Last week, portions of Maryland and Virginia entered a second phase of their reopening plans, with restaurants allowed to offer dining indoors and group gatherings of up to 50 people permitted. At the same time, tens of thousands of people in Washington and elsewhere – some masked, some not – protested police brutality and the killing of George Floyd in Minneapolis police custody.

Local officials say they are watching virus-related data closely for signs of a resurgence – or for evidence that the pandemic may be receding in the region.

On Monday, Maryland Gov. Larry Hogan, a Republican, said hospitalizations for the virus had fallen below 1,000 for the first time since April 10, to 979. The rate of people testing positive dropped to a new low of 7.38%.

The tally of coronavirus infections in the District of Columbia, Maryland and Virginia reached 119,044 Monday, with officials reporting 1,058 new cases.

But with the total number of cases partly driven by increased testing, local officials have been focused more on rates of infection, daily hospital admissions and the capacity of area hospitals to absorb a spike in cases.

They have also worked to increase testing and contact tracing, while beefing up their supplies of personal protective equipment. As the number of tests has increased, the rate of people testing positive has declined significantly.

Officials say the spread of the virus has not yet slowed enough in D.C. and its closest suburbs to lift Phase 1 restrictions that, among other things, limit restaurants to outdoor dining and gyms and fitness centers to outdoor exercise classes.

D.C. reported two new covid-19 deaths Monday – both of them older residents – for a total of 491 fatalities. According to D.C. health officials, the city has had seven days of a “sustained decrease in community spread.” As of Saturday, D.C. had a 12% positivity rate. That marked four days of the city being at a less than 15% positivity rate.

Maryland reported 27 new deaths Monday, bringing the number of people who have died of covid-19, the disease caused by the novel coronavirus, in the state to 659.

Montgomery County had three new deaths, and Prince George’s County added four. The positivity rate in the two counties – which have been hit harder by the virus than anywhere else in Maryland – has dropped to 11.83% in Prince George’s and 10.26% in Montgomery.

Maryland also reported the coronavirus-related death of a corrections officer who worked at a Baltimore City facility. The employee, whom authorities did not identify, was in his or her 60s and had been a correctional officer for 20 years, according to the Maryland Department of Public Safety and Correctional Services.

AFSCME, the union that represents workers in Maryland’s prisons, said the officer was the first union member in the state to die as a result of being exposed to the virus on the job and called for more protections for employees.

Virginia reported five new deaths, for a total of 1,477. Its statewide positivity rate was 10% as of Thursday, down from a high of about 22% in mid-April. In northern Virginia, the positivity rate was 14.3%, compared with 35.9% in mid-April.

With unemployment rates having spiked amid the prolonged coronavirus shutdown, Virginia Gov. Ralph Northam, a Democrat, announced a moratorium on all evictions through June 28, ordered by Virginia Supreme Court Chief Justice Donald Lemons. Northam said he will spend the next three weeks implementing “a comprehensive rent relief program for the thousands of Virginians facing housing insecurity in the midst of this public health crisis.”

“Access to safe and stable housing is critically important, and this action will keep thousands of families in their homes as we work to get them the support they need,” he said.

Gears of New York’s great economic machine that had gone idle for months began to turn as the city eased out of a stay-at-home order. Democratic Mayor Bill de Blasio estimated that between 200,000 to 400,000 workers returned to work throughout the city’s five boroughs.

“All New Yorkers should be proud you got us to this day,” de Blasio said at a news conference Monday morning at the Brooklyn Navy Yard, a manufacturing hub.

Monday marked the first, limited phase of a four-part reopening plan. Wholesale sellers and manufacturers were allowed to resume business and the construction industry made its noisy return. Workers in hard hats swarmed a site in south Queens, installing walls and machinery within the skeleton of a tower that had been mostly hollow since March.

Florists, clothing shops and other retail establishments that have been shuttered for weeks welcomed customers to pick up goods at the curb – with masks and social distancing required. The Brooklyn Grange, a 5.6-acre farm that grows herbs and vegetables on three large roofs in New York, will host its first rooftop farmers market of the season on Saturday and Sunday, said co-founder Anastasia Cole Plakias.

The gradual reopening of New York does not mean the city is returning to the way it was before the coronavirus, said New York City health commissioner Oxiris Barbot. She cautioned that people with weakened immune systems, the elderly and others who are at high risk for serious complications from the coronavirus should stay indoors as much as possible. She urged New Yorkers to wear face coverings outdoors, vigorously wash hands and use hand sanitizer.

