A rural town’s prescription for a nation weighing what’s next

Washington Post, Todd C. Frankel, May 12, 2020 at 9:23 a.m. EDT

DANVILLE, Pa. — The pathologist stood in the kitchen on his 40-acre farm and cut the crust from a ham and cheese sandwich for his 7-year-old son’s packed lunch. He took a swig of his morning coffee. He’d been up late answering calls, hustling to launch a clinical trial to test blood plasma as a possible treatment for covid-19, hashing out the details between rides on his Peloton stationary bike and taking rifle shots at nuisance groundhogs.
Now, he needed to get to the hospital, along with his son.

“Hey, Damien, we’ve got to go, bud,” Gustaaf de Ridder said as they headed toward his GMC Denali.

De Ridder had his feet in two worlds, living in a small town with a huge hospital — a rural community that is the unlikely home to one of the highest concentrations of hospital workers in the nation. Social distancing comes easy in these parts, and with just 50 COVID-19 cases and zero deaths, there is little apparent need to mobilize forcefully against the virus.

Yet almost everyone here is bracing for a medical battle, akin to the feeling of a military town on war-footing.

This rare combination shows how the push to reopen the economy and the need to control a deadly virus can coexist, with fewer of the tensions that have popped up across the country, such as an anti-quarantine protest that drew hundreds to Harrisburg, Pa., just 65 miles away. And President Trump, who won 62 percent of the vote in surrounding Montour County, tried to add more pressure to the situation Monday with a tweet accusing the state’s Democratic leadership of being too slow to reopen and claiming, “The great people of Pennsylvania want their freedom now, and they are fully aware of what that entails.”

“Health-care workers seem to have gone from heroes to the enemy because it’s like we’re making people wear masks,” said Mary Jane Reed, a critical care surgeon in Danville. “But I haven’t seen that here.”

“It might sound strange,” de Ridder said, “but it helps when you have so many health-care workers in the region giving the message directly. There’s less resistance. Less suspicion. Because we want this to go right, too.”

De Ridder, 40, runs the blood transfusion lab at Geisinger Medical Center. His wife works for the hospital’s supplier of protective face masks. With schools closed, his son was going to the hospital, too, to attend a day camp where children wear face masks decorated with bears.

Life in Danville has always seemed to revolve around what some locals call the “Big G,” the hospital on the hill that employs more than 10,000 people in a borough of 4,600, with as many medical evacuation helicopters at its disposal (nine) as Danville has stoplights.

Farmers and machine shop workers are neighbors to doctors and nurses. They all shop at Beiter’s Department Store. Many of their kids take piano lessons from the same teacher.

The pandemic had only intensified those connections, as virtually everything but the two covid-19 wings of the hospital shut down in preparation for the pandemic. One Geisinger doctor turned spare vacuum bags into respirator face masks; medical residents spent their free time cutting protective gowns out of surgical drapes; hundreds of volunteers sewed masks for home health nurses.

As parts of Pennsylvania, including Danville, took steps toward reopening some businesses on Friday, locals see the low caseload as evidence their efforts paid off.

“We’ve weathered this shockingly well,” said Sandy Green, a cardiologist who lives on a farm with his family just outside of town. “It would be much better if the rest of the world handled it like this.”

The hospital has been in Danville for more than a century, founded by the widow of an iron mining magnate in 1915 and forced to open its doors two weeks early to deal with a typhoid outbreak. It has grown over the years to become the flagship teaching hospital for one of the nation’s largest rural health-care networks, serving 3 million patients over parts of Pennsylvania and New Jersey.

Today, the hospital born into one infectious outbreak aims to face down another.

Signs of change

De Ridder’s morning commute shows how much has changed.

He drove his pickup past a billboard for Knoebels, an amusement park that had gone from delaying its regular April opening to postponing it indefinitely. A Perkins restaurant posted a handwritten sign, “We are open to go,” and Unida Pizza promoted “Takeout only.”

He continued past the mural proclaiming Danville “Home of the T-Rail” — a nod to its long-ago starring role in iron manufacturing.  The marquee outside Danville Area High School still read “Go Ironmen” — despite classes being canceled weeks ago.

