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Covid-19

    THE CLOTH

    Where Faith Leaders Find Solace

    Humbled by not having answers, they work, garden, and hum

    By

    church
    Stained glass window detail at St. Peter the Apostle Catholic church in Provincetown. (Photo Nancy Bloom)

    PROVINCETOWN — Kate Wilkinson is tired.

    Which is no surprise. Who isn’t? It’s hardly controversial to write that hardly anything is going well right now. (I ask Tom Ryan, former president of the Cape Cod Council of Churches and current chair of its Migrant and Refugee Committee, how he’s coping with this chaos. “Which element of the chaos do you mean, specifically?” Ryan answers.)

    So, like the rest of us, Kate Wilkinson is tired. And? Here’s the point: Kate Wilkinson is not like the rest of us. She’s the Rev. Kate Wilkinson, minister of Provincetown’s Unitarian Universalist Meeting House. That’s not a position that allows for much tiredness.

    To be a faith leader is to be responsible for a community’s hope. “I’m humbled by that task,” says Wilkinson. To be a faith leader is to provide a sense of mission and purpose, to make a community cohere. It’s to build a tribe, to offer up an address for belief. Faith leaders are expected to have answers.

    “People presume that I am more in touch with the sacred texts, with humanity,” says Ryan, a former Catholic priest and former coordinator of the Barnstable County Human Rights Commission. “They presume that I know some of the wisdom of the centuries, the ancient answers.”

    And “goodness me,” says the Rev. Terry Pannell, rector of Provincetown’s Church of St. Mary of the Harbor. “It is incredibly challenging right now.” With worship largely virtual, church leaders moonlight as movie producers and I.T. teams. But the pandemic’s technological challenges affect all kinds of organizations. What’s unique to faith leaders is its emotional toll. Preaching into a video camera, says Wilkinson, is “like preaching into a void — draining.”

    Handshakes, hugs, and hospital visits have flown off the table and onto a screen. “To have a parishioner who has died in a nursing home from Covid and not be able to be with them, for them not to be with their family,” says Pannell, “that’s the most painful thing I’ve had to go through as a member of the clergy.”

    As their communities lean on them for solace and support, where have the leaders themselves turned? And how, amidst all Ryan’s specific elements of chaos this year, have they managed to find meaning? How do they keep, and share, hope?

    Finding Solace

    “I’m digesting all of this along with my people,” says Wilkinson. “I also miss my family and want to run to the store for one thing when I forget it.”

    And Wilkinson’s resident faith leader is, well, Wilkinson. Which means that when it comes time for her to recharge or heal or regain a crumb of sanity, she’s leaned on nature, outdoor visits with friends, and, crucially, her plot at the Wellfleet Community Garden. She’s spent more time there than ever before, last summer growing beans, peas, carrots, Asian greens, beets, radishes, and tomatillos. “I just got my seeds for this year,” she says. “I’m dreaming of getting back to the garden.”

    Ryan and Pannell skip the tomatillos. Ryan’s anchor has been work (“I wish it were exercise”): throwing himself into the Eastham 400 program. He has also found himself humming, especially the refrain of a hymn based on Psalm 91, which he says is “useful for our hearts.” In the refrain, one is carried along: God raises you up to “hold you in the palm of his hand.”

    Pannell meets weekly via Zoom with the 18 other Episcopal clergy of the Cape and Islands. “It’s a place we can talk about our own feelings, struggles, the challenges of being a church while not being in person,” he says. “We’re a family.”

    And centering prayer — meditative, silent prayer, which Pannell has practiced and preached for years — has helped him, too. “Before you can effectively deal with the chaos around you, you first have to deal with the chaos within you,” he says.

    “I’m not someone who thinks everything happens for a reason,” says Wilkinson. “But I do think we can make meaning out of every experience. That’s the task here: not understanding why this happened, what the point of it all was, but making some meaning out of what we’ve all learned personally during this time.”

    There Is Hope

    Ryan has turned to reading the biographies of figures like St. Catherine of Siena, born just as the Black Plague reached Italy in 1347. But reading stories of previous plagues, he says, really makes clear that “there isn’t any one answer. It’s just about holding on, getting through this, groaning through this.”

    Chapter eight of the letter from Paul to the Romans includes a long section about the spirit of God groaning with us. “We’re all groaning, including God, in this act of becoming, in this evolution of our world,” says Ryan. “I see this as one great groaning, an act of birthing. We’ll get to the other end.”

    Pannell offered Matthew 6:28. “Consider the lilies of the field, how they grow; they toil not, neither do they spin.” (The same is also found in Luke 12:22-32.) Translation? “Jesus is inviting his disciples to be grounded in something greater than our worries and the chaos going on around us,” Pannell says. “And that is love. Our love for one another and for our communities provides the necessary grounding and the clarity of vision needed to make our way through challenging times like these. Where there is love, there is hope.”

    And Wilkinson read Dan Albergotti’s 2008 poem “Things to Do in the Belly of the Whale”: “Measure the walls. Count the ribs. Notch the long days./ Look up for blue sky through the spout. Make small fires/ with the broken hulls of fishing boats … Listen for the sound of your heart./ Be thankful that you are here, swallowed with all hope,/ Where you can rest and wait…”

    “Optimism is a feeling,” says Ryan. “Hope is a virtue. It can be bashed up, and still, you can hold to it.”

    Editor’s note: Due to a fact-checking error, a previous version of this article incorrectly identified Tom Ryan’s former and current titles. He is the former coordinator of the Barnstable County Human Rights Commission and the current chair of the Migrant and Refugee Committee of the Cape Cod Council of Churches.

     

    HOPE IN A VIAL

    Long-Awaited Covid Inoculations Begin for Health Workers

    A sense of hope, a little guilt, and renewed optimism

    By

    PROVINCETOWN — Dr. Andrew Jorgensen received a much-hoped-for gift just before Christmas this year, in the form of an initial dose of the Moderna Covid-19 vaccine. He’s on track for the second and final dose later this month.

    “I have the chills just talking about it,” he said.

    Jorgensen, chief medical officer for Outer Cape Health Services, spends half his time on administrative tasks and the other half seeing patients at the Provincetown Community Health Center, where he and fellow staff risk coming in contact with the novel coronavirus every day.

    “You assume every patient can have Covid, so you’re taking precautions,” Jorgensen said.

    Dr. Andrew Jorgensen, chief medical officer of Outer Cape Health Services, welcomes the Covid-19 vaccine. (Photo courtesy Outer Cape Health Services)

    In the run-up to the holidays, staff at Outer Cape Health centers in Provincetown, Wellfleet, and Harwich Port were eagerly awaiting a delivery of the vaccine. As health-care workers, they would be among the first to receive it on the Outer Cape.

    “It was like waiting for Santa Claus,” the chief medical officer said.

    When a box arrived Monday, everyone assumed that it was the vaccine, only to find it contained gloves and needles.

    “We thought the vaccine would arrive on Tuesday,” Jorgensen said, but the day passed without a delivery.

    “We were ready when we got the vaccine on Wednesday, and started administering it within a few hours,” he said. Each of the three Outer Cape Health centers received a box with 10 vials of vaccine. Each vial contained 10 doses, for a total of 100 shots per center.

    Jorgensen was inoculated in Provincetown.

    “It felt like a tetanus shot,” he said, noting that you should expect your arm may hurt for a day or two. “The first night, I would roll over and that arm would wake me up, but it made me smile, because I knew the pain was from the vaccine.”

    Many of his colleagues had no reaction at all from the first inoculation. “The worst I heard was a swollen hand — someone’s engagement ring got a little tight,” Jorgensen said.

    Some staff did turn down the shot. Jorgensen said most of them wanted to wait a couple of weeks to see the reaction of colleagues who were inoculated.

    “Part of our position is not forcing anyone,” Jorgensen said.

    But Jorgensen had no doubt about his decision to receive the vaccine. As chief of the medical staff, he had carefully reviewed the studies. “I had a pretty good understanding of how the vaccine was developed and the safety measures taken during testing,” he said.

    Asked whether he felt relief on being inoculated, Jorgensen said “relief” was not the right word. “We have many serious months ahead, and people will continue to die,” he said. “I also have a little bit of guilt because I got the vaccine, but my husband won’t have it for a long time.”

    Under the phased process for vaccination, younger people with no health factors that put them at high risk will likely have to wait until late spring or even summer.

    Jorgensen called the rollout a highly significant moment.

    “It’s the first day in the process of ending the pandemic,” he said. “For me, it’s a reaffirmation of a sense of hope.”

