “the big three” — masks, hand-washing, and distancing — the country can avoid a post-holiday spike, Schaffner says.

“There is still plenty of room for people to enjoy themselves,” he says.


William Schaffner, MD, professor of medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine.

 Aaron E. Glatt, MD, chairman of medicine, Mount Sinai South Nassau.

Journal of Applied Microbiology: “Evaluation of the potential for virus dispersal during hand drying: a comparison of three methods.”

Physics of Fluids: “Can a toilet promote virus transmission? From a fluid dynamics perspective.”



© 2020 WebMD, LLC. All rights reserved.

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No Federal Mandates For Masks On Planes Or Empty Middle Seats : NPR

Airlines tired of largely empty flights because of coronavirus fears want to fill planes — and the federal government isn’t stopping them — now that more travelers are venturing out.

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Airlines tired of largely empty flights because of coronavirus fears want to fill planes — and the federal government isn’t stopping them — now that more travelers are venturing out.

Justin Sullivan/Getty Images

The Trump administration is urging airlines to leave some airplane seats empty to help protect travelers and crew members from the coronavirus but it is stopping short of requiring airlines to keep seats open to create physical distancing on flights.

The federal COVID-19 guidelines also encourage all passengers to wear face coverings or masks but again, the administration will not mandate it.

And that’s a problem, according to some consumer groups, public health officials, airline employee unions and members of Congress, who say there needs to be enforceable federal rules that are consistent across the air travel industry to minimize the risk for transmission of the virus.

As air travel demand begins to slowly recover from the pandemic, the U.S. Departments of Homeland Security, Transportation, and Health and Human Services jointly issued guidelines for the air travel industry Thursday in a report called the Runway to Recovery.

It encourages airlines and airports to promote social distancing, enhance disinfection and cleaning procedures, create barriers such as plastic shields at counters, conduct health assessments of passengers and employees and collect passenger information for possible contact tracing; all are measures most airlines and airports have already implemented, as they follow recommendations issued by the Centers for Disease Control and Prevention months ago.

A Transportation Department press release says, “The guidance will enhance public health risk reduction to support an increase in travel volume while ensuring that aviation safety and security are not compromised.”

“This document provides clear guidance to airlines and airports to protect the traveling public, and we encourage people to pay attention to it,” added Transportation Secretary Elaine Chao in a statement.

But traveler and consumer advocacy groups say the guidelines are inadequate.

“Americans are rightfully concerned that they may be putting their health and safety at risk if they choose to fly during a global pandemic,” said William McGee, aviation advisor for Consumer Reports. “The DOT shouldn’t leave it up to the airlines and airports to decide which COVID-19 safety precautions they will follow to keep passengers safe.”

Consumer groups, airline employee unions and some members of Congress say the Trump administration needs to create mandatory public health standards to ensure passengers are protected when they travel during the pandemic.

“There’s very few, I think, worse environments to be in than trapped in a tube that’s crammed full of people who are rubbing shoulders with recirculated air for five or six hours while flying across the country,” said Rep. Peter DeFazio, D-Ore., chair of the House Transportation Committee, who says the administration “should require masks under the penalty of federal law on airplanes.”

While many airlines are requiring passengers masks or face coverings, enforcement has been inconsistent. United, Delta and a few others say they have removed some passengers from planes and prohibited others from boarding for not wearing masks, but such enforcement actions have only been taken recently after a rising number of complaints from other passengers.

And flight attendants are somewhat frustrated because they are the ones who often must police the mask wearing and social distancing requirements.

“Without a federal mandate and a coordinated effort to address these issues, we’re left to the airlines putting in place policies that are inconsistent, leave people confused and leave us to deal with the consequences on the front lines,” said Sara Nelson, president of the Association of Flight Attendants.

The new federal guidance encouraging airlines to leave some seats open comes in a week in which American Airlines joined rival United and discount carrier Spirit in saying they’ll fill every seat on every plane if there is enough demand.

It’s a move that drew sharp criticism from two of the nation’s top public health officials in a Senate committee hearing on the coronavirus pandemic Tuesday.

“I think it sends the wrong message,” said Dr. Robert Redfield, director of the Centers for Disease Control and Prevention.

“Obviously that is something that is of concern. I’m not sure what went into that decision making,” Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease and a member of the White House coronavirus task force told senators. “I think in the confines of an airplane that (lack of physical distancing) becomes even more problematic.”

Other airlines, including Delta, Southwest and JetBlue say they will continue to temporarily block out middle seats or keep planes no more than two-thirds full in order to create more space between passengers.

But officials at United and American defend their decisions to fully book flights saying social distancing is impossible on a plane. Even if the middle seats are empty, passengers are less than three feet apart, and there is even less distance between rows in economy seating.

“You can’t employ distancing on an airplane like you can in a grocery store line,” said Nick Calio, president of the industry group Airlines for America in a conference call with reporters this week. He contends other safety measures, such as enhanced cleaning of airplane cabins, physical distancing when boarding and deplaning, and wearing face coverings will minimize the risk of transmitting the coronavirus.

“We don’t fly people if we feel it’s not safe to fly them,” Calio said.

Nonetheless, many people are still reluctant to return to flying.

In regard to where to travel safely and how to get there this summer, “things are still incredibly uncertain and confusing,” says Melanie Lieberman, senior travel editor at The Points Guy website, who adds, “Air travel is definitely one of the more complicated ways of traveling.”

To minimize potential risk, she suggests travelers consider short haul flights rather than long haul flights, airlines that have more stringent airplane cleaning regimens, and airlines that are still blocking out middle seats or restricting capacity in other ways.

Some airline pilots would like to see more government help in that regard. The Allied Pilots Association, which represents pilots at American Airlines, wants the next federal coronavirus relief package to include funding to “purchase enough seats on each flight to eliminate the need for any passenger to sit next to a stranger.”

APA President Capt. Eric Ferguson says under that sort of “uniform social distancing, passengers would be encouraged to fly more, airlines would be encouraged to operate more flights, and the government would ensure the preservation of critical transportation infrastructure and associated jobs.”

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