De Ridder pulled up next to a Geisinger office building. He and his son were checked for fever. Damien retrieved the mask he’d been using for the week. The plastic cords looping over his ears annoyed him. He preferred his dad’s N95 respirator face mask.

As de Ridder jumped into his truck and pulled away, a woman in a mask ran after him.  “You forgot your son’s lunch!”  “I was up all night,” he explained, finding the lunch in his truck. “I’m a little tired.”

The hospital was quiet. The parking lots were mostly empty. The only signs of life were the few staff members milling outside white tents serving as temporary screening areas for the coronavirus before patients enter the hospital. It was the kind of languid scene that inspired online videos aimed at driving claims that the pandemic was overblown. One video had been shot at another Geisinger hospital in northern Pennsylvania.

The medical center was empty because elective surgeries had been canceled for weeks to prepare for the virus. Routine checkups and cancer follow-ups were delayed. The bulk of the hospital’s regular business was shut down. Visitors were discouraged.

Geisinger has resumed some medical procedures, but it has suffered financially. The hospital’s top executives announced they’d take a pay cut. But the hospital has so far avoided layoffs or furloughs.

The hospital’s steady employment normally inoculates the region against economic downturns and keeps unemployment lower here than in surrounding counties, said Fred Gaffney, president of the Columbia Montour Chamber of Commerce. But the pandemic’s economic pain was all around them.

In late April, almost every storefront was closed along Mill Street, in the town’s commercial heart. The governor shuttered most nonessential businesses, and even some businesses that could have stayed open locked their doors. Beiter’s owner Tom Beiter said he voluntarily closed his variety store because the virus made his employees fearful about coming to work. He is talking to his workers and planning to hold a soft reopening to see how it goes.

Andy Bower, owner of the Cherokee Tap Room, said his business was down 70 percent since it was forced to move to takeout-only — restrictions that would not change under the governor’s plan. He was growing increasingly anxious to reopen, but he said he and other business owners needed to do so with caution. It’d take time. The blow was softened by his wife’s job as a Geisinger physician assistant.

It’s not an unusual situation. “It’s hard not to know someone who works at Geisinger,” Bower said.

Geisinger has kept doctors on staff despite few patients to see and little to do. Green, the cardiologist, had most of his schedule cleared by the coronavirus. Same for his wife, Jamie Green, a kidney specialist. “They’re really trying to preserve their base” of health-care workers, Sandy Green said of the hospital. He knew that when the emergency passed, he and the other doctors would be expected to work hard to clear a backlog of patients.

He also knew Geisinger might need him and his wife sooner.

They were the specialists who would be called on first to replace critical care doctors sickened by the coronavirus.

Masks from vacuum filters

Karen Korzick saw the hospital’s supply of face masks and protective gowns was tight in March, just as the pandemic began.  She’s co-director of Geisinger’s critical care program — in charge of caring for covid-19 patients. In her rare off-hours, Korzick tried to craft her own supplies. She knew how to sew. She noticed her canister vacuum cleaner had a HEPA-filter bag. She went to work, cutting and stitching. She made her own N95 respirator mask using the vacuum bag. She conducted fit testing to make sure the mask seals were tight. It seemed to work.  Sandy Green, also worried about shortages, struck a deal with Korzick. She’d help engineer the gear. He’d raise funds and find volunteers to help.

They each contributed $4,000 of their own money. Jaime Green pitched in. They launched a GoFundMe campaign, raising more than $24,000. They found 300 volunteers to sew masks offering different levels of protection. Local businesses signed up to help.

They branched out, making protective gowns from old surgical drapes. Green hunted down contacts among the region’s manufacturers and middlemen, buying up surplus N95s and hospital masks. They started a project with Geisinger staff members and nearby Bucknell University professors to engineer a reusable respirator face mask using 3-D printers. They printed face shields.

Korzick’s basement was transformed into a staging area for volunteer efforts.

In one corner, dozens of bottles of bleach were stored in case Geisinger ran out of the disinfectant wipes used to clean covid-19 patient rooms.  In another, three medical residents cut the surgical drapes into shapes seamstresses could stitch into gowns. Plastic drop cloths were cut so they could cover COVID-19 patients when hospital workers needed to get extremely close — like during emergency CPR. The plastic cloths already were being used in crash carts at the hospital.