    A Wellfleet Nurse Is Thankful

    Marcia Peaslee may not work in the emergency room or intensive care center at Cape Cod Hospital, but as a nurse practitioner, she still has contact with possible Covid carriers every day. She and her co-workers at Cape Cod Healthcare’s Infectious Disease Clinical Services in Hyannis were inoculated with the Pfizer vaccine three weeks ago.

    Peaslee, who lives in Wellfleet, is scheduled to get the second shot this week.

    She received the initial shot at Cape Cod Hospital at 5:45 on a Thursday morning, as Cape Cod Healthcare worked long hours to get the vaccine into the arms of all their staff.

    Nurse practitioner Marcia Peaslee is thankful to be among the first to be inoculated against Covid. (Photo Nancy Bloom)

    “Shots were being administered from 5 a.m. until 8 or 9 at night,” she said.

    Physically, Peasley said, the shot was no big deal. “All I had was a sore arm,” she said. The only staff member in her office to turn down the shot was a woman who is currently breast-feeding.

    The emotional impact of the injection was much bigger. The last several months have been a “roller coaster of anxiety,” Peaslee said. “It’s been terrible on so many levels: physically, socially, emotionally, and financially.”

    Now, she’s optimistic. “I was thankful about being able to be vaccinated so early on, and for the peace of mind it gives me,” she said. “This is no small thing. I realize that many people will have to wait possibly months for the same opportunity.”

    One big question on the Outer Cape is whether enough people will get vaccinated to achieve vaccine-induced “herd immunity.” That may be a challenge, considering the immunization rates found among kindergartners here in recent years: as previously reported by the Independent, they are among the lowest in the state.

    In 2019, for example, only 77 percent of the kindergartners at Wellfleet Elementary School had been fully inoculated against such diseases as hepatitis B, measles, mumps and rubella, polio, and chicken pox. At Eastham Elementary, only 83 percent had received a full series of vaccines.

    For diseases like measles, herd immunity is achieved only if 95 percent of the population has been inoculated.

    According to the National Institutes of Health’s website, herd immunity from Covid will be achieved only if 75 to 80 percent of a community’s population is inoculated. Other scientists have placed the threshold even higher.

    Peaslee hopes people will choose to get the shot.

    “Certainly, a lot of people are anti-vaccine, and this is a new vaccine,” Peaslee said. But, she said, “I also talk to a lot of people who say, ‘Sign me up.’ They understand getting Covid is a lot more dangerous than getting the vaccine.”

    Peaslee said she is convinced the vaccine received adequate scrutiny.

    “I really reviewed the study data and the trials,” she said. “A lot of people were in the trials. I don’t think they compromised the process. I think they just cut through some of the red tape.”

    WORKOUT WOES

    As Mass. Locks Down, Walks Are the New Squats

    Gyms face reduced capacity, but not much changes

    By

    workout
    Even during the summer months, Johannes Husson-Cote found plenty of time to sanitize between visitors at Mussel Beach. It’s even quieter there now. (Photo Nancy Bloom)

    PROVINCETOWN — As statewide Covid-19 rates spiked last week, Gov. Charlie Baker tightened pandemic restrictions from the Boston State House. Designed to tamp down the carnage of the holiday season, his measures went into effect at 12:01 a.m. on Dec. 26; they’ll last at least until Jan. 10, 2021, with the possibility of extension.

    The new rules limit indoor gatherings to 10 people, outdoor ones to 25. And they lower capacity limits for a wide variety of businesses from the 40- to 50-percent range to 25 percent. That affects driving schools, casinos, movie theaters, restaurants — and gyms.

    When Covid shuttered fitness centers last March, gym rats of all sorts, from protein-based to Pilates-obsessed, found themselves at a loss. “The first thing we did was cry,” the Boston-based Scott Eischen and Mike Bruning (Herculean both) told the Independent this summer.

    Straits proved less dire for people like Dave Oliver, owner of Provincetown’s Cape Tip Sportswear, who said he was inundated with requests for hard equipment: dumbbells, resistance bands, yoga mats, TRX systems. “No one’s ever asked me for those things before,” he said in August.

    But now, five months after Phase Three initially reopened gyms and ten months since the start of this new American normal, the news that Massachusetts health clubs are inching back towards shutdown is, at least on the Outer Cape, inciting a different, much less frenzied reaction.

    “To be honest,” said Joseph LeBlanc, manager of the Provincetown Gym, “I hadn’t even thought about the new rules affecting us.”

    The Provincetown Gym had a normal, pre-pandemic capacity of 182 people: 156 upstairs, 26 downstairs. But the combination of plexiglass barriers between the machines and requisite social distancing “seriously limits space,” said LeBlanc. Since July, the gym has operated at a reduced maximum of 25 people — just 13.7 percent of capacity.

    “We haven’t reached that maximum once since we opened,” said LeBlanc. “I don’t even think we’ve come close. Our numbers are down drastically compared to normal winters, which are really slow anyway. It feels so empty.”

    Mussel Beach Health Club, Provincetown’s other fitness destination, is now allowing in 18 people at once, exactly 25 percent of its 72-person capacity, down from 30 people, or 40 percent, last week. It is more of an off-season hub than is the Provincetown Gym, but still, the two establishments face similar situations. “Sometimes we have people,” said Mussel Beach’s Natalie Ballesteros. “Sometimes.”

    The gyms’ waning popularity makes sense in pandemic terms; for all but the most devoted fitness freaks, the thought of entering an enclosed space where patrons breathe heavily on purpose can seem daunting. But, said LeBlanc, it makes sense for another reason, too.

    Before Covid, people relied on gyms and in-person classes for their fitness. Thus those early requests to Cape Tip Sportswear’s Oliver for personal gym equipment: worried about quarantine blubber, people sought, early on, to replicate the gym at home. As the months have ticked on, though, it seems there’s been a collective shift in what people want from exercise.

    For swaths of people stuck at home in front of Zoom screens all day, exercise has become less about intensity and aesthetics, more about re-grounding, reconnecting, and above all interacting with the world around them. Even in winter weather.

    “I never get asked for yoga mats and dumbbells and all that anymore,” said Oliver. “It’s all about sneakers, gloves, hats, socks. We’re almost out of long underwear. Everybody wants to be outside — biking, walking, seeing people, breathing fresh air.”

    And, said Oliver, it’s not just that his sneaker sales are through the roof. Shoe-shoppers are looking for distinctly higher-quality products than they used to.

    “They don’t just want the shoes they can wear to the gym once a week,” he said. “They’re planning on being out there way more often, putting a lot of miles on their shoes.” And biking fanatics would usually have tailed off by this point in the season, “but,” he said, “they just keep coming in.”

    LeBlanc recognizes the phenomenon that’s leeching his business. He doesn’t resent it. “Staying healthy is very much a mindset,” he said. “You gotta do what you gotta do. The gym doors will stay open. People will come back when they’re ready.”

    ECONOMY

    For Wellfleet Shellfishermen, Farmers Market Is ‘Pure Good News’

    On the town pier: oysters to go

    By

    solstice
    SOLSTICE TREE — As the solstice brought the turning of the season to the Outer Cape, trees were lighted and adorned with treasured ornaments and children asked Santa questions old and new. (Photo Marnie Crawford Samuelson)

    WELLFLEET — For local shellfishermen, good news this fall was in short supply. Covid’s shuttering of restaurants across the country had wreaked havoc on the wholesale distribution chain, usually a reliable summer boon. Winter — a tight season, even in the Before Times — loomed with no chance of a national reopening by Christmas.

    The market, said Wellfleet Shellfish Constable Nancy Civetta, “had just crashed.” That left farmers, draggers, and foragers strapped for cash and short on hope. And efforts to regain their footing proved limited by, of all things, their home state.

    Other New England states allow commercial shellfishermen to sell directly to consumers. Even if restaurant sales dry up, fishermen can offer their product to friends, family, and neighbors. Massachusetts takes a different approach. It restricts the sale of shellfish to licensed wholesale dealers, whose distribution patterns Covid-19 left in tatters. This fall, Wellfleet’s shellfishermen found themselves faced with a pileup of legal, viable, delicious product — and no way to sell it.

    shellfish
    Cars lined up on the Wellfleet pier for the second shellfishermen’s market day on Dec. 19. (Photo Maureen Dalby)

    “There’s a lack of parity with the other states, which is a real problem,” said Ginny Parker, president of the Wellfleet Shellfishermen’s Association (WSA). In November, Parker said, she petitioned the state Div. of Marine Fisheries (DMF) to temporarily allow direct grower sales. The division denied her request.

