Visualizing new life choices within the context of the COVID-19 pandemic

The impacts on health in early life cumulatively influences the next stages all the way through old age. The life course model allows us to visualize new life choices within the context of COVID-19 (summary table at the bottom).


Everyone is affected including persons not yet born and those in early life. The stress felt by pregnant women and expectant fathers translate in utero and can lead to premature births. Additionally, fathers may be more involved with young children because of the shift to at-home work which benefits young children. However, toddlers are sensitive to changes that they cannot yet understand and will need to be monitored to prevent lasting negative health effects.


Children tend to develop anxiety in seeing parents distressed in tandem with an introduction of new social rules about dangers that they cannot see. Children may experience lasting scars from poor nutrition, anxiety, family instability, domestic violence since they are undergoing stress during pivotal times in development.

Adolescent and Young Adulthood

Adolescents and young adults may be more prone to PTSD diagnoses in the future due to excessive screen exposure prompted by the pandemic. Additionally, they may experience forgone educational opportunities limiting their ability to succeed in future endeavors.

Young adults are often blamed for disregarding protective measures. Furthermore, young adults may experience difficulty gaining work experience and never catch up to earlier cohorts in socio-economic attainment which ultimately leads to poorer health outcomes.


Adulthood career and family formation are disrupted. This adds “insult to injury” for millennials in their thirties who went through the 2008 recession. Relationships at this stage are at risk–partnerships may be difficult to form and sustain. Additionally,  excess stress has been put on women of working age to support themselves, their families, potentially newborns; all of which they may have to tackle alone.


The Elderly are faced with increased instances of discrimination and loneliness as they may be forced into permanent retirement. COVID-19 protocols have required many people of old age to say goodbye from a distance and die alone. They may opt to age in place instead of at elderly centers because these places have become high risk for contracting COVID-19, especially when they are more likely to develop a severe case. At this stage, more elderly have shown a greater value for positive and meaningful life  experiences due to these dire circumstances.


The pandemic has underscored the reality that life’s choices are limited. Cohorts may never catch up to earlier and later cohorts; have continuing disadvantages that lead to poor health outcomes later in life. Markets have stagnated and people may be stranded away from loved ones due to travel restrictions.

The lasting effects of outliving a partner, child, or loved ones who died from COVID-19 destabilizes mental health. However, the pandemic has highlighted existing inequity and led to more instances of the use of collective action to address systemic racism. The cumulative effects of COVID-19 requires that we address the weaknesses in our social systems. The life course model allows us to acknowledge intervention points at each life stage to help us all work toward a healthier future.

HealthPersonal Control & PlanningSocial Relationships & Family
Education & Training
Work and Careers
Migration & Mobility
The stress felt by pregnant women and expectant fathers translates in utero and can lead to premature births

Fathers more involved; toddlers sensitive to changes that are not understood


ChildhoodLasting scars from poor nutrition, anxiety, family instability, domestic violence; excessive screen exposure can lead to PTSDAmount/lack of resources affects remote learning quality
High unemployment rates and greater health risk as “Gig Economy” workersMaybe blamed for disregarding protective measuresDifficulty gaining work experienceDelayed educational transitions and adulthood in navigating labor, housing and relationships 
Cumulative impact from loss of training, experience and promotion

Postponed or forgone education abroad or career moves

AdulthoodDisruption and delayed careIncreased burden from supporting relatives how may not be settled in employment and housingPostponement of partnering or accelerated separation; child delivery/birth alone; maybe thrusted into a caregiver roleLong-term earning negatively impacted for those entering workforceLabor market exclusion; “lost generation” with truncated career and family formation; adding “insult to injury” for cohort in thirties who went through 2008 recession
Families left behind by seasonal workers
Old Age
Higher risk for severe COVID-19Optimize positive and meaningful experiencesDying alone or saying goodbye from a distanceAgeism and forcing permanent retirementAging in place instead of elderly centers that have become high risk for COVID-19
Lifetime/ cumulativeCohorts may never catch up to earlier and later cohorts; have continuing disadvantages that lead to poor health outcomes later in lifeUsing collective agency to address systemic racism when individual control loss
Outliving partner or child who died from COVID-19
More openness and responsiveness for ongoing educationCareer inequalities; fewer “weak/bridge ties” lessen employment opportunitiesLimited migration, stranded and less globalization of labor markets


Under-represented groups are rightfully nervous about getting the COVID-19 vaccine

Updated on April 27th, 2021 with summary table on how common COVID-19 vaccine concerns are addressed and their sources at the bottom.

