Alcoholism-related liver disease was a growing problem even before the pandemic, with the condition around the country, and with hospitalizations .

But the pandemic has dramatically added to the toll. Although national figures are not available, admissions for alcoholic liver disease at Keck Hospital of the University of Southern California were up 30% in 2020 compared with 2019, said Dr. Brian Lee, a transplant hepatologist who treats the condition in alcoholics. Specialists at hospitals affiliated with the University of Michigan, Northwestern University, Harvard University and Mount Sinai Health System in New York City said rates of admissions for alcoholic liver disease have leapt by up to 50% since March.

High levels of alcohol ingestion due to toxic byproducts associated with the metabolism of ethanol. In the short term, these byproducts can trigger that leads to hepatitis. In the long term, to the accumulation of fatty tissue, as well as the scarring characteristic of cirrhosis — which can, in turn, cause liver cancer.

Since the metabolism of alcohol varies among individuals, these diseases after only a few months of heavy drinking. Some people can drink heavily without experiencing side effects for a long time; others can suffer severe immune reactions that rapidly send them to the hospital.

Leading liver disease specialists and psychiatrists believe the isolation, unemployment and hopelessness associated with covid-19 are driving the explosion in cases.

“There’s been a tremendous influx,” said Dr. Haripriya Maddur, a hepatologist at Northwestern Medicine. Many of her patients “were doing just fine” before the pandemic, having avoided relapse for years. But subject to the stress of the pandemic, “all of a sudden, [they] were in the hospital again.”

Across these institutions, the age of patients hospitalized for alcoholic liver disease has dropped. A trend toward increased disease in people under 40 “has been alarming for years,” said Dr. Raymond Chung, a hepatologist at Harvard University and president of the American Association for the Study of Liver Disease. “But what we’re seeing now is truly dramatic.”

Maddur has also treated numerous young adults hospitalized with the jaundice and abdominal distension emblematic of the disease — a pattern she attributes to the pandemic-era intensification of economic struggles faced by the demographic. At the same time these young adults may be entering the housing market or starting a family, entry-level employment, particularly in the vast, crippled hospitality industry, is increasingly hard to come by. “They have mouths to feed and bills to pay, but no job,” she said, “so they turn to booze as the last coping mechanism remaining.”

Women may be suffering disproportionately from alcoholic liver disease during the pandemic because they than men. Lower levels of the leads to higher levels of the toxin in the blood and, in turn, more extensive organ damage in women than in men who drink the same amount. ( that women have one drink or less per day, compared with two or fewer for men.)

Socially, the “stress of the pandemic has, in some ways, particularly targeted women,” said Dr. Jessica Mellinger, a hepatologist at the University of Michigan. Lower wages, less job stability and the burdens of parenting tend to fall more heavily on women’s shoulders, she said.

“If you have all of these additional stressors, with all of your forms of support gone — and all you have left is the bottle — that’s what you’ll resort to,” Mellinger said. “But a woman who drinks like a man gets sicker faster.”

Nationwide, more adults are turning to the bottle during the pandemic: One study found rates of alcohol consumption in spring 2020 compared with the same period in 2019 and drinkers consumed than in pre-pandemic months. Unemployment, isolation, lack of daily structure and boredom all have of heightened alcohol use.

“The pandemic has brought out our uneasy relationship with alcohol,” said Dr. Timothy Fong, an addiction psychiatrist at UCLA. “We’ve welcomed it into our homes as our crutch and our best friend.”

These relapses, and the hospitalizations they cause, can be life-threatening. More than 1 in 20 patients with alcohol-related liver failure the hospital, and alcohol-related liver disease is the .

The disease also makes people more susceptible to covid: Patients with liver disease die of covid without it, and alcohol-associated liver disease has been found to increase the risk of death from covid by an additional to .

Some physicians, like Maddur, are concerned the stressors leading to increased alcohol consumption and liver disease may stretch well into the future — even after lockdowns lift. “I think we’re only on the cusp of this,” she said. “Quarantine is one thing, but the downturn of the economy, that’s not going away anytime soon.”

Others, like Lee, are more optimistic — albeit cautiously. “The vaccine is coming to a pharmacy near you, covid-19 will end, and things will begin to get back to normal,” he said. “But the real question is whether public health authorities decide to act in ways that combat [alcoholic liver disease].

“Because people are just fighting to cope day to day right now.”

This story was produced by , which publishes , an editorially independent service of the .

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During the week, Bruce practiced what he preached, caring for prisoners at a Georgia hospital. On March 27 he began coughing, and on April 1 he was hospitalized. He’d tested positive for covid-19. The virus swept through his household, infecting his wife and daughter and hospitalizing their disabled son. Ten days after landing in the hospital, Bruce died.

