Recommendations for healthy voting 2020 — an open letter to California election officials

12 min readAug 25, 2020

Voting is a health issue in 2020 — as health professionals in California we believe strongly that no one should have to sacrifice their health to vote. Health professionals have a role to play in supporting election procedures that minimize transmission of COVID-19.

It may surprise doctors unfamiliar with the details of voting that infection control procedures are not the only issues that need to be addressed for healthy voting. Trust in the system, and design of the process play a critical role in protecting health for voters and poll workers alike.

We are sending the letter below to every County election official in California to help support them as they carry out healthy voting procedures during the COVID-19 pandemic.

Although this letter is specifically aimed at California election officials, some of the concepts and details may be useful in other states as well.

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August 26, 2020

Dear California County Election Officials:

Thank you for all the absolutely essential work you do to support voting, the bedrock of our democracy. We understand that you are being tasked with implementing major changes on short notice, with great uncertainty. Protecting health in the midst of this pandemic involves much more than simply superimposing distancing and sanitizing procedures onto the usual voting processes. Protecting Public Health In the 2020 Election makes clear that healthy voting means ensuring free, fair, and safe elections that voters trust. California is off to a good start with passage of AB860 for Universal Vote By Mail and new mandates in SB 423, but challenges remain.

We are Climate Health Now, representing over 350 medical professionals from across the state of California. We are concerned that every Californian — many of whom are our patients and their families — be able to stay healthy while exercising their right to vote during the COVID-19 pandemic. That is why we are collaborating with the Union of Concerned Scientists, the UCLA Voting Rights Project, and the Voting Rights Lab on the project: Voting in the Year of COVID. We are reaching out to you to open a conversation about your preparations to keep all of our patients safe while voting in November and to see if there are ways we can help as Californian health professionals. Of course your local County Public Health Officer should be your primary resource for health guidance, but given the demands on their resources, the many faceted interactions between technical administrative aspects of voting and their impact on health, and evolving expert opinion, we would like to offer some thoughts.

We must start with first principles: the absolute best thing that counties can do to safeguard voters and election workers is to get the pandemic under control. This requires face coverings, social and physical distancing, accessible testing that is resulted within 48 hours, and contact tracing. County leaders have a role to play in implementing, normalizing and enforcing these efforts. Unfortunately, public health experts fully expect the pandemic to be with us into the fall. Our comments below are based on, and meant to complement, clarify, update and strengthen, the generally excellent guidance provided by the California Secretary of State (SoS) in Election Administration Guidance under COVID-19. We emphasize certain areas of special importance to maintain health and trust in the process so that voters can exercise their political franchise without compromising their health. As the COVID pandemic has hit certain communities especially hard, we have applied that knowledge to the recommendations. As we have learned more about SARS-CoV-2 transmission and best practices are evolving, we have tried to upgrade and clarify recommendations. The recommendations in this letter are current to late August 2020 but, of course, we must all stay attuned to changes in state and local health guidelines.

Vote by mail (VBM) is clearly the safest option to decrease exposure to the SARS-CoV-2 for both voters and election workers. However, universal VBM is not a panacea for a number of reasons: it may disenfranchise voters through receipt, delivery, and counting issues; some voters will still need the assistance provided with in-person voting, especially those who face language barriers or who are handicapped; some will choose in-person voting due to distrust of VBM or historical preference. This is especially true for disadvantaged and minority communities, already hard hit by COVID and at greatest risk of both transmitting and suffering from COVID if they do choose in-person voting. All of this means that trust in our Vote By Mail system is now a health issue. Voters must trust that VBM is secure and equitable in order to use it. Voters must be familiar with the process to use it successfully. The known higher rejection of VBM ballots and fears about the US Postal Service’s operations have created distrust. Measures to improve trust — normally considered to be technical or administrative issues in election procedures — are now, in 2020, crucial to preserving health. As voters’ confidence in the security and reliability of VBM increases, the pressure to vote in person and risk infection with SARS-CoV-2 decreases. A public health campaign to educate voters on how to seal, sign, and deliver their ballot on time is crucial to prevent simple mistakes that can disenfranchise many voters. Many of us have active clinical practices and would be willing to help get out the message that using VBM is safest for health, especially for voters already burdened by disproportionate rates of COVID, yet least likely to use VBM.

Vote by mail recommendations to maximize health for both election workers and voters:

VOTE BY MAIL (VBM) BALLOTS:

● Provide clearly written instructions on all VBM ballots and envelopes at a grade school reading level in the voter’s language of choice.

● Provide clear instructions with the VBM ballots that if voters decide to vote in-person, they must bring the unused VBM ballot with them to surrender at the polls in order to avoid being required to use a provisional ballot and longer transaction times.

● Launch a state-wide campaign to educate voters on new processes, the health benefits of VBM, and to assure them of a secure chain of custody for ballots and procedures for accurate counting and audits. This educational outreach needs to be culturally and linguistically appropriate. This is an area where our health voice could be valuable.

