The coronavirus crisis has upended American life, and fresh ideas are needed for dealing with the problems it’s creating. Here is a collection of smart solutions.
Lift restrictions on blood donations from gay men
At a White House Coronavirus Task Force news conference on March 19, Surgeon General Jerome M. Adams outlined one action that young people like us can take to help our country during the coronavirus: “We know many of you are home practicing the president’s guidelines for social distancing, but one thing we should all consider, especially our millennials and Gen Z, is donating blood.”
Dr. Adams, we hear you and we want to help. The Red Cross is asking for blood donations, as thousands of drives have been canceled across the country because of coronavirus fears. Our country is facing a dire blood shortage, and yet we, along with millions of other healthy gay men, are being turned away.
At the height of the AIDS epidemic in the 1980s, the Food and Drug Administration barred gay men from donating blood. In 2014, the FDA modified this ban to prevent gay men from giving blood if they have had any sexual contact within the past year, even if they test negative for HIV, practice safe sex and are in a monogamous relationship. Meanwhile, straight men and women, all of whom are capable of having HIV, face no restrictions on blood donation (even if they engage in risky sexual activity).
It is long past time to lift this discriminatory policy. Other countries, such as Italy and Spain, have moved toward individual risk assessments rather than discriminatory bans on gay men, and have faced no issues with HIV in the blood supply. The United States is in a national crisis: the coronavirus threatens our health care system, and a blood shortage only adds to the stress. We call on President Donald Trump to sign an executive order revising the blanket restriction to an individual risk assessment, accounting for HIV testing and safe sex practices. This is an opportunity for the administration to respond quickly and effectively to our current crisis. Millions of gay men want to help. Please let us.
Kevin Ballen and Reese Caldwell
The writers are sophomores at Harvard College studying sociology and molecular and cellular biology, respectively.
Let foreign-trained physicians join the fight
As the coronavirus crisis puts intense pressure on the health care system, the Veterans Affairs medical system and some governors are asking doctors and nurses to come out of retirement. And in some hospitals in New York, final-year medical students are already working as clinical observers and note-takers to help manage the spread of COVID-19.But there’s another resource hospitals should examine: foreign-trained physicians.
There are an estimated 65,000 doctors in the United States who have not done any residency training in the country and therefore cannot be licensed to practice. Many of these doctors have extensive medical schooling and postgraduate training and possess clinical competence in diagnosing and managing infectious diseases. Due to the highly competitive nature of U.S. residency programs and restrictions from the Balanced Budget Act of 1997, which limits the annual number of residency slots supported by Medicare, many U.S. medical graduates and foreign-trained doctors do not make it into residency programs.
This contributes significantly to the increasing deficit in the physician workforce. The Association of American Medical Colleges predicts that over the next decade, the United States will see a shortage of more than 120,000 physicians. Addressing the health care labor shortage by asking retired nurses and doctors to come back to work may temporarily boost the health workforce, but certainly doesn’t address future outbreaks. Also, these retired professionals are mostly seniors with a higher mortality risk for COVID-19 in any clinic setting.
Tapping into the massive pool of foreign-trained physicians could ameliorate gaps in health care quality resulting from a high patient-to-physician ratio, especially during health crises such as the COVID-19 pandemic. The system should decide how to use these doctors, perhaps by engaging them in community preventive medicine and population health planning or offering easy paths to restricted licenses in infection prevention and control. Given the emergency before us, why would we turn away their expertise?
The writer is a foreign-trained physician and independent health care consultant in Lynchburg, Va.
Emergency responders can help besieged hospitals. Here’s how.
COVID-19 is straining the capacity of America’s hospitals, so why not consider alternate models?
Right now, reimbursement for emergency ambulance service is tied almost exclusively to the transportation of a patient to a hospital emergency room. But it doesn’t have to be that way.
The Centers for Medicare and Medicaid Services and the Department of Health and Human Services have the authority to grant waivers that would compensate first responders for providing care for some patients in their homes.
Waivers could also be issued to reimburse ambulance providers who transport patients that need less intensive care to alternate destinations, such as urgent-care facilities. If a patient requires ongoing monitoring, emergency first responders can assist with ensuring regular telemedicine visits are scheduled to allow them to maintain contact with their medical teams without having to leave home — minimizing potential community spread.
This approach would reduce crowding in hospitals, allow them to preserve scarce beds for those patients who need them and ensure doctors and nurses can devote more time and resources to the patients most in need of the highest level of care.
Giving paramedics, EMTs and other front-line health care providers priority access to personal protective equipment would also help ensure there is manpower to fuel this alternate delivery model. The national shortage of gloves, masks and other equipment put America’s paramedics, EMTs and fellow first responders at an unacceptable heightened risk. It is imperative that lawmakers include a provision in the next phase of the stimulus requiring the health and human services secretary to issue guidance ensuring that ambulance providers and suppliers are given priority access to such equipment.