By Michelle Rufrano & Jean-Ezra Yeung

Executive Summary

  • Multiple COVID-19 vaccine surveys show that the plan to get the vaccine is about half of the U.S. population, and Blacks showed the highest level of concern
  • Contemporary racism is compromising vaccine access for communities of color
  • Clinical trials should adapt representation to accommodate the highest burden of disease
    • This includes any under-represented group (e.g. age, gender identity, ability, immigrant status, etc.)
  • The surveys show that the top concern is side effects
    • Some vaccine concerns were unfounded (acquiring infection from vaccine and costs) from mis/dis-information, but others reflect a fundamental mistrust

Many articles have heavily leaned on historic racism as way to explain away the presence of vaccine hesitancy in communities of color, but action can only be taken if we address the ways racism is expressed today. Black and Brown Americans are the most distrustful of the vaccine, yet they are also have the highest mortality and morbidity rates due to the coronavirus itself. Contemporary racism, therefore, manifests in cultivating an environment where communities of color distrust something that they need more than any other group.

This phenomenon is supported across four COVID-19 vaccine surveys (see summary table at the bottom) and clinical trial data. The survey data shows that only about half of the U.S. population is planning on getting vaccinated — Blacks have the strongest level of concern. Across all groups, the top concern is side effects, which have been documented in sizable proportions from clinical trials. Most of the other concerns can be categorized as mis/dis-information, and mistrust in medical research, development and practice. The clinical trials conducted by Pfizer-BioNTech, Moderna, and Johnson & Johnson’s Janssen all mirror lack of representation in recruitment of study participants. Under-represented groups are rightfully nervous about getting a vaccine if people with their specific social identities are not adequately included at the research stage.

This phenomenon is known as the “Tuskegee effect” or the lingering distrust of participation in medical trials aptly named by a one of the most well-known historic disregard for black male health specifically needs to be addressed. Furthermore, acknowledgement of how racism manifests today is tantamount to helping people of all backgrounds access care. The COVID-19 pandemic shows us how a disproportionate impact on a subgroup affects everyone in the (global) community, alongside dire strains on (public) health systems. Consequently, clinical trials and public health efforts should adapt representation to accommodate those with the highest burden of disease.

Dec. 2020
Jan. 2021
Kaiser Family Foundation (KFF)
Feb. 2021
Pew Research Center
Mar. 2021
The decision to get vaccinated or individuals who got vaccinated is split around the middle47% plan to get the vaccine51% plan to get the vaccine if they haven’t yet55% received at least one doseHalf of U.S. plan to get the vaccine, if they haven’t already
There are racial differences, specifically Blacks had a stronger level of concern and there was a lack of confidence that there was adequate testing on their race/ethnicityBlacks (24%) are less likely to plan to get the vaccine than Whites (53%) and Hispanics (34%)Non-Hispanic Blacks (30%) are least likely to plan to get the vaccine compared to Hispanics (47%), Non-Hispanic Whites (56%), and non-Hispanic Asians (66%)Vaccine enthusiasm is higher in Whites (61%) than in Hispanics (52%) and Blacks (41%)

Half of Blacks (50%) and one third of Hispanics (34%) were not confident the vaccine was adequately tested on their race/ethnicity
Blacks (61%) are the least likely to plan to get the vaccine or already did compared to White (69%), Hispanic (70%), and Asians (91%)

Yet Blacks expressed a higher level of concern about the pandemic across six questions, such as getting infected and being hospitalized or knowing someone that did

Blacks expressed less confidence in the vaccine research and development process
There are myriad vaccine concerns and side effects is at the top of the list*The top reason for not getting the vaccine or being unsure are side effects (71%), development/approval process (57%), infection from the vaccine (37%)The top concerns were side effects (51.2%) and plan to wait and see if it is safe (50%)The top concern is side effects (56%), followed by out-of-pocket costs (35%), missed work from side effects (34%), get COVID-19 from vaccine (33%) and won’t be able to get it at a trusted place (30%)The major reason is side effects (72%), vaccine developed too quickly (67%), want to know more how they work (61%), seen too many medical system mistakes in the past (46%), don’t need it (42%), and don’t get vaccines in general (36%)

*Some of the concerns are unfounded, such as out-of-pocket costs (only for the vaccine, not the administration if not the only service in visit) and getting the infection.

Note: I would say the KFF and Pew Center Research surveys were the most comprehensive, if you wanted to look at them in more detail.

