Why did we fail to protect those MOST at risk?

Chapter 1 of the Articles of Inquiry asks the most important questions

Over the next weeks we’ll be dolling out sections of the Articles of Inquiry so you can digest these themes more prominently. Follow the links within the document for robust support and sources for each assertion. Download the entire document here.

Background

COVID-19 does not harm all people equally. Age is the single most important risk factor in predicting hospitalization or death from SARS-CoV-2 infection, with more than a thousand-fold higher risk of poor outcomes for older people relative to young children, a fact known from the beginning of the pandemic. Others with chronic conditions such as obesity, and some immunocompromised populations, also face elevated mortality and morbidity risk. Early on, particularly pre-vaccination, institutionalized populations, including those in nursing homes and jails, also faced specific challenges, as did high- risk indigenous populations.

Given these epidemiological facts, it was a critically important public health priority to properly protect these high-risk populations in order to reduce their risk of infection. It is therefore vital to conduct an honest evaluation of the successes and failures of state, local, and national public health agencies to protect the most vulnerable Americans.

A) Long-Term Care Facilities

Residents of long-term care facilities constituted 40% of COVID-19-attributed deaths in the US, and in some states it reached as high as 80%, highlighting the lack of proper protection of this population. While partially due to frailty and declining health of nursing- home residents, the high mortality rate was also due to a failure to limit transmission from other residents, staff, and visitors.

1.    Why did some state governors order hospitals to discharge infectious COVID-19 patients to long-term care facilities causing infection to spread to other residents? Specifically, what decisions led to nursing-home disasters in New York, Pennsylvania and Michigan? How many people died from COVID-19 because of these decisions?

2.    To minimize risk of infection, residents should be cared for by a static, rather than rotating, group of staff members. This infection control policy is essential during a pandemic. However, it was common for staff to work multiple jobs at different facilities during the same day or week. Why were there no efforts to change this practice during the pandemic? Did care facilities have financial incentives, such as avoiding overtime pay? Were there any efforts from care companies, state health departments, or the CDC to reduce staff rotation?

3.    Protective services such as rehabilitation and physical therapy were severely restricted or discontinued, as were visits from family and friends, even post vaccination. Such activities would have helped older people maintain physical and mental health and reduced dementia due to isolation. Were the effects of severe isolation and lack of services taken into consideration in this population, particularly post-vaccination?

4.    Very low reinfection rates (peer reviewed by Dec 14, 2020) early on in the pandemic, including evidence documented in Pfizer’s trial data (Table 8 page 27), suggested that infection-acquired immunity was protective against reinfection, severe disease, and death from COVID-19. Within several months, immunological studies confirmed robust and long-lasting protection (See Infection-Acquired Immunity, Chapter 7). Why did the CDC not release data on reinfection rates during the first 6-8 months of the pandemic? Were long-term care facilities encouraged to hire COVID-19-recovered individuals?

5.    In her 2022 testimony to Congress, released in June, 2022, Dr. Deborah Birx, former White House COVID-19 Response Coordinator, stated “I knew all of these infection loopholes that existed not only in nursing homes and in the country, and I felt strongly that there was no way to protect the vulnerable of America without stopping community spread.” Did policy experts know about pre and early pandemic statements in which experts cast doubt on the ability of quarantine and lockdown measures to stop community spread without excessive collateral damage? Why did Dr. Birx purposely avoid meeting with public health experts who had specifically proposed such measures?

B) Older People Living Outside of Residential Facilities

During the pandemic, protecting older people living at home should have been an urgent priority.

1.    To protect seniors, some civic organizations organized grocery delivery so that older people would not have to be exposed in supermarkets. This type of protection was also implemented among family, friends and neighbors. Was this strategy effective? If so, why was it not used more widely?

2.    Some supermarkets offered apps for ordering food online, either for home delivery or curbside pick-up. How widespread was this practice, both in terms of availability and use, and what barriers prevented greater implementation and use among those at highest risk?

3.    Senior-only hours in grocery stores were used to try and protect older high-risk people. While seniors can be infected by anyone, including other seniors, the rationale was that such restricted hours would reduce crowds. Was this effective? Have there been any studies evaluating the effectiveness of these and other measures? Is there evidence that older people are less likely to transmit the virus to others?

