We seek your advice and your assistance for our people, the 92,000 residents of the Commonwealth who live in public and subsidized housing for elderly and disabled persons.

We are looking for people with experience who can share their ideas and skills in order to develop solutions to the problems arising from social distancing, specially for elderly and disabled in public or subsidized housing communities.

Services are essential

Elderly and disabled people now face deadly risk should they leave their homes for shopping or essential medical services. Any type of public or shared transportation can expose them to COVID-19.

The best and only protection from an epidemic that lacks reliable treatment is to avoid infection. People at very high risk should not be using any shared transportation services and should not do their own shopping. For health care, telephone, secure mail services, or telehealth consultation can help to bridge the gap.---Coronavirus Safety Guide by Andrew Junkin, MD. https://medium.com/@dr.junkinmd/coronavirus-safety-guide-3f3b8c18e79e

While some individuals may be able to use services like "Meals on Wheels," or deliveries from a food bank, others have specific health or religious dietary requirements and prepare their own food.  A weekly or biweekly shopping/delivery service would meet their needs. And given the very tight budgets of those living on a fixed income, these emergency services should be organized and funded by an agency capable of managing the process.

At present, food delivery services are unable to meet the need in a timely fashion. People who work in grocery stores and those who shop and deliver food are at increased risk for exposure and infection. These workers should be compensated for their risk and they should be provided with essential protective equipment including masks, gloves, and hand sanitizer.

Therefore, as a community we need to develop methods to reliably deliver food and health care without exposing people to infection.

Dealing with isolation

For those individuals whose isolation is causing deterioration, there should be telehealth or other resources for support.

"As the coronavirus disease 2019 (COVID-19) pandemic progresses, social distancing has emerged as an effective measure to restrain the spread of infections. Many people are now confining themselves to indoor spaces and communicating with their loved ones only through the use of electronic tools. This may have a detrimental effect on mental health, especially for adults over the age of 65, who may be less comfortable with virtual solutions. We must work to prevent social distancing from becoming social isolation among this vulnerable group."

"Social isolation in seniors has been linked to increased depression and suicidal impulses as well as to inflammatory and decreased anti-viral immune responses (2–4). These effects may further increase the susceptibility of this population to COVID-19. Health care systems and communities must consider the mental health burden of social distancing for the elderly and find ways to keep them engaged and motivated. Existing mental health support hotlines could add outgoing calls during which mental health professionals could reach out to the elderly and screen for symptoms of anxiety and depression. These measures could improve older adults' compliance with social distancing and help reduce the impact of COVID-19 on their mental health." ---Ali Jawaid,  Protecting older adults during social distancing. Science  10 Apr 2020: Vol. 368, Issue 6487, pp. 145DOI: 10.1126/science.abb7885

Doing something positive helps

One partial solution is for each person to have agency and to have something meaningful to contribute to the community. This can be as simple as checking on the well-being of their neighbors, or providing feedback to their landlords or agencies about concerns affecting tenants. They could make protective masks, they could create poems and they might draw or paint. For those with a smart phone or computer and internet access, they can engage with others for social connection and then go beyond to learn about and join others for advocacy on social problems.

I have been disturbed by the thoughtless and dangerous behavior of a few tenants in several housing developments, including where I live. I have urged the landlord and manager to educate tenants and to reinforce the need for social distancing and wearing a mask and frequent hand washing. I have also contacted the local health department, and they are setting out new regulations that can be enforced, regulations that can help everyone stay safe. And I will follow up to make sure that the landlord actually does the cleaning of high touch surfaces in the building. I urge you to take similar initiatives where needed, you may be able to save your own life and the lives of your neighbors.

Music for the season

And then there is music for every season, including celebrations of family and community rituals.

Bach - Easter Oratorio: Kommt, eilet und laufet BWV 249 - Van Veldhoven | Netherlands Bach Society
https://www.youtube.com/watch?v=62fawgUUpg8

Israel Philharmonic offers Passover medley for holiday
https://www.youtube.com/watch?v=rT0XziWZrfU

Chava Alberstein Had Gadya https://www.youtube.com/watch?v=xResWVCd4B8

Shoshana Damari Had Gadya https://www.youtube.com/watch?v=xResWVCd4B8

Thank you for your consideration, and we await your ideas and actions.

HAPPY SPRING, HAPPY PASSOVER, HAPPY EASTER!