“We’re still in what I would say is a moderate transmission phase,” Barbot said. “There are still, on a daily basis, hundreds of people that are newly diagnosed with covid-19. ”

More than 207,000 have tested positive for the coronavirus in New York City and more than 25,000 have died.

Many businesses remained closed. In Lower Manhattan, where City Hall and most city agencies are based, lunch spots were still closed or boarded up. Vehicle traffic was light and there was a fraction of the foot traffic that would normally clog sidewalks. In Foley Square, a few people sat on benches, enjoying the springtime weather.

The park, which is across the street from the headquarters of the New York City Police Department, state and federal courthouses and a major federal agency building, has been the site of protests over the death of George Floyd; one began Monday afternoon.

Transit riders appeared to show up on buses and subways in increased numbers Monday. Over the past three weeks, the system has seen ridership increase by 20,000 to 25,000 passengers per day, said Tim Minton, a spokesman for the Metropolitan Transportation Authority.

Ridership bottomed out at around 500,000 trips on April 9, Minton said; by the end of last week it had risen to 1.5 million across the subway and buses.

De Blasio announced a plan Monday to create 20 miles of new bus lanes by October, which the city estimated will serve 750,000 daily riders.

“More service equals less crowding equals more health and safety,” he said.

The agency did not have an official head count for Monday’s commute, though Minton and interim MTA president Sarah Feinberg said they anecdotally observed more people than in previous days.

Over the weekend, workers stuck decals and stenciled markings to subway car floors in six-foot increments to encourage social distancing. The city deployed 800 school safety agents to subway stations to distribute masks and hand sanitizer in tiny squirt bottles. The transportation agency plans to give 2 million masks to riders.

The subway will continue to shut down from 1 a.m. to 5 a.m. to disinfect and clean the train cars until the pandemic is over.

Among the masked riders who took the subway Monday morning was New York Democratic Gov. Andrew Cuomo. He greeted other straphangers with a wave or an elbow-bump.

“Reopening of New York City – we did it all based on data and facts,” Cuomo said at a news conference Monday.

He added: “We went from the worst situation in the nation – frankly, one of the worst situations on the globe – to not only flattening the curve, but to bending the curve.”

New York City is the last place in the state to start reopening. It must meet several thresholds to continue with the reopening plan, such as keeping the hospitalization rate below two per 100,000 residents. Testing – with rate of at minimum 30 per 1,000 residents – and tracing are two key metrics that allow restrictions to lift. Jackie Bray, the deputy executive director of New York City’s Test and Trace Corps, said that the city recently set a record by testing 33,000 New Yorkers in a single day. More than 3,000 tracers have been hired to follow up with possibly exposed contacts.

That tracing program, which launched Monday, made thousands of calls last week, said Test and Trace Corps Director Ted Long.

“We called 100% of every contact listed where we had a phone number,” he said.

Officials urged people who participated in protests against police brutality to get tested for the coronavirus and said they would be monitoring for a spike in infections over the next two weeks. There are more than 150 locations citywide where people can receive a free coronavirus test.

“We need you to get tested,” Bray said, “if you’ve been out in a protest. ”

Stay-at-home orders such as New York’s prevented 60 million coronavirus cases in the United States, per an estimate published Monday in the journal Nature.

“We got this far by hard work and discipline,” de Blasio said. “We’ve got to stick to it so we can get to the next phase and the next phase and the next phase. ”

In the second phase of reopening, retail and office work can resume; in the third, restaurants can seat customers; in the fourth, schools, arts, entertainment and recreation return. The city must remain in a phase for at least two weeks before it progresses to the next.

The reopening comes after months of suffering. The outbreak summoned legions of out-of-town medical workers, the National Guard and a Navy medical ship. White tents of a field hospital went up in Central Park. The intensive care unit was chaotic inside Manhattan’s Mount Sinai Hospital at the height of the pandemic, said 24-year-old nurse KP Mendoza.

Patients were doubled up in small rooms. “We’re trying to keep our I.V. pumps outside the doors,” Mendoza said, though nurses would step on the tubing by accident. “It’s messy, it’s hard.” As he went to sleep he lit lavender candles to erase the hospital’s deathly odor.