4.    The immune system benefits from overall good health, including exercise. Why were many physical activity spaces, particularly outdoor spaces, closed during lockdowns? Why did some locations ban or discourage outdoor physical activities, such as going to the beach or the park, when there was little evidence of outdoor transmission?

5.    When schools closed, some low-income parents had to leave their children with grandparents during normal school hours. To what extent did this increase the exposure of older people, by, for example, having to take the bus to and from their grandchildren's home and doing activities with the children? When schools were closed, did local, state, and federal leaders consider these negative consequences of school closures? Were there CDC warnings about these risks?

C) High-Risk People in the Workforce

Many older Americans work, especially immigrants and low-income people. While some older people were able to work from home, many had to continue in high-exposure jobs such as working as cab drivers, health care workers/aides, and supermarket clerks. Some older day care workers also had to care for large numbers of children who normally would have been in school.

1.    Why were work-from-home orders and opportunities not age-dependent? More specifically, why were all teachers working from home rather than only those over 60?

2.    What role did teachers unions play in shifting the burden of risk to grandparents and day care workers (who may have been older) to care for children during school days?

3.    Why were there only limited efforts to replace older high-risk essential workers in high exposure settings with young low-risk workers? Why did the CDC not launch such efforts? Why did the federal or state government not provide financial incentives to accomplish this?

4.    Taxi drivers were one of the professions most exposed to the virus. Why did some hospitals send COVID-19 patients home in taxis driven by older drivers in high-risk groups instead of providing safer forms of transportation?

5.    Protection of older high-risk Americans was especially important during higher-risk seasonal time periods of two or three months every year. Why did the federal government not make accommodations to offer those over 60 years of age the ability to temporarily use social security benefits or sick leave so that they could stay at home during peak infection periods?

D) Multi-Generational Homes

Some older Americans live with their adult children and grandchildren in multi- generational households. In Sweden, living with a working-age adult increased the risk of infection for older people compared to living with other older people, but living with a child under the age of 12 did not further increase that risk. Another study in California found that exposure to children actually decreased the risk of severe COVID-19 in adults.

1.    Why did university presidents create additional multi-generational homes by abruptly closing campuses, sometimes with only a week’s notice, and sending young people back home to live with older parents and/or grandparents rather than

keeping them at school with their low-risk peers? How many older Americans died because of these actions by universities?

2.    Why did the CDC not initiate a public campaign to encourage older retired people in multi-generational homes to temporarily relocate to live with a same-age sibling, or with a relative or friends instead of with their working-age children?

3.    During the height of the pandemic, many hotel rooms were empty. Why were these not offered as temporary housing for older people from multi-generational homes?

4.    Israel and other countries created facilities for people hospitalized with COVID-19 to prevent early release and subsequent exposure to other family members. Why did the CDC and federal health authorities not work with city and county governments to ensure that such facilities were free and available? This would have been particularly important for essential workers who lived in multigenerational families in small apartments in crowded urban environments such as New York City and Los Angeles.

E) Information Exchange

Policies to protect at-risk populations must necessarily be implemented at the local level because the needs of vulnerable populations differ by community. It was thus vital for public health officials to freely share information about best practices derived from the successes and failures of local public health policies. However, the failure to communicate these lessons from the local level to national level resulted in slow dissemination of critical information that communities could have used to keep their vulnerable populations safer.

1.    Why was there no strategy for evaluating local efforts to specifically protect the vulnerable, and to share success stories across the nation?

2.    When specific proposals for targeted protection of high-risk Americans were proposed, why were they dismissed and ruled out as impossible without discussion or debate?

3.    Why did the CDC continue to focus on masks for protection of high-risk populations even when randomized studies found they were unreliable for protection. Did some very high-risk people acquire severe or fatal Covid-19 because they believed a mask would provide reliable protection in indoor gatherings? What are the implications of the CDC not being entirely transparent about disease-mitigation data?

4.    When infection rates were high, why were most governmental efforts focused on community-wide suppression efforts and few efforts focused on protecting high- risk Americans through strategies outlined here (hotels for quarantining, use of extra sick leave/social security benefits for older people, keeping university campuses open, etcetera)?