Mental Health

Army Pvt. 1st Class Lucas Ternell, a volunteer firefighter, and a member of the 20th Military Police Company, Maryland National Guard, puts out a small debis fire in the yard of a house fire in Salisbury, Md., Aug. 27. Ternell was aboard Rescue 16, which was one of several fire and rescue engines that reported to the fire inside a residential neighborhood. Guard members and civilian first responders are providing area support during the Hurricane Irene response. U.S. Army photo by Sgt. Darron Salzer

Similar bills to help first responders with health issues are in front of legislators. They’re likely to have different outcomes.

May 4, 2021 by Rose Hoban Leave a Comment

Similar bills to help first responders with health issues are in front of legislators. They’re likely to have different outcomes. - North Carolina Health News

A bill to help firefighters with cancer returns with a new way to pay for their care, while another bill to help first responders cope with trauma may have a harder road.

By Rose Hoban

In a year when the important role of first responders has become increasingly visible to members of the public, several bills to provide enhanced benefits to public employees such as police, firefighters and EMTs who sustain illness or injury related to their jobs have been introduced at the legislature.

One bill, House Bill 535, addresses an issue that’s been advocated for by firefighters’ organizations for several years, namely, a higher incidence of some forms of cancer experienced by firefighters. Long-term studies conducted by the National Institute for Occupational Safety and Health confirmed that firefighters more often develop digestive, oral, respiratory, and urinary cancers, along with mesothelioma, a cancer that’s related to exposure to asbestos.

A second bill, House Bill 492, would provide coverage for first responders who suffer trauma on the job, whether they were participants in a traumatic event or they witnessed some of the horrors that humans can inflict upon one another in the course of their workdays.

And while both bills received favorable treatment in the House Health Committee last week, their fates are likely different, in part because of how the different groups are asking for their coverage to be paid.

Witnesses to suffering

For half a decade, the advocacy group Blue HELP has been collecting data on law enforcement personnel who take their own lives. According to their records, 645 law enforcement personnel, including corrections and federal officers, have died by suicide since the beginning of 2018.

Law enforcement are not the only first responders to have large numbers of suicides, according to Rep. Donna White (R-Clayton), who is a sponsor of HB 492 and who introduced the bill last week in committee.

“In 2020, according to Firefighter Behavioral Health Alliance, 97 firefighters 26 EMTs, and one communication specialist, a 911 dispatcher, committed suicide,” she reported. “The Alliance believes those statistics are 65% reporting.”

And those statistics don’t even represent those first responders killed in the line of duty.

“When you drive along the highway and you see a wreck, do you stop?” White asked. “Our police officers are patrolling and they have no choice. They stop. They see decapitations. They see limbs that are missing and they don’t even know where they are in the pile.”

She went on to describe some of the traumatic scenes witnessed either in person, or sometimes, in the case of 911 dispatchers, over the phone.

“When you do this 365, many times several shifts a day or a week. You don’t get over it. You can’t just brush it away,” she said.

The bill would allow those responders who have developed post traumatic stress disorder from some of the things they’ve witnessed and experienced to claim workers compensation for their treatment.

“Every shift, when you see it day in and day out, it does take a toll,” said Rep. Mike Clampitt (R-Bryson City), a retired firefighter. “I’m here to tell you, it does take [a toll] and I never think about it till something like this comes up. And it’s all that scene and all that emotion, everything flows back through me again.”

Personalized treatment

Treatment for post traumatic stress is complicated and varies according to what works for each person, said Cherene Allen-Caraco, a mental health provider and head of Charlotte-based Promise Resource Network.

While many people think of therapy as something that happens while the patient lies on a couch and talks, there are now many forms of therapy specifically geared towards helping people heal from both physical and psychological traumas.

Some therapies are in the experimental stage, such as those being studied by local researchers who use injections to block nerve pathways to calm the body’s reactivity to stress.

Allen-Caraco, who both practices trauma-focused therapy with clients and has been through the therapy herself said that other forms of trauma therapy involve helping people get in tune with what is happening in their bodies. Once patients identify the places where they are tense, they can then increase their awareness and work toward releasing that tension; that can involve learning deep breathing techniques or movement to reduce muscle tightness. Other forms of therapy use eye movement to defuse the memories of trauma.

“It could be sensing, so it could be more of a grounding, hearing, smelling, seeing,” she said. “It could be engaging your senses, you’re learning how to regulate your nervous system or calm your nervous system down.”

She said that it’s important for first responders to have done this work if they’ve experienced trauma in their past. They frequently walk into complicated and tense situations and need to be aware of the unconscious forces playing inside themselves, especially if people’s lives are at stake.

“What you want to do is be grounded enough in that moment,” she said “You want your thinking brain online, not your primitive brain, you’re not just reacting based on fear and feelings.

“You don’t want fight flight or freeze to take over.”

The problem, Allen-Caraco said, is that frequently, insurance doesn’t cover enough treatment.

“Sometimes what happens is insurance will pay for three sessions, five sessions, you know, they’re going to pay for very short term treatment,” she said. “It doesn’t mean people are gonna have to do it for years. But to think that we could just cure people in three sessions… there has to be flexibility to choose a modality based on what you’ve experienced. And based on what would work for you.”

Scott Mullins, head of the Professional Fire Fighters and Paramedics of North Carolina, spoke to lawmakers last week to press for the firefighters about the psychological toll his line of work takes on people. “Every year, it just gets worse and worse and worse,” Mullins said. “PTSD and depression rates among firefighters, EMS personnel, and police officers are nearly five times higher than the general population. Even when suicide doesn’t happen, untreated mental illness occurs and it has a great impact on our physical health and impairs decision making.” Screenshot courtesy: NCGA Youtube channel

Higher cancer incidence

In the past, the state’s firefighters have also pushed to be paid through the state workers compensation system to have their cancer treatment reimbursed and to be paid for their time off while they’re sick.

“North Carolina is the only state in the country who’s not taking care of our firefighters on the issue of cancer,” bill sponsor Rep. Destin Hall (R-Lenoir) told the committee. “We’re the only state again, the only state without any presumptive cancer coverage for our firefighters.”

This year, the Firefighters Fighting Cancer Act of 2021 is finally predicted to pass, because the firefighters and those opposed to the bill in the past have negotiated a way around having reimbursement come via workers comp.

Spokesman Scott Mooneyham from the North Carolina League of Municipalities said that previously, his organization – and others – opposed paying for these treatments with workers’ compensation.