Resources

Maintaining Emotional Health & Well-Being During the COVID-19 Outbreak Resources and tips to help boost emotional health and well-being during the COVID-19 outbreak.

For most non-emergency health issues, contact your doctor by phone or email; some health services will provide in-home visits when appropriate.

Check your town or city government web site for local services; senior centers and social service agencies may also have programs for transportation, food delivery, shopping, and medical appointments.

Check with your landlord, housing authority, or manager for resources and help they may provide or can help you get.

Reach out to agencies such as the Centers for Independent Living and Elder Service Agencies.

Some supermarkets offer special hours for elderly shoppers only; some food delivery services may be operating.

The INTERFACE Referral Service is a free and confidential helpline operated by William James College and provides referral services across 58 communities within Massachusetts.  Residents in those locations can access the Helpline by calling 1-888-244-6843 Monday through Friday between the hours of 9 AM and 5 PM. The Helpline assists callers by gathering information about their or their child’s mental health concern and uses a database of over 9000 licensed providers to connect the caller to outpatient mental health professionals that best match their needs based on location, specialty, insurance or fee structure, and appointment availability.

Salem Together Community resources for facing coronavirus; An example of coordinating volunteer efforts.

City of Salem COVID-19 Response Update - April 9, 2020; An example of a city health department and police department acting to limit actions that can spread COVID-19, including in common areas of public housing buildings.

The social norms that devalue people of age and disability are choices. The choices made by the Commonwealth of Massachusetts in Crisis Standards of Care: Planning Guidance for the COVID-19 Pandemic attempt to avoid bias, but nevertheless are affected by bias. Other choices can and should be made.

Crisis Standards of Care: Planning Guidance for the COVID-19 Pandemic provides guidance for physicians making decisions on patient care in a crisis. Triage is the process of determining the priority of patients' treatments based on the severity of their condition or likelihood of recovery with and without treatment; it has the goal of increasing the number of survivors.

In a crisis such as the COVID-19 epidemic, the lack of adequate medical resources may make it impossible for doctors to do everything possible to save each patient. Instead, they may be forced to choose among patients, who will live and who will die. The Commonwealth has created protocols intended to avoid bias but that value each patient in terms of the patient's future value to the community, instead of treating every life as of equal worth.

Leaders of the medical and public health community have been forced to confront the failure of our society leading to our inadequate medical systems in the face of COVID-19.

In fact, the health care system has been failing many people for a long time, and the current crisis exacerbates and makes visible the problems.

Further, our society has failed to make provision for disasters which are inevitable, if unpredictable as to when and where they fall: hurricanes, floods, fires are already becoming more frequent and extreme, driven by an already-changed climate. There are no adequate stocks of personal protective equipment, ventilators, and other essential supplies, despite repeated warnings by qualified experts. Even when a crisis such as COVID-19 is marching towards us, some of our leaders and our institutions have denied the reality and have delayed action.

But the real source of the problem is not the doctors or the state agencies who compose the protocols or must make life-or-death decisions, it is society which devalues the poor, the disabled, the elderly as well as people of color and immigrants. That negative valuation leads to less money to support services for these groups and to a woefully lacking system of accountability and of preparation.

"Crisis care must be the best care it can be in light of the circumstances and available resources. The purpose of this document is to provide guidance for the triage of critically ill patients in the event that the public health emergency caused by the COVID-19 pandemic creates demand for critical care resources that outstrips the supply."

"The foundation of the Commonwealth’s approach to crisis standards of care is that such tragically difficult decisions must be based on criteria that ensure that every patient has equitable access to any care from which they might benefit.  These criteria must be as clear, transparent, and objective as possible, and must be based on biological factors related only to the likelihood and magnitude of benefit from the medical resources.  Factors that have no bearing on the likelihood or magnitude of benefit, including but not limited to race, disability, gender, sexual orientation, gender identity, ethnicity, ability to pay, socioeconomic status, perceived social worth, perceived quality of life, immigration status, incarceration status, homelessness or past or future use of resources, are irrelevant and not to be considered by providers making allocation decisions."---Crisis Standards of Care: Planning Guidance for the COVID-19 Pandemic

I have been looking at the triage guidelines and see that if someone my age gets COVID-19 it is effectively a death sentence. I naively think that the decades of experience and accumulated wisdom we elderly have won are strengths that today enable us to contribute to society; I know that many of my peers continue to be important to their family and their communities.

Clearly, the same sense that every person has value applies to people with a disability as well as people of color and the poor.