    That led to a brainstorming session with Civetta, Selectman Ryan Curley, Assistant Harbormaster Will Sullivan of the Wellfleet Shellfish Advisory Board, and Joshua Reitsma, a fisheries and aquaculture specialist with the Cape Cod Cooperative Extension.

    From that meeting emerged the Wellfleet Shellfishermen’s Farmers Market, a collaborative effort in which the town handled negotiations with DMF and the state’s Dept. of Public Health along with inspections, WSA serves as the promoter, and Wellfleet’s Holbrook Oyster Company, a licensed distributor, is acting as the dealer of record.

    The first shellfish market was held on the Wellfleet pier on Dec. 12, the second a week later.

    “We know what it’s like to not have a market,” said Zack Dixon, a co-owner, with Jacob and Justin Dalby, of Holbrook Oyster. “So, if there’s anything we can do to help create a market, of course we’re going to do it.”

    The market is open to all Wellfleet commercial shellfishermen, who can opt in on a week-by-week basis. Their names, products, and prices are posted on WellfleetShellfishermen.org, where customers can order oysters and clams until 10 a.m. on market days (upcoming dates are Dec. 30, then every Saturday starting again Jan. 9).

    Three vendors participated in the market’s first go-around on Dec. 12. Holbrook Oyster sold its own product, as well as distributing other shellfishermen’s. Evan Bruinooge of Outta Bed Oyster Company offered farmed oysters and will have cherrystone and topneck clams, too. Austin and Jared Ziemba sold wild Wellfleet oysters. Three additional shellfishermen joined for the operation’s second week, on Dec. 19: Sonya Woodman, a wild picker, and farmers Jeremy Storer and Pete Brundage.

    The variety of vendors and the chance to learn about them is a good thing, said Civetta. She also made the point that oysters from different locations can taste different, even though they are all grown in Wellfleet. The market, she said, “offers a taste of all the different nuances and flavors and nooks and crannies of Wellfleet Harbor.”

    “Each oysterman and woman is kind of developing his own following,” said Parker. And just two weeks in, business is strong. Civetta said Dec. 12 saw about 65 preorders and a few dozen walk-up customers. On Dec. 19, over a hundred preorders and a fresh slew of walk-in customers generated so much traffic that a line of cars stretched all the way from the pier to Mayo Beach; the next market will take place at the bandstand to avoid a pileup.

    The organizers would not provide exact numbers on how many customers came or how much shellfish was sold. But Civetta did say that the first market sold more than 2,000 oysters and clams and that number jumped to more than 5,000 on Dec. 19. Parker said that, both weeks, every vendor completely sold out of his or her product.

    Each shellfisherman sells any preordered product to Holbrook Oyster before it gets distributed to customers. Oysters go to consumers for a dollar a piece; Holbrook collects a nickel per oyster, and credit card processing fees shave off a few more cents. So, although their market reach is reduced, the shellfishermen’s per-oyster profits are high.

    For all its success — Civetta called the market “extremely well-supported” by the community, and Parker called it “pure good news” — worry is still a constant.

    That’s because the market doesn’t come close as a replacement for the kind of business shellfishermen are missing right now. “I don’t ever see this taking the place of the normal commerce that happens,” Civetta said.

    VISITING THE SICK

    Hospitals Can Be Flexible on No-Visit Policy

    But sometimes you have to fight to get them to do it

    By

    Among all the challenges of the Covid-19 pandemic, perhaps the greatest is not being able to visit elderly loved ones. In some cases, Covid patients have died in health-care facilities without family members present.

    “It has been one of the most difficult and heartbreaking consequences of the pandemic,” said Chris Hottle, director of the Provincetown Council on Aging.

    But the issue of leaving loved ones at the front door of a facility goes far beyond end-of-life separation.

    For people with cognitive impairment, for example, including a large population of dementia and Alzheimer’s disease patients, the no-visitor policy at hospitals means that patients lose their spokesperson at a time they need it most. There can be dire medical consequences.

    In recent weeks, the number of hospitalized Covid-19 patients on Cape Cod has more than doubled. As of Dec. 13, Cape Cod and Falmouth hospitals reported 37 patients with Covid, eight of whom were in the I.C.U. Less than three weeks earlier, on Nov. 24, there were 15 cases in the two hospitals, and zero in the I.C.U.

    For people living with dementia or Alzheimer’s, going to the hospital without a caregiver can be like sending someone to a place where they don’t speak the language, said Melanie Braverman, co-founder of the Alzheimer’s Family Support Center of Cape Cod.

    Caregivers of dementia patients are not just visitors, said Alan Johnson, a Provincetown resident and an Alzheimer’s and dementia social worker with Cape Cod Healthcare. Without a caregiver, dementia patients are unable to explain their own medical history, how they feel, or their exact symptoms. Elderly patients often have many pre-existing conditions, making it hard for doctors to know their baseline, he said.

    That is why, this spring, at the urging of patient advocates, Cape Cod Healthcare — which operates both Cape Cod Hospital in Hyannis and Falmouth Hospital — broadened its initial Covid-19 policy, which prohibited all visitors, to add special circumstances, including caregivers of patients with dementia or Alzheimer’s, Johnson said.

    But now, as hospitals and other health care centers are locking down again, there is confusion about the shifting policies. Johnson said it’s critically important to advocate for your loved ones. Staff members of large medical complexes like nursing homes and hospitals are not always able to keep up with the rapidly changing rules.

    Magic Word: ‘Lawyer’

    Johnson runs a support group for dementia caregivers. One of his clients reported that she had recently been denied entrance into an emergency room in Brockton with her loved one. She demanded to talk to someone in charge, Johnson said. She was turned down by the first receptionist, but kept pushing, eventually dropping the word “lawyer,” and that made the difference, Johnson said. A higher-up was summoned and she made it in.

    lauf
    CCHC CEO Michael Lauf received $2.9 million in compensation in 2018.

    According to Cape Cod Healthcare’s printed policy, effective Nov. 30, visitors are prohibited at all of CCHC’s 17 facilities, including Cape Cod Hospital. But exceptions include cases when a caregiver is considered “of benefit to either the patient or the provider.” Under this policy, one caregiver is allowed to accompany a patient with cognitive impairment, memory impairment, or dementia.

    Although the most recent policy includes some leeway for special cases, visits are not guaranteed. Clinical staff evaluate patient needs for accompaniment on a case-by-case basis, said CCHC spokesperson Christina Peaslee.

    The Independent’s senior reporter, K.C. Myers of Wellfleet, experienced first-hand the confusion created by the policy when her mother, Cate, was admitted to the hospital two days before the Nov. 30 policy went into effect. Since Cate has dementia resulting from a stroke, Myers was concerned that, without a familiar voice and face in the room, her mother could get hospital-induced delirium — which had occurred in April when the hospital prohibited all visits.

    Hospital-induced delirium is among the most common complications among older patients resulting from hospitalization, occurring at rates ranging from 26 to 94 percent. When it is not addressed, it can result in long-term health problems. People with dementia are more likely to develop delirium while hospitalized. Having a caregiver or family member close can help prevent it.

    Before the ambulance arrived on Saturday, Nov. 28, Myers looked at the visitor policy on the CCHC website and called the hospital to make sure she could visit her mother. A nurse told her she would most likely get an exemption under the new policy. The following day, another nurse wouldn’t guarantee she could visit her mother, but told her to explain the situation to the shift supervisor.

    On the day the policy went into effect, Myers spoke to the shift supervisor over the phone and was told that neither she nor another caregiver could visit her mother. The policy for accompaniment, she was told, was for patients coming into the hospital for procedures.

    Eventually, Cape Cod Hospital staff made a special allowance and a caregiver was allowed to stay with Cate. The nurses were kind and supportive, said Myers, but she had to make multiple phone calls over the course of two hours to make it happen.

    A Lack of Training

    Johnson said it appears that Myers was a victim of the lack of hospital-wide training about dementia — something that every Massachusetts hospital is required to implement by 2023. According to the 2018 Act Relative to Alzheimer’s and Related Dementias in the Commonwealth, all hospitals are mandated to have an operational plan “for recognizing and managing individuals with dementia.”

    “Imagine the number of encounters at Cape Cod Healthcare where people need lab work, or to use the E.R., or hip surgery,” said Johnson, “and every one of those departments is focused on hips or labs and they are not focused on dementia.”