“Our organization saw that as both creating a situation where the costs would be undetermined, and it wouldn’t solve the problem,” he said. Even if workers compensation paid the bills, a municipality could still be sued.

The current bill was hammered out when all of the stakeholders sat down and gave a little. For one thing, Mooneyham said that this year’s firefighter bill includes volunteer firefighters, who were not included in previous years’ bills.

And this new bill provides a firefighter diagnosed with cancer with a $25,000 lump sum upon diagnosis, as much as $12,000 to cover deductibles, copays and other out of pocket costs and a monthly benefit that’s tagged to the firefighter’s salary. Volunteer firefighters would receive the same lump sum benefits along with $1,500 each month. For both kinds of workers, the benefit tops out at $50,000.

Mooneyham predicted that the bill would have an easy trip through the legislature and would land on Gov. Roy Cooper’s desk for a signature.

But the PTSD treatment bill? Mooneyham predicted that HB 492 didn’t have a chance, because it – like previous iterations of the firefighters’ bills – relied on the workers compensation system for reimbursement.

“There are a lot of interest groups beyond the league that are not comfortable with making substantial changes to the worker’s comp system,” he said.

“I think that any entity that wants to pass a piece of legislation to provide some type of benefit needs to look beyond the workers’ compensation system, if they want to achieve that. And I think this cancer firefighters bill is evidence of that,” he said.

“I think that’s where this state is right now.”

Behind needle exchange bill, a spat between Asheville site and its new neighbors

April 20, 2021 by Taylor Knopf Leave a Comment

Behind needle exchange bill, a spat between Asheville site and its new neighbors - North Carolina Health News

As opioid deaths continue to rise in the wake of the pandemic, a bill filed at the North Carolina legislature aims to put restrictions on syringe exchanges that advocates say would shut down many.

By Taylor Knopf

Proposed state legislation filed in response to a years-long feud between an Asheville neighborhood and a local needle exchange could threaten syringe exchanges across North Carolina. Senate Bill 607 seeks to ban mobile exchanges, require engraved needles, background checks, forced treatment and more.

Meanwhile, opioid overdose deaths are at an all-time high.

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A neighborhood group in west Asheville has tried for several years to put restrictions on the Steady Collective, which runs syringe exchanges for people who use drugs at several locations in Buncombe County, including a bookstore in West Asheville once a week. Based on comments on the group’s Facebook page, they are concerned about used needles in community spaces.

“West Asheville started experiencing an increase in crime and litter that was new to the community in 2017,” reads the group’s About section on Facebook.

Steady Collective Director Hillary Brown says what really changed in 2017 was the neighbors, not the drug use. In 2017, Asheville was ranked number two in the nation on a list of fastest gentrifying cities. Brown said their harm reduction organization serves people in this area because the need has always been there. In fact, there were underground needle exchanges in Asheville long before the state legalized them.

Screenshot of a post in the west Asheville neighborhood Facebook group

Asheville city officials looked into the issue and determined in 2019 that the syringe exchange could continue operating out of the bookstore in West Asheville. Brown believes that since the city didn’t shut their operation down, the neighborhood group has worked around local officials, going directly to the state legislature to fight this battle. The Substance Use Disorder Safety Act, introduced by Sen. Check Edwards (R- Flat Rock), has similar language to proposed restrictions presented by the neighborhood group to city officials.

A representative of the West Asheville neighborhood group declined to give an interview or statement to NC Health News.

However, Senate Bill 607 wouldn’t just apply to the Asheville needle exchange, it would have implications for all of North Carolina’s syringe exchanges. Edwards didn’t respond to NC Health News’ multiple requests for comment by phone and email.

shows a group of people wearing facemasks standing in front of an ambulance that now acts as a mobile needle exchange outlet. The words — Dr. Bayla Ostrach, Kim Roney, Hillary Brown and Reid Getty take part in a Steady Collective community syringe pickup in April 2021. Photo courtesy of Hillary Brown

Leaders in North Carolina’s harm reduction community say they were not consulted about this bill which would greatly alter or eliminate some needle exchanges.

“In short, if this bill were passed as written it would probably end all syringe exchange programs in the state,” the NC Harm Reduction Coalition, which runs dozens of exchanges, wrote to supporters in an urgent email.

Mandatory substance use treatment

The proposed legislation would require needle exchanges to carry $1 million in liability insurance and to operate out of a facility offering substance use treatment. The bill would require those coming to needle exchanges for clean drug use supplies to enroll in substance use treatment.

Requiring treatment flies in the face of harm reduction philosophy which seeks to lessen the damage caused to a person by their use of drugs and “meet people where they are.” Harm reduction organizations offer people who use drugs clean needles and supplies so they don’t reuse or share needles, therefore reducing the spread of HIV and hepatitis C infections. Many also provide free testing for these bloodborne infections, and they are a major distributor of naloxone, an overdose reversal drug.

While harm reduction workers will link people to substance use treatment if they ask for it, it’s not a requirement. Forced substance use treatment has not been shown to improve health or treatment outcomes for people who use drugs and can lead to higher rates of overdose death.

“The point of harm reduction is to respond to what the person is asking for,” the Steady Collective’s Brown said. “You don’t come with an agenda.”

If this bill passes, the Steady Collective could not continue to operate, they said.

“The requirements are absurd, and I’m not going to make people go to treatment. So if I’m made to violate all of my values and the principles of harm reduction, I’m not going to do the work,” they said. “That’s not fair to participants.”

“I don’t feel like I will be able to support them and advocate for people effectively with these requirements, and that will result in a dramatic increase in hepatitis C and HIV infections. And it will result in a great deal of death. We are the most effective way to get naloxone into the hands of people using drugs,” Brown concluded.

Engraved needles, background checks and no mobile exchanges

Harm reduction workers say some provisions in Senate Bill 607 would be impossible to comply with — such as a requirement to engrave sterile needles with the program logo. By definition, sterile needles come in sealed packages.

Another bill provision requires all needle exchange workers to pass a background check. This would make many ineligible to work because many people working in harm reduction have a history of substance use, which often includes past encounters with the criminal justice system. Their experience makes them effective at relating in a non-judgmental way to people seeking clean drug use supplies.