But when Gwendolyn Davis received her husband’s death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.

“He wouldn’t have had kidney failure if he didn’t have covid,” Gwendolyn said.

After Bruce died, his wife applied to two pandemic relief programs seeking help with $1,500 in missed payments on a truck and an electricity bill. But, she said, she was denied because his death certificate didn’t mention covid-19.

“I think it’s wrong,” Gwendolyn said. “It’s almost like we didn’t count.”

The count has profound implications for families and the country. Omitting covid-19 on death certificates threatens to undercount the toll of the pandemic nationwide. For Davis’ family and others, it can pile financial hardship onto emotional despair, as death benefits and other covid-19 relief programs are withheld. Interviews with families across the U.S. shed light on reasons covid deaths are being undercounted — and the consequences loved ones have endured.

When covid patients die, is always something else, such as respiratory failure or cardiac arrest. Residents, doctors, medical examiners and coroners make the call on whether covid was an underlying factor, or “contributory cause.” If so, the diagnosis should be included on the death certificate, according to the Centers for Disease Control and Prevention.

Even beyond the pandemic, there is wide variation in how certifiers describe causes of death: “There’s just no such thing as an objective measure of cause of death,” said Lee Anne Flagg, a statistician at the CDC’s National Center for Health Statistics.

Partly because of a lack of training in how to fill them out, “the quality of the death certificates is not good,” said Dr. James Gill, vice president of the National Association of Medical Examiners. And in cases in which people had other chronic conditions, it can be difficult to determine whether covid was a contributing cause of death, he said. That was especially true early on, when reliable testing was not widely available.

Since early in the pandemic, the certifiers who suspect covid as a cause of death to list it on the death certificate as “probable” or “likely.”

Still, some clinicians are “reluctant to certify a death as a covid death without a test in hand,” Gill said.

It’s not clear how Bruce Davis’ case slipped under the radar. His death was certified by William Ken Garland, deputy coroner in Baldwin County. Reached by phone, Garland said the causes of death were provided by Dr. Joseph Coppiano, a medical resident who pronounced Davis dead at Augusta University Medical Center, about 90 miles away. No autopsy was done.

“I did certify the record, but that’s about all I did,” Garland said.

Hospital spokesperson Danielle Harris declined to comment on the case, citing patient privacy. She said the hospital follows Georgia Department of Public Health guidelines.

In the absence of certainty, the CDC has encouraged coroners to document the virus. “We’re not worried that we’re overcounting the number of [covid-19] deaths,” Farida Ahmad, epidemiologist and mortality surveillance team leader at NCHS, .

Missed cases are one reason that experts agree covid deaths are being undercounted nationwide. As evidence for that, they point to the vast number of excess deaths — additional deaths compared to what would be expected based on prior-year numbers and demographic trends.

Over the past year, the U.S. had as of Jan. 6, with 68% directly attributed to covid, according to the CDC.

These excess deaths “tend to track pretty closely with covid cases, trailing by a couple of weeks,” said Daniel Weinberger, an epidemiologist at Yale School of Public Health who has on this topic. “This strongly suggests that a large proportion of these uncounted deaths are due to covid but not recorded as such.”

We may never know how many covid deaths went uncounted: Postmortem tests can detect the virus, but it’s “unlikely that this type of testing will be performed at a [sufficient] scale,” Weinberger said. Early in the pandemic, especially in the Northeast, many of those who were treated clinically for covid and then died were not tested for the virus — so they never made it into the statistics.

Testing Troubles Affect Lawsuits, Hospital Bills

Inaccurate death certificates can make it harder to pursue a lawsuit or win a workers’ compensation case when a loved one dies after contracting covid on the job. Gwendolyn Davis did win workers’ compensation death benefits from Bruce’s employer, a state psychiatric facility in Milledgeville, by providing medical records. But problems with covid testing can complicate the process.

Bruce’s supervisor at work, Mark DeLong, also died after contracting covid, but it did not appear on his death certificate with the other causes: cardiopulmonary arrest, respiratory failure and diabetes.

The omission on DeLong’s certificate seemed to stem from a delay in test results: His covid-positive results didn’t arrive until three days after he died, according to his widow, Jan DeLong. She has asked the local coroner to correct the record.

In New Jersey, attorney Paul da Costa represents 75 family members who lost loved ones at veterans homes in Menlo Park and Paramus in April and May. He said he knows of at least five patients whose death certificates did not list covid-19 despite evidence suggesting it killed them.