    Johnson said the hospital needs to do that training. And, in the meantime, people should know that he and a nurse run a program to help guide and support caregivers. The Cape Cod Healthcare Dementia & Alzheimer’s Caregiver Support Program offers group support session classes, telephone advice, referrals, respite care grants, and counseling sessions.

    ECONOMY

    Disaster Loans a Quiet Lifeline for Outer Cape

    $32 million for small businesses came in nick of time

    By

    eidl
    During early summer’s eerily slow start, the Outer Cape’s seasonal business owners held their breaths, waiting for disaster money to come through. (Photo Nancy Bloom)

    PROVINCETOWN — The Covid-19 Economic Injury Disaster Loan (EIDL) program was so bedraggled in its rollout and early execution, it’s hard to pick which sadsack metaphor to use for it. It was the runt of the litter and a forgotten stepchild and an ugly duckling. Any story with an inauspicious start will basically give the plot.

    But newly released data show that the program eventually delivered 465 low-interest emergency loans averaging about $70,000 to businesses on the Outer Cape. Overall, $32.6 million dollars arrived here through the program.

    Almost as important is when these loans were delivered — overwhelmingly, in May and June, as businesses were reopening, and before the summer season hit.

    That means that, at essentially the last possible moment, the EIDL program did its job. Disaster loans are meant to put a significant amount of cash into businesses that have been radically disrupted, so they can replenish inventory, deal with new expenses, bring back staff, or simply survive a year of reduced sales.

    The loans were originally designed to cover six months of operating expenses; they are paid back over 30 years at low interest rates. Lots of cash up front and a long repayment schedule are meant to keep businesses alive through an extended tough time.

    Yet throughout this year, hardly anything was known about the main program actually meant to save small business. There was a rival, the Paycheck Protection Program (PPP), and it was flashier. PPP promised “free money!” — forgivable loans — and then its own drama played out in public. The money ran out, some big companies took it, everybody shamed them, Congress put more money in — it was like a soap opera filmed at the Treasury Dept.

    Meanwhile, the government would confirm almost nothing about the disaster loans — how many, how much, on what schedule. Businesses that applied in the horrific last weeks of March received no response at all for months. The EIDL program was like Schrödinger’s cat — possibly dead already, but if nobody knows, no one can say, even if it is supposed to be saving the economy.

    A Court-Ordered Data Release

    Soon after the programs were announced, several large news organizations sued the Small Business Administration for data about both the PPP loans and the EIDLs. In November, they won their case, and on Dec. 1 the government published full lists every loan issued, of both types.

    Taken together, there are 3.7 million disaster loans. The data were published in four huge spreadsheets with nearly a million loans on each one. The Independent reviewed them to learn how many loans were written to Outer Cape businesses, how much money came in through these loans, and when they arrived.

    A total of $32,628,000 came to the Outer Cape this year through the EIDL program. The average loan was for $70,168. This number could have been larger: the original formula for disaster loans was six months of operating expenses, defined as gross revenue in a normal year minus the cost of physical inputs like food ingredients or inventory. That means payroll, rent, utilities, insurance, taxes, everything except physical inputs, could be covered for six months by a loan to be paid back over 30 years.

    The $2.2 trillion CARES Act stimulus signed on March 27 didn’t include enough money to write that many large loans, however. After issuing loans for two weeks, the SBA paused, and then lowered the cap on loan size from $500,000 to $150,000.

    That meant most larger businesses, like restaurants and hotels, would receive exactly $150,000, far less than the intended loan size. Smaller businesses with revenue under $500,000 were less likely to hit the cap, and more likely to get a loan proportionate to their needs. Disaster loans were also available to owners of rental properties, and to self-employed people like plumbers, barbers, and massage therapists. These tend to be the smallest loans on the list, mostly $20,000 or less.

    There were 261 disaster loans written to Provincetown businesses, worth $20 million in total; 61 Truro businesses received loans totaling $3.5 million; 65 businesses in Wellfleet received $4.3 million in loans; and 78 businesses in Eastham received a total of $4.7 million in loans.

    Help Without Fanfare

    For a region that makes its money in July, August, and September, these loans may have come just in the nick of time.

    The data show only 11 loans in all of April. But three-quarters of the loans that were written to Outer Cape businesses arrived in May and June. There were no announcements or fanfare, but by the time the July 4th weekend arrived, 357 local businesses had received an infusion of CARES cash.

    The results were still uneven. Information on how the loan amounts were calculated was scarce, and there was no real instruction on how to tally business costs. A review of the loan spreadsheet shows several local businesses received minuscule loans compared to their size, including galleries, retail outlets, guest houses, and at least one restaurant. Other businesses that should have qualified for loans may have been rejected outright — the data include only successful loans, not total applications.

    As for the value of the program to the businesses that participated, there is one potential indicator. Of the 465 local businesses that received disaster loans, it appears that only six have canceled their loans and returned the money.

    COVID TESTING, PART 4

    County to Open Affordable Testing Sites

    Falmouth, Hyannis will open next week; OCHS sites to follow

    By

    PROVINCETOWN — Cape Cod’s struggle to get expanded access to Covid testing took a big step forward this week.

    Legislators and county leaders announced that drive-through testing sites will open in Falmouth and Hyannis next week. Pat Nadle, C.E.O. of Outer Cape Health Services, said that asymptomatic testing will begin in Provincetown and Wellfleet the week after that, just before Christmas.

    Testing at these sites isn’t through the state’s Stop the Spread program and won’t be free for everyone. Instead, in order to stretch limited resources, the tests will be billed on a sliding scale, and some tests will be billed to insurance. Local legislators have been agitating for a Stop the Spread site on Cape Cod, because it would offer free, no-appointment testing, paid for by the state. The availability of tests on Cape Cod is among the lowest in the commonwealth, even though a serious outbreak is spreading through the middle Cape.

    On Monday, Gov. Charlie Baker announced five new free testing sites in Western Mass., plus “expanded testing” in Falmouth. A closer look reveals that four of those Western Mass. sites will be Stop the Spread (Great Barrington, Greenfield, Pittsfield, and North Adams), while the sites in Amherst and Falmouth are described as “free community testing.” This appears to refer to the sliding-scale arrangement, in which many people are eligible for free tests, some tests are billed to insurance, and other people pay out of pocket.

    The cost should be less than a commercially available PCR test, although how much less is not yet known.

    “I want to note that not all these tests will be free,” said state Rep. Dylan Fernandes (D-Falmouth). “They shouldn’t cost more than $60 per test, with less expensive options available, and anyone who cannot afford a test will not be turned away.”

    Barnstable County Health Director Sean O’Brien cautioned that the exact numbers for the sliding scale haven’t been fully worked out. “We should have a better idea [of the out-of-pocket cost] by the end of the week,” said O’Brien.

    The tests will cost less than $150, though, because they’re being processed at the Broad Institute, an independent research laboratory affiliated with M.I.T. and Harvard. Broad is charging universities as little as $25 per sample, as opposed to the roughly $100 charged by many commercial labs.

    Making a Lasting Program

    There’s more than $1 million behind the county’s new testing program, but leaders are preparing to stretch that money into the spring. That’s because much of the funding has come from one-time allocations that legislators put into the budget — and the state delayed paying for months. With the money finally in hand, leaders are looking to make it last.

    State Rep. Dylan Fernandes speaks at a press conference at the new drive-through Covid testing site in Falmouth. (Photo courtesy Frank Schulze)

    An earmark of $300,000 was inserted by Rep. Fernandes in July, specifically to support testing in Falmouth. Another $250,000 was earmarked by state Sen. Susan Moran (D-Falmouth), which will go to support the Hyannis drive-through site. Cape Cod Healthcare is matching that $250,000 with a donation. The Hyannis location should be able to process 1,500 to 2,000 tests a week, according to O’Brien and Cape Cod Healthcare C.E.O. Michael Lauf.

    The Barnstable County commissioners voted to release $125,000 from an emergency fund to support the expansion of testing. And state Sen. Julian Cyr (D-Truro) added another earmark to the budget currently being considered. That $200,000 has made it through conference committee, according to Cyr’s office, but the overall budget bill still needs to be passed by the legislature and signed by the governor.

    In total, that would be $1,125,000 for expanded testing on the Cape. That is a significant achievement, representing the coordinated work of many people — but the scope of the problem is vast. At even the lowball price of $60 a test, $1,125,000 would fully pay for 18,750 tests. That’s fewer than the 19,800 people who were tested in Barnstable County in the last two weeks of November.

    The $1.1 million is enough to double testing for two weeks. Then it would be used up. Hence the need for some people to pay on a sliding scale, and the need to bill insurance for some tests.