Shows five people gathered around the back of a van, the hatch is open, showing supplies inside. — Mike Page and Hyun Namkoong meet a group of people in their neighborhood to hand out syringes and other supplies as part of NCHRC’s mobile syringe exchange in 2017. Photo credit: Taylor Knopf

Both Brown and the director of the NC Harm Reduction Coalition Jesse Bennett have prior criminal records. Bennett said the government cannot tell private organizations not to hire people with criminal backgrounds.

The bill would also require needle exchange programs to be located outside of a three-mile radius of schools, which would give them few options. For example, the three needle exchanges currently operating in Asheville — including one located at the county health department — would be in violation of this buffer.

The proposed legislation aims to eliminate mobile needle exchanges, which harm reduction workers say is one of the only ways to reach the homeless, along with rural residents and those without access to transportation.

“This is just more war on drugs policy. It’s attacking the most vulnerable and coming after homeless people,” Bennett said. “There’s nothing based in science in any of the provisions in this bill.”

Pandemic increased overdoses

These proposed restrictions on needle exchanges come on the heels of a pandemic that has fueled overdoses and the prevalence of contaminated street drugs, making them more deadly. Harm reduction workers across the state said that pandemic-related stressors — such as job loss and homelessness — drove increases in drug use, overdoses and a return to drug use for some.

In 2019, even before the pandemic struck, an average of six North Carolinians died each day from drug overdoses. Illegal opioids such as fentanyl and heroin made up 78 percent of overdoses in that year.

Though 2020 drug death data isn’t finalized, the state health department says that all indicators — particularly emergency room data — point toward an increase in overdoses.

There was a 24 percent increase in overdose-related emergency room visits in 2020 over the previous year. North Carolina data shows an 89 percent increase in EMS responses to opioid overdose from February 2020 to February of this year.

Due to the increase in drug use and overdoses, last week HepConnect, an initiative funded by pharmaceutical drugmaker Gilead, pledged an additional $5 million to fight hepatitis C infections in Appalachia. In the past, HepConnect funds have flowed through multiple harm reduction groups in North Carolina, including the Steady Collective, and four surrounding states.

New national data shows that synthetic opioids, such as fentanyl, are driving up overdoses in the U.S., and the number of deaths surged even higher after the pandemic lockdowns began.

More than 87,000 Americans — a record high — died from a drug overdose in the 12-month period ending in September 2020, according to new provisional data from the Centers for Disease Control and Prevention. That’s a 27 percent increase over the previous 12-month period.

Data behind needle litter

In order to address concerns about used needles in the community, Brown said Steady Collective is one of the few exchanges in the state that requires the needle return. In 2019, Brown said program participants insisted on this policy change because they didn’t want to lose the program.

To combat low needle take-back rates, Bennett said the NC Harm Reduction Coalition is piloting a new biohazard takeback program by giving participants who bring back used needles swag, such as backpacks, sunglasses, etc.

In a comparison study of a city with syringe exchange programs and one without, researchers found eight times more improperly disposed syringes in the city without exchange programs. Another study looked at the prevalence of used needles in Miami, Florida before and after the implementation of syringe exchange programs and found a 49 percent reduction after the exchange programs began.

Many law enforcement officers also support syringe exchanges because needlestick injuries on the job are not uncommon for them. In a 2014 survey of North Carolina law enforcement officers, the majority said that contracting HIV on the job from used needles was a big concern for them and that they believed needle exchanges would be good for the community and law enforcement. Syringe exchange programs have been shown to reduce these incidents among law enforcement, reducing their risk of exposure to HIV or hepatitis C.

Spokesmen for the NC Sheriffs’ Association and NC Association of Chiefs of Police told NC Health News via email that they do not have a position on Senate Bill 607. However, North Carolina law enforcement agencies put their support behind the original bill that legalized syringe exchanges in 2016.

Advocates push back

Bennett said the NC Harm Reduction Coalition has been trying to build and expand its linkage to care program. They opened a health hub in Wilmington that offers classes and more support for people who use drugs, as well as a food bank in Raleigh, he said.

He added that retention rates for treatment are already low, and in light of that, forcing more people into treatment who don’t have a desire to go won’t lead to better outcomes.

“What’s even more insane is the fact that this General Assembly won’t pass Medicaid expansion, but yet want all these people to go to treatment,” he said. “I don’t understand how that’s going to be paid for.”

A recent analysis by Health Affairs shows people who use drugs are referred to substance use treatment much more frequently in states that expanded Medicaid.

Data and graphic courtesy of Health Affairs

Bennett said there is no way to make Senate Bill 607 good legislation, and that he will make no concessions. He and others in the harm reduction community are nervously watching a similar bill move through the West Virginia legislature.

“We feel like if it gets too watered down or convoluted it could be more dangerous, they might get Democrats to sign on and it would be harder to veto,” he said.

Bennett said he believes Gov. Roy Cooper would veto Senate Bill 607 as written.

handcuffs against a black background, which many county sherrifs departments use for transporting psychiatric patients

Despite pitfalls, counties leave psych patient transport in sheriffs’ hands

March 23, 2021 by Taylor Knopf

Despite pitfalls, counties leave psych patient transport in sheriffs’ hands - North Carolina Health News

When given the chance to rethink police involvement in responding to people in mental health crisis, most counties maintained the status quo. This is the third part in an occasional series examining the consequences of North Carolina’s increased use of forced psychiatric treatment.

By Taylor Knopf

It’s common for law enforcement officers to respond to people in mental health crises. Desperate family members often call 911 if they believe a loved one is at risk of harming themselves. If a patient expresses suicidal intent, health professionals will sometimes call for the police assistance.

And in North Carolina, sheriffs’ deputies are responsible for transporting psychiatric patients — often in shackles — when they need to go from one hospital to another for forced treatment.

This process, known as involuntary commitment (IVC), is the legal means by which a layperson or medical professional asks a judge to order mental health or substance use treatment for an individual against their will. It’s supposed to be used as a last resort when a person is an immediate “danger to themselves or others.”

Nonetheless, a group of advocates compiled data from across the state and found that involuntary commitments increased by 91 percent over a decade, far outpacing the state’s population growth. A recent national study also found that the rate of involuntary commitment is climbing three times faster than the population growth in 25 states for which IVC data is available.

This is the case, despite the fact that transporting patients in a fragile state of psychiatric crisis in handcuffs by police is widely criticized by mental health advocates. They argue the practice can be traumatic and stigmatizing for patients.

In the wake of protests around policing that rocked the U.S. last summer, the use of law enforcement to respond to mental health crises is being questioned across the country. Advocates are asking if there are other agencies better suited for these roles in the mental health system.