First responders and those we serve need government leadership and dedicated funding to support new, innovative approaches during this crisis.
The writer is president of the American Ambulance Association.
It’s time for emergency physicians to put away our stethoscopes
Since 1986, federal law has mandated that any patient requesting emergency medical care must be evaluated by a physician to assess for any threatening conditions. The law, often referred to as the “anti-dumping law,” requires that physicians perform a medical screening evaluation, including a physical examination.
Over time, the interpretation of this mandate has slowly expanded, not by law so much as by custom. This is why emergency rooms have become our nation’s safety net for care. Despite increasing popularity of urgent-care clinics and telehealth, many patients who could have safely been cared for elsewhere still end up in emergency rooms.
While many of us embrace that mission with pride, it is dangerous and wasteful in the coronavirus pandemic. We need to course-correct to keep everyone safe. Exposing patients to emergency rooms is now far riskier than it was before. In turn, health care workers must assume that all patients are infected. This forces us to blow through personal protective equipment that we desperately need so that we do not become infected ourselves.
Over the past few decades, we have learned that many, if not most, of our physical examination maneuvers provide little reliable information. In most cases, the information we need can be obtained simply by interviewing patients. But old habits die hard, and patients seem to love our stethoscopes. In our current situation, that simply won’t do.
We need the federal government to allow us to perform medical screening exams via video or through glass doors, even for patients entering emergency rooms. The removal of the requirement that we evaluate every patient by hand will save resources and keep everyone safer.
In recent meetings and phone calls with stakeholders, the Centers for Medicare and Medicaid Services has signaled that it is seriously considering making this change. But it has not materialized, and time is of the essence. The moment to act is now.
Jeremy Samuel Faust
The writer is an emergency physician at Brigham and Women’s Hospital in the Division of Health Policy and Public Health, and an instructor at Harvard Medical School.
Include local media in the stimulus package
Local news outlets across the country are providing essential, up-to-the minute information aimed at keeping communities safe. Even in cities under virtual lockdown, the news media has been recognized as an “essential service” for public health and safety, alongside hospitals and grocery stores. Local media outlets have been rising to the occasion, breaking stories, guiding the public on do’s and don’ts, and holding leaders accountable for life and death decisions. Many have dropped paywalls on their COVID-19 coverage, recognizing that it represents an essential public service.
But while they may seem to be thriving, local media outlets still suffer from the disintegration of longstanding, advertising-based business models. That, coupled with the mass migration of consumers to social media platforms, has stripped local news outlets of their prime source of revenue, leading to the closure of one out of every five local newspapers and the slashing of newsroom staffs in half over the past 15 years. The spread of COVID-19 has made this chronic illness acute: The closure of local businesses and slowdown in economic activity are depriving local news outlets of essential revenue to keep operations going. In recent weeks, several publications have dropped print editions, or made plaintive appeals to readers for the financial support necessary to sustain operations.
As Congress and state legislatures contemplate massive stimulus bills aimed to keep our economy and society afloat, local media outlets should be part of the package. Funds to replace lost revenue and ensure that local news outlets continue to provide essential coverage of the pandemic and other topics will enable communities to stay informed, healthy and connected through this crisis. The moneys need to be carefully safeguarded to ensure that the infusion of public funds does not compromise editorial integrity or deter hard-hitting coverage. Local media is among the vital organs of our democracy and must not be allowed to fail.
Suzanne Nossel and Viktorya Vilk
Nossel is chief executive of PEN America. Vilk is the director of digital safety and free expression programs at PEN America.
Lift tariffs on Chinese medical equipment
China, where the coronavirus epidemic seems to have peaked and life is slowly returning to normal, currently has a surplus of protective medical gear, including masks, gloves and gowns. The country mobilized resources to manufacture the equipment and is now ready to export it to countries in need. On March 9, China announced it would export 5 million masks to South Korea. China has also provided testing kits, masks and protection suits to more than 80 countries, including Italy, France, Pakistan, Japan and Iran.
Why, then, isn’t the United States buying the equipment it needs from China? Because President Trump’s tariffs are standing in the way.
Since 2018, the Trump administration has imposed more than $400 billion dollars of tariffs on imports from China; $360 billion dollars of duties remain in place. Critical medical products, including face masks, gloves, protective goggles and thermometers, have been subject to Section 301 import tariffs.
The administration has offered to grant exclusions from import tariffs for certain medical products imported from China. But on March 5, the office of the U.S. Trade Representative (USTR) approved just 200 specific requests from individual companies to have their purchase of items needed to handle the epidemic excluded from the tariff; some of the requests from health care companies were denied. On March 10 and 12, the administration said it would temporarily reduce some tariffs on Chinese products to address the pandemic, yet the list covers only a handful of urgently needed products.
