Why COVID-19 is killing U.S. diabetes patients at alarming rates

By Chad Terhune, Deborah J. Nelson and Robin Respaut

(Reuters) – Devon Brumfield could hear her father gasping for breath on the phone.

Darrell Cager Sr., 64, had diabetes. So his youngest daughter urged him to seek care. The next day, he collapsed and died in his New Orleans home.

The daughter soon learned the cause: acute respiratory distress from COVID-19. His death certificate noted diabetes as an underlying condition. Brumfield, who lives in Texas and also has type 2 diabetes, is “terrified” she could be next.

“I’m thinking, Lord, this could happen to me,” she said of her father’s death in late March.

She has good reason to fear. As U.S. outbreaks surge, a new government study shows that nearly 40% of people who have died with COVID-19 had diabetes.

Among deaths of those under 65, half had the chronic condition. The U.S. Centers for Disease Control and Prevention analyzed more than 10,000 deaths in 15 states and New York City from February to May.

Jonathan Wortham, a CDC epidemiologist who led the study, called the findings “extremely striking,” with serious implications for those with diabetes and their loved ones.

A separate Reuters survey of states found a similarly high rate of diabetes among people dying from COVID-19 in 12 states and the District of Columbia.

Ten states, including California, Arizona and Michigan, said they weren’t yet reporting diabetes and other underlying conditions, and the rest did not respond – rendering an incomplete picture for policymakers and clinicians struggling to protect those most at-risk.

America’s mortality rates from diabetes have been climbing since 2009 and exceed most other industrialized nations. Blacks and Latinos suffer from diabetes at higher rates than whites and have disproportionately suffered from COVID-19.

“Diabetes was already a slow-moving pandemic. Now COVID-19 has crashed through like a fast-moving wave,” said Elbert Huang, a professor of medicine and director of the University of Chicago’s Center for Chronic Disease Research and Policy.

Keeping diabetes under control – among the best defenses against COVID-19 – has become difficult as the pandemic disrupts medical care, exercise and healthy eating routines.

The high price of insulin has also forced some people to keep working – risking virus exposure – to afford the essential medicine. And as the country grapples with an economic crisis, millions of Americans have lost their jobs and their employer-sponsored health insurance.

Much of this could have been anticipated and addressed with a more comprehensive, national response, said A. Enrique Caballero, a Harvard Medical School endocrinologist and diabetes researcher.

Top health officials should have done more to emphasize the threat to people with diabetes and assuage their fears of hospital visits, he said, while also focusing more on helping patients manage their condition at home.

Policymakers had ample warning that COVID-19 posed a high risk for diabetes patients. In 2003, during the coronavirus outbreak known as SARS, or Severe Acute Respiratory Syndrome, more than 20% of people who died had diabetes.

In 2009, during the H1N1 flu pandemic, patients with diabetes faced triple the risk of hospitalization.

Most recently in 2012, when the coronavirus Middle East Respiratory Syndrome, or MERS, emerged, one study found 60% of patients who entered intensive care or died had diabetes.

The COVID-19 pandemic, however, has unearthed previously unknown complications because it has lasted longer and infected many more people than earlier coronavirus epidemics, said Charles S. Dela Cruz, a Yale University physician-scientist and Director of the Center of Pulmonary Infection Research and Treatment.

Doctors warn that the coronavirus pandemic may indirectly lead to a spike in diabetes-related complications – more emergency-room visits, amputations, vision loss, kidney disease and dialysis.

“My fear is we will see a tsunami of problems once this is over,” said Andrew Boulton, president of the International Diabetes Federation and a medical professor at the University of Manchester in England.

‘ONE BIG PUZZLE’

Researchers have scrambled for months to unravel the connections between diabetes and the coronavirus, uncovering an array of vulnerabilities.

The virus targets the heart, lung and kidneys, organs already weakened in many diabetes patients. COVID-19 also kills more people who are elderly, obese or have high blood pressure, many of whom also have diabetes, studies show.

On the microscopic level, high glucose and lipid counts in diabetes patients can trigger a “cytokine storm,” when the immune system overreacts, attacking the body. Damaged endothelial cells, which provide a protective lining in blood vessels, can lead to inflammation as white blood cells rush to attack the virus and may cause lethal clots to form, emerging research suggests.

“It’s all one big puzzle,” said Yale’s Dela Cruz. “It’s all interrelated.”

Many of their vulnerabilities can be traced to high blood sugar, which can weaken the immune system or damage vital organs. COVID-19 appears not only to thrive in a high-sugar environment but to exacerbate it. Recent evidence suggests the virus may trigger new cases of diabetes.

