Public health in housing for elderly and disabled
Many of the management and community measures that will help to prevent and mitigate COVID are similar to those that can prevent or mitigate bullying in housing.
In November, when the two-week positivity rate was 2.5%, I predicted a rapid rise in COVID and sought protective action by the landlord. Since then, while a wave of COVID has killed and sickened many and threatened to collapse the health care system, I have pressed for action. Four months later, while the wave is subsiding, I am still seeking an effective accommodation to protect my health (and that of all the tenants, staff, and visitors).
I have proposed to negotiate an effective accommodation under auspices of the Mass Commission Against Discrimination (MCAD) with my landlord, along the lines suggested below. I believe there is still value in reaching an agreement so that when we identify a new threat of airborne infection, COVID or some new disease, we can rapidly work to protect ourselves. Infectious waves go up and down in a predictable pattern, let’s be ready for the next.
Will the new CDC guidelines protect us?
No, they are designed to protect hospitals from being overwhelmed by severe COVID cases. We need to focus on our immediate local community and the places where we live. We can do this by paying attention to the rate of disease transmission and by working together.
The current guidelines of the Centers for Disease Control and Prevention (CDC) ignore the less severe cases, "mild disease," that can nevertheless create long COVID with continuing, disabling, chronic harm.--- Xie, Y., Xu, E., Bowe, B. et al. Long-term cardiovascular outcomes of COVID-19. Nat Med (2022). And the CDC guidelines leave those at greatest risk unprotected by community actions, including children too young to be vaccinated, those with compromised immune systems, elderly, disabled, and those with various conditions making them more susceptible. Therefore, it is imperative that such vulnerable populations take all possible steps to protect against infection and to mitigate disease.
Nursing homes, assisted living homes, and housing for the elderly and disabled are all high-risk environments. Clearly, avoiding infection remains important.
The vulnerable people must not be expected to protect themselves without the collaboration of their neighbors and their community. It is too dangerous to participate in a society that fails to consider the needs of the most vulnerable. Marney A White, Professor of Public Health at Yale University, argues for society to provide effective accommodations to enable vulnerable people to function.
I am one of the 7 million Americans who is immunocompromised. I am also a professor of public health at Yale University.
In public health, we quantify health outcomes in a variety of ways, including indices for one's ability to function in daily life. That means the ability to attend school, work, navigate public settings and participate in society.
To truly "protect the vulnerable," society must make accommodations. That means really examining what daily life is like for the immunocompromised and our families, and problem-solving ways to help and protect us.
It is insufficient to assert that "we must protect the vulnerable" without providing practical strategies, services and education. Otherwise, "protect the vulnerable" reads as an afterthought—because it is.---Marney A. White, Protecting the Vulnerable—It's Time to Move Beyond the Rhetoric | Opinion, Newsweek, March 10, 2022.
Who will save us?
Charity Dean MD, MPH&TM was Assistant Director for the California Department of Public Health and was a key member of the executive team directing the COVID-19 outbreak response. A brilliant and dedicated physician and public health leader, Dean concluded that our public health system is not adequate. She said,
‘Stop waiting for someone to come and save you. Because no one is coming to save you.’---Lewis, Michael. The Premonition: A Pandemic Story (p. 42). W. W. Norton & Company. Kindle Edition.
I have been frustrated by the failure of our national and state public health responses, and see that our local health department, which has been responsive, is constrained by the policies of state and regional public health departments, by citizens who don't want mandated restrictions, and by a lack of resources.
So, perhaps we can follow the lead of Charity Dean and adapt her idea for local responsibility. She proposed that each local community would have to use local data to determine what actions they would take, what level of risk they were willing to tolerate. If people took these decisions into their own hands, they could stop blaming the government.
It wasn’t just the effects of the virus that needed to be mitigated. The effects of the culture did, too. For the plan to work, Charity thought, it needed to be locally controlled. ---Lewis, Michael. The Premonition: A Pandemic Story (p. 236). W. W. Norton & Company. Kindle Edition."
Unfortunately, in my opinion, our country has divided along political and belief systems so that it is hard to see how a purely democratic approach to public health can succeed even at the local community level. The problem is that public health requires a communal response, and individualistic decisions are not able to have the same strong impact to limit disease spread as early, coordinated communal actions.
We will have to save ourselves
Nevertheless, we can try to develop practical solutions based on collaboration between landlord and tenants. In residential situations that I have studied, where the landlord and management take leadership roles and work with tenants, all are protected from COVID and all—staff as well as tenants—have a more positive experience as a community.