● Communicate clearly, early and often with voters about the multiple methods, locations, and timing for returning their ballot (e.g. postmark for mail, drop box availability, in-person drop off locations and times).

● Provide a convenient method to request a replacement ballot, including drive-through service, in case of spoiled, lost, or never received ballot.

● Prepare election workers to handle the increased number of voters dropping off their VBM ballot in person.

● Count VBM ballots as soon as they are received from the 29th day before the election (October 5th) as allowed per AB 860 to maximize time and accuracy.

● Use standardized procedures and trained election workers for signature verification to avoid disenfranchising legitimate voters. (Note: SB 759 requires elections officials to notify voters of mismatched signatures at least eight days prior to the certification of an election. Ballots would then be counted by elections officials if a signature verification statement is returned no later than 5:00 p.m. two days prior to the certification of the election).

● Adopt procedures that prevent disenfranchising voters through excessive ballot rejection for minor technical errors on the VBM ballot, such as signature below the line or stray marks.

● Provide ballot tracking including notification of rejected ballots with the opportunity to cure any problems by the canvassing deadline.

DROP BOXES:

● Ensure that a greater number of drop boxes are distributed within the communities least likely to use VBM, which are communities of poverty and color that are already overburdened by COVID-19.

● Place drop boxes in locations that are secure, convenient, and accessible to all voters, whether voters are driving, walking, using a mobility device, or using public transportation.

● Provide as many exteriorly located, tamper-proof drop boxes as possible, as early as possible in the election season.

● Implement public preferences for drop box locations.

● Communicate to voters the drop boxes locations and that ballots may be deposited from October 5 through close of polls at 8:00pm on Election Day, November 3, 2020.

In-person voting is still necessary because some voters need in-person assistance, some distrust the mail system, and some simply prefer coming in person. Cruelly, in the pandemic and associated economic crisis, changes of address may interfere with stable registration and obtaining VBM ballots.

COVID-19 precautions will need to be implemented and enforced as per the Secretary of State’s Election Administration Guidance under COVID-19. Designing the voting place to facilitate physical distancing coupled with avoiding long lines by ensuring smoothly functioning processes may well be as important as the infection prevention procedures themselves. Keeping voting transaction times below 15 minutes is a fundamental goal to decrease transmission of SARS-CoV-2, as 15 minutes is the duration considered to be “close contact.” The assumption must be that any person may transmit SARS-CoV-2, so standard precautions must be maintained at all times.

In-person voting recommendations to maximize health for both election workers and voters:

● Open early voting polling places for the longest possible number of days in order to spread voters over time.

● Ensure that vote centers are concentrated in the communities least likely to use VBM, which are communities of poverty and color already overburdened by COVID-19.

● Communicate to voters early and often that they must bring and surrender their VBM ballot to avoid use of a provisional ballot and the resulting longer transaction times.

Steps to decrease the risk of SARS-CoV-2 infection at polling places by reducing time in the voting process and physical proximity of voters with each other and with poll workers:

● Provide large, spacious vote centers (e.g. open air stadiums, other stadiums, gymnasiums).

● Prepare for a surge in provisional voting since all voters received a VBM ballot.

● Implement procedures for the fastest possible check-in process.

● Minimize wait times to reduce the number of people standing in line.

● Configure a one-way flow of people.

● Keep 6 foot distancing of voting stations where it is feasible without limiting an adequate number of stations. Alternatively, install physical barriers if a 6 foot distance cannot be maintained and transaction times are expected to be long — eg for voters needing assistance.

NOTE: Some experts suggest the Guidance for 6 foot spacing of voting stations may actually increase overall risk of transmission if it limits the number of stations the polling location can accommodate, thus causing long lines. In such instances, closer spacing of voting stations may be preferable, as long as the duration of time in the voting station is under 15 minutes.

● Ensure six foot distancing for all other activities such as waiting in line, checking in, and checking out.

Steps for election workers to decrease the risk of SARS-CoV-19 infection at polling places by minimizing exposure to SARS-CoV-2 particles:

● Optimize ventilation and/or open doors and windows at indoor vote centers.

● Install physical dividers where possible.

● Post clear, simple instructions for voters to minimize exposure: wear masks, keep 6 feet apart, sanitize hands at entry and exit, use contactless procedures, do not share items, be prepared with sample ballot and unused VBM ballot.

● Require all people to wear a face covering over their nose and mouth.

○ Offer masks to any voter who presents without one

○ Refer to section below on high contagion risk voters if mask is refused

● Wear masks in any indoor area that other people may enter or use, not just when others are present.

● Wear face shields especially for high exposure activities such as symptom screening, customer service, welcoming, or other high-traffic sites.

● Offer curbside voting for COVID impacted voters.

● Follow the infection control Guidance per the SoS as below:

○ Use gloves according to [election worker] guidelines (required in high traffic, high contact areas, and for handling used ballots).