David Thrasher, a pulmonologist in Montgomery, Alabama, said up to half of COVID-19 patients in his local hospital ICU have diabetes. “They are often my most challenging patients,” he said, and the immune system response may be a big reason why.

‘DIABETES BELT’

The pandemic has ripped through several southern states with some of the nation’s highest diabetes rates. A Reuters examination of state data found that nearly 40% of COVID-19 deaths were people with diabetes in Alabama, Louisiana, Mississippi, North Carolina, South Carolina and West Virginia. Much of this area lies within what the CDC calls the “diabetes belt.”

Alabama has the highest percentage of adults with diabetes at 13.2%, or more than 550,000 people, CDC data show. Diabetes patients accounted for 38% of the state’s COVID-related deaths through June, officials said. Karen Landers, Alabama’s assistant state health officer, said she is particularly heartbroken at the deaths of diabetes patients in their 30s and 40s.

Medical professionals in these states say they struggle to keep patients’ diabetes under control when regular in-person appointments are canceled or limited because of the pandemic.

Sarah Hunter Frazer, a nurse practitioner at the Medical Outreach Ministries clinic for low-income residents in Montgomery, Alabama, said diabetes is common among her COVID-19 patients. With clinic visits on hold, she stays in touch by phone or video chat. If a problem persists, she insists on an outdoors, face-to-face meeting. “We meet them under a shade tree behind the clinic,” Frazer said.

In similar fashion, doctors at the University of North Carolina stepped up their use of telemedicine to reach at-risk rural patients. Despite those efforts, John Buse, a physician and director of the university’s diabetes center, said he’s certain some foot ulcers and dangerously high blood sugars are being missed because people avoid health facilities for fear of the virus.

‘UNDER CONTROL’

Many diabetes patients with severe or deadly cases of COVID-19 were in good health before contracting the virus.

Clark Osojnicki, 56, of Stillwater, Minnesota, had heard early warnings about the risks of the coronavirus for people with diabetes, said his wife, Kris Osojnicki. But the couple didn’t think the admonitions applied to him because his glucose levels were in a healthy range.

“He was incredibly active,” she said.

On a Sunday in mid-March, Osojnicki jogged alongside his border collie, Sonic, on an agility course for dogs inside a suburban Minneapolis gym. Three days later, Osojnicki developed a fever, then body aches, a cough and shortness of breath. He was soon in the hospital, on a ventilator. Clark, a financial systems analyst, died April 6 from a blood clot in the lungs.

Osojnicki is among 255 recorded deaths in Minnesota of people with COVID-19 and diabetes mentioned on their death certificate as of mid-July, according to state data. The records describe people who died as young as 34.

WORKING FOR INSULIN

For years, the skyrocketing cost of insulin has fueled much of the national outrage over drug prices. Early in the pandemic, the American Diabetes Association asked states to eliminate out-of-pocket costs for insulin and other glucose-lowering medications through state-regulated insurance plans.

But no state has fully followed that advice, the ADA said. Vermont suspended deductibles for preventive medications, like insulin, starting in July. Other states ordered insurers to make prescription refills more available but didn’t address cost.

Robert Washington, 68, knew his diabetes put him at risk from COVID-19. When his employer, Gila River’s Lone Butte Casino in Chandler, Arizona, reopened in May, he decided to keep working as a security guard so he could afford insulin.

Washington’s supervisors had assured him he could patrol alone in a golf cart, said his daughter, Lina. But once back at work, he was stationed at the entrance, where long lines of gamblers waited, most without masks, Robert told his daughter.

“He was terrified at what he saw,” Lina said.

He tested positive for the virus in late May and was admitted to the hospital days later. He died from complications of COVID-19 on June 11, his daughter said.

A week after Washington’s death, the casino again closed as COVID-19 cases exploded in the state. The casino did not respond to a request for comment.

“It’s hard to accept he is gone. I have to stop myself from wanting to call him,” said Lina, a sports anchor and reporter at a Sacramento, California, TV station. “A lot of these deaths were in some way preventable.”

(Reporting by Chad Terhune, Deborah J. Nelson and Robin Respaut; Editing by Brian Thevenot)

U.S. eviction bans are ending. That could worsen the spread of coronavirus

By Michelle Conlin

NEW YORK (Reuters) – Last month, as the coronavirus was surging in Houston, recently unemployed hospital secretary Ramzan Boudoin got more bad news: She had six days to vacate her apartment for failing to pay the rent.

A Texas ban on evictions had enabled Boudoin to keep the two-bedroom place she shared with her daughter and granddaughter while she searched for another job. But that moratorium expired on May 18. The landlord took legal action and Boudoin couldn’t come up with $2,997 plus interest to settle the judgment.