Hospitals ran out of rooms to treat patients and transformed lobbies and cafeterias into ICUs. Some ran out of space to store the dead. In April, police found dozens of bodies stacked in two moving trucks parked outside a Brooklyn funeral home.

But after seven years, the couple was surprised when the doctor informed them she was opting out of Medicare, the couple’s insurer.

“It’s a serious loss,” Resnikoff said of their doctor.

Patients can lose doctors for a variety of reasons, including a physician’s retirement or when either patient or doctor moves away. But economic forces are also at play. Many primary care doctors have long argued that Medicare, the federal health insurance program for seniors and people with disabilities, doesn’t reimburse them adequately and requires too much paperwork to get paid.

These frustrations have prompted some physicians to experiment with converting their practices to more lucrative payment models, such as concierge medicine, in which patients pay an annual fee upfront to retain the doctor. Patients who cannot afford that arrangement may have to search for a new physician.

The exact number of physicians with concierge practices is unknown, health-care experts said. One physician consulting company, Concierge Choice Physicians, estimates that roughly 10,000 doctors practice some form of membership medicine, although it may not strictly apply to Medicare patients.

Shawn Martin, senior vice president of the American Academy of Family Physicians, estimated that less than 3 percent of its 134,000 members use this model, but said the number is slowly growing.

The move to concierge medicine may be more prevalent in wealthier areas.

Travis Singleton, executive vice president for medical staffing company Merritt Hawkins, said doctors switching to other payment systems or those charging Medicare patients a higher price for care are likely “in more affluent, well-to-do areas where, frankly, they can get fees.”

It is far easier for physicians than hospitals to opt out of taking Medicare patients. Most hospitals have to accept them since they rely on Medicare payments to fund inpatient stays, doctor training and other functions.

The majority of physicians do still accept Medicare, and most people insured by the federal health insurance program have no problem finding another health-care provider. But that transition can be tough, particularly for older adults with multiple medical conditions.

“When transition of care happens, from one provider to another, that trust is often lost and it takes time to build that trust again,” said Fatima Sheikh, a geriatrician and the chief medical officer of FutureCare, which operates 15 rehabilitation and skilled nursing centers in Maryland.

Shuffling doctors also heightens the risk of mishaps.

A study of at least 2,200 older adults published in 2016 found that nearly 4 in 10 were taking at least five medications at the same time. Fifteen percent of them were at risk of drug-to-drug interaction. Primary care providers mitigate this risk by coordinating among doctors on behalf of the patient, said Kellie Flood, a geriatrician at the University of Alabama at Birmingham.

“You really need the primary care physicians to serve as the quarterback of the health-care team,” Flood said. “If that’s suddenly lost, there’s really not a written document that can sum all that up and just be sent” to the new doctor.

Finding a physician who accepts Medicare depends partly on workforce demographics. From 2010 to 2017, doctors providing primary care services to Medicare beneficiaries increased by 13 percent, according to the Medicare Payment Advisory Commission (MedPAC), a nonpartisan group that advises Congress.

But the swell of seniors who qualify for Medicare has outpaced the number of doctors available to treat them. Every day, an estimated 10,000 Americans turn 65 and become eligible for the government program, the Census Bureau reported.

The impact: In 2010, MedPAC reported, there were 3.8 primary care doctors for every 1,000 Medicare enrollees. In 2017, it was 3.5.

Authors of a MedPAC report out last June suggested that the number of available primary care providers could be an overestimate. Their calculation assumed all internal medicine doctors provided these services when, in reality, many specialize in certain medical conditions, or accept only a limited number of Medicare patients into their practices.

But MedPAC concluded seniors are not at a disadvantage finding a doctor.

“We found that beneficiaries have access to clinician services that is largely comparable with (or in some cases better) access for privately insured individuals, although a small number of beneficiaries report problems finding a new primary care doctor,” the MedPAC researchers wrote.

The outbreak of the novel coronavirus has complicated the ability for many Americans to access care, regardless of their insurer. But many older patients now have an opportunity to connect with their doctors virtually after the Centers for Medicare and Medicaid Services (CMS) broadened access to telemedicine services under Medicare.

Experts said the long-term effects of the coronavirus on doctors and Medicare remain unknown. But Martin said the shortage of cash that many doctors are experiencing because of the coronavirus epidemic has revealed the shortcomings of how primary care doctors are paid.

“The covid crisis really brought to life the challenges of fee for service,” Martin said.

Despite these challenges, the number of doctors choosing to opt out of Medicare has been on the decline, according to CMS data.