The root problem, he said, was a “complete dearth of testing.” Patients were transferred to hospitals, or dying in the veterans facilities, without ever being tested, he said.

The gap between excess deaths and confirmed covid deaths has “narrowed over time as testing has increased,” Weinberger said.

Early testing inaccuracy may also have led to undercounting, which creates a different burden: hospital bills. Without a diagnosis, families can be on the hook for thousands of dollars in charges that otherwise under the CARES Act.

Correcting the Record

In some cases, families have sought to have death certificates changed to reflect covid. Dorothy Payton, 95, who lived in the ManorCare nursing home in Denver, first showed covid symptoms April 5. Five days later, Payton — known as “Nana Dee” — tested positive for it. And on April 13, her husband, Edward Benjamin, received a call that she had died.

The death certificate offered a litany of causes: vascular dementia, atrial fibrillation, congestive heart failure, gait instability, difficulty swallowing and

But not covid-19. So it “seemed logical to fight for listing her cause of death under her cause of death,” Benjamin said.

After a few calls, her husband was able to get the certificate amended. ManorCare could not be reached for comment.

For Benjamin, it wasn’t about public health statistics or financial considerations. It simply offers a sense of closure.

“I want her life and death remembered the way it was, and I’m glad we set the record straight,” he said. “It’s the first step towards moving on.”

This story is part of “,” an ongoing project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please .

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As a boy, Robert Weber chased the blazing lights and roaring sirens of fire engines down the streets of Brooklyn, New York.

He hung out at the Engine 247 firehouse, eating ham heroes with extra mayonnaise, and “learning everything about everything to be the best firefighter in the world,” said his wife, Daniellle Weber, who grew up next door.

They married in their 20s and settled in Port Monmouth, New Jersey, where Weber joined the ranks of the more than 1 million firefighters America calls upon when stovetops, factory floors and forest canopies burst into flames.

Weber was ready for any emergency, his wife said. Then COVID-19 swept through.

Firefighters like Weber are often the first on the scene following a 911 call. Many are trained as emergency medical technicians and paramedics, responsible for stabilizing and transporting those in distress to the hospital. But with the pandemic, even those not medically trained are suddenly at high risk of coronavirus infection.

Firefighters have not been commonly counted among the ranks of front-line health care workers getting infected on the job. investigating 1,500 such deaths in the pandemic, including nearly 100 firefighters.

In normal times, firefighters respond to 36 million medical calls a year nationally, according to Gary Ludwig, president of the International Association of Fire Chiefs. That role has only grown in 2020. “These days, we pump more oxygen than water,” Ludwig said.

In mid-March, Weber told his wife he noticed a new pattern in the emergency calls: people with sky-high temperatures, burning lungs and searing leg pain.

Within a week, Weber’s fever ignited, too.

‘This Job Isn’t Just Meatball Subs and Football Anymore’

Snohomish County, Washington — just north of Seattle — reported the first confirmed U.S. COVID case on Jan. 20. Within days, area fire departments “went straight into high gear,” Lt. Brian Wallace said.

Within weeks, the Seattle paramedic said, his crew had responded to scores of COVID emergencies. In the ensuing months, the crew stood up the city’s testing sites “out of thin air,” Wallace said. Since June, teams of firefighters have performed over 125,000 tests, a critical service in a city where as of late October.

Wallace calls his team a “public health workforce that’s stepped up.”

Firefighters elsewhere did, too. In Phoenix’s Maricopa County, which is still notching new peaks in COVID cases, firefighters each shift receive dozens of emergency calls for symptoms related to the virus. Since March, firefighters have registered over 3,000 known exposures — but “that’s just the tip of the iceberg,” said Capt. Scott Douglas, the Phoenix Fire Department’s public information officer, “this job isn’t just meatball subs and football anymore.”

In Washington, D.C. — with tallied since March — firefighters have been exposed in at least 3,000 incidents, said Dr. Robert Holman, medical director of the city’s fire department.

They’ve helped in other ways, too: Firefighters like Oluwafunmike Omasere, who serves in the city’s poverty-stricken Anacostia neighborhood, have bridged “all the other social gaps that are killing people.” They’ve fed people, distributed clothes and offered public health education about the virus.

“If it weren’t for us,” Omasere said, “I’m not sure who’d be there for these communities.”

‘We’re Going In Completely Unarmed’

For the more than 200 million Americans living in rural areas, one fire engine might cover miles and miles of land.