For their part, law enforcement leaders say that transporting IVC patients takes officers off of other duties, sometimes for hours, as they drive across the state to a psychiatric hospital. It can put a strain on smaller departments with fewer resources.

Read other stories in this series:
More NC psych patients are ending up handcuffed in a police car. Why?

NC didn’t track the data on mental health commitments, so some advocates did it instead.

State lawmakers on both sides of the aisle agree that the current practice of shackling mental health patients for transport needs to change. North Carolina counties were given the chance to rethink police transport of psychiatric patients in response to a law that went into effect in 2019. However, the majority of counties opted for minimal to no reform.

The transportation dilemma

As an increasing number of mental health patients wait in emergency rooms, hospitals search the state to find inpatient psychiatric care for them. In 2020, state data shows the average patient waited more than a week in the emergency room for a psychiatric hospital bed. Unfortunately, long waits like these have been common in North Carolina for more than a decade.

As a result, more patients have been involuntarily committed and moved across counties to available beds. Advocates claim that a breakdown in preventive and community mental health services has resulted in more people being committed, which is supposed to be used as a last resort option, not as the standard of care.

In 2018, lawmakers passed Senate Bill 630 which was intended to change North Carolina’s IVC law and reduce the number of people languishing in emergency departments. The new law required behavioral health management organizations (LME-MCOs) to work with the counties they cover to create community crisis plans, which include transportation of IVC patients. The law went into effect in 2019.

“I think we all agreed that current use of law enforcement to transport patients was suboptimal, and in effect criminalizing the involuntary commitment process,” said Duke University Psychiatry Professor Marvin Swartz, who was part of a work group brought together by the North Carolina Healthcare Association to help write the bill.

“Now in light of rethinking police response to mental health and other kinds of problems, this is really much more obvious,” Swartz explained. He said using sheriffs’ deputies to transport patients is “really only a matter of convenience. It’s not free to transport patients by law enforcement. It’s just cost shifting.”

By law, counties are responsible for providing transportation for IVC patients. It is also legal for a loved one to transport an IVC patient to an available psych bed. However, many times medical institutions are not comfortable with the liability risk of putting a patient in a private vehicle. They want secure transportation.

“Everybody is so risk averse, they won’t think about the human consequences,” Swartz said. “We were hoping in asking those counties to redo their crisis plans that they would rethink this and look at some of the options.”

Rethinking transportation for IVC patients

As a result of Senate Bill 630, a handful of counties did make changes to the way they transport IVC patients. But of the 60 county transportation plans NC Health News examined, the overwhelming majority will continue only using law enforcement to transport these vulnerable patients.

A few counties — such as Mecklenburg, Wake and Forsyth — are using a combination of law enforcement and a private contracted company to transport their mental health patients to a psychiatric bed. Guildford County’s plan included a combination of law enforcement and EMS personnel for transporting patients.

A significant number of county plans included efforts to destigmatize law enforcement transports, such as encouraging officers to dress in plain clothes, to use unmarked vehicles and to remind patients that they are not under arrest. Many said they would refrain from handcuffing patients under the age of 10. Several plans encouraged same gender transports, meaning female officers would drive female patients.

However, a couple counties lumped jail inmates and mental health patients together in outlining their transportation plans.

“Senate Bill 630… made it very clear that it is perfectly legal in North Carolina to transport individuals under IVC with entities other than law enforcement,” said Carrie Brown, chief medical officer for behavioral health at the NC Department of Health and Human Services.

Brown noted that the creation of these crisis and transportation plans forced conversations and collaboration between agencies and officials who might not have been communicating regularly, such as LME-MCOs, law enforcement, hospital officials and magistrates.

Officials from Vaya Health, the LME-MCO covering 22 counties in the far western part of the state, said their groups had “lengthy discussions about IVC transportation and the likelihood of options other than law enforcement transport,” according to the agency’s report on community crisis plans.

Right now, law enforcement does almost all IVC transportation in Vaya’s catchment area. A few counties are exploring other options for the future. Vaya officials wrote that sheriffs’ deputies must sometimes drive patients six or more hours to their next hospital bed.

When the patient is eventually discharged, law enforcement is also responsible for their return trip home, Vaya officials wrote.

North Carolina Sheriffs’ Association spokesman Eddie Caldwell said this is an issue for sheriffs across the state.

“We’ve heard stories of people from the far west having to take people down east to Cherry Hospital [in Goldsboro], and people from the east have to take people to the hospital in Morganton,” he said. “The availability of beds is an issue.”

Vaya officials wrote that these long trips contribute to the greatest strain on manpower and cost for law enforcement.

“This responsibility is cited among law enforcement across the focus groups as a duty that could be provided by non-law enforcement entities, if safety and liability issues arising in such situations are adequately addressed,” Vaya officials concluded in their report.

More trainings, health screenings

Under the updated crisis and transportation plans, LME-MCOs pushed counties to require Crisis Intervention Training and/or mental health first aid training for their officers and any personnel from contracted transportation agencies.

CIT is a specialized, weeklong training program that gives law enforcement officers tools to work with people in mental health crises. Officers learn techniques to de-escalate tense situations and appropriate methods of getting people to treatment, rather than jail. Likewise, mental health first aid is a training program that gives people basic skills and strategies to help someone in both crisis and non-crisis situations.

Cardinal Innovations included special offerings of these trainings for magistrates, officers and other transport providers.

When asked how many sheriffs deputies have completed CIT training, Caldwell said the association doesn’t keep track. He added that while CIT training is important, pulling officers off duty for any kind of training can be challenging.

When Senate Bill 630 went into effect in 2019, it allowed DHHS to create more IVC training programs for the additional health workers who were enabled by the law to do first examinations of mental health patients, such as social workers, physician assistants and certain nurse practitioners. In order to uphold an IVC petition, a health provider must examine the patient and determine that an IVC is necessary.

The new law also included the creation of a screening tool for the first examination to help health providers direct patients to proper care. It includes a flow chart to help determine if the patient’s symptoms are the result of a behavioral health issue, physical issue or a combination of both.

For example, someone with an intellectual or developmental disability might not be able to fully verbalize the pain from a urinary tract infection, constipation or a toothache. This tool and training aims to prevent that patient from being committed to a psychiatric hospital due to an acute health problem.