Updated on April 27th, 2021 with summary table on how common COVID-19 vaccine concerns are addressed and their sources:

Concern AnswerSource
 Side effectsIn clinical trials, the most common side effects (>50%) were at the injection site (e.g. pain) and others (>~40%) include fatigue, fever, muscle pain, headache. Allergies were reported. Rare events occurred but were not related.FDA, NEJM, NIH (see bottom of table for links)
Vaccine development and approval processResearch, development and approval were accelerated from: genetic sequencing technology and sharing; existing coronavirus research; no financial risk from US government’s Operation Warp Speed funds; ease of participant recruitment; and Emergency Use AuthorizationNature, Medical News Today, FDA
Infection from vaccinePfizer-BioNTech, Moderna and Johnson & Johnson’s Janssen vaccines (mRNA or viral vector) do not use the COVID-19 virus, but they help generate the spike protein that triggers antibody and immune responses against COVID-19.CDC (mRNA, viral vector)
InconvenienceThe vaccine and its administration in a visit without other services should be covered by insurance (providers can request administration reimbursement from the government for uninsured). Certain states passed law to give employees hours aside from sick time to get the vaccine (e.g. New York State on March 21 for 4 hours per vaccine dose).CDC, New York State
Mistrust of healthcare systemPeople haven’t viewed doctors and medical researchers as trustworthy when it comes to transparency and responsibility. Also for healthcare providers, people felt rushed and confused about instructions.Pew

Side effects sources:

When does a COVID-19 variant become a concern (for you)?

Executive Summary

  • The UK, South African and Brazilian variants are of concern because of increased prevalence and they carry mutation(s) such that vaccine and antibody therapies have shown less neutralizing activity in the lab
    • Early Novavax clinical trial findings showed lower vaccine efficacy against the South African variant compared to the UK variant
  • The New York variant is of concern because of increased prevalence and it carries a mutation (like the South African variant) where vaccine and antibody therapies have shown less neutralizing activity in the lab

My first blog post was about whether the vaccines would address variants and I noted that scientists needed to do more research. Some of that research is now suggesting how current vaccines could be less effective against variants if they carry specific mutations.

I started out trying to understand how variants are defined and there are three nomenclatures. I will use the PANGO lineage here since it is the most detailed and can help track emerging variants (the other two are GISAID and Nextstrain).

In the media, you may have heard about the UK (B.1.1.7), South African (B.1.351) or Brazilian (P.1) variants of concern, but these are not technical terms (I’ve put the PANGO lineage in parentheses). These are variants of concern because of increased prevalence and they carry mutations where vaccine and antibody therapies have shown less neutralizing activity in the lab. Furthermore, the South African variant (versus the UK variant) showed lower efficacy in preliminary findings of the Novavax vaccine study. In America, the New York variant (B.1.526) is currently a variant of concern because it showed increased prevalence and was reported as the carrying the mutation (E484K) where vaccine and antibody therapies showed less neutralizing activity in the lab.

Which COVID-19 test is relevant for you?

Updated on May 13th, 2021 with summary table on COVID-19 tests and their sources at the bottom.

Executive summary

  • A diagnostic test directly affirms the presence of the COVID-19 virus
  • Rapid (molecular), antigen and antibody tests were deployed for more widespread testing at a lower cost to develop baseline infection rates, especially in outbreak or congregate settings, such as nursing homes and schools. They maybe less accurate than the diagnostic test
  • If you have symptoms or COVID-19 exposure, it is recommended you get a diagnostic test

Quite quickly, the different types of COVID-19 tests caused me confusion as to which one I would need and when. In New York City, there is a one-size-fits-all message to get tested. It is recommended by the Test & Trace Corps (published January 6, 2021) to get tested immediately if you have symptoms or (possible) exposure, and periodically if you work outside of your home. However, it is still not clear which test you should get.

The antigen test is recommended (published October 17, 2020) in New York State for use in congregate settings like nursing homes and schools. It is relatively less expensive but less sensitive than a diagnostic test. However, there are recommendations to get the diagnostic test as a confirmation of a positive result. A rapid molecular test was also developed to be used in contexts like nursing homes and schools, similar to the antigen test, and it also recommends a confirmatory diagnostic test for positive results.

New York State uses the antibody test to develop a baseline infection rate. The test developed by the state detects antibodies in the blood, specifically IgG, which is usually developed three to four weeks after infection. It is not recommended to take this test until twenty-one days after a positive diagnostic test or the symptoms of COVID-19 started. Only the diagnostic test itself detects the virus’ genetic makeup.