Case in point: the miles surrounding Dakota City, Nebraska. That’s steak country, home to one of the country’s largest meat processing plants, owned by Tyson Foods. And it’s on Patrick Moore, the town’s first assistant fire chief, to ensure the plant’s 4,300 employees and their neighbors stay safe. The firehouse has a proud history, including in 1929 buying the town’s first motorcar: a flame-red Model A.

“We made a promise to this community that we’d take care of them,” Moore said. COVID-19 has tested that promise. By the time at Tyson’s plant on April 30, calls to the firehouse had quadrupled, coming from all corners of its 70-square-mile jurisdiction. “It all snowballed, so bad, so fast,” Moore said.

Resources of all kinds — linens, masks, sanitizer — evaporated in Dakota City. “We’ve been on our own,” Moore said.

Ludwig, of IAFC, said firefighters have ranked low on the priority list for emergency equipment shipped from the Strategic National Stockpile. As stand-ins for “the real stuff,” firehouses have cobbled together ponchos, raincoats and bandannas. “But we all know these don’t do a damn thing,” he said.

In May, Ludwig sent a letter to Congress requesting additional emergency funding, resources and testing to support the efforts of firehouses. He’s been lobbying in D.C. ever since. Months later, the efforts haven’t amounted to much.

“We’re at the tip of the spear, yet we’re going in completely unarmed,” Ludwig said. It’s been “disastrous.”

As of Dec. 9, more than 29,000 of the International Association of Fire Fighters’ 320,000 members had been exposed to the COVID virus on the job. Many were unable to get tested, said Tim Burn, the union’s press secretary. Of those who did, 3,812 tested positive; 21 have died.

Moore, in Dakota City, got it from a man found unconscious in his bathtub. The patient’s son told the crew he was “clean.” Yet three days later, Moore got a call: The man had tested positive.

Within days, Moore’s energy level sunk “somewhere between nothing and zero.” He was hospitalized in early June, recovered and was back on emergency calls by Independence Day. He couldn’t stand for long, so he took on the role of driver. Moore said he’s still not at full strength.

As the virus has pummeled the Great Plains, calls to Moore’s department are up nearly 70% since September. Only a handful of his guys are still making ambulance runs, and most have gotten sick themselves. “We’re holding down the fort,” he said, “but it ain’t easy.”

For the first time in my life, I questioned my career choice.

Chief Peter DiMaria

It’s the same story inside firehouses across the nation. In Idaho’s Sun Valley, Chief Taan Robrahn — and one-fifth of his company — contracted COVID after a ski convention. In New Orleans, Aaron Mischler, associate president of the city’s firefighter union, got it during Mardi Gras — as did 10% of the force. In Naples, Florida, almost 25% of Chief Peter DiMaria’s members got it. And in D.C., Houston and Phoenix collectively, over 500 firefighters tested positive — while an additional 3,500 were forced into quarantine.

Quarantining, of course, can put loved ones at risk too: Robrahn’s wife and their three-year-old twins got it. “Mercifully,” Robrahn said, the family recovered.

DiMaria, whose 18-year-old has a heart defect, has been spared so far. But after Big Tony, a close colleague under his command, died of COVID-19 — and after spending months resuscitating people with heart attacks and respiratory distress induced by the virus — he’s as concerned as ever.

“For the first time in my life,” DiMaria said, “I questioned my career choice.”

‘It Weighs Heavy’

The distress of these emergency calls resounds in gasps, wailing, tears.

Some departments — including Houston and Dakota City — have taken on another burden: removing the bodies of those killed by the virus. “You can’t unsee this stuff,” said Samuel Peña, chief of Houston’s department, “the emotional toll, it weighs heavy on all of us.”

Into winter, firefighters have endured a second surge. “We’re battle-weary,” Peña said, “but there’s no end in sight.”

Meanwhile, Mischler said, tax revenue is plummeting, forcing budget cuts, layoffs and hiring freezes, “at the very moment we need the reinforcements more than ever.” And in the volunteer departments, which constitute 67% of the national fire workforce, recruitment pipelines are running dry.

So people like Robert Weber filled the gaps on nights and weekends, which for the New Jersey firefighter proved disastrous.

On March 26, the day after his fever rose, Weber was hospitalized. His was an up-and-down course. On April 15, his wife got a call: Come immediately, the doctor said.

Weber died before she pulled into the hospital parking lot.

This story is part of “Lost on the Frontline,” an ongoing project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please .

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

That’s how she knew where her 35-year-old son was.

The traveling nurse had “a tremendous work ethic,” routinely putting in 80 hours a week, said his brother, Daniel.