“One of the major concerns is someone that actually is either having a physical health crisis that is masquerading as a behavioral health crisis or is having both the behavioral health crisis and a physical health crisis simultaneously,” Brown said. “It’s just so crucial that you’re able to identify both of those.”

Lawmakers criticize shackling of patients

Several state lawmakers agreed that more needs to be done to improve the IVC process and detangle the mental health system from the law enforcement.

Rep. Graig Meyer (D-Hillsborough), who is a social worker who has assisted police in de-escalating mental health crises, told NC Health News that he consistently hears from unhappy constituents about IVC transportation.

“Most people are really shocked when they learn that their loved one — especially a minor — is going to be handcuffed for transport,” he said. “And they’re also just generally shocked at how little role parents and family members play once someone has been involuntarily committed.”

Meyer said it’s a tricky situation because sheriffs need to provide security and safety, but he said he understands why patients and their families are frustrated that there isn’t “more individualization.”

“There’s common ground between police and justice advocates and mental health advocates in that none of those groups want police officers to be mental health workers,” Meyer said. “We really need to be thinking about how we respond to community mental health crises and ways to do that only with law enforcement support where absolutely necessary.”

In an interview with NC Health News, Rep. Verla Insko (D-Chapel Hill) said she thinks shackling young mental health patients should be illegal.

“The idea of putting a 5-year-old in shackles is just obnoxious,” Insko said, adding that she’s found nothing in the law that requires shackling.

The problem of rising psychiatric hospitalization comes back to a lack of community resources and a shortage of providers and insurance options, she said. Insko added that North Carolina has never properly invested in community mental health.

“If your first step breaks down, then you are going to use your second or third step,” Insko said. “We’re hurting ourselves putting people in institutions and having them go through these traumatic experiences. It makes them worse, not better. And so we end up with more and more people in prison, and we end up with more and more people in institutions.”

Rep. Marcia Morey (D-Durham), a former District Court judge, said she’s presided over many IVC hearings where patients are in full shackles in her courtroom.

“I think we need to keep safety in mind, but there’s often ways to do this without the extraordinary means of shackling,” Morey said during a discussion on involuntary commitment during the annual Legislative Breakfast on Mental Health in January. (NC Health News was a media sponsor for this event and NC Health News editor Rose Hoban moderated a legislative panel during the event.)

Morey said the health system should look into the least restrictive way for people to move through an involuntary commitment, while transporting patients as little as possible. The COVID-19 pandemic has shown society just how much can be accomplished virtually, she said.

“If you’ve never either been in handcuffs or had a family member in handcuffs, that’s traumatizing for a person that is completely without any type of mental health issues,” said Rep. Robert Reives (D-Sanford) during the breakfast.

If specialized, trained teams were used instead of law enforcement, there would be less need for shackling of mental health patients, he said.

The issues around mental health crisis care have only worsened during the pandemic, Rep. Carla Cunningham (D-Charlotte) added.

“During COVID, we’ve had people laying on the floors within triage facilities. We’ve had them lined up outside waiting to get in because they need emergency health services for a mental health issue that’s going on,” she said. “We’re in a crisis, but we’ve got to invest in it going forward because we were already in crisis before.”

Sen. Jim Burgin (R-Angiers) told others at the breakfast how troubled he was to receive a call from a constituent whose child with a mental health issue had been handcuffed to a bed for three days.

“We don’t need to do things like that,” he said. “Taking someone who’s having a mental episode and restraining them is never good.”

Rep. Pat Hurley (R-Asheboro) suggested the formation of a legislative mental health caucus to examine problems such as IVC transportations. Those watching the virtual discussion on Zoom applauded her proposal.

Shows a woman during the pandemic in a surgical mask and hospital scrubs using soap and water to scrub her arms.

‘Why do I put my life on the line?’ Pandemic trauma haunts health workers

March 21, 2021 by Pew Trusts

‘Why do I put my life on the line?’ Pandemic trauma haunts health workers - North Carolina Health News

Nationwide, an increasing number of health care workers are experiencing mental health symptoms related to the trauma of caring for COVID-19 patients.

By Christine Vestal

Stateline

Brittany Bankhead-Kendall, 34, was a newly minted surgeon when the COVID-19 pandemic began. At first, like thousands of other health care professionals, she worked tirelessly in crisis mode.

But by last fall, she was experiencing random and repeated physiological symptoms, including a racing heart and dimmed vision. She diagnosed herself as suffering from post-traumatic stress disorder.

The worst of the pandemic may be behind the country. But for frontline health workers such as Bankhead-Kendall, the psychological scars from the chaos and uncertainty they’ve lived through, and the suffering and death they’ve witnessed, may take much longer to heal.

Health care workers across the country say they feel underappreciated by their employers and disillusioned with the medical profession, according to ongoing research at the University of Washington in Seattle.

More than half of the 300-plus doctors, nurses and other frontline health workers who participated in the study said the pandemic has decreased the likelihood they will remain in their profession.

Nationwide, psychiatrists who specialize in trauma-related mental conditions say they’re seeing increasing numbers of health professionals with work-related depression, anxiety, post-traumatic stress disorder, substance use disorders and insomnia—and they expect to see even more in the months ahead.

A provision aimed at addressing the mental distress of health care workers is included in the $1.9 trillion COVID-19 relief package President Joe Biden signed last week. Named for Dr. Lorna Breen, an emergency physician who died by suicide after caring for COVID-19 patients in New York City at the height of the first surge, the initiative will provide $40 million in grants providers can use to promote mental and behavioral health among their workers.

The provision also includes $80 million to train health care and public safety professionals in strategies to reduce suicide, burnout and mental and behavioral health conditions, and $20 million for a federal Centers for Disease Control and Prevention awareness campaign to encourage health care workers and first responders to seek treatment for their own behavioral health concerns and identify and respond to risk factors in themselves and others.

Bankhead-Kendall took a brief break from the hospital and her home life, went to a wellness retreat, and said in a recent interview with Stateline that she feels replenished. She’s back at her post as a trauma surgeon at Texas Tech University Medical Center in Lubbock. And as an associate professor at the university, she says she encourages the resident physicians she works with to take time off if they need it.

“When I see that look in their eyes, I tell them, ‘It’s okay to feel that it’s not okay,’” she said.

On the edge

Before the pandemic, one doctor died by suicide every day in the United States, the highest rate of any profession including the military and twice the rate of the general population, according to a review of research presented at the 2018 annual meeting of the American Psychiatric Association. Part of the reason, researchers found, was untreated depression. According to data from the American Foundation for Suicide Prevention, 28 percent of medical residents experience a major depressive episode compared with 7 percent to 8 percent of similarly aged people in the general population.