○ Avoid touching surfaces as much as possible.

○ Sanitize high touch surfaces frequently.

○ Offer and encourage use of hand sanitizer and hand washing opportunities, especially at entrance, exit, and voting machine/ballot marking area.

○ Use contactless procedures wherever possible.

○ Avoid sharing items.

○ Disinfect items that must be shared between each use (e.g. stylus, pens, activation cards, e-poll books).

○ Follow the Secretary of State’s Election Administration Guidance for COVID-19 training, screening, and protection of election workers.

○ Follow the Election Administration guidance for any election workers known to have a SARS-CoV-2 exposure or symptoms of COVID-19 disease.

Extra steps to decrease the risk of SARS-CoV-2 infection at polling places for high contagion risk voters: COVID-impacted voters (COVID-19 positive, close contacts, those displaying symptoms of COVID-19) and voters refusing to wear a mask:

Shortening the duration of contact and maximizing distance remain fundamental, especially in these high contagion risk patients. If rapid testing and results become available by November, offering extended days for voting could afford enough time for many contacts and symptomatic patients to receive negative tests for COVID-19 and then vote in the usual way.

● Post signs discouraging COVID impacted voters from entering the polling place and provide options such as a designated polling place, curbside voting, or VBM.

● Provide contactless curbside voting.

● Use additional protective equipment and training for poll workers assisting COVID-impacted voters. It must be appreciated that ideal personal protective equipment, such as N95 masks with fit-testing, may not be available or may need to be reserved for medical personnel. Properly fit- tested N95 masks with face shields are ideal. Medical grade surgical masks with face shields are a very good alternative. Cloth masks are not considered personal protective equipment, so would be a distant third choice to be used only if higher grade face coverings are unavailable. If waterproof gowns are unavailable, alternatives include a waterproof apron, or an outer garment that can be removed after leaving the high risk location (such as a cloth gown or lab coat.)

For reference, CA SoS Guidance calls for “providing a full set of protective equipment and additional safe operating procedures,” which may align with CDC guidance, but does not use the same specific language, leading to uncertainty regarding what protective equipment must be supplied. Current CDC recommendations include “personal protective equipment to include respiratory protection, face shields, gowns, gloves and training in appropriate use of this equipment. Masks are not meant to be a substitute for personal protective equipment such as surgical masks, N95 respirators, or other medical personal protective equipment.”

● Use additional physical distancing per SoS Guidance. Escort the voter to maintain distance from others.

● Speed the voter through the process as much as possible.

● Sanitize the area and voting machine immediately afterwards, before use by any other voter.

● Offer the voter hand sanitizer before and after handling the ballot.

● Place ballots in a separate container and quarantine for 3+ hours if possible.

● Disinfect any clipboard (washable) used for curbside voting immediately after each user.

● Change gloves and sanitize hands between each COVID-19 positive voter.

● Minimize confrontation with voters who refuse to wear a mask. Instead make every effort to speed the voter through the process; relocate the voter to an area with more physical distancing, supervise their movement and voting wearing a faceshield, mask and gloves; sanitize the polling station and machine before use by other voters.

Steps to decrease the risk of SARS-CoV-2 infection at polling places by avoiding long lines of people waiting through anticipating administrative challenges;

● Anticipate increased moves, evictions and homelessness due to the pandemic that will increase registration demands at the polls.

● Anticipate a surge of provisional voters and have ample supplies.

● Make back-up paper poll books available in case of power loss or outage.

● If using electronic voting machines, provide hand-marked ballots in case of power loss or outage.

● If using electronic voting machines, provide backup hand-marked paper ballots for any line of voters requiring over a 30 minute wait.

In conclusion, we would like to thank you for taking time in this very busy pre-election season to engage with us. Voting in 2020 is a health issue. We would like to help you in protecting public health in this election. We hope that by emphasizing the need for trust in Vote-By-Mail that we have made clear the connection between how you administer VBM and safeguarding the public health. We hope that emphasizing the disproportionate impact of COVID on the same communities that are likely to be most impacted by changes in voting procedures makes clear the need for extra outreach with increased siting of both drop boxes and vote centers for these communities. Finally, we hope that discussion of the principles to decrease transmission and presentation of current best practices makes it easier for you to understand, implement and follow them. We would like to serve as a resource to ensure that voting is conducted in as safe a manner as possible to keep our patients and fellow Californians healthy. We hope that you will reach out to us for any clarification on the above recommendations or if there are other ways we could help provide support. Please let us know if you would be interested in taking part in a virtual meeting to discuss this further or if there are other specific ways in which our health voices could be useful.

Sincerely,

Cynthia Mahoney, MD

Karina Maher, MD

Amanda Millstein, MD

Margie Chen, MD

Janet Perlman, MD, MPH

Renata Kiefer, MD, MPH

Sarah Koster, FNP, MPH

Ashley McClure, MD

Climate Health Now

We can be reached at caclimatehealthnow@gmail.com

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