We should use the two-week positivity rate as reported on the COVID-19 Dashboard, Massachusetts Department of Public Health, because it is a good indicator of current community transmission. Masking is one key element of a protective system, there are many additional elements.
I have reported to you on my efforts to have protection from COVID by having all persons wear a mask in the common, public areas of the residential facility. See: Advocacy Example: Reasonable Accommodation Request Reasonable Accommodation Request: Making it Stick For a collection of information and explanations on current best practices for protection against COVID, see: The New "How to Avoid COVID"
Here is the solution that I am proposing to my landlord.
When the two-week positivity rate of either My County or My City rate is below 1%, masking is not required; take down the signs requiring masking in all public areas of the residential facility; masking is optional, encourage for people with symptoms or exposure or special vulnerability.
When the two-week positivity rate of either My County or My City is 1.5% or higher, commence masking and post signs.
Improved management policies.
Establish COVID safety requirements for the vulnerable population of tenants, determine and follow levels for masking and non-masking using objective criteria.
When there is, among tenants, staff, or others in the building, a known case of COVID or exposure to COVID, impose masking regardless of community positivity rate and use daily rapid tests with negative result to permit each person to enter or remain in any shared public areas (common rooms, lobby). Assure support system for any person in seclusion due to infection or exposure.
Free distribution of N95 masks with guidance for rotation. Masks to be worn correctly, covering nose and mouth, and without leaks. For after hours, a dispenser for masks in the entrance lobby to encourage use.
Availability of rapid tests.
Continuing education about COVID, understand aerosol transmission.
In common areas for gatherings and meetings, assure ventilation, HEPA filters; fan in elevator because aerosols can linger for hours.
Address problem of spread of aerosols and infection that can be spread by the building vent system—adjoining apartments share vent connection and vertical vents connect apartments. Clean vents, establish negative pressure, install exhaust fans with automatic shutter.
The landlord will meet their obligations for quiet enjoyment and support and enforce their rules to assure the wellbeing and safety of all tenants. While the apartments are for “independent living,” nevertheless landlord-tenant obligations must be met.
Effective enforcement is essential, however results will be best when enforcement is used when collaboration fails and persuasion is ineffective.
The landlord will establish a visible onsite presence of a manager and/or service coordinator. Interact with tenants to create trusting relationships. Listen to the tenants, what do they want, what do they need, what are their suggestions? Management will seek resources and solutions to meet the needs and concerns of tenants.
Use the front sitting room as temporary office to enable the manager to see and be seen.
Management will educate tenants, offer a mask to any unmasked person in the building, remind them of the importance of following this rule. Use enforcement as needed. See something, say something. Use positive reinforcement to enourage compliance with rules.
Provide N95, KN95, or KF95 masks, gift bags with sanitizer, etc. Ideally to present in person to establish and reinforce relationships.
Posted rules should replace “face covering” with properly worn N95, KN95, or KF95 respirator. N-95 type masks provide greater protection than cloth masks because they block less well; or surgical procedure masks because they leak around the edges.
I write based on available evidence and statements by epidemiologists and researchers, even when that evidence is not conclusive or has not been peer-reviewed. I have read experts' research, but I am not an expert on this topic. I do ask experts to review these writings. This writing is not medical advice. Keep your doctor informed on your symptoms and status.
Jerry on twitter: @coordinatingnow I follow leaders in public health and COVID
AARP Massachusetts and Dignity Alliance Massachusetts are sponsoring a one-hour training on advocacy and public policy objectives. The free, online session is scheduled for Wednesday, March 9th from 12:00 to 1:00 p.m, and is open to any and all advocates.
Jessica Constantino, Massachusetts Director of Advocacy, AARP will be our presenter, and she will be joined by Senator Richard T. Moore, Co-chair of the Dignity Alliance MA Legislative Work Group. The session will include an overview of the legislative process, including the processes by which bills become laws and budgets are determined; timely tips and tactics; and ways that we can turn our passion into action.
Register for Legislative Training for Advocates
Please contact Rachel Chartier with registration questions or accommodation requests at firstname.lastname@example.org or 617-338-6665 x 203.
The ombuds bill, S1084, has been sent to study. Although this is often the end of a bill during the current legislative session, we are working closely with Senator Joan B. Lovely to revise and strengthen the language of the bill and seek to advance it even in this session.