    “We are pretty confident this is not going to meet all of the needs,” said Cyr. “If you look at the public service announcements on TV — ‘Go get tested! It’s free!’ — that’s not what we’re able to do with these sites, because we have limited resources and we’re uncertain if more will be provided. We have to be judicious about the million in resources that we have cobbled together to solve this problem. We’ve got to make that stretch.

    “This will put a dent in that ‘testing desert,’ ” Cyr continued. “It will be a big, big help. But we want to be clear that this is not a Stop the Spread site. The delegation will continue to make the clear case that we need additional ongoing resources here.”

    The state has spent $150 million on free Covid testing thus far. That, more than anything, helps explain why a million-plus is both great news and just the beginning of what’s needed.

    PANDEMIC

    Wastewater Testing Yields Messy Data

    But it’s a still a valued tool for detecting Covid outbreaks

    By

    wastewater
    Boston’s wastewater test results include large error bars around individual samples, that nonetheless form a clear trend line.

    PROVINCETOWN — Testing wastewater for Covid was an unproved idea at the start of this pandemic. If it worked, it would be a way to cheaply test entire communities at once, because everyone connected to the sewer system makes a “contribution” to it, every single day. No one could say how meaningful the data would be, though: if they jump around too wildly from reading to reading, then there’s no pattern to discern, and not much to be gained.

    Months of wastewater test results from Boston, Nantucket, and Provincetown show that, while the data are indeed jumpy, they can still send clear signals, especially when things are going bad. Health directors in Nantucket and Provincetown have relied on wastewater data to warn their populations of coming trouble.

    In Nantucket, three different surges in discovered cases were preceded by spikes in wastewater testing data. In Provincetown, no cases have been discovered since early November, but a significant spike in wastewater data led the health dept. to warn residents that “the virus is present in our community.”

    Ain’t Easy Being Small

    Boston started testing its wastewater extremely early in the pandemic, on March 9. Its data include the March-April wave in Boston and then a long period of very low results from June to August.

    From a data standpoint, having both kinds of result is extremely valuable — it’s clear what kind of numbers would correspond to a wave of real cases. When Boston’s wastewater numbers began to rise after Oct. 18, and then dramatically accelerate in November, no one doubted that the numbers indicated something real.

    For smaller communities, though, it’s not that simple. Nantucket started testing wastewater at its Surfside treatment facility in April. Provincetown started testing in August. There were hardly any active cases in either town when testing started. Most of the early results were “below the threshold of detection.”

    When positive results did exist, it wasn’t clear what they meant. The test can’t distinguish between dead and living virus, nor can it distinguish between day-trippers and residents. Nor was it clear what 2 or 5 or 10 real cases would look like. Would they escape detection entirely, or would they be off the charts?

    “It doesn’t always extrapolate to small numbers the same way,” said Nantucket Health Director Roberto Santamaria. “You get noisier results with small numbers.”

    Even in the summer lull, Boston had hundreds of active cases at a time. When it comes to sampling, hundreds is a much easier number to work with than single digits.

    Noise, Then a Signal

    Nantucket went through a major Covid outbreak that began in late June and accelerated in September. According to Santamaria, wastewater testing was a leading indicator that allowed him to alert the island to danger before cases were actually discovered by individual testing.

    “It doesn’t tell us an exact number” of upcoming cases, said Santamaria, “but it does give us time to be proactive. When we see that spike coming, we reach out to the Chamber of Commerce, the builders and landscapers associations, and try to create hypervigilance. I’ll do videos in English and Spanish and push those out to the community through Facebook and the newspaper.”

    The Independent reviewed the timing of individual positive test results and wastewater testing on Nantucket. A wastewater spike on June 8, when there were no identified active cases on the island, may have foreshadowed the eight cases that were discovered in the last week of June. Another spike on Aug. 31 may have been an early sign of the 30 cases that were found in the second week of September.

    The data are noisy; it’s hard to say for certain that these test results correlate to these cases. An unmistakable signal appeared, however, in tests on Oct. 19 and Nov. 2 and 10. The number of virus copies per milliliter of wastewater went to three times, then 10 times, and then 12 times the prior record. From June through September, the highest readings had been 38 copies per mL. By Nov. 10 it was 463 copies per mL.

    Even in a noisy data set, when something goes up tenfold and stays there, that’s a signal. Nantucket has identified more than 110 new cases since Oct. 19. That’s 40 percent of all the cases that have ever been found there.

    A Warning in Provincetown

    Provincetown uses a different company for wastewater testing than Nantucket, but the data show the same basic patterns. There was one early outlier, some bouncing around at relatively low levels, and 10 tests that showed no results at all. Then, results from Nov. 8 and 10 appeared (Provincetown tests on Sundays and Tuesdays to try to account for weekend and weekday occupancy.) The Sunday test was 15 times the average of the prior four weeks: 274 copies per mL. The Tuesday test was 108 copies per mL, or six times the prior average.

    Based on that, the health dept. notified the public: “Although there are currently no positive cases in Provincetown, the latest results of the town’s wastewater system reveal an upward trend which indicates the virus is present in our community. Some people in town are carrying the virus. We ask that everyone be especially cautious.”

    That statement was dated Nov. 18, and there still were no detected cases in town as of Nov. 30. Wastewater testing picked up a signal that testing of symptomatic people still hasn’t confirmed.

    “For us, it’s another measure to try to understand what’s going on in the community,” said Provincetown Health Director Morgan Clark. “I really want people to observe all of these precautions all the time, not just when we are posting case numbers, or viral loads in the wastewater.”

    Provincetown receives the wastewater readings about a week after samples are taken. “Even with a lag in the data, we are still getting a heads up on what’s out there,” said Clark. “Also, we could be getting a heads up that someone who was here last weekend is now gone, and getting symptomatic somewhere else. I’m not going to make the assumption that viral load in our wastewater is actually from people who live here.”

    Provincetown’s sewer system covers only about half the town, but that includes nearly all the tourism businesses on Commercial Street.

    “We’re looking at the science behind the septic testing that some colleges are trying at the level of individual dormitories,” said Clark. “It’s really experimental, with volumes that small. But we are looking into it, because the school isn’t on the sewer system, and I would really like to get the best information possible to protect our school.”

    According to state Sen. Julian Cyr, 96 percent of Cape Cod is on septic systems, not sewers. But schools, nursing homes, churches, and many large workplaces could potentially use septic testing, if it is proved to work.

    Wastewater testing isn’t expensive. Nantucket is paying $1,500 per sample, or about the cost of 10 individual Covid tests. Provincetown’s tests are through a joint venture between Columbia University and the private company AECOM, and cost $550 each. Organizations such as schools could someday find frequent wastewater testing to be significantly cheaper than widespread individual testing.

    Towns, however, have the extra benefit of a professional DPW staff. The real barrier to widespread septic testing may not be the cost — it may be finding enough plumbers to do the job.

    PANDEMIC

    As Others Act, Outer Cape Still Lacks Asymptomatic Testing

    Upper Cape and Nantucket adopt multipronged approach

    By

    PROVINCETOWN — In the popular children’s book Stone Soup, the soup is started with no great resources — in fact, it’s just a large pot of water with one stone in it. But as every villager brings something to add — carrots here, potatoes there — the soup grows into something real.

    This “everybody brings something” method resembles the approach to asymptomatic testing on Nantucket and at the Community Health Center (CHC) of Cape Cod, which serves the towns of the Upper Cape. In both locations, a variety of actors are contributing resources to make asymptomatic testing a reality. That’s in contrast to the Outer Cape, which has no asymptomatic testing.

    The importance of asymptomatic testing was highlighted by state Sen. Julian Cyr last week, citing a map released by the state.

    “The map confirms our suspicions that barriers around appointment times and symptom requirements have resulted in lower testing rates on Cape Cod as compared to the rest of the state,” Cyr said.

    “Molecular tests are lower in Barnstable County than its percentage of the statewide population,” he added. “The Mid Cape has an active outbreak, and this is among the lowest testing rates in the state. We are in a dangerous phase, and what we do now is going to determine how dark of a winter we have on Cape Cod.”

     

    Testing rates on Cape Cod are low, particularly compared with Nantucket and Martha’s Vineyard. (Source: Mass. Dept. of Public Health)

     

    To dramatically expand testing involves both rules and resources. The key questions are: Who is eligible for a test? Who will pay for it?

    Since the CARES Act passed in March, insurance has been obligated to pay for testing for people with symptoms and people who have been identified by contact tracers as exposed to Covid.