John E. Winske, the Former Executive Director, Disability Policy Consortium (DPC), writes in the April 13 edition of the Disability Policy Consortium Weekly Update:

"Our Commonwealth seems to have lost their way with the standards for rationing ventilators and care. Our public officials did not live up to their capabilities of building a more inclusive health care policy. They did not match our Commonwealth's illustrious history of thinking about ALL of our residents."

"When it came to the issue of rationing care in a pandemic, I hoped and prayed we would be different. The Disability Policy Consortium (DPC) spent the last 18 months educating staff at MassHealth, EHS and Health Care for All about Quality of Adjusted Life Years (QALY). As a reminder QALY is an economic data tool which values the life of a person living with a disability lower than that of a healthy person. In short, it assumes we, people with disabilities, lead unhappy, unfulfilled and thus less worthy lives. I wanted to believe that our educational efforts were paying off."

"There is no way to square the scoring statement with the non-discrimination clause. You are asking human beings to assign a score and to decide who is in better health and will live longer. A crystal ball is needed to determine who will live longer. Just by asking who is in better health you are bringing ableism to the table. We also know that people of color are more likely to be in poorer health for a wide variety of reasons. This policy is throwing the social determinants of health out the door."

"Sadly, this policy only reinforces privilege. It favors people in our society who are healthy and able to maintain their health. The Commonwealth tasked people of privilege (bioethicists) to design a policy, to be overseen by a group of people (doctors) who are more likely than not to come from privilege to determine who lives and who dies. Really? What could go wrong?"---John E. Winske

On Monday, April 13, 2020, Michelle Holmes, MD, DrPH told  Jim Braude on WGBH News’ Greater Boston program why she was critical of the new guidelines and proposed the use of a lottery for scarce medical resources as a less unfair method. Holmes is affiliated with Brigham & Women's Hospital (BWH); Harvard Medical School; and Harvard School of Public Health. The guidelines penalize poor health and age, but Holmes views ageism as an outdated cultural prejudice, and she sees poor health as the result of societal prejudice against people of color. She is critical of the special status given only to health care workers, without consideration of the comparable exposure to infection experienced by vital workers in transportation and food distribution, workers who are people of color and relatively poor.

Holmes recognizes the good intentions of those who wrote the guidelines, but asserts that fairness and justice require that anyone in need of essential care with a ventilator must be allocated care by a lottery, provided that they can be expected to recover with that care and that they have chosen to undergo the intrusive procedure of ventilation.

She has posted her position in a petition to Jerome Adams MD, U. S. Surgeon General; Deborah Birx MD, Coordinator for the White House Coronavirus Task Force; and to Anthony Fauci MD, Director National Institute on Allergies and Infectious Disease.

In the Governor's daily briefing on April 13, 2020, Mary Lou Sudders, Secretary of the Executive Office of Health and Human Services, stressed that the guidelines were intended to avoid bias and provide fairness and equity to all, and that there is an appeals process. These guidelines would not replace existing guidelines and protocols in any institution, and hospitals are expected to consult with the state department of health. She also spoke to the need to mitigate over time the existing institutional barriers to equity.

"We have met the enemy and he is us," said Pogo, a character in a comic by Walt Kelley. Our society has failed us as a community, we have not provided equitable resources and opportunity to everyone. People of color, immigrants, poor people, disabled, elderly: all have experienced overt or covert discrimination.

In housing, the lack of resources and accountability is a reflection of social norms that consider the elderly and the disabled as of lesser value. That is because we, the recipients of government benefits, are not considered to be equal members of the community. We as a society prefer to value individuals whose worth is measured in health, youth, power, and money. We do not embrace all humans as of equal worth, we don't value human rights or civil rights.

Now we have elaborate protocols for triage of patients under crisis conditions. Doctors must switch from saving every life to caring for those most likely to contribute to the community for the longest time. In other words, the elderly and disabled people who have a severe health condition due to COVID-19 are less likely to get the scarce medical resource that might keep them alive and return them to the community.

As Mary Lou Sudders has recognized, these circumstances are a reflection of social and institutional barriers to equity. We must all work  towards tearing those barriers down. And we must not wait until the next disaster, but instead prepare ourselves well in advance.

Reference

The Commonwealth of Massachusetts, Executive Office of Health and Human Services Department of Public Health, Crisis Standards of Care: Planning Guidance for the COVID-19 Pandemic, April 7, 2020