On March 20, USTR announced that it was considering “possible further modifications to remove duties from additional medical care products” related to the COVID-19 virus and would collect comments from interested parties until at least June 25. Yes, that’s three long months away, a period in which thousands of doctors, nurses and patients could die because they lack protective gear.
Public health and safety demand that President Trump immediately lift all tariffs on the medical products we need. American lives are at stake.
Susan Shirk and Yanzhong Huang
Shirk is research professor and chair of the 21st Century China Center School of Global Policy and Strategy at University of California, San Diego. Huang is a senior fellow of global health at the Council on Foreign Relations and a professor at Seton Hall University’s School of Diplomacy and International Relations.
Let foreign-born health care workers live in peace
While, as a nation, we are praising and proud of the herculean job being done by health care workers, what we don’t realize is that more than 1 in 6 of U.S. health care workers are immigrants. For U.S. doctors, the statistic is even more pronounced, at 1 in 4. In the states hardest hit by coronavirus, California and New York, more than a third of all health care workers are immigrants.
These individuals, who are being forced to work night and day as our doctors, nurses and pharmacists during our national crisis, must also confront unfair immigration provisions such as the administration’s travel ban, administrative processing roadblocks, arbitrary green card caps and the new public charge rule. President Trump’s policies are adding undue stress to an already stressful existence to these workers. Close to 30,000 DACA recipients are health care workers, including 200 who are slated to be doctors, yet they will probably lose their status come June, as the Supreme Court will likely allow Trump to eliminate the program. And there are rumors that the Department of Homeland Security may be planning raids and deportations against these DACA recipients who are saving the lives of Americans.
We shouldn’t ask these immigrants to risk their lives in labor for us but spend their waking hours under threat of losing their status or deportation. Trump should suspend his Byzantine immigration policies for these health care workers immediately, work with Congress to exempt health care workers from any immigration caps and set up task forces within DHS and the State Department to expedite their current cases — whether those cases be non-immigrant visa renewals, Green card applications or naturalization. We, as a nation, cannot afford to lose them. This is the least we can do for them after all they have done for us.
The writer is a former U.S. diplomat and immigration attorney.
Unleash fourth-year medical students
On March 20, around 20,000 fourth-year U.S. medical students learned which hospital they are assigned for their residency during the annual National Resident Matching Program. Normally, they would begin serving patients in July, but there’s a way to do it now.
If medical schools instead confer MD degrees immediately, instead of waiting until the end of the semester, these hospitals could hire, train and deploy an extra 20,000 physicians at a time when we are straining to “flatten the curve” of the COVID-19 coronavirus. This proposal is a few weeks old and has already passed from Columbia University to New York State. But others should take up the idea of accelerating fourth-year medical students into their chosen life of service.
At Columbia, most of our medical students — representative of similar medical students throughout the country — want to help, even if it is not their time. But the fourth-year students are fully prepared. They have completed all the clinical rotations required for the MD degree. Under normal circumstances they would now be taking electives or conducting research, perhaps not even seeing a patient during the final few months of medical school. They would in the normal order receive their MDs in May and begin as interns (first-year residents) by July.
I propose instead that medical students be graduated now and given the opportunity to serve in this time of great need. I imagine most would jump at the opportunity. If they were not caring for COVID-19 patients directly, they could free more experienced physicians to undertake that necessary work.
Donald W. Landry
The writer is physician-in-chief, chair of the Department of Medicine and director of the Division of Experimental Therapeutics at New York-Presbyterian Hospital/Columbia University Medical Center.
House mild cases in hotels
One of the toughest decisions facing physicians and public health officials is where to send patients who test positive for the COVID-19 coronavirus. For the small but significant proportion with severe or critical illness, the decision to hospitalize is trivial. But where to send the apparently large majority of cases that are mild or even symptom-free?
These patients, often young, need to be isolated to reduce spread. But using a hospital bed for isolation alone takes up capacity, puts others at risk and chews through protective equipment that doctors, nurses and other staff desperately need.
A natural alternative is to send people home, with clear instructions to self-isolate. But in some cases that is not feasible, and it poses evident risks. The World Health Organization recommends placing mildly ill patients in dedicated COVID-19 facilities as the gold standard for isolation. While countries such as China have the logistical capability to erect new hospitals for this purpose in a matter of days, most places cannot achieve that.
Fortunately, there is a potential answer: America’s prodigious hotel industry. And in case you haven’t noticed, there is plenty of room at the inn.
The federal government should use its financial and legal resources to temporarily convert some large hotels, reeling from the current economic situation, into COVID-19 isolation facilities. Under recently issued federal guidance, these spaces are not required to provide medical attention.
Under ordinary circumstances, the suggestion that the federal government might seek to take over a hotel would run into serious legal objections. But under current conditions, we suspect that many hotel executives would line up to draft temporary and renewable lease agreements with the government. This could also help stave off unemployment in the travel industry.