    Asymptomatic testing means that people without symptoms or definite exposure are eligible to get tested as well. Once the doors are thrown open to this larger group of people, the question of who pays comes next.

    Large-scale testing is expensive. In all of Barnstable County, there have been 116,231 Covid tests performed since March. At $150 per test, that’s $17 million just in this county. The 7 million tests that have been done statewide cost about a billion dollars.

    When insurance can’t be billed, the money for expanded testing needs to come from somewhere else.

    Everybody Pitch In

    Nantucket began its asymptomatic testing program back in June, and it features a hybrid model in which the town pays for certain high-risk workers, individuals pay for themselves, and employers pay for their whole organization. The Nantucket Select Board allocated $100,000 to the program, but only about half that money has been used so far, according to Nantucket’s health director, Roberto Santamaria.

    That $50,000 of town money represents roughly 330 tests, or about 10 percent of the asymptomatic program, which is called CastNet.

    “We did, for a while, have a lot of employers paying,” said Santamaria. “Some of the landscaping companies had their whole crew tested. The golf club paid to test their entire membership, as well as their employees.”

    About 3,300 people had been tested through CastNet by mid-October, when a worsening outbreak caused the state to step in and open a Stop the Spread site on Nantucket. Stop the Spread is a state-financed asymptomatic testing program that is made available to communities with major outbreaks. Between Oct. 15 and Nov. 16, there were 1,841 tests done at the Stop the Spread site on Nantucket, according to Jason Graziadei, information officer at Nantucket Cottage Hospital.

    On Nov. 4, the CHC of Cape Cod, which has locations in Bourne, Falmouth, Mashpee, and Centerville, announced that it will begin offering asymptomatic testing as well.

    “We’ll be evaluating patients on a case-by-case basis,” said Karen Gardner, CEO of CHC of Cape Cod. “There are people who haven’t been contacted by a tracer, but feel they may have been exposed, maybe through a family gathering, or they hear by word of mouth that a friend of a friend has been exposed. Many times, you can bill insurance, and our triage nurse will go through a series of questions to determine whether it’s clinically appropriate,” said Gardner.

    “In other cases — say, someone’s planning to visit a family member, and they just want a test — we wouldn’t bill insurance,” Gardner added. “They either self-pay or we have a sliding scale for incomes under 200 percent of federal poverty level.” Two hundred percent of the FPL is $25,500 per year for a single person, or $52,400 for a family of four.

    Self-payment would be around $150, said Gardner, which covers the specimen collection and the laboratory fee. “We’re not charging it as a doctor visit,” said Gardner.

    CHC of Cape Cod received a donation from Martha’s Vineyard Savings Bank, which helped underwrite the scheduling software behind the asymptomatic program. “It takes a tremendous amount of I.T. interface and data entry work, and the grant, in part, is funding that,” said Gardner.

    “We were doing about 100 tests a week, right before we opened it up” to asymptomatic people, Gardner added. “At the end of last week, our staff said our phone calls had doubled and we had basically doubled our capacity. If we have much growth beyond that, we’ll need to expand our testing hours and have a dedicated testing team. We have the physical capacity — it’s just a matter of restructuring staffing to meet the demand.”

    Why Not Here?

    Right now, Outer Cape Health Services tests only symptomatic and contact-traced people. The nearest site for asymptomatic testing is CareWell Urgent Care in Dennis.

    For many months, there were essentially no Covid cases on the Outer Cape. Provincetown’s health dept. ran three separate asymptomatic testing events, timed to follow high-traffic weekends in the summer and fall. Health Director Morgan Clark couldn’t be specific about the results of those tests, but case reports from those months show a long string of zero cases in Provincetown. Wellfleet and Truro showed a string of zeros as well.

    Now, however, the data are changing rapidly. There were four cases in Provincetown at the end of October. There are four cases in Wellfleet this week. Fall River, New Bedford, Rhode Island, and Nantucket have an explosion of cases.

    “I worry that we do not have the testing capacity that we need here,” said Cyr. “We’re going to continue to work on this. We need more testing resources if we are going to meet the challenges of this moment.”

    ELDER CARE

    State Releases Partial Data on Covid Deaths in Assisted Living

    One Cape Cod facility has had 11 previously unreported fatalities

    By

    Since late May, the state has provided detailed reports on fatalities from Covid-19 in nursing homes, but for assisted living facilities, the same information is hard to come by.

    The most recent “Weekly Covid Report” from the governor’s office offers 40 pages of data on nursing homes — everything from case number ranges to staff testing regimens.

    But the report includes only five pages on assisted living facilities. And there is nothing about the number of deaths at those facilities.

    The Commonwealth’s Executive Office of Elder Affairs provided this chart in response to the Independent’s public records request on Covid fatalities in assisted living facilities on Cape Cod.

    The Independent filed a public records request for fatality information at the 17 assisted living facilities on Cape Cod. The results are printed here. As of press time, state officials have not answered questions about why this information is not provided in the state’s weekly reports to the public.

    In the report provided to the Independent, any number between 1 and 10 in the columns for number of cases (“Positive [Res]”) and deaths reported was redacted from the data and marked “Exemption C.” The reason, according to Lesley Moreau, the records access officer at the Executive Office of Elder Affairs, was HIPAA — the Health Insurance Portability and Accountability Act of 1996.

    According to the Poynter Institute for Media Studies, a journalism school and research organization, some health institutions and government agencies have misinterpreted HIPAA rules, with the result that important Covid-19 information is unreported.

    “Let’s be clear,” wrote Al Tomkins in an explainer to journalists published on the institute’s website in April, “HIPAA was intended to protect individual medical and health information.” But, he added, “the key word there is ‘individual.’”

    Nursing home data appear to be handled differently from data on assisted living facilities. In reporting on nursing homes, any number of deaths between 1 and 4 is condensed into a range: 1-4. The Independent could not establish before press time why privacy is protected in this way in the case of nursing homes, and in a different way in the case of assisted living facilities. That is, it appears that the state can report that five people died in a nursing home, but cannot report that five people died in an assisted living facility.

    In the meantime, the numbers for assisted living facilities appear to be more or less in line with those from nursing homes. Broadly speaking, elder-care homes of all kinds were either spared or were hit very hard. That is, either cases and fatalities are both zero, or cases are in double digits, and fatalities nearly so.

    Harbor Point at Centerville, which appears to generally receive high marks from the public for its services, had the highest number of positive cases, 17, and deaths, 11, in this report. It is a facility that specializes in “memory care” for people with dementia.

    Two other assisted living facilities on the Cape had more than 10 cases: Brookdale Cape Cod in Hyannis and Cape Cod Senior Residences in Pocasset. There were deaths at each of these, but because there were 10 or fewer, the exact number was not made available.

    Two other Cape assisted living facilities had 10 or fewer cases: Atria Woodbriar Place in Falmouth and Maplewood at Brewster. Both had at least one death. Again, due to the number of deaths being 10 or fewer, the exact numbers are redacted from the report.

    Overall, 12 assisted living facilities on Cape Cod escaped unscathed; five did not. These numbers are consistent with other evidence from around the region.

    The Kaiser Family Foundation reported in September that most states don’t report data for assisted living facilities, but those that do showed coronavirus cases and deaths rising over the summer.

    PANDEMIC

    Cyr Calls Out Gov. Baker on Testing Funds

    Asymptomatic testing is key to controlling new outbreaks

    By

    covid
    An antibody test looks for proteins made in response to infections. (Photo courtesy CDC)

    PROVINCETOWN — In a recent press call, state Sen. Julian Cyr sounded an alarm about coronavirus testing on Cape Cod.

    “We see the cases coming south and east towards Cape Cod,” said Cyr. “We have an opportunity to get ahead of this. Gov. Baker’s administration hasn’t released $550,000 in funding to Barnstable County for testing. My patience is wearing thin on the failure to release this money.

    “These are resources that state Sen. Moran and state Rep. Fernandes secured in the legislature,” Cyr continued, “specifically for Covid testing to be coordinated by the Barnstable County Dept. of Health. We want expanded asymptomatic testing. We want these resources released.”

    Allowing those without symptoms to be tested has become an issue because the number of Covid infections is rising dramatically in mainland Massachusetts. Given the nature of human transmission, health officials expect cases will travel here as well.

    covid
    A PCR test looks for the genetic material of the coronavirus, which is detectable when a person is actively infected. (Photo courtesy CDC)

    Indeed, four cases were reported in Provincetown in the last days of October, and contact tracers established that all four were related to travel, according to Provincetown Health Director Morgan Clark.