Singleton, of Merritt Hawkins, said concern about doctors leaving the Medicare system is part of larger workforce issues. Those include the need to recruit more medical students to concentrate on primary care.

One estimate predicts the nation will face a shortage of 23,600 primary care physicians by 2025. The majority of residents in internal medicine – those who care for adults – are choosing a subspecialty such as cardiac care or gastroenterology, MedPAC reported.

In 2017, MedPAC reported, the median compensation for all doctors was $300,000 a year. Among primary care doctors, it was $242,000.

Creative business models can make up that difference. Under the concierge model, the doctor charges patients an annual fee – akin to a gym membership – to access their practice. The provider still bills the insurer – including Medicare – for all patient care.

Another model, called direct primary care, charges the patient an annual fee for access and care; doctors do not bill health insurance plans.

Proponents say that the model enables them to take more time with their patients without dealing with the bureaucracy of getting paid by health insurers.

“I think what is most attractive to direct primary care is that they just practice medicine,” Martin said.

The size of a physician practice can also determine whether it accepts Medicare. Large practices can better offset the lower Medicare payment rates by leveraging their influence with private insurers to raise those reimbursements, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. But small, independent clinics may not have the same clout.

“If you’re a large primary care practice, private insurers are really going to want to have you in their network,” he said. “And they’re willing to pay more than they might pay an individual solo practitioner who they’re not as concerned (with) because it’s only one physician.”

In Carrier and Resnikoff’s case, after more than a dozen calls they found another primary care doctor. They said she accepts Medicare and impressed them during their meet-and-greet with her knowledge of their medical history. She also met their age and expertise criteria.

“At this point in our lives, I’d be eager to find somebody who’s young enough that they might be in practice for the next 10 years,” Carrier said.

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This report is a product of Kaiser Health News, a nonprofit news service covering health issues. It is not affiliated with Kaiser Permanente.

What is toxic stress? It’s prolonged adversity and/or abuse – not having enough to eat or being exposed to violence. It’s the kind of stress that puts you on edge and keeps you there, day after day after day.

If you’re familiar with the Centers for Disease Control and Prevention-Kaiser Permanente study from the 1990s, you know that factors such as divorce, domestic violence or having an incarcerated parent are called adverse childhood experiences (ACEs). Four or more ACEs can result in chronic health conditions such as heart disease or diabetes. In the long term, living with ACEs or other negative factors, such as poverty, can literally change your brain chemistry.

“Ms. Apple said that I have a traumatized brain,” my daughter, Cleo, said matter-of-factly after school one day. Her counselor had shown her a video and talked with her about why she reacts the way she does to certain triggers, such as someone blocking a door. Telling me this, Cleo sounded relieved, even empowered: It finally made sense to her.

As a director at a nonprofit group for preventing child abuse, I’ve known about ACEs for a long time. But it wasn’t until I brought a 12-year-old foster child into my life that I fully understood their impact. What does it look like for a young person to live with several ACEs and no supports? As custodial guardian to my daughter, now 16, I can only speak from my own observations.

For Cleo, it’s not being able to sleep without the light on. It’s eating even when she’s full. For a while, she was what the school called a “runner” – she left school whenever she was upset. For a while, this happened every day. She’d make it halfway across town before I caught up with her.

She was a cutter; she was suicidal. She had trouble forming appropriate friendships. She trashed her room several times; in one fight-or-flight moment, she climbed out of her window and tumbled one story to the snowy ground. She once jumped out of my car (which was, thankfully, not moving very fast). On several occasions, I had to restrain her by wrapping my arms around her shoulders or waist, using all my strength to keep her from leaving or hurting herself.

When she reacted in those ways, impulsively and without thought, I would tell her over and over, “Stop, calm down, I love you.” One day, when I raised my hand to motion toward something, she flinched. No, that’s not right – she ducked. And my heart broke for this young woman, who should know by now that I would never hit her.

I became a foster parent because I thought I had things to give – time and care and love – to kids who needed them. Initially, I was the person whom the county calls when a child is removed from a home and has nowhere else to go, or when a foster family needs a break. That’s what I signed up for: emergency respite.

Then I met Cleo.

She was all elbows and colt legs, a talented artist who had been in and out of the child-welfare system most of her life. That first weekend with her, I found out that we both like cute kitten videos and television shows about vampires. I saw a child who wanted to be happy but who, after a lifetime of abuse and neglect, didn’t know how.