The three residents said they knew they were living through history. They wanted to be part of it in any way they could. The COVID-19 pandemic would become their war story — the kind older doctors love to tell young residents. “That’s the story we’ll tell,” said Miya McKnight, an internal medicine resident.

The volunteer project has pushed masks out to people who need them the most. Home health aides. Cancer patients. People on dialysis. Nursing home staff. Ambulance crews. The staff at a nuclear power plant 30 miles away. “Can you imagine if all those workers got sick?” Sandy Green said. “Whose is going to run it then?”

Green said he does not expect the supply-making effort to end even if the pandemic fades. He wants to keep it going as a nonprofit foundation so the community won’t need to look to outsiders for help during the next medical crisis.

Especially if the next crisis is like this one, with a virus that had everyone spooked — especially those who saw it up close at the hospital.

Reed and Korzick talked about what they would do if one of them got the virus. It felt like it was just a matter of time before a doctor or nurse got sick and was put on a ventilator. These two critical care doctors saw death frequently. But this pandemic was showing them something new.

They talked about the lives they’d led and their lack of fear about what was ahead. This was the job, Korzick said, voluntarily dedicating yourself to meeting the needs of others.

“You don’t want your friend who you’ve worked with for 10 years to feel bad if they can’t save you,” Reed said.

Getting ahead of the surge

De Ridder was working the same problem from another angle. He hoped to find a way to prevent patients from needing a ventilator.

The plasma of patients recovered from the infection should be rich in protective antibodies, the result of the body’s natural reaction to fighting the virus. Giving that plasma to an ill person should boost their immune system.

But it wasn’t a clear cure. During his medical residency at Duke University in Durham, N.C., de Ridder had been involved in a trial using plasma to treat influenza. That failed. But he believed it was worth a shot with the coronavirus. Big institutions like the Mayo Clinic and Johns Hopkins were trying it. He thought it could help people here.  He just needed a donor.

He found one in Patrick Konitzer, a Geisinger anesthesiologist. Konitzer believed he was infected returning home from a March trip to Dublin with his family. Trump had just announced American citizens in Europe should return home. Konitzer was stuck in a long airport line with people around him coughing.  He got sick a few days later. So did his daughter and his fiancee — a Geisinger nurse — along with her daughter.  They all recovered.

Konitzer’s plasma donation was scheduled to start at 1 p.m. at a blood bank about an hour away.  De Ridder later learned other recovered patients in the Geisinger system had donated plasma. Soon he had just enough plasma to give it to every COVID-19 patient who needed it.

At day’s end, de Ridder picked up Damien at camp. He asked his son about his homework and marveled at the construction paper flower he’d made.  They drove home — this time passing near the town’s Memorial Park, filled with monuments to the soldiers of past wars.

His wife, Rupa Ray, who has a doctorate in microbiology, was working from home. Normal dinner table talk was about immunology or diseases like sickle cell anemia.

But this night, they sat at the dining room table, covered by a 1,000-piece puzzle of a library painting. Damien said he didn’t feel like going to his taekwondo class via Zoom videoconferencing. He read a graphic novel while his parents talked.

De Ridder mentioned the anesthesiologist and how he hoped it was the start of something big, a way to change the course of this disease.

“Oh,” Ray said, “did he donate?”

“Yeah,” he said. “It went fine.”

It was just the beginning.

The U.S. Department of Agriculture (USDA) has announced the availability of $900,000 for local governments to host a Community Compost and Food Waste Reduction (CCFWR) pilot project for fiscal year (FY) 2020. The cooperative agreements will support projects that develop and test strategies for planning and implementing municipal compost plans and food waste reduction plans. The agreements are offered through USDA’s Office of Urban Agriculture and Innovative Production..