    Asymptomatic testing is important early in an outbreak. Because so many people can have few or no symptoms, an outbreak can be well on its way before people start showing up sick at clinics. Catching infections through asymptomatic screening can find cases early enough that contact tracing and isolation orders are still very effective.

    The catch, of course, is that testing large numbers of healthy people isn’t cheap. And if it’s overdone, it can gum up the labs that process tests and delay everyone’s results. Even when testing is kept well in line with lab capacity, the costs can add up quickly. Martha’s Vineyard seems to have found a way around this, however, by doing something bold: billing the insurance companies.

    How to Handle Costs

    The simplest approach to minimizing costs is emphasizing what insurance definitely will pay for — that’s testing for people with symptoms, and testing identified close contacts of those who have tested positive. The list of symptoms is quite long, and includes things like headache and fatigue. Who isn’t a little tired these days?

    But frontline workers are specifically instructed not to work if they feel any symptoms at all. It can be hard to coax them into a test.

    Both Provincetown and Nantucket have targeted frontline workers with free testing sites that are explicitly for asymptomatic people. Provincetown ran one such event on July 22, timed to follow the busy Fourth of July weekend.

    Nantucket has had a rolling invitation to various groups of frontline workers — including home health aides, grocery workers, clergy, and transportation workers. Provincetown spent $15,000 on the July 22 event, while the Nantucket Select Board allocated $100,000 to its testing-by-invitation program.

    At an industry-standard $150 a test, though, $100,000 would cover only 667 tests. Even at scale, and with labor costs trimmed by using volunteers where possible, Cyr said the per-test cost is between $80 and $140. At the lower number, $80, Nantucket’s $100,000 would fully cover 1,250 asymptomatic tests.

    That sounds like a lot, until you look at the scale of some testing efforts. Nantucket has done 12,000 tests in all since the pandemic started. Martha’s Vineyard has done a total of 26,000.

    Make Insurance Pay

    Three-quarters of the tests done on the Vineyard have been at a drive-through, anyone-can-come testing site for asymptomatic people. It relies on a mix of staff and volunteers to help lower costs, but 19,500 asymptomatic tests is still a lot of money.

    The Vineyard is relying on a mix of strategies to make this test center work, but one of the key ones is just billing health insurance companies.

    “We think there’s a gray area here, and it can be captured in two words — medically necessary,” said Cynthia Mitchell, CEO of Island Health Care. “We have chosen to interpret ‘medically necessary’ very broadly: it’s to protect people from getting Covid.”

    “Whether we’ll get the reimbursements we’re due across the board remains to be seen, but we are billing, and we’re getting a fair amount of revenue in,” Mitchell added.

    “This is a drive-through, so we’re billing for the specimen collection, and that’s all we’re billing,” Mitchell continued. Quest has not been donating the processing fees.

    “Quest Diagnostics bills the insurer for processing the sample,” said Mitchell.

    Mitchell said Island Health has had great support from Quest staff — Quest’s CEO is a seasonal resident of the Vineyard — who helped set them up with an online registration system for setting up appointments. This has been important, she said. “But it was actually our revenue cycle contractor that worked with us to get the insurance coding right, so the reimbursements would come,” she added.

    Mitchell isn’t aware of another community health center using this approach. “It was ambitious,” she said.

    The program also benefited from early support from Martha’s Vineyard Bank, which donated $100,000 to help cover testing for the uninsured. And seven Island families gave $150,000 in July to help staff the new online registration system.

    Mitchell also cited the CARES Act. “Every health center in the country received $500,000 as a base, and then there was a per-patient number tacked on,” she said. “Because we’re so small, the benefit of that $500,000 was wonderfully disproportionate.”

    When to Test

    “Who pays?” isn’t the only riddle to solve, though — when to test is important too.

    It’s possible to spend a lot of money to consistently find no cases. A long string of zeroes is a relief, of course, but it can also feel like a waste of resources — until suddenly it’s not.

    chart
    Wastewater testing in the northern and southern Boston metro area shows an alarming spike in the second half of October. Source:
    mwra.com/biobot/biobotdata.htm

    Martha’s Vineyard had a very low case rate for a long time. Now, however, the asymptomatic testing program has found 47 infections, and, according to Mitchell, some of the other 96 cases on the island were discovered because they’re contacts of those 47. Detecting that outbreak early has allowed for effective contact tracing, said Mitchell.

    “I worry that we relied on green / yellow / red to allocate testing resources,” said Cyr. Barnstable County had few cases, in other words, and now it’s doing little testing, leaving it exposed as the statewide situation grows worse.

    One possible solution involves testing wastewater for evidence of RNA from SARS-CoV-2, the virus that causes Covid-19. There’s no evidence that people can get sick with Covid from wastewater, but testing it can provide an indication of when large-scale screening should be deployed.

    A review of wastewater test results on Nantucket showed that the data tends to be “noisy” — but there were three significant spikes in the numbers, and they were each followed by a wave of newly discovered cases. Wastewater testing isn’t widely used yet, but if it can tell us when to roll out large-scale testing programs, it could help solve the when-to-spend puzzle.

    THE THIRD WAVE

    Baker Issues New Covid Rules, Curfew

    This time, restrictions target late-night activity

    By

    PROVINCETOWN — Gov. Charlie Baker announced three new executive orders on Monday, Nov. 2, and a 10 p.m. to 5 a.m. curfew, all of which will go into effect on Friday, Nov. 6.

    The three orders involve wearing masks, the size of public and private gatherings, and the mandatory closure of 16 types of businesses between 9:30 p.m. and 5 a.m. The orders are enforceable by boards of health and police depts; the curfew is advisory only.

    The new rules narrowly target late-night socializing.

    “As a policy nerd, I appreciate that the governor is making data-informed policy decisions,” said Morgan Clark, director of the Provincetown Health Dept.

    “We can assume that they are seeing spread when people are out late drinking,” added Clark. “Instead of punishing the entire economy, they are trying to enact policies that get at what is contributing to the spread.”

    The categories of business that must close by 9:30 p.m. include in-person dining and sales of alcohol and recreational marijuana. Takeout food service may continue past 9:30, and stores may continue to sell products other than alcohol and recreational marijuana.

    Also obligated to end by 9:30 are events of all kinds, including movies, sporting events, and live performances.

    The maximum size of public and private gatherings was also reduced. Indoor gatherings, capped since Aug. 7 at 25, will be dialed back down to 10 at most. Outdoor gatherings of up to 100 people will still be allowed in “lower-risk communities” — those that have not been designated “red” during the last three weeks. In the 54 towns that recently turned red — with more than eight active cases per 100,000 people — outdoor gatherings will be limited to 50 people.

    No town on Cape Cod has been coded red in the last several months, though Nantucket had an outbreak recently, and is currently red.

    Cape Cod still has many fewer cases per 100,000 people than mainland Massachusetts.

    In addition to numeric limits, the new order requires that public and private gatherings end at 9:30 p.m. These restrictions apply to weddings, conferences, concerts, and private parties — one-time events that might not otherwise be regulated. The limits don’t apply to standing operations such as restaurants, theaters, and medical facilities, which are already covered by their own guidelines.

    The expanded mask order requires a face covering anywhere open to the public, whether indoors or outdoors, even if six feet of social distance can be maintained. Because it applies to “public streets and ways,” it also applies to town beaches, which are a “public way,” according to Provincetown Board of Health Chair Steve Katsurinis.

    The Cape Cod National Seashore is not bound by the governor’s orders. It currently instructs visitors to wear a face covering whenever social distancing cannot be maintained.

    Fortunately, the sun now sets before 5 p.m. on the Outer Cape. By 10 o’clock, it feels much later now than it did in July, and there’s far less late-night activity. But the rise in cases on the mainland could still find its way to the Cape. Provincetown currently has four active Covid cases, after months of having zero. Due to patient privacy, Clark couldn’t say much about the cases, except that they “are all travel-related.”

    Truro has two active cases, and Eastham has three, with only Wellfleet still reporting zero cases. In all of Barnstable County, there have been 119 new positive tests in the last 14 days.

    Provincetown is participating in a wastewater testing experiment, run by Columbia University and AECOM, in which the town’s wastewater is tested twice a week for coronavirus RNA, Clark said.

    “We generally hover right around the undetectable threshold — one sample might be just over the threshold of detection, but then the next one isn’t,” Clark said. “Recently, we had a slight rise in the results that didn’t go back down. We were able to get an indication from the wastewater before we saw the individual test results come in.”