But when Perea took a job at Lakeside Health & Wellness Suites — a Reno nursing home that has of safety citations since 2017 from the Centers for Medicare & Medicaid Services — Dominga was “scared silly.”

During Perea’s stint, nearly one-fifth of Lakeside’s residents were infected , according to state health records. Lakeside’s “top priority is the safety of those who live and work in our facility,” a spokesperson said.

When her son didn’t respond to her text on April 6, Dominga knew something was wrong. Perea had COVID-19. He died days later.

As COVID-19 surges across the country, health care systems continue to suffer critical shortages, especially among non-physician staff such as nurses, X-ray technicians and respiratory therapists.

To replenish their ranks, facilities have relied on “travelers” like Perea. Staff agencies have tens of thousands nationally since March outbreaks in the Northeast.

Now the virus is tearing through rural areas — particularly in the Great Plains and Rocky Mountain states — stressing the limited medical infrastructure.

Rural hospitals have relied largely on traveling nurses to fill staffing shortages that existed even before the pandemic, said Tim Blasl, president of the North Dakota Hospital Association. “They find staff for you, but it’s really expensive labor,” he said. “Our hospitals are willing to invest so the people of North Dakota get care.”

The arrangement presents risks for travelers and their patients. Personnel ping-ponging between overwhelmed cities and underserved towns could introduce infections. As contractors, travelers sometimes feel tensions their full-time colleagues do not. Frequently employed by staffing agencies based thousands of miles away, they can find themselves working in crisis without advocates or adequate safety equipment.

In 2020, the upsides of their jobs — freedom and flexibility — have been dwarfed by treacherous conditions. Now the ranks of travelers are thinning: The work is exhausting, bruising and dangerous. Thousands of front-line health workers have gotten the virus and hundreds have died, according to reporting by KHN and The Guardian.

On April 17, Lois Twum, a 23-year-old traveling nurse from New Orleans, was one of four passengers on a flight to New York’s John F. Kennedy Airport.

When the self-described “adventure-seeking adrenaline junkie” arrived for her first shift at Columbia University’s Irving Medical Center, she said, she was assigned four patients on a COVID-19 unit. (Intensive care nurses typically care for two or three patients.) As these “constantly crashing” patients required resuscitations and intubations, “there was practically no one to help,” Twum said, because “everyone’s patient was critical.” The hospital did not respond to requests for comment on the workplace conditions and treatment of travelers.

Meanwhile, as hospital employees got sick, quit or were furloughed amid budget cuts, travelers picked up the slack. They were redeployed, Twum said, assigned more patients as well as the sickest ones.

“It was like we were airdropped into Iraq,” Twum said. “Travelers, we got the worst of it.”

On social media and in email groups, recruiters for travelers circulate photos of sun-splashed skylines or coastlines emblazoned with dollar signs, boasting salaries two or three times those of staff nurses. They promise signing bonuses, relocation bonuses and referral bonuses. They make small talk, ask about travelers’ families and suggest restaurants in new cities.

But when it comes to navigating workplace issues, “these people can just disappear on you,” said Anna Skinner, a respiratory therapist who has traveled for over a decade. “They are not your friends.”

Caught between the hospitals where they report for duty and remote staffing agencies, their worker protections are blurred.

For instance, under the Occupational Safety and Health Act, providing protective equipment is the agency’s responsibility — but the travelers who spoke with KHN said agencies rarely distribute any.

Perea’s family said they believe David did not have adequate PPE. His employer said it was the nursing home’s responsibility to provide it. “It is up to each of our clients to provide PPE to our staff while they are working assignments through MAS,” said Sara Moore, a spokesperson for Perea’s agency, MAS Medical Staffing.

Sometimes travelers are assigned to emergency rooms or intensive care units with which they have little experience. Skinner, a pediatric specialist, said she landed in adult ICUs when deployed to the University of Miami Health System in April. She received an hour of orientation, she said, but “nothing could have prepared me for what I had to deal with.”

Over five weeks, she said, she intubated one patient after another; suctioned the blood pouring into patients’ lungs and out of their noses and mouths; and dealt with families who were aghast, angry and afraid. Under the stress, Skinner said, she couldn’t sleep and lost weight. The hospital did not respond to requests for comment on workplace conditions for travelers.

Travelers often face “incredibly onerous” hurdles to the overtime, sick leave or workers’ compensation they are entitled to under the Fair Labor Standards Act, said Nathan Piller, a lawyer at Schneider Wallace Cottrell Konecky, an employment and business litigation firm.