So this month Boudoin, 46, packed her family into a 2008 Nissan compact and headed to New Orleans, where she moved in with her mother and her sister’s family. In all, nine people share the packed three-bedroom house. Bedouin said her mother suffers from chronic obstructive pulmonary disease, or COPD, a lung illness that makes her particularly vulnerable to COVID-19 in a city where cases are rising at an alarming pace.

“Every minute, we are worried someone is going to give it to her,” Boudoin said.

As the coronavirus began to shut down large swaths of the U.S. economy in March, spiraling millions of Americans into unemployment, a patchwork of state and federal eviction bans were enacted to keep people in their homes. Now those protections are vanishing. Moratoriums have already expired in 29 states and are about to lapse in others. On Friday, a federal stay, which protects roughly one-third of American renters who live in buildings with mortgages backed by the federal government, will run out unless Congress acts fast.

As many as 28 million people could be evicted in coming months, according to Emily Benfer, a visiting law professor at Wake Forest University who is the co-creator of Princeton University’s Eviction Lab, a national research center on evictions. That’s nearly triple the estimated 10 million Americans who lost their homes during the years after the 2008 mortgage crisis.

Public health and housing experts say such a massive displacement of renters would be unprecedented in modern history. In addition to the hardship that comes with losing one’s home, they say, the evictions could lead to a second-wave public health crisis as the newly homeless are forced into shelters or tight quarters with relatives, increasing the risk of spread of COVID-19.

Evictions have resumed in cities including Houston, Cincinnati, Columbus, Kansas City, Cleveland and St. Louis, according to data compiled by Princeton University at its Eviction Lab. No single, comprehensive source exists to track U.S. evictions nationwide.

In Milwaukee, eviction filings dropped to nearly zero after Wisconsin instituted an emergency 60-day ban on evictions on March 27. But after that order was lifted May 26, evictions surged past their pre-pandemic levels. Milwaukee recorded 1,966 eviction filings in the seven weeks following the ban’s expiration, an 89% increase from 1,038 notices filed in the seven weeks leading up to the moratorium, the Princeton data show.

Dr. Nasia Safdar, an infectious disease physician and the medical director for infection prevention at the University of Wisconsin School of Medicine and Public Health, said it’s impossible at this point to establish a scientific correlation between evictions and COVID-19 spread and deaths; diagnosed coronavirus cases are up 150% in Milwaukee, for example, since the eviction moratorium ended.

What is not in doubt among public health experts, she said, is that evictions are dangerous during a pandemic. “A key tenet of prevention in a pandemic is to have the infrastructure that will minimize transmission from person to person,” Safdar said. “Any activity that breaks down that structure … makes containment of a pandemic exceedingly difficult.”

A July 17 study from the Federal Reserve Bank of Cleveland found that in 44 U.S. cities and counties, eviction filings by landlords have almost returned to their usual levels in places where moratoriums have expired, or where bans were never enacted.

That study said evicted tenants are “at greater risk of contracting, spreading and suffering complications from COVID-19” because precariously housed people often are unable to shelter in place, and because they tend to use crowded emergency rooms for their primary medical care.

As evictions rise in some coronavirus hot spots, displaced families are doubling up with relatives or moving into shelters, creating conditions for the virus to spread widely, according to Diane Yentel, president of the Washington, D.C.-based National Low Income Housing Coalition, the U.S.’s premiere affordable housing policy group.

“In these cases where social distancing is difficult or impossible, the likelihood of them contracting and spreading coronavirus increases exponentially,” Yentel said.

A fragile safety net is adding to the strain. Enhanced $600 weekly unemployment benefits provided by the federal government are set to evaporate next week, at a time when the national unemployment rate is 13.3%.

Landlords say the pandemic is a crisis for them as well. Bob Pinnegar, CEO of the National Apartment Association, says eviction is always a “last resort,” but “the rental housing industry alone cannot bear the financial burden of the pandemic.”

He said nearly half the country’s landlords are mom-and pop operators who have invested in rental property for retirement income.

COVID POSITIVE, AND FACING EVICTION

For weeks, eviction courts across America were shuttered due to COVID-19. Now, over Zoom, conference calls and even in person in some places, proceedings are ramping up again.

In Houston’s Harris County, more than 5,100 eviction cases have been filed since the virus upended the U.S. economy in March, according to data compiled by Houston-based data science firm January Advisors.

That’s still roughly half of pre-pandemic levels. But it’s worrisome to public health advocates given that Harris County has seen confirmed coronavirus cases jump 500% since Texas’s eviction ban was lifted May 18, the Reuters COVID tracker shows.

Swapnil Agarwal is the 39-year-old founder of Nitya Capital, one of the largest landlords in Texas and owner of the Providence at Champions Apartment Homes from which Boudoin was evicted. During the pandemic, the company has filed more than 120 eviction notices against renters in Houston, a Reuters review of court records found. Houston-based Nitya has $2 billion in real estate assets under management, according to its website.