    Nearly 150 frontline workers in Provincetown were tested last Thursday, Oct. 29, as part of a free asymptomatic testing program by Concentric by Gingko in the Massachusetts schools. Clark said she couldn’t comment on the results of those tests — but she reiterated that the four positive cases in Provincetown are all connected to recent travel.

    “I would also like to mention — we’ve published a resource guide going into the winter,” Clark said. “We’re focusing on mental health and connection, and on food and security. We’re working with the social service groups, the churches, trying to identify gaps and fill them.” The guide can be found at provincetown-ma.gov/1324/Resources.

    “I also want to encourage people to be outdoors, see your friends outdoors, and don’t use the change in daylight or the change in rules to isolate further than you have to,” said Clark. “We still need to connect as we move into these colder, darker months.”

    FIGURE SKATING

    Figure Skaters Squeeze In a Cyber Competition

    But statewide rink closure takes them off the ice for now

    By

    In only its second year, the Nauset Figure Skating Club is having a lot of new experiences, including cyber skating.

    The club participated in the first-ever Fall Cyber Challenge through U.S. Figure Skating earlier this month. Instead of competing against other teams in front of a panel of judges, the skaters performed maneuvers on their own, with no crowd at Charles Moore Arena (CMA) in Orleans.

    skaters
    After getting summer and fall practices and one cyber competition in, the Nauset Figure Skating Club now must wait until at least Nov. 7 to get back on the ice. Pictured are skaters Delaney Shaw, Piper Kavanaugh, Isabella Valentino, Ashley Tortora, Alexa Hoffman, and Ella Raye at Charles Moore Arena last week. (Photo courtesy Tamsyn Shaw)

    Club coach Tamsyn Shaw filmed the sessions and sent the videos to a panel of judges for them to review and score. Shaw said the team should receive its scores in about a week.

    There are 10 levels in high school figure skating, from beginner to senior, so skaters participate based on their skill. Team maneuver events consist of at least two skaters performing synchronized choreographed moves.

    Three Nauset skaters participated together in the intermediate level of competition, and three competed together at the high level. At each level, skaters had to execute nine different elements (jumps, spins, sequences, etc.).

    In all, Shaw sent in 18 different videos for evaluation.

    It was the club’s first competition of the year, and it came just in time, because indoor skating rinks across Massachusetts were shut down on Oct. 23 for at least two weeks per order of Gov. Charlie Baker.

    “There have been at least 30 clusters of Covid-19 associated with organized ice hockey activities in the Commonwealth,” according to a statement from the Mass. Dept. of Public Health. “Each of these clusters has two or more confirmed or probable Covid-19 cases, totaling 108 confirmed cases and more than 225 exposed contacts. There is at least one hockey-associated case of Covid-19 in at least 66 cities and towns in the Commonwealth.”

    “It’s a big bummer,” Shaw said. “We just went back in person last week. It was nice for them to socialize and see their skating friends.”

    The figure skating club took first place in its first-ever competition last year at the Harvestfest competition in Dover, N.H., on Oct. 6. The club then competed twice more before a final showcase scheduled for May was canceled. But the Orleans arena opened back up in the middle of the summer, so skaters who could were able to participate in individual practices, according to Shaw.

    The arena was open for skating and hockey lessons this fall until just last week, when the statewide shutdown was announced.

    Recording the skaters’ moves on video had some advantages and disadvantages.

    “If they messed up, I could take a new video,” Shaw said. But what made it challenging, she added, was that the team had the ice for a club skating session, so skaters did not get their own individual ice time.

    A second cyber challenge through U.S. Figure Skating is scheduled for February and Shaw is hopeful the team will be able to participate.

    “It’s an artistic freestyle,” she said. “Each individual skater will be skating to music of their choice.”

    After that, Shaw said, the hope is that U.S. Figure Skating will do some in-person competition. “Though, at this point, that type of planning can’t happen, we’d love to host one at CMA again,” she said.

    Shaw said the skaters were happy that the remote setup was in place so they could compete in some fashion. Now, the club can only wait to see if the statewide rink shutdown ends on Nov. 7 or continues after that.

    COVID-19

    Health Board Wants Masks at Town Hall

    Mandatory workplace safety standards may be imposed in Wellfleet

    By

    WELLFLEET — The board of health is considering a set of mandatory safety standards for municipal workplaces after a visit to town hall set off alarms last week.

    Health Agent Hillary Greenberg-Lemos told the board at its Oct. 14 meeting that she was worried about the health and safety of town staff because they were not wearing masks in shared spaces and in meetings inside town hall and the DPW building.

    “Nobody should be answering the front door of town hall without a mask on,” Greenberg-Lemos said, adding that one of the only ways to prevent transmission of the coronavirus was to wear a mask when in the presence of other people. “That’s not negotiable,” she said.

    The health agent was accompanied on the visit by health board member Janet Drohan and by Assistant Health Agent Doug Guey-Lee.

    Staff have returned to work full-time at the town offices, Greenberg-Lemos reported, but there appears to be no enforcement of mask use rules. “I don’t want my staff, my colleagues, to be put in unnecessary risk,” she said. “I shouldn’t be hearing from staff that they are nervous, they’re uncomfortable, and they’re worried.”

    “It is evident that we need to take a stand,” agreed Drohan.

    Town Administrator Maria Broadbent told the Independent on Tuesday that staff members were not required to wear masks at town hall, but it wasn’t a problem because the building is not open to the public. Employees are able to do their jobs, she said, while staying at least six feet away from each other.

    “They can certainly wear a mask if they’re comfortable,” said Broadbent. “We have very few in-person meetings that happen among staff. I think there’s probably people on the board of health that would like people to wear masks all the time. People have to do what they’re comfortable with. They’re much further away from each other than the state requires.”

    Greenberg-Lemos said that she had talked to town staff, sent out emails, and put together the draft document that was reviewed during the Oct. 14 meeting: the Town of Wellfleet Covid-19 Mandatory Safety Standards and Workplace Training Manual.

    The front door of town hall is the only location in the building where there is a sign stating that face coverings are required. Drohan said there needed to be a change of attitude about wearing masks. “The mission here,” she said, “is the safety of our town.”

    The health board discussed options for mask enforcement. They agreed that the first step was the mandatory safety plan, including mandatory staff training. If there is still noncompliance after the training, the health board agreed to consider options for enforcement, including notifying the select board.

    COVID UPDATE

    Eastham Student Is First in District to Get Virus

    Entire fifth-grade class sent home to quarantine

    By

    EASTHAM — The fifth-grade class at Eastham Elementary School will be quarantined for 14 days and educated remotely after a student tested positive for Covid-19 last week.

    Principal William Crosby sent a message to fifth-grade parents on Saturday, Oct. 17, telling them, “Your child has been a close contact with an individual who has tested positive…. Due to the fact that your child’s entire class will be out of school for 14 days, we will transition your child’s class to a remote teaching and learning model.”

    The remote learning began on Tuesday, Oct. 20. The principal’s memo did not specify, but the Independent has learned that the person who tested positive is a student, not a staff member.

    It’s unknown whether anyone else has tested positive related to the school case. Health Agent Jane Crowley said there have been new cases since Eastham last posted numbers, which is done every Wednesday, the day after the Independent’s deadline. As of Oct. 14, Eastham had one active case and 16 cases total.

    Contact tracing and related testing was ongoing as of Oct. 20, according to Crowley, who would not provide the number of new cases, saying results were “preliminary.”

    This is the first positive test since school began on Sept. 16 in the entire Nauset Regional School District, which runs from Wellfleet to Brewster, and comprises a total of 2,361 students. School Supt. Tom Conrad said the elementary school rolled out the health and safety protocol planned for such a scenario.

    First, Conrad said, the school and district nurses worked with the local health agent and contact tracers to determine who should be considered a close contact — that is, someone near the positive person for at least 15 minutes unmasked during the two days before the symptoms began.

    In this case, Crowley said, the school took a conservative approach and considered the entire class to be close contacts.

    “We are dealing with children and we need to think of any scenario where they may be in close contact,” Crowley said.

    Children’s unmasked contact with each other is hard to control during recess, bus rides, and other situations, Conrad added.

    Parents and siblings of the quarantined students who have not tested positive are not considered close contacts, Conrad said. Therefore, they don’t have to get tested or quarantine, unless they show symptoms or other contact tracing reveals a need.

    But, Crowley said, the entire class should quarantine for the full 14 days — even those whose test results come back negative before then.

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