“Health care workers already were on the edge of burnout and exhaustion before the pandemic,” said Dr. Megan Ranney, an emergency physician and public health professor at Brown University in Rhode Island. “Now, many of us are physically and emotionally exhausted. We’ve never seen as much consistent death and hopelessness as we have in the past year.”

But that’s only part of it, Ranney said. “There’s also a feeling that the system has failed us and our patients. With the lack of personal protective equipment in the early months, it felt like we were being asked to go out and sacrifice ourselves.”

Those feelings of disillusionment and abandonment were compounded, Ranney said, by political divisions over COVID-19 data and the refusal by many Americans to comply with public health restrictions. On top of that, pandemic-related financial problems in the medical industry forced layoffs, pay cuts and the closure of many rural and safety net hospitals.

“All of that together has created a sense of moral injury that goes beyond depression and exhaustion,” Ranney said. “Many of us are asking, why do I put my life on the line, deal with death and dying every day and feel I can never do what I want to for my patients? Why would I do that to myself?”

A woman with redness in her face is looking at the camera — A Vidant Health nurse takes her mask off after a long hospital shift. Photo credit: Vidant Health

During the pandemic, nearly one-quarter of all health care workers surveyed by researchers at Yale University reported signs of probable post-traumatic stress disorder and 43 percent had probable alcohol use disorder, according to a study published in February.

Psychiatrists interviewed by Stateline said they anticipate that even more health care workers will experience mental and behavioral health symptoms related to the pandemic in the coming months, and they expect many to seek treatment.

“The invisible wounds don’t show up until after you come off the battlefield,” said Dr. Christopher Bundy, a professor of clinical psychiatry at the University of Washington and president of the Federation of State Physician Health Programs. “Once the war is over with COVID, that’s when health care workers are going to start showing up with their mental health concerns.”

Trauma and repetition

For Bankhead-Kendall, a Texas native who moved to Boston in 2019 for a one-year fellowship at Massachusetts General Hospital, the symptoms of her post-traumatic stress disorder didn’t emerge until months after her first stint in a COVID-19 ward.

Instead of honing her surgical skills, Bankhead-Kendall was enlisted to care for the critically ill COVID-19 patients who kept streaming into the hospital after the virus slammed Massachusetts and other Northeastern states early in the pandemic.

“I could see the fear in their eyes. They were dying and none of us knew how to treat them,” she said.

After Massachusetts schools shut down, she spent her time off helping her sons with remote learning and reading everything she could to understand how to treat the new virus.

Since her husband was also working as an emergency physician treating COVID-19 patients, the couple decided to send their children back to Texas for four months to live with their grandparents.

“I got through it,” she said. “In surgery training, we’re taught to just move on and power through. So, I did.”

By the summer, Boston’s surge had eased and Bankhead-Kendall’s fellowship had ended, and she prepared to return to Texas with her husband to start her first job at the Texas Tech University Health Sciences Center.

As Bankhead-Kendall settled in Texas in the fall, her home state and much of the rest of the Southwest was hit hard by COVID-19. “Here I am in a new job and I think I’ve gotten through the COVID demons during my fellowship. But I didn’t really have a chance to recover over the summer. And that’s when it hit me,” she said.

“As soon as I walked through the doors of the COVID unit in Texas and saw people dressed in those white bunny suits (protective gear), my heart started racing and my eyes glazed over,” she said. “I just couldn’t face it again.”

During her wellness retreat, Bankhead-Kendall said she read a couple of books about post-traumatic stress disorder and learned that the set of symptoms she had been suffering is often triggered when a person is subjected to repeated trauma with no way to escape. “It was that repetition, day after day after day, that got to me,” she said.

“And then, just walking into another COVID ward set off a powerful visceral reaction.”

Seeking help

Health care professionals are trained to see themselves as self-reliant. But even for those who recognize their own mental distress, finding a trusted mental health professional is not easy.

Barriers to mental health care for medical workers are worsened by concerns that their professional licenses could be revoked if they seek mental health or substance use treatment. In fact, many state medical license applications include a question about past mental or behavioral health conditions, and sometimes the answers to those questions have professional consequences.

Dr. Jessica Gold, a clinical psychiatrist and professor at Washington University School of Medicine in St. Louis, said penalizing doctors for mental health issues “is not legal, but they do it anyway.” Health care professionals who deal with high-stress, high-stakes, life-and-death issues every day arguably need mental health services more than most people, she said.

On top of their professional concerns, health workers have had to worry about their personal safety and that of their households. As a result, many have chosen to live separately from their families, Gold said. “On top of all that, like everyone else, many of us in health care have lost colleagues, friends and family to COVID. We still haven’t had time to breathe and deal with that grief.”

“Trauma doesn’t follow a straight line,” Gold added. “It’s not like, ‘Oh, the pandemic’s over, we’re all good.’ The emotional wounds will still be coming out months and years from now.”

At the University of Washington, Dr. Rebecca Hendrickson, a clinical psychiatrist and lead researcher on the school’s health care worker study, said the correlation between the intensity of COVID-related care and the severity of mental health symptoms echoed studies of veterans’ mental health.

“What was striking to me was that the level of distress in health care workers was quite similar to what I’m used to seeing from combat veterans.”

Psych nurses want freedom from old law putting their practices at risk

March 17, 2021 by Taylor Knopf

Psych nurses want freedom from old law putting their practices at risk - North Carolina Health News

Psychiatric nurse practitioners are helping fill the huge gaps in mental health care across the state. But North Carolina’s law tying them to a physician has put some of their practices and patients in jeopardy.

By Taylor Knopf

Olehonna Lynch started Pembroke Center for Wellness in 2010 because she wanted people in her home community to receive the best mental health care possible.

Lynch, a psychiatric nurse practitioner, said that before she started her practice the residents of Robeson County waited up to three months for an outpatient psychiatric appointment. When people can’t get help for their mental health issues in the community, they often end up in an emergency room in crisis.

Once they are stabilized, those patients return back home to again wait weeks for an outpatient follow-up appointment.

In contrast, Lynch said she can get a new patient in to see her in less than a week.

“It came down to one of those things where if you want it done right, do it yourself,” she said. “So that’s what I ended up doing. I realized there weren’t many options besides working at the hospital.”