Yes, all of this needs to be paid for, and strong steps would have to be taken to reduce health risks to housekeepers and staff. But whatever the upfront costs and risks may be, the downstream benefits — in terms of health, economics and more — are likely to exceed them.
Jeremy Samuel Faust and Cass Sunstein
Faust is an emergency physician at Brigham and Women’s Hospital in the Division of Health Policy and Public Health and an instructor at Harvard Medical School. Cass Sunstein is Robert Walmsley University Professor at Harvard and a former administrator of the White House Office of Information and Regulatory Affairs.
Forget stimulus checks. Send prepaid cards instead.
The administration and members of Congress have proposed giving Americans a significant amount of cash to stimulate the economy, such as a check for $1,000 or more to every American adult.
Stimulating the economy by providing spendable cash is a good idea, but what would prevent those in the financially well-off categories from simply investing that money instead of stimulating the economy by spending it?
One way is to provide immediate cash to all adult Americans, but in the form of prepaid Mastercard or Visa cards that expire in a certain time — such as three months — rather than in the form of paper checks.
This approach has several advantages. First, it virtually guarantees that recipients will spend the cash. Facing the possibility that their stimulus cash will expire, recipients in all financial brackets will be anxious to use the money. Even the well-off will hate the idea of losing free money that they could have spent.
Second, recipients of prepaid cards can use them immediately, whereas a check needs to be deposited first. Although electronic banking with online check deposit is increasingly common, many people do not have access to such a service. And going to the bank violates infection-control guidelines.
Third, amounts on prepaid cards that are not injected into the economy can revert to the U.S. Treasury and perhaps be recycled for later use. With paper checks, the Treasury recovers only those that are not deposited, whether or not they are spent.
The fundamental principle is to increase the likelihood that spendable cash sent to consumers will be spent immediately. Regardless of the details of such stimulus program, that principle should be observed.
The writer is a senior research scholar and the Hank J. Holland Fellow at Stanford University.
Provide health care at the neighborhood level
As a neurologist living in a Washington, D.C., suburb, I want to propose a strategy to help reduce the burden on hospitals as this pandemic plays out.
Many doctors have begun practicing telehealth from our home offices. But I wonder if clinicians might be able to organize, in concert with their local hospitals, to help their communities in some way.
Once organized, and if given some medical supplies, we might help with screenings at our neighbors’ houses. Perhaps we could monitor neighbors recently discharged from hospitals. Or, in my own field, I might visit a person concerned that their facial weakness might be a stroke. A simple examination or an online consult might determine it to be a less serious Bell’s palsy, potentially avoiding an emergency-room visit.
I don’t know if this is practical, and I know hospitals do not have the resources to set up such a system or offer supplies right now. But with the help of social-networking services for neighborhoods, clinicians could self-organize. They could indicate their expertise, their availability and what they would be willing to do. It is not a lot of work to do it now and perhaps it may pay off.
The writer is a neurologist at the Parkinson’s & Movement Disorders Center of Maryland.
Let patients test themselves at home
Missing from the current discussion about rapidly ramping up testing for COVID-19: doing it at home. Testing for the coronavirus can be performed using a nasal swab (the equivalent of putting a Q-Tip in your nostril). There is little scientific reason as to why this can’t be done by people at home under the direction of a doctor. Research on seasonal flu comparing the accuracy of self-collected swabs vs. professionally collected swabs shows that they are nearly equivalent.
Here is how at-home testing could work:
Step 1: Individuals with symptoms call in to their doctor’s office or use a telemedicine service to be assessed by a qualified health care professional who can order tests, often billing a patient’s insurance company directly.
Step 2: Those who meet CDC guidelines for testing and are able to test themselves and be safely managed at home are sent a testing kit by overnight mail or direct delivery from a nearby facility (which could include labs, pharmacies or specially set-up public-health depots).
Step 3: Individuals would then self-swab, guided by an instructional video or a virtual health care professional, and then mail the sample to a testing facility or drop it off. All three steps could be done completely from home — not only convenient for those who are already feeling ill but also ensuring social distancing.
Governments and private organizations should issue guidance on at-home testing for clinicians, laboratories and public health professionals. Also needed: removing state and local regulatory barriers that slow down and sometimes prevent labs from processing samples collected by patients. And government and private organizations should provide funding to laboratories and researchers to invest in validating and improving the effectiveness of at-home testing.
With swift action, at-home testing could ensure widespread, equitable availability of care and slow the spread of COVID-19.
Shantanu Nundy and Marty Makary
Nundy is a primary-care physician and chief medical officer at Accolade Inc. Makary is a professor at the Johns Hopkins School of Public Health, editor in chief of MedPage Today and author of “The Price We Pay.”