There was something about this kid that moved me. She tried so hard. Emotionally, she was much younger than 12, but she was also more resilient than most adults I knew. She came to stay with me every weekend after that, until a couple of months later, when her foster family decided that they’d had enough (she was “challenging,” she was “too much”). They sent her to residential care.

Believing that she belonged in a home, I fought with the county social service agencies to bring her home with me. Another year later, I supported a reunification with her biological mother – but, when that didn’t work out, I agreed to share custody. Cleo came to live with me and our dog, Zelda. A host of friends and family cheered us on.

Cleo and I worked hard, both with therapists and on our own, to build her coping skills. We sat together for hours over her schoolwork. I got her an individualized education plan that allowed for smaller classes and more breaks when she needed them. She had near-perfect attendance for the first time ever and glowed when she brought home a good grade. We set aside one hour each night to cuddle on the couch and watch those vampire shows. We had structure. We had routine.

We’d liked each other right away, but trusting each other took time. I’ll never forget the first time she asked, “Can I hug you?”

It’s been four years now. We persevere. We’re in this together, and we are resilient. I’ve taken pains to build a fortress of protective factors around my girl. Protective factors are those things that most of us take for granted – a friend to call when we need advice; someone to help when that car I mentioned won’t start. Some of us are born with built-in protective factors (a supportive family, enough money); others need to collect them (a family made up of friends, perhaps).

For Cleo, protective factors include school supports – not just teachers and staff who are kind, but trauma-informed teachers and staff who understand how ACEs can be reflected in behavior. Her protective factors are as simple as my giving her a night-light, and as complex as my helping to facilitate her relationships with the aunts she hadn’t seen in years. Her biggest protective factor? A dog who shows her unconditional love.

There are so many young people like my daughter everywhere. National data shows that more than 20 percent of children up to age 17 have experienced two or more ACEs. I’ve given a lot of thought to the ways that we, as a society, could help to ease and hopefully heal trauma in children. Here are my ideas:

First, we need to acknowledge that brain toxicity exists. Yes, a child can have post-traumatic stress disorder; PTSD is not reserved for combat veterans. Or maybe it is – maybe we need to start seeing these children as refugees from a war zone. We need to educate ourselves about ACEs and look at all people through a trauma-informed lens. We need to admit that ACEs are not limited to low-income neighborhoods, and that the domestic violence and substance abuse that take place in higher income homes are just as toxic.

We need to stop asking “What’s wrong with you?” and ask, instead, “What happened to you?”

Second, we need to stop treating children who’ve been affected by trauma as if their behavior doesn’t make sense. We need to approach them with understanding and compassion, and give them tools to help them cope. In the state of New York, every April 30 is ACEs Awareness Day, and the state mandates trauma training for domestic-violence shelter workers and child-care providers. My wish list includes trauma training for child-protective services workers, family court and law enforcement personnel, and for physicians. We also need to increase mental-health supports, so that there are therapists and crisis-response teams to refer to.

Finally, we must not see these children as damaged or doomed. They’re only lost causes if we make them so by giving up on them or telling them they’re worthless. Treating them as if their trauma is their fault, or as if their reactions make no sense, doesn’t help anyone. We need to shore up (or perhaps create) a safety net: The child-welfare, mental-health and education systems must work together to serve the whole child, or kids will fall through the cracks.

When I look at my daughter, I see the way her whole face lights up when Zelda licks it. I see how proud she feels when someone praises her for a job well done. I see the baby steps we make every day (not lashing out, not running away) and call them progress – and they are. One night, this teenager who rarely made eye contact as a child went around the room after a party and hugged every adult there.

When I told her that I was writing this piece, she said that she wanted adults to know this: “Records only tell part of the story. Nobody takes into account what the kids are dealing with. You can’t treat kids with trauma like kids without trauma. You have to treat us differently – but don’t make us feel different. You can’t tell us how to feel, or drug us up with medication. You have to listen.”

Cleo is remarkably resilient. How do I know this? Because she gets up every morning and tries again.

She hasn’t given up. So I won’t give up on her. And I hope others don’t, either.

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O’Connor is director of policy and advocacy at Prevent Child Abuse NY and director of the NYS Home Visiting Coordination Initiative. This essay originally appeared on Pulse – Voices From the Heart of Medicine, which publishes personal accounts of illness and healing.