Updated on May 13th, 2021 with summary table on COVID-19 tests and their sources.

Nucleic acid amplification (e.g. RT-PCR)
TypeDiagnostic, detects virus’ DNADiagnostic, detects spike protein on virus’ surfaceNon-diagnostic, detects antibodies fighting against virus
UseMost accurate for current infectionLess accurate but more affordable for current infectionCheck for prior infection (requires 1-3 weeks after infection)
ScenarioKnown exposure or symptoms; lab version to confirm less accurate test (positive, or symptomatic but negative test from antigen or non-laboratory version)Known exposure or symptoms; high-risk congregate settings; routine screeningSurveillance
Vaccinated alreadyWill not test positiveMay be exempted from routine screeningMay test positive, so cannot assess immunity
Turnaround time1-2 days15 minutes30 minutes (field) to 2 hours (lab)
Cost (government benchmark cash prices)Non-High Throughput: $51.31
High Throughput: $100 ($75 if not done within 2 calendar days)
$45.23 (e.g. ELISA)Multi-step: $42.13
Single-step: $45.23


What are the out-of-pocket costs for COVID-19 treatment, if any?

Executive Summary

  • If you have Commercial (non-grandfathered, non-self-funded), Medicare Advantage or Medicaid, insurers have been waiving cost-sharing for COVID-19 treatment (the largest insurers so far have set time frames and extensions until at least end of 2020)
  • If you are on traditional Medicare or in a Commercial Obamacare-compliant health plan and do not have cost-sharing waived, you may have to pay out-of-pocket.
    • Pneumonia has been used to estimate out-of-pocket costs and this could start at $1,300 depending on complications (e.g. ventilator usage), deductible amount based plan type (large group, small business, individual); and balance/surprise billing is estimated to occur for one in five cases
  • If you are uninsured, the Provider Relief Fund can reimburse your provider if they apply for it

The American media has heavily focused on coverage and accessibility to COVID-19 testing and vaccines, but I saw little coverage on COVID-19 treatment should you unfortunately need it. I looked into what it might cost you out-of-pocket for the entire treatment.

The Kaiser Family Foundation laid out how traditional Medicare would cover hospital stays but beneficiaries would need to pay deductibles ($1,484), whereas it is recommended for Medicare Advantage plans to waive cost-sharing. They also projected COVID-19 hospital cost using historical claims on pneumonia for private (employer-sponsored) health insurance (published March 13, 2020). They estimate out-of-pocket costs exceeding $1,300 but private insurers have been waiving cost-sharing requirements so far. Medicaid patients have no cost-sharing for COVID-19 treatment per the CARES Act. If you are uninsured, the Provider Relief Fund could reimburse providers for treatment but that is up to the provider to apply for it, otherwise, you may be liable for the bill.

The LA Times reported a situation where COVID-19 treatment became a huge financial burden ($42,000 in out-of-pocket) because the individual had a grandfathered self-insured plan which does not have an out-of-pocket maximum limit (grandfathered plans do not have to comply with the Affordable Care Act/Obamacare out-of-pocket maximum limit elimination and self-insured plans are not subject to the same federal regulations). The article compared how another person with a similar total cost of care but an out-of-pocket maximum limit ended up with out-of-pockets costs around $1,000.

The American Health Insurance Plans (AHIP) has compiled an inventory of what insurers are doing in response to the pandemic (visited March 1st, 2021). Here are the highlights from the five major insurers on COVID-19 treatment cost-sharing (deductibles, co-pay, co-insurance) or out-of-pocket costs. They are essentially are waiving cost-sharing but the date ranges and extensions vary.

  • Aetna previously waived cost-sharing for inpatient admission treatment for COVID-19 (announced September 23rd, 2020 and effective until December 31st, 2020 for Commercial and Medicare Advantage.
  • United Healthcare has extended its COVID-19 treatment cost-sharing waiver for Individual and Group during the month of January 2021, and for Medicare Advantage there is no cost-sharing until March 31st, 2021.
  • Cigna is waiving cost-sharing for COVID-19 treatments until February 15, 2021, but that is only mentioned on the AHIP website and not date-stamped on Cigna’s website itself.
  • Humana is waiving cost-sharing for COVID-19 treatment for all lines of business (Commercial, Medicare Advantage and Supplement, Medicaid) with not definite expiration date.
  • Anthem has extended its COVID-19 treatment cost-sharing waiver until of January 31, 2021.