CMS Releases Additional Waivers for Hospitals and Other Facilities

CMS continues to release waivers for the health care community that provide the flexibilities needed to take care of patients during the COVID-19 Public Health Emergency (PHE). CMS recently provided additional blanket waivers for the duration of the PHE that:

• Expand hospitals’ ability to offer long-term care services (“swing beds”)
• Waive distance requirements, market share, and bed requirements for Sole Community Hospitals
• Waive certain eligibility requirements for Medicare-Dependent, Small Rural Hospitals (MDHs)
• Update specific life safety code requirements for hospitals, hospice, and long-term care facilities

For more information, see Emergency Declaration Blanket Waivers.

Price Transparency: Requirement to Post Cash Prices Online for COVID-19 Diagnostic Testing

The Coronavirus Aid, Relief, and Economic Security (CARES) Act includes a number of provisions to provide relief to the public from issues caused by the pandemic, including price transparency for COVID -19 testing. Section 3202(b) of the CARES Act requires providers of diagnostic tests for COVID-19 to post the cash price for a COVID-19 diagnostic test on their website from March 27 through the end of the public health emergency. For more information, see the FAQs.

 

The Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma penned a letter to nursing home management and staff. Administrator Verma shared her gratitude for the unwavering dedication and commitment of nursing home management and staff in keeping residents safe and for continuing to compassionately care for those who rely on them during this unprecedented time. The letter also provides links to previously shared infection control resources.

Click here to access the letter.   Dear Nursing Home Worker.5-4-20

With nearly 75 percent of patients hospitalized for coronavirus being at least 50 years old, and around 90 percent having pre-existing conditions, it’s important for states with larger vulnerable populations to have greater protective measures. Vulnerability isn’t just health-related, though, as many people are harmed by the economic effects of the pandemic. To show where the biggest concentrations of “at-risk” people live, the personal-finance website WalletHub today released its report on the States with the Most Vulnerable Populations to Coronavirus, as well as accompanying videos.

To identify which states have the highest concentration of vulnerable people, WalletHub compared the 50 states and the District of Columbia across 28 key metrics in 3 overall categories: medical vulnerability, housing vulnerability and financial vulnerability. Our data set ranges from the share of the population aged 65 and older to the share of the homeless population that is unsheltered and the share of the entire population living in poverty. Below, you can see highlights from the report, along with a WalletHub Q&A.

States with Most Vulnerable Populations	States with Least Vulnerable Populations
1. West Virginia	42. Wisconsin
2. Louisiana	43.Wyoming
3. Mississippi	44. Connecticut
4. Arkansas	45. Iowa
5. Alabama	46. Montana
6. Kentucky	47. Vermont
7. Florida	48. Massachusetts
8. Tennessee	49. Minnesota
9. South Carolina	50. Colorado
10. Georgia	51. Utah

Key Stats

• Florida has the highest share of the population 65 years and older, 19.70 percent, which is 1.9 times higher than in Utah, the lowest at 10.50 percent.
• California has the highest share of the homeless population that is unsheltered, 71.68 percent, which is 33.3 times higher than in North Dakota, the lowest at 2.15 percent.
• Texas has the highest share of the population that is uninsured, 17.40 percent, which is 6.2 times higher than in Massachusetts, the lowest at 2.80 percent.
• Wyoming has the highest share of households in poverty not receiving food stamps, 76.16 percent, which is 1.7 times higher than in Rhode Island, the lowest at 44.21 percent.
• North Carolina has the lowest unemployment recipiency rate, 9.32 percent, which is 6.1 times lower than in New Jersey, the highest at 57.17 percent.

To view the full report and your state’s rank, please visit:
https://wallethub.com/edu/states-with-the-most-vulnerable-populations-to-coronavirus/73821/

In response to the COVID-19 crisis, the U.S. Department of Labor (DOL) released a new rule that temporarily extends the period in which eligible employees can elect COBRA health insurance coverage. The ruling also extends the deadline for eligible employees to begin making COBRA premium payments and it extends the time for plan participants to file benefit claims or appeal denied claims. On May 4, the DOL and IRS jointly published Extension of Certain Timeframes for Employee Benefit Plans, Participants, and Beneficiaries Affected by the COVID-19 Outbreak. The DOL also posted a new set of COVID-19 FAQ’s for Participants and Beneficiaries to help both employees and employers navigate the new rule.