Even the number of hours they can count on working is out of their control, Skinner said. Contracts reviewed by KHN authorize travelers to work a set number of hours, but only a fraction of those hours are guaranteed, and must be approved by on-site managers. The guaranteed hours may be compensated at rates hovering around minimum wage, and may require working holidays, which are not uniformly recognized.

The terms can be “modified from time to time during employment,” according to the contracts.

In 2018, AMN Healthcare, one of the country’s largest travel nursing agencies, for wage violations involving nearly 9,000 travelers. Violations “appear fairly commonplace across the industry,” said Piller, who worked on the settlement.

Travelers, Skinner said, are left to advocate for themselves to managers they might have just met — and “complaining just isn’t an option.”

KHN reviewed travel nursing contracts issued by Aya Healthcare, a large staffing agency, and found that any disputes — wrongful termination claims; claims of discrimination, harassment or retaliation; wage claims; and claims for violation of federal, state or other laws or regulations — must be settled out of court, in arbitration.

Officials at the Service Employees International Union, the American Nurses Association and National Nurses United said their constituents have been suspended or fired from traveling worker agencies for speaking to the news media, posting on social media or otherwise voicing concerns about unfair practices.

Matthew Wall, a longtime traveling nurse, knows this all too well. In July, two days into his assignment at Piedmont Henry Hospital in Stockbridge, Georgia, Wall said, he reported to hospital administrators “undeniably unsafe” conditions for himself and patients, including inadequate PPE, long hours and high patient-to-staff ratios.

Instead of addressing his concerns, Wall said, the hospital — which is by the federal government for workplace safety issues after of COVID-19 in mid-March — canceled his contract. “Travelers are treated like dog chow,” Wall said. “The second you become a liability, they dispose of you.”

“We continue to closely follow Centers for Disease Control and Prevention guidelines paired with our best practices in patient care and safety for all,” said John Manasso, a hospital spokesperson, who declined to comment on Wall’s case.

Some see an impossible choice. “We all know, if not for us, these patients would have no one,” Twum said, “but watching each other get sick left and right, it makes you wonder, is this worth my life?”

Skinner, for her part, took a job as a staff nurse in Aspen, Colorado. After his current contract in New Orleans ends, Wall is planning a break from nursing.

It was like we were airdropped into Iraq.

Lois Twum

Dominga Perea finally received a text back the night of April 6: “Don’t panic, Mama, I have the COVID.

“Pray for me.”

She saw David over FaceTime on Easter. “He struggled even eating mashed potatoes” she said, “because he couldn’t breathe.” The next morning he went on a ventilator and never woke up.

Months later, Lakeside hadn’t filled Perea’s position. “Ideal candidate must be a caring individual dedicated to providing high quality care,” the job listing read, and “able to react to emergency situations appropriately when required.”

KHN Mountain States editor Matt Volz contributed to this report.

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The employer, a home health care agency called Together We Can, was paying a premium — $13 an hour — after it started losing aides when COVID-19 safety concerns mounted.

Williams-Ward, a 68-year-old Indianapolis native, was a devoted caregiver who bathed, dressed and fed clients as if they were family. She was known to entertain clients with some of her own 26 grandchildren, even inviting her clients along on charitable deliveries of Thanksgiving turkeys and Christmas hams.

Without her, the city’s most vulnerable would have been “lost, alone or mistreated,” said her husband, Royal Davis.

Despite her husband’s fears for her health, Williams-Ward reported to work on March 16 at an apartment with three elderly women. One was blind, one was wheelchair-bound, and the third had a severe mental illness. None had been diagnosed with COVID-19 but, Williams-Ward confided in Davis, at least one had symptoms of fatigue and shortness of breath, now associated with the virus.

Even after a colleague on the night shift developed pneumonia, Williams-Ward tended to her patients — without protective equipment, which she told her husband she’d repeatedly requested from the agency. Together We Can did not respond to multiple phone and email requests for comment about the PPE available to its workers.

Still, Davis said, “Sue did all the little, unseen, everyday things that allowed them to maintain their liberty, dignity and freedom.”

He said that within three days Williams-Ward was coughing, too. After six weeks in a hospital and weeks on a ventilator, she died of COVID-19. Hers is one of more than 1,200 health worker COVID deaths that , including those of dozens of home health aides.

During the pandemic, home health aides have buttressed the U.S. health care system by keeping the most vulnerable patients — seniors, the disabled, the infirm — out of hospitals. Yet even as they’ve put themselves at risk, this workforce of — of whom — has largely been overlooked.

Home health providers scavenged for their own face masks and other protective equipment, blended disinfectant and fabricated sanitizing wipes amid widespread shortages. They’ve often done it all on poverty wages, without overtime pay, hazard pay, sick leave and health insurance. And they’ve gotten sick and died — leaving little to their survivors.