What does the COVID-19 antibody test result mean for me?

Executive summary

  • Your test results could be impacted by the time between when you were infected and get the test
  • You could get a positive result for other reasons besides COVID-19

I spent the beginning of my career looking at research studies for healthcare interventions, including pharmaceuticals, diagnostics and devices. However, I have never been close to requiring the information for a personal decision. The COVID-19 pandemic has made this decision close for the mass, so I decided to take a look into the types of tests that one could get in New York City. The New York City website talks about the antibody test, but it mostly focused on providing the public information on where to get it and open times. The New York State website has information on antigen, antibody and molecular testing.

I read the FDA emergency use authorization for the New York State antibody test they developed and found the following notes interesting:

  • Interpretation of results. On the fourth page, there is a table that shows what values were used to translate to categorical results of negative, indeterminate or positive.
  • Cross-reactivity. Although there is only one on page 4-5, the West Nile virus sample came up positive and three others were indeterminate with the test.
  • Clinical performance. On page six, there is a table showing the sensitivity increasing from 17.9% to 79.3% as the days from onset ranges increased (from less than 7 to greater than 20 days – there are five ranges). The results were from over six clinical studies totaling 753 subjects.
  • Limitation. There could be false results for patients taking biotin supplements.

Based on these notes, if I got the antibody test I would like to know my value before the categorical result (to know if I’m borderline) and contextualize the test to when I may have been exposed (if I got a negative result but was potentially exposed less than 20 days ago I may question the result). If I’m also positive, I would consider if I could possibly have the West Nile virus and check if I have biotin in anything I take.

Does the COVID-19 vaccine protect against all variants?

Executive Summary:

  • There is evidence that the vaccine is effective against some variants
  • It is uncertain whether the vaccine will be effective against future variants, in which case they will need to be updated

Whether you’re considering the COVID-19 vaccine or not, you may be wondering whether the vaccine protects against new variants being discovered. Although I’m public health professional, I didn’t stay up-to-date with the latest scientific research, because I knew that there is nothing safer than preventive measures: self-quarantining first and foremost; and physical distancing and wearing a mask when outside and in public spaces. As we launched cshell health, we realized that we needed to fundamentally address health literacy in the context of the present: COVID-19 vaccine and variants. So the first thing I did was go to the global authority source, the World Health Organization (WHO) to see what they had to say on variants (published December 31th 2020 and visited on January 21st 2021).

I discovered that in June 2020, the variant that was spreading globally was not the original strain identified in Wuhan, China. Furthermore, additional strains were found in Denmark and the United Kingdom in August/September and end of the year in 2020, respectively. In December 2020, a new variant in South Africa was spreading that was different from an earlier variant. This new variant showed that it was more likely to spread but there was no evidence at the time of worse outcomes.

WHO mentioned four factors in characterizing new variants:

  • is it more contagious?
  • is there a higher likelihood of mortality and morbidity?
  • how likely is reinfection?
  • how do antibodies respond to new variants?

The WHO risk assessment is that, all else equal, if new variants are more contagious, then that could lead to more deaths and hospitalizations.

I also checked what the Center for Disease Control and Prevention had to say on new variants (visited on January 21st 2021 and page last updated January 15th 2021). They have a section on what they do not know, including how new variants spread, the nature of the disease, and what this means for vaccines and therapies.

From what I can tell now, there is no robust evidence on how new variants would respond to the current vaccine. I found an article from CNN on a study suggesting how the vaccine protects against new variants (published January 20th 2021 and visited on January 21st 2021). I read the pre-published study cited, which was published January 19th 2021 by researchers from The Rockefeller University, California Institute of Technology, National Institutes of Health (and its Clinical Center) and Howard Hughes Medical Center. These institutions are reputable in medical science, technology and clinical practice. I noticed that the sample size was small of only 20 volunteers (of which 16 were Caucasian, 8 were females, 14 received the Moderna vaccine) in the report and that activity against some variants have been reduced by “a small but significant margin”. In the Discussion section, they suggest on-going vaccines update and immune monitoring to address viral evolution.

As I was writing this, Dr. Fauci returned to the media spotlight. What the New York Times summarized was aligned with what I found: vaccine may be effective for new variants for now but may need to be updated for mutations. I would say that he is good with not causing any unnecessary public alarm and focusing on when a positive outcome would be due if we followed the necessary public health steps, specifically vaccination rates to reduce the spread, mutation and pressure on health systems.