Lynch has a background as a family nurse practitioner and later got her post-master’s certification in psychiatry because she said there was such a “huge need.” Lynch is the owner of her practice where she sees 80 to 100 patients a week and employees an individual and family therapist.

But her practice is tied to a psychiatrist who acts as her “supervisor.”

A North Carolina law passed in the 1970s requires advanced nurse practitioners to have a “collaborative agreement” with an overseeing physician. Essentially, Lynch pays $500 per month for that psychiatrist’s signature twice a year. The supervising physician doesn’t need to approve any treatment decisions or medications for Lynch’s patients. The physician doesn’t even need to be in the same building, or the same city or even the same county.

“I try to utilize her expertise more so that it’s not just a signature,” Lynch said. “If I have a difficult case, I will set up an appointment for my patient to meet with her for a second opinion. So I try to get more out of the collaborative agreement than just a signature and exchange of money.”

Lynch’s supervising psychiatrist works for Veterans Affairs at the local hospital and is planning to retire soon. When she stops practicing, the only psychiatrist in Robeson County — a county with 130,000 people — will be gone.

Unfortunately, this is not uncommon in North Carolina. In 2017, the Sheps Center for Health Services Research at the University of North Carolina found that 10 counties have no psychiatrists and 28 counties have less than the equivalent of one full-time psychiatrist per 10,000 people.

The retirement of Lynch’s collaborating psychiatrist also puts Lynch’s practice in jeopardy. Unless the law changes this legislative session, Lynch must have a supervisor to continue running her practice.

The SAVE Act

A bipartisan group of lawmakers has been trying for several years to pass a bill called the SAVE Act to remove that collaborative agreement requirement and allow advanced nurse practitioners to practice in North Carolina with more autonomy.

If the SAVE Act passes, Lynch said she will continue to collaborate with mental health professionals as needed. She said as it is, she consults other medical specialists regularly. Lynch said other advanced nurse practitioners contact her interested in starting their own practices, wanting to learn more about how to do it.

But the collaborative agreement requirement does deter some from moving forward, she said.

Healthier patients, cost savings

If lawmakers would have passed the SAVE Act in 2019, North Carolina could have already saved at least $866 million in health care expenses, argued Sen. Joyce Krawiec (R-Kernersville).

“We can cut costs without cutting corners, and that’s what this bill does in a very effective way. Most bills that are introduced in these chambers usually cost a lot of money,” Krawiec said. “This legislation costs the citizens of North Carolina nothing and the benefits will be staggering.”

The North Carolina Nursing Association cited a 2015 study from the Duke University Center for Health Policy and Inequalities Research which concluded that removing barriers such as the physician supervision requirement would save the state “between $433 million and $4.3 billion per year while creating more than 3,800 jobs.”

“This is an opportunity to lessen the impact of physician shortages without compromising quality of health care,” said Sen. Jim Burgin (R-Angier). “Modernizing regulations is an important part of an evolving health care system.”

Rep. Gale Adcock (D-Wake), the only advanced practice registered nurse in the General Assembly, said the health outcomes of advanced nurse practitioners’ patients are “as good and sometimes better” than their physician colleagues.

Rep. Gale Adcock_2021 — Rep. Gale Adcock, the legislature’s only advanced practice nurse, during a 2021 press conference introducing the SAVE Act. Photo credit Taylor Knopf

“We intend to continue to work with our physician colleagues as true colleagues interdependently as all health care providers do,” said Adcock, who has been a practitioner for 34 years. She just retired from a job where she actually was the boss to the physicians who were her supervisors.

The state is in the middle of transitioning the Medicaid program from one where reimbursement comes for every visit, test and procedure to one where providers get paid a lump sum to deliver more value and healthier patients.

Patient outcomes will be one of the key benchmarks for measuring how well providers are doing.

“You’re paying for how healthy your patient is, and that is not just how healthy is your healthiest patient, but how healthy is your sick patient,” Adcock said. “Advanced practice registered nurses bring a lot of bang for the buck. Because we keep people out of the hospital, we keep them in their homes and out of nursing homes.”

They also tend to be less costly to employ than physicians.

Adcock said that 23 other states and the District of Columbia have allowed their advanced nurse practitioners more autonomy, “and their citizens have not suffered from it.” And no state has reversed that decision, she added.

Mental health provider shortage

Dona Francis is a psychiatric nurse practitioner who runs a mental health practice in Sunset Beach where she sees around 100 patients a week. Right now, she has a big dilemma. The 69-year-old wants to retire but cannot find someone to take over her practice. She says the collaborative agreement requirement is a contributing factor.

Francis’ supervising psychiatrist lives in the Charlotte area, and there are no psychiatrists practicing in Brunswick County. Francis is the only mental health provider in her county of 142,000 residents. The closest psychiatrist is in Wilmington, and the wait for an appointment is at least a month, she said. Many of her clients in Sunset Beach are older and do not want to travel that far.

“A lot of people don’t want to have to go an hour away when they’re already dealing with anxiety and depression,” Francis said. “And COVID has added another layer to that. They feel isolated being unable to see their family, children and grandchildren. Anxiety and depression has increased tenfold from where it was a year ago.”

She’s received a lot of new patients during the pandemic and said she gets new referrals every week. Francis said primary care providers don’t feel comfortable treating a psychiatric diagnosis, and they often don’t feel qualified or have time to do talk therapy with a patient.

“They have people for 15 minutes in their office and they’re out,” Francis said. “They don’t have an hour to sit with someone, help them process what’s going on, deal with their grief or help them with coping skills.”

Francis has been actively talking to nursing schools in the state in a quest to find her replacement. But she said graduating psychiatric nurse practitioners struggle to find a collaborating psychiatrist.

As she continues to search, Francis said she feels like she has an “ethical responsibility to stay the course, until I can get someone here.”

a boy smiles at his ABA therapy counselor

“I can sleep better tonight.” New priority for people with disabilities.

March 3, 2021 by Rose Hoban

“I can sleep better tonight.” New priority for people with disabilities. - North Carolina Health News

Families and advocates are cheering the decision to bump up vaccine priority for people with disabilities.

By Rose Hoban

Linda Guzman has been lying awake nights, worried about her son JJ, a young man in his twenties who has autism.

“It could be catastrophic for JJ if he contracted the virus with all his other health issues,” Guzman wrote in an email to John Nash, head of The Arc of North Carolina, an organization that provides services and advocacy for people with intellectual and developmental disabilities.