Speaking out about their work conditions during the pandemic has triggered retaliation by employers, according to representatives of the Service Employees International Union in Massachusetts, California and Virginia. “It’s been shocking, egregious and unethical,” said David Broder, president of SEIU Virginia 512.

The pandemic has laid bare deeply ingrained inequities among health workers, as Broder puts it: “This is exactly what structural racism looks like today in our health care system.”

Every worker who spoke with KHN for this article said they felt intimidated by the prospect of voicing their concerns. All have seen colleagues fired for doing so. They agreed to talk candidly about their work environments on the condition their full names not be used.

***

Tina, a home health provider, said she has faced these challenges in Springfield, Massachusetts, one of the nation’s poorest cities.

Like many of her colleagues — , according to a survey by the National Domestic Workers Alliance — Tina has lacked protective equipment throughout the pandemic. Her employer is a family-owned company that gave her one surgical mask and two pairs of latex gloves a week to clean body fluids, change wound dressings and administer medications to incontinent or bedridden clients.

When Tina received the company’s do-it-yourself blueprints — to make masks from hole-punched sheets of paper towel reinforced with tongue depressors and gloves from garbage bags looped with rubber bands — she balked. “It felt like I was in a Third World country,” she said.

The home health agencies that Tina and others in this article work for declined to comment on work conditions during the pandemic.

In other workplaces — hospitals, mines, factories — employers are responsible for the conditions in which their employees operate. Understanding the plight of home health providers begins with American labor law.

The Fair Labor Standards Act, which forms the basis of protections in the American workplace, was passed in an era dually marked by President Franklin Delano Roosevelt’s New Deal changes and marred by the barriers of the Jim Crow era. The act excluded — including maids, butlers and home health providers — from protections such as overtime pay, sick leave, hazard pay and insurance. Likewise, standards set by the Occupational Safety and Health Administration three decades later “domestic household employment activities in private residences.”

“A deliberate decision was made to discriminate against colored people — mostly women — to unburden distinguished elderly white folks from the responsibility of employment,” said , a law professor at St. Louis University.

In 2015, several of these exceptions . “The law itself is very clear. The problem lies in the ability to hold these companies accountable,” said Burkett McInturff, a civil rights lawyer working on behalf of home health workers.

The Occupational Safety and Health Administration has “abdicated its responsibility for protecting workers” in the pandemic, said Debbie Berkowitz, a director at the National Employment Law Project. Berkowitz is also a former OSHA chief. In her view, political and financial decisions in recent years have hollowed out the agency: It now has the fewest inspectors and conducts the fewest inspections per year in its history.

Furthermore, some home health care agencies have classified home health providers as contractors, akin to gig workers such as Uber drivers. This loophole protects them from the responsibilities of employers, said , an Indiana University associate professor of law. Furthermore, she said, “these workers are rarely in a position to question, or advocate or lobby for themselves.”

Should workers contract COVID-19, they are unlikely to receive remuneration or damages.

Demonstrating causality — that a person caught the coronavirus on the job — for workers’ compensation has been extremely difficult, Berkowitz said. As with other health care jobs, employers have been quick to point out that workers might have caught the virus at the gas station, grocery store or home.

Many home health providers care for multiple patients, who also bear the consequences of their work conditions. “If you think about perfect vectors for transmission, unprotected individuals going from house to house have to rank at the top of list,” said , a professor specializing in civil rights law at Syracuse University. “Even if someone didn’t care at all about these workers, we need to fix this to keep Grandma and Grandpa safe.”

Nonetheless, caregivers like Samira, in Richmond, Virginia, have little choice but to work. Samira — who makes $8.25 an hour with one client and $9.44 an hour with another, and owes tens of thousands of dollars in hospital bills from previous work injuries — has no other option but to risk getting sick.

“I can’t afford not to work. And my clients, they don’t have anybody but me,” she said. “So I just pray every day I don’t get it.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The global pandemic has ordinary health care workers going to extremes in a desperate hunt for medical supplies. Community clinics, nursing homes and independent doctors, in particular, find themselves on the fringe of the supply chain for masks, gowns, gloves and ventilators.

Their missions have the cinematic quality of the drug trade or a black-market arms deal: Desperate administrators wire money to mysterious offshore bank accounts, wary of the flimflam man.

Most medical supplies ― from isolation gowns to the filtration components of N95 masks ― originate in China, in vast factories that manufacture so-called spunbond polypropylene out of toxic chemicals. Decades of honing has turned the supply chain into an efficient, just-in-time wonder of globalization. But that system crumbled in the midst of the pandemic as countries, states, cities and health care providers all sought the same things at the same time.