Agarwal said his firm evicted Boudoin because she was behind on her rent and “we realized that there was no intention to pay,” an allegation she disputes. He said Nitya has gone to great lengths to keep tenants in place and has provided $4 million in rent assistance to those who lost their jobs.

Meanwhile in Milwaukee, Mariah Smith was served an eviction notice on July 1. A shipping clerk for an aircraft parts maker, she lost her job in May. Smith said she hasn’t been able to pay her rent because she never received her $1,200 federal stimulus check and is still waiting to receive unemployment benefits.

Her fortunes have only gotten worse. Smith, 25, last week was diagnosed with coronavirus after experiencing chills, body aches and a sore throat. She said just walking leaves her winded.

On Thursday, she faces a court hearing on her eviction. Nick Homan, an attorney with the Legal Aid Society of Milwaukee, agreed to help. He said he’s handling around 25 eviction cases a week now, more than double his typical load.

After Reuters contacted Smith’s landlord — a limited liability company named LPT 46 — an attorney representing the firm, Marvin Bynum II, said the company just learned of Smith’s COVID diagnosis. “The landlord is hopeful that Ms. Smith recovers soon, and is confident the parties can swiftly reach a mutually amicable resolution,” Bynum said.

Homan said he’ll see what happens Thursday, but the larger issue remains.

“There’s nobody in any position of authority to stop eviction right now,” Homan said. “I don’t see anybody making decisions on public health. I only see landlords making decisions about their finances.”

(Reporting by Michelle Conlin; Editing by Tom Lasseter and Marla Dickerson)

Barbara Bush, wife of ex-President George H.W. Bush, in ‘failing health’

FILE PHOTO: Former first lady Barbara Bush listens to remarks during the christening ceremony of the USS George H.W. Bush at Northrop-Grumman's shipyard in Newport News, Virginia, U.S., October 7, 2006. REUTERS/Kevin Lamarque/File Photo

WASHINGTON (Reuters) – Barbara Bush, the wife of former U.S. President George H.W. Bush, is in “failing health” and has decided to no longer seek medical treatment, the office of the ex-president said in a statement from Houston on Sunday.

The former first lady, who is also the mother of former President George W. Bush, “will instead focus on comfort care,” the statement said. She is 92 years old.

The brief statement did not indicate the nature of Bush’s illness but said that she had had a series of recent hospitalizations.

CNN reported that Bush was suffering from chronic obstructive pulmonary disease (COPD) and congestive heart failure. A Bush family spokesman said she was being cared for at her home. He did not provide information on the nature of her illness.

FILE PHOTO - Former U.S. President George H.W. Bush participates in the coin toss ahead of the start of Super Bowl LI between the New England Patriots and the Atlanta Falcons as former first lady Barbara Bush looks on in Houston , Texas, U.S., February 5, 2017. REUTERS/Adrees La

FILE PHOTO – Former U.S. President George H.W. Bush participates in the coin toss ahead of the start of Super Bowl LI between the New England Patriots and the Atlanta Falcons as former first lady Barbara Bush looks on in Houston , Texas, U.S., February 5, 2017. REUTERS/Adrees Latif

“She is surrounded by a family she adores and appreciates the many kind messages and especially the prayers she is receiving,” the statement added.

As first lady from 1989 until the start of 1993, Bush was a popular national figure known for her sometimes blunt talk and self-deprecating wit.

Her husband, the 41st U.S. president, is 93 years old. Her son, the 43 U.S. president, is 71.

Another son, Jeb, is a former governor of Florida who ran unsuccessfully for president in 2015 and early 2016, quitting after a series of lackluster performances highlighted by tough skirmishes with then-candidate Donald Trump.

White House spokeswoman Sarah Sanders said: “The president’s and first lady’s prayers are with all of the Bush family during this time.”

With hair that had turned white prematurely, Bush was known by family members as the “Silver Fox.”

Her work as first lady focused on promoting literacy and reading. At the time, she said she was more interested in running a household than in helping her husband run the country.

“Barbara Bush has a character that is as big, inspiring and iconic as Texas,” Texas Governor Greg Abbott said in a statement on Sunday. The Bushes moved to Texas in the mid-1940s.

Bush holds a unique place in U.S. history.

She is the only woman to see her husband and son sworn in as U.S. president. Abigail Adams, first lady from 1797 to 1801, was a major influence on husband John Adams, the nation’s second president, but died before her son, John Quincy Adams, was elected president in 1824.

(Reporting by Richard Cowan and Will Dunham; Additional reporting by Jeff Mason; Editing by Sandra Maler)