“I have done my best to protect him, but the stress and anxiety of doing so have been overwhelming at times,” the Chapel Hill mother wrote. She gave Nash permission to share her email with NC Health News.

Nash received the email around 5 p.m. on Tuesday, after Mandy Cohen, the secretary of the state Department of Health and Human Services, announced that people with intellectual and developmental disabilities would be given higher priority for receiving COVID vaccines. With the addition of the new Johnson & Johnson one-shot vaccine to the arsenal of weapons to fight COVID-19 this week, North Carolina is opening up vaccination opportunities to more people.

Nash and other advocates for people with disabilities have been pressing for this policy change for weeks.

“For me, this is such a relief,” Nash said. “I spent the last several months now, since December, really trying to put this together trying to get enough momentum to be able to be heard.”

Now, after sitting down with DHHS officials and laying out the case, the advocacy has paid off.

“As a historically marginalized population, the I/DD community has long struggled for recognition, understanding, and support, and we greatly appreciate this step to bring us closer to parity with our fellow North Carolinians,” Nash wrote in a statement sent to people on The Arc’s contact list.

‘An important priority group’

At a press conference on Tuesday afternoon, Cohen said that so-called Group 1 vaccine recipients will be expanded from just including health care personnel and residents of nursing homes to include those who have been receiving home and community-based services for more than 30 days. This sweeps in people who have disabilities who receive their care at home.

“This includes home and community-based services for persons with intellectual and developmental disability, private duty nursing, personal care services, home health and hospice,” Cohen said.

But many people with disabilities don’t get formal services, and there are at least 12,000 people with intellectual and developmental disabilities in North Carolina who are languishing on a years-long waiting list for Medicaid-funded services. Instead, those people often receive care from family members, friends and people paid privately to take the burden of care off of aging parents and siblings.

“In addition for group four, we’ve clarified that higher risk medical conditions include intellectual and developmental disabilities such as Down syndrome and neurological conditions such as dementia,” Cohen said on Thursday.

“This is an important priority group,” said Julia Adams, who lobbies on behalf of people with disabilities at the General Assembly. “Many individuals with disabilities are living at home, are being cared for by either paid or unpaid caregivers.”

While some of those caregivers, in particular older parents of some people with disabilities, have already received vaccines, Adams said, there are still significant gaps that leave people with disabilities at risk.

“You’re only maybe vaccinating one other person in that house, you still may have kids in that house, you may have neighbors in that house who are coming in who have not been in a vaccination priority pool yet,” she said.

More exposure, more risk

It’s hard to know just how many people will benefit from this policy change, just as it’s hard to know how many people with disabilities have died from COVID in the past year.

North Carolina does not include disability status in its data collection about people who are getting vaccinations and there’s little data about people with disabilities who have been among the more than 11,288 North Carolinians who have died from the coronavirus. That’s in contrast to some other states, such as California, which have been collecting information on disability status, along with data such as age, gender, race, ethnicity and some pre-existing conditions.

But Nash said that the science has become clear that people with disabilities, particularly those with intellectual and developmental disabilities, are at increased risk of contracting and dying of COVID-19.

“Every couple of days, somebody comes out with some study that says people with (intellectual and developmental disabilities) are at greater risk,” said Jennifer Mahan, director of public policy with the Autism Society of North Carolina. “Yes, they’re a greater risk because many of them live in some kind of group setting for different kinds of group settings, but some kind of group setting. But they’re also more at risk because they have underlying physical and genetic conditions, some of which we don’t even know about.”

She also said that many of these people are simply exposed to more workers, more family members, more caregivers – more people – because of their conditions.

“It would be the same if you had any other condition that requires somebody to come in your home and take care of you, or provide some kind of support for you to be able to live,” Mahan said.

According to an analysis done last fall by researchers from the Johns Hopkins University School of Medicine and a private consulting firm, people with disabilities were found to be about three times more likely to die from COVID-19 if they were developmentally or intellectually disabled than people without comorbidities. Those were even higher odds for death than for people with Alzheimer’s disease, cancer or kidney disease. Those people with mobility impairments were even more likely to die from COVID than people with heart failure, spinal cord injury or liver disease.

Nash said his agency provides a lot of guardianship services for people with disabilities and those guardians have seen too many deaths from COVID.

“When somebody passes, we do a pretty healthy review of what went on to make sure that everything handled was handled the way it was supposed to and that there weren’t things that shouldn’t have happened,” Nash said. “And just in the last two months, we’ve done probably a dozen COVID deaths.

“Those are so hard because the staff that works with that individual, they get close to the person,” he said. Nash noted that one of his staff members had two guardians die within a two-week period. “It’s just devastating.”

bar graph shows high risk for death from COVID for people disabilities. — COVID-19 patients across all age groups had greater odds of dying if they had any of the 15 comorbidities shown for the patients studied from April – August, 2020. Data were adjusted for age and gender. Data, graph courtesy: Risk Factors for COVID-19 Mortality among Privately Insured Patients, A FAIR Health White Paper in Collaboration with the West Health Institute and Marty Makary, MD, MPH, from Johns Hopkins University School of Medicine, Nov. 2020.

A recent analysis from the Kaiser Family Foundation notes North Carolina is among the states that does not separately list deaths from COVID among people with disabilities. Before Tuesday, the state’s vaccination plan did not specifically prioritize these people, other than noting higher priority for people with “high-risk medical conditions.”

The KFF analysis notes that the high-risk medical conditions group does not always put nonelderly people with disabilities who receive direct care services on an equal footing with people who live in nursing homes or other congregate settings.

“As of early February there had been 111,000 cases and 6,500 deaths from COVID-19 across 31 states that report data in settings such as group homes, personal care homes, adult day care programs, as well as in institutional settings such as intermediate care facilities and psychiatric institutions,” reads a press release from KFF about their data analysis.

The analysis also notes that few state vaccination plans have specifically mentioned direct care workers who provide long-term services in settings other than nursing homes, such as homes and in group homes, according to a different data set compiled by researchers from Johns Hopkins University. Until now, North Carolina has not explicitly mentioned people with disabilities who live in home- and community-based settings in the vaccination plan.

“Statewide, the number of people who are now eligible has grown exponentially,” Guzman wrote to Nash. “I am thinking there are thousands of families right now, crying tears of joy as I am.”

Guzman’s son is scheduled to receive a vaccine on Thursday, March 4.

Additional Thanks

Categories

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