“You had all these brokers entering the market looking for arbitrage,” said Michael Alkire, president of Premier, a company that negotiates supply contracts for hospitals. “Unless you were a significant player, it was hard to get access.”

That’s how Carol Silver Elliott, president of the Jewish Home Family in Rockleigh, New Jersey, ended up here: “We wired ‘the parking lot guy’ half the money,” she said. “I swear I don’t know his name.”

At the end of May, the “parking lot guy” remained her go-to source. The nursing home is spending “significant money,” Silver Elliott said, but the risk is worth it if she can outfit her staff with adequate personal protective equipment, known as PPE.

As the at major hospital systems in urban centers like New York, Seattle and Detroit, the collateral damage is becoming apparent elsewhere.

The burden of managing the disease long term is to nursing homes, safety-net clinics and outpatient medical practices. As these facilities brace for rolling waves of new infections, they are hustling to stock up on essential medical supplies — masks, gowns, testing kits, even disinfectant wipes — needed for basic care.

Thus far, things are not going well.

***

The first time Andy Behrman pulled up to the warehouse in Ocala, it was empty.

Behrman, director of the Florida Association of Community Health Centers, had spent the beginning of April trying to get gowns, gloves and masks for community clinics across the state’s 67 counties.

During that time, he ventured into dark corners of the internet to identify 15 distributors, spent hours on the phone vetting vendors, traveled to Tallahassee to obtain a six-figure bank draft, rented a warehouse and loading trucks, and then hired staff for the three-day distribution operation. Getting the goods was “a complete free-for-all, a feeding frenzy,” Behrman said. Sourcing has “basically come down to a huge dose of ‘God, I hope these guys are legit.’”

Despite his best efforts, the original order — placed the second week of April with a vendor from Tulsa, Oklahoma — was delayed for hours, then days. It had been diverted to Cincinnati — the opposite direction. One hundred thousand N95 masks were expected. Only 50,000 arrived and they were KN95s, which do not meet U.S. quality standards. The bill due was the same: $180,000. After the distributor phoned on a Saturday morning to report another delay and request credentials to access funds in the secure FedEx account, Behrman said, he had “so much angina that [he] couldn’t practically breathe.” He called it off.

Nearly a week later, on April 24, a different vendor drove masks overnight from Duluth, Georgia, and 600 clinics had more of what they needed to safely treat their patients.

Behrman is still hunting for gowns and gloves. Without bulk donations from organizations like Direct Relief, a provider of humanitarian aid, and the philanthropic arms of companies like Centene, a health insurer, “I don’t know what the hell we’d do,” he said. To get a leg up in negotiations, he’s been teaching himself rudimentary Chinese.

International Community Health Services (ICHS), a nonprofit health center in Seattle, depends on LabCorp for nasal swabs needed for testing but recently has been receiving oral swabs instead. Over the past two months, to alleviate shortages of various supplies, the organization “had to get extremely creative,” said Rachel Koh, chief operating officer. They tried to get equipment from Hungary, “but that didn’t really work out,” Koh said. In the end, an ICHS physician knew a local businessman who knew an international distributor in Hong Kong, who could coordinate the logistics and arrange to import the supplies they needed.

“We are always on the hunt for new suppliers,” Koh said, “but you have to be brave, because you don’t know [whom] you can trust anymore.”

Likewise, throughout April and May, Dr. Ian Smith — a cardiologist in South Carolina — tried to find necessities for the two clinics he owns. “I stopped at every general store between them,” he said, “but all their shelves were cleared out.”

Then he turned to “shady characters” halfway across the world ― learning a bit of Lithuanian in the process ― to no avail. So he’s taken on patient safety as a Sunday “do-it-yourself” project: ordering products like ethyl alcohol, aloe vera and storage vessels from Amazon and Etsy to mix his own hand sanitizer.

Dr. Paula Muto, a general surgeon in Massachusetts, has struggled to find lidocaine and saline. Both are critical during surgery. “All the doctors are competing with each other to get this stuff,” she said.

Muto anticipates that when routine procedures begin again, given the fragility of the health care supply chain, “all the supplies you can’t buy at Staples” may go on back order. This includes almost everything except hand sanitizer and disinfectant wipes — assuming she can find those on shelves.

But she has “a backup plan.” A distributor she knows in Alabama sources supplies from Spain and other European countries.

“We’re already stocking up,” she said. “We’re trying to make sure we’re at the top of every distributor’s list.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .