The harsh wind-hammered tundra sometimes complicates the prospect, as do the polar bears. But the children are enthusiastic pupils.
Perhaps the most exciting aspect of modern hip replacement is the increasing use of robotic surgery.
Black Americans are receiving covid vaccinations at dramatically lower rates than white Americans in the first weeks of the chaotic rollout, according to a new KHN analysis.
About 3% of Americans have received at least one dose of a coronavirus vaccine so far. But in 16 states that have released data by race, white residents are being vaccinated at significantly higher rates than Black residents, according to the analysis — in many cases two to three times higher.
In the most dramatic case, 1.2% of white Pennsylvanians had been vaccinated as of Jan. 14, compared with 0.3% of Black Pennsylvanians.
The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that’s typically racially diverse made up of physicians, hospital cafeteria workers, nurses and janitorial staffers.
If the rollout were reaching people of all races equally, the shares of people vaccinated whose race is known should loosely align with the demographics of health care workers. But in every state, Black Americans were significantly underrepresented among people vaccinated so far.
Access issues and mistrust rooted in structural racism appear to be the major factors leaving Black health care workers behind in the quest to vaccinate the nation. The unbalanced uptake among what might seem like a relatively easy-to-vaccinate workforce doesn’t bode well for the rest of the country’s dispersed population.
Black, Hispanic and Native Americans are dying from covid at nearly three times the rate of white Americans, according to a Centers for Disease Control and Prevention analysis. And non-Hispanic Black and Asian health care workers are more likely to contract covid and to die from it than white workers. (Hispanics can be of any race.)
“My concern now is if we don’t vaccinate the population that’s highest-risk, we’re going to see even more disproportional deaths in Black and brown communities,” said Dr. Fola May, a UCLA physician and health equity researcher. “It breaks my heart.”
Dr. Taison Bell, a University of Virginia Health System physician who serves on its vaccination distribution committee, stressed that the hesitancy among some Blacks about getting vaccinated is not monolithic. Nurses he spoke with were concerned it could damage their fertility, while a Black co-worker asked him about the safety of the Moderna vaccine since it was the company’s first such product on the market. Some floated conspiracy theories, while other Black co-workers just wanted to talk to someone they trust like Bell, who is also Black.
But access issues persist, even in hospital systems. Bell was horrified to discover that members of environmental services — the janitorial staff — did not have access to hospital email. The vaccine registration information sent out to the hospital staff was not reaching them.
“That’s what structural racism looks like,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Those groups were seen and not heard — nobody thought about it.”
UVA Health spokesperson Eric Swenson said some of the janitorial crew were among the first to get vaccines and officials took additional steps to reach those not typically on email. He said more than 50% of the environmental services team has been vaccinated so far.
A Failure of Federal Response
As the public health commissioner of Columbus, Ohio, and a Black physician, Dr. Mysheika Roberts has a test for any new doctor she sees for care: She makes a point of not telling them she’s a physician. Then she sees if she’s talked down to or treated with dignity.
That’s the level of mistrust she says public health officials must overcome to vaccinate Black Americans — one that’s rooted in generations of mistreatment and the legacy of the infamous Tuskegee syphilis study and Henrietta Lacks’ experience.
A high-profile Black religious group, the Nation of Islam, for example, is urging its members via its website not to get vaccinated because of what Minister Louis Farrakhan calls the “treacherous history of experimentation.” The group, classified as a hate group by the Southern Poverty Law Center, is well known for spreading conspiracy theories.
Public health messaging has been slow to stop the spread of misinformation about the vaccine on social media. The choice of name for the vaccine development, “Operation Warp Speed,” didn’t help; it left many feeling this was all done too fast.
Benjamin noted that while the nonprofit Ad Council has raised over $37 million for a marketing blitz to encourage Americans to get vaccinated, a government ad campaign from the Health and Human Services Department never materialized after being decried as too political during an election year.
“We were late to start the planning process,” Benjamin said. “We should have started this in April and May.”
And experts are clear: It shouldn’t merely be ads of famous athletes or celebrities getting the shots.
“We have to dig deep, go the old-fashioned way with flyers, with neighbors talking to neighbors, with pastors talking to their church members,” Roberts said.
Speed vs. Equity
Mississippi state Health Officer Dr. Thomas Dobbs said that the shift announced Tuesday by the Trump administration to reward states that distribute vaccines quickly with more shots makes the rollout a “Darwinian process.”
Dobbs worries Black populations who may need more time for outreach will be left behind. Only 18% of those vaccinated in Mississippi so far are Black, in a state that’s 38% Black.
It might be faster to administer 100 vaccinations in a drive-thru location than in a rural clinic, but that doesn’t ensure equitable access, Dobbs said.
“Those with time, computer systems and transportation are going to get vaccines more than other folks — that’s just the reality of it,” Dobbs said.
In Washington, D.C, a digital divide is already evident, said Dr. Jessica Boyd, the chief medical officer of Unity Health Care, which runs several community health centers. After the city opened vaccine appointments to those 65 and older, slots were gone in a day. And Boyd’s staffers couldn’t get eligible patients into the system that fast. Most of those patients don’t have easy access to the internet or need technical assistance.
“If we’re going to solve the issues of inequity, we need to think differently,” Boyd said.
Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, said the limited supply of vaccine must also be considered.
“We are missing the boat on equity,” he said. “If we don’t step back and address that, it’s going to get worse.”
While Plescia is heartened by President-elect Joe Biden’s vow to administer 100 million doses in 100 days, he worries the Biden administration could fall into the same trap.
And the lack of public data makes it difficult to spot such racial inequities in real time. Fifteen states provided race data publicly, Missouri did so upon request, and eight other states declined or did not respond. Several do not report vaccination numbers separately for Native Americans and other groups, and some are missing race data for many of those vaccinated. The CDC plans to add race and ethnicity data to its public dashboard, but CDC spokesperson Kristen Nordlund said it could not give a timeline for when.
One-third of Black adults in the U.S. said they don’t plan to get vaccinated, citing the newness of the vaccine and fears about safety as the top deterrents, according to a December poll from KFF. (KHN is an editorially independent program of KFF.) Half of them said they were concerned about getting covid from the vaccine itself, which is not possible.
Experts say this kind of misinformation is a growing problem. Inaccurate conspiracy theories that the vaccines contain government tracking chips have gained ground on social media.
Just over half of Black Americans who plan to get the vaccine said they’d wait to see how well it’s working in others before getting it themselves, compared with 36% of white Americans. That hesitation can even be found in the health care workforce.
“We shouldn’t make the assumption that just because someone works in health care that they somehow will have better information or better understanding,” Bell said.
In Colorado, Black workers at Centura Health were 44% less likely to get the vaccine than their white counterparts. Latino workers were 22% less likely. The hospital system of more than 21,000 workers is developing messaging campaigns to reduce the gap.
“To reach the people we really want to reach, we have to do things in a different way, we can’t just offer the vaccine,” said Dr. Ozzie Grenardo, a senior vice president and chief diversity and inclusion officer at Centura. “We have to go deeper and provide more depth to the resources and who is delivering the message.”
That takes time and personal connections. It takes people of all ethnicities within those communities, like Willy Nuyens.
Nuyens, who identifies as Hispanic, has worked for Kaiser Permanente Los Angeles Medical Center for 33 years. Working on the environmental services staff, he’s now cleaning covid patients’ rooms. (KHN is not affiliated with Kaiser Permanente.)
In Los Angeles County, 92% of health care workers and first responders who have died of covid were nonwhite. Nuyens has seen too many of his co-workers lose family to the disease. He jumped at the chance to get the vaccine but was surprised to hear only 20% of his 315-person department was doing the same.
So he went to work persuading his co-workers, reassuring them that the vaccine would protect them and their families, not kill them.
“I take two employees, encourage them and ask them to encourage another two each,” he said.
So far, uptake in his department has more than doubled to 45%. He hopes it will be over 70% soon.
“There will be a period of epic withdrawal,” warned one addiction specialist, once schools, activities and social life return to normal.
Over the past year, as the health authorities have tried to curb the Covid-19 pandemic, researchers have trained their scientific attention on a variety of potentially risky environments: places where large groups of people gather and the novel coronavirus has ample opportunity to spread. They have swabbed surfaces on cruise ships, tracked case numbers in gyms, sampled ventilation units in hospitals, mapped seating arrangements in restaurants and modeled boarding procedures in airplanes.
They have paid less attention to another everyday environment: the car. A typical car, of course, does not carry nearly enough people to host a traditional super-spreader event. But cars come with risks of their own; they are small, tightly sealed spaces that make social distancing impossible and trap the tiny, airborne particles, or aerosols, that can transmit the coronavirus.
“Even if you’re wearing a face covering, you still get tiny aerosols that are released every time you breathe,” said Varghese Mathai, a physicist at the University of Massachusetts, Amherst. “And if it’s a confined cabin, then you keep releasing these tiny particles, and they naturally would build up over time.”
In a new study, Dr. Mathai and three colleagues at Brown University — Asimanshu Das, Jeffrey Bailey and Kenneth Breuer — used computer simulations to map how virus-laden airborne particles might flow through the inside of a car. Their results, published in early January in Science Advances, suggest that opening certain windows can create air currents that could help keep both riders and drivers safe from infectious diseases like Covid-19.
To conduct the study, the research team employed what are known as computational fluid dynamic simulations. Engineers commonly use these kinds of computer simulations, which model how gases or liquids move, to create racecars with lower drag, for instance, or airplanes with better lift.
The team simulated a car loosely based on a Toyota Prius driving at 50 miles per hour, with two occupants: a driver in the front left seat and a single passenger in the back right, a seating arrangement that is common in taxis and ride shares and that maximizes social distancing. In their initial analysis, the researchers found that the way the air flows around the outside of the moving car creates a pressure gradient inside the car, with the air pressure in the front slightly lower than the air pressure in the back. As a result, air circulating inside the cabin tends to flow from the back of the car to the front.
Next, they modeled the interior air flow — and the movement of simulated aerosols — when different combinations of windows were open or closed. (The air-conditioning was on in all scenarios.) Unsurprisingly, they found that the ventilation rate was lowest when all four windows were closed. In this scenario, roughly 8 to 10 percent of aerosols exhaled by one of the car’s occupants could reach the other person, the simulation suggested. When all the windows were completely open, on the other hand, ventilation rates soared, and the influx of fresh air flushed many of the airborne particles out of the car; just 0.2 to 2 percent of the simulated aerosols traveled between driver and passenger.
The results jibe with public health guidelines that recommend opening windows to reduce the spread of the novel coronavirus in enclosed spaces. “It’s essentially bringing the outdoors inside, and we know that the risk outdoors is very low,” said Joseph Allen, a ventilation expert at the Harvard T.H. Chan School of Public Health. In an op-ed last year, he highlighted the danger that cars could pose for coronavirus transmission, and the potential benefits of opening the windows. “When you have that much turnover of air, the residence time, or how much time the aerosols stay inside the cabin, is very short,” Dr. Allen said
Because it’s not always practical to have all the windows wide open, especially in the depths of winter, Dr. Mathai and his colleagues also modeled several other options. They found that while the most intuitive-seeming solution — having the driver and the passenger each roll down their own windows — was better than keeping all the windows closed, an even better strategy was to open the windows that are opposite each occupant. That configuration allows fresh air to flow in through the back left window and out through the front right window and helps create a barrier between the driver and the passenger.
“It’s like an air curtain,” Dr. Mathai said. “It flushes out all the air that’s released by the passenger, and it also creates a strong wind region in between the driver and the passenger.”
Richard Corsi, an air quality expert at Portland State University, praised the new study. “It’s pretty sophisticated, what they did,” he said, although he cautioned that changing the number of passengers in the car or the driving speed could affect the results.
Dr. Corsi, a co-author of the op-ed with Dr. Allen last year, has since developed his own model of the inhalation of coronavirus aerosols in various situations. His results, which have not yet been published, suggest that a 20-minute car ride with someone who is emitting infectious coronavirus particles can be much riskier than sharing a classroom or a restaurant with that person for more than an hour.
“The focus has been on superspreader events” because they involve a lot of people, he said. “But I think what sometimes people miss is that superspreader events are started by somebody who’s infected who comes to that event, and we don’t speak often enough about where that person got infected.”
In a follow-up study, which has not yet been published, Dr. Mathai found that opening the windows halfway seemed to provide about the same benefit as opening them fully, while cracking them just one-quarter of the way open was less effective.
Dr. Mathai said that the general findings would most likely hold for many four-door, five-seat cars, not just the Prius. “For minivans and pickups, I would still say that opening all windows or opening at least two windows can be beneficial,” he said. “Beyond that, I would be extrapolating too much.”
Welcome. Before weekdays and weekends were indistinguishable, we left the house. Now, we’re inside, many of us, most of time. With the same people and pets, or on our own; the same routines and rooms; and, everywhere we turn, the same stuff, so much stuff. What used to be décor is now clutter. What once was cozy is now claustrophobic. This is when I turn to The Annoying Bag.
The Annoying Bag is any paper or plastic bag I have lying around, or — when disposable shopping bags are scarce, as they have been in my apartment lately — a clear produce bag or threadbare reusable tote. Annoying Bag in hand, I prowl my apartment, dropping anything I deem “annoying” at that moment into it. I collect half-burned candles and stray socks; broken sunglasses, old magazines, jars of condiments that have been squatting in the fridge so long I forgot they’re not on the lease.
The Annoying Bag is an exercise to be performed quickly, impulsively. This is not a closet overhaul or cupboard clean-out. You don’t hold an item close and ask if it sparks joy before it goes in the Annoying Bag. The KonMari Method, spring cleaning — those are thoughtful, sustainable processes in which clothes get donated and yogurt containers get recycled. The Annoying Bag is all remorseless id: You might throw away the T-shirt you’re wearing because it’s annoying you. Three pennies that have been gathering dust on the counter, waiting to be put into a coin jar? A set of cake-decorating tips that you’ve used once but are taking up half a drawer? Don’t think about it. Throw them in.
After about ten minutes of snatch-and-toss, I knot the Annoying Bag and take it to the trash — not my trash can, but the trash on the curb, permanently out of the house. I have never once missed anything that left the house in the Annoying Bag. The impulses for disposal that occur in these feverish bursts of decluttering are always correct. The relief is instant and exhilarating.
Online shopping has been tempting during the pandemic. My usual thinking goes something like, “Stores are risky, distractions are limited, I’m feeling blue, better buy this teakettle.” A friend told me once that everything you buy makes each thing you own a little less valuable. I’m trying to keep that in mind, trying to buy less and keep annoying stuff out of the house in the first place. “Getting and spending, we lay waste our powers,” wrote Wordsworth, exhorting us to dispense with materialism and get back to nature, which seems like a worthy pursuit right now.
Or, if you’re not feeling outdoorsy, consider Marie Kondo’s advice: “Use this time at home to take inventory of your possessions — and to re-evaluate your relationship with them. Cultivate an awareness of what you have. On a practical level, this will prevent overbuying things, but I hope it will also bring a renewed appreciation for all that you do have.”
Instead of stress shopping this weekend, check out “The Essential Octavia Butler,” our guide to getting started with the science-fiction writer.
The Hold Steady has a new single, “Heavy Covenant,” and it’s a good one for nostalgia. When Craig Finn sings, “It seems a single body is a couple different people in this one life,” it’s nearly impossible not to be transported to 2006.
And the community Ask MetaFilter has some excellent ideas for dealing with pandemic fatigue.
How do you contain your clutter? What are your best strategies for keeping your home tidy and organized? Write to us: firstname.lastname@example.org. Include your name, age and location and we might publish your response in a forthcoming newsletter. We’re At Home. We’ll read every letter sent. More ideas for how to spend your time this weekend appear below. See you next week.
Seven years ago, Laura McKowen started a drinking journal. She knew alcohol was an issue for her — she knew it when her 4-year-old daughter helped her clean up the morning after a blackout, and she knew it the 10th time she drove to work hung over — but she needed to see it.
“Something very interesting happens when we put things on paper,” Ms. McKowen said, “because we have a lot of cognitive dissonance around drinking.” She couldn’t deflect around what she saw on the page, though: two bottles of wine a night. She got sober, and went on to help others do the same through coaching and teaching workshops.
Last January, Ms. McKowen published “We Are the Luckiest: The Surprising Magic of a Sober Life” and in March, she began hosting free sobriety support meetings on Zoom. By May, she had 12 employees and a company called The Luckiest Club, which offers classes and access to its community.
It’s no surprise Ms. McKowen found an eager client base. According to the 2019 National Survey on Drug Use and Health, more than 14 million American adults suffer from alcohol use disorder (A.U.D.), which is a term medical professionals prefer to alcoholism.
You don’t need an A.U.D. diagnosis to find your drinking problematic, though. Alcohol can impair sleep, cause weight gain, exacerbate anxiety, or subtly change your personality. A study conducted by the RAND Corporation in September suggests Americans are drinking 14 percent more often in response to pandemic-related stress, especially women, whose heavy drinking days increased by 41 percent in 2020.
When we go to work every day during non-pandemic times and don’t have an inordinate amount of stress, it’s fairly easy” to limit drinking to Friday nights, said James G. Murphy, a psychology professor and researcher at the University of Memphis who published a paper in November about alcohol and drug use during the pandemic. “When all of that structure is ripped away — when you’re worried about finances and your kids’ home-schooling and you don’t have to be anywhere in the morning, so no one will see if you’re hung over — alcohol can be way more difficult to manage.”
This is one reason you might be seeing more Dry January hashtags in your social media feeds this year. One month off from drinking can be an opportunity for the sober-curious to examine their alcohol use.
If any of this sounds familiar, here are some suggestions to help you navigate your relationship with alcohol or bring it to an end.
Take note of how much you’re drinking, as well as the pros and cons of that consumption. Are you opening that bottle of Riesling because it pairs well with your Chinese takeout, or are you hoping the third glass will drown out those voices in your head that are telling you you’re mediocre? Study your own habits — and be honest about them.
To give you some perspective, the federal government’s 2020-2025 U.S. Dietary Guidelines for Americans recommend no more than one drink per day for women or two for men (though some suggest fewer), and Dr. Murphy suggests the free alcohol screener at the website CheckUp & Choices. Take the questionnaire, which is used by health care providers, and use the score to assess your drinking. Similarly, Drinks Meter is an app with a daily calculator that helps put your own behavior into perspective using an anonymous database of over 6,000 people’s drinking habits worldwide.
“You don’t have to have things figured out, aside from wanting to make a change,” said Holly Whitaker, the author of “Quit Like a Woman: The Radical Choice to Not Drink in a Culture Obsessed with Alcohol” and creator of an online A.U.D. recovery program called Tempest. “You’re doing it right now, by being brave enough to read this article.”
Clear out the alcohol.
If you’ve decided alcohol is having a negative impact on your life, try distancing yourself from it for a while. Remove bottles from your physical spaces and booze-related content from your virtual ones. Cleanse your phone and computer of anything that might tempt you to drink.
It’s not about having a siloed existence or avoiding anything that creates an urge to drink, said Ms. McKowen, it’s about dismantling the myth that drinking is what makes life fun. “You want your online world to reflect the energy of where you’re going,” she said.
Then try not to drink for a month. Pick a date and stick with it. Experts say this is the best way to evaluate your alcohol use, and it’s a jump start on reducing your consumption, if that’s what you decide to do.
“Detoxification literally means removing the toxin,” said George F. Koob, director of the National Institute on Alcohol Abuse and Alcoholism. This can be done on your own unless you have moderate to severe A.U.D., in which case you should seek medical help. Untreated severe alcohol withdrawal can be fatal.
But fill the space with something else.
Alcohol does have positive effects: It squashes tension and lowers inhibitions. Remove it and you will miss it, at least initially.
So, identify other activities you love and increase them. Whether it’s exercise or spending time with friends, “we need another outlet to fill the void that alcohol leaves,” Dr. Murphy said.
Find your people.
You’re more likely to successfully abstain from alcohol if you have support. “Tell as many of your friends and family members who feel safe as you can about this,” Dr. Murphy said.
It also helps to connect with others who share your goal. In-person support meetings have become difficult to access in the pandemic, but help has proliferated online. Free sobriety support communities with virtual meetings include Alcoholics Anonymous, SMART Recovery, SheRecovers, In the Rooms, Eight Step Recovery, Refuge Recovery, Recovery Dharma, and LifeRing, among others. Neither good lighting nor charisma is required or expected; join from your phone while walking in a park or sitting in your car.
“I go to two meetings a day now,” said Braunwyn Windham-Burke, a reality TV star whose sobriety journey is currently playing out on season 15 of “The Real Housewives of Orange County.” “It’s so easy, because it’s in my bedroom.”
One Tempest member, Valentine Darling, 32, of Olympia, Wash., finds virtual meetings to be more L.G.B.T.Q.-friendly as well. “I feel safe sitting next to my house plants, so I’m more fully present and I’m also more authentically me: I wear dresses and express my gender queerness without worrying that anyone will follow me home.”
Many organizations have meetings specifically for people of color, certain age groups or even professions. Ben’s Friends is a sobriety support group geared toward restaurant workers. “We speak a common language in restaurants,” said co-founder Steve Palmer. “You find out that, ‘OK, he’s a line cook. She’s a bartender. These are my people.’”
Understand what recovery means for you.
If your month of sobriety was relatively easy to accomplish, then simply consider it a reset. But if you’re having trouble sticking to your plan, you might need more than group meetings. You may have A.U.D., which is a disease, not a moral failing, and it requires treatment like any illness. The most effective form of recovery usually involves long-term behavioral therapies and community support as well as medication, if needed.
The N.I.A.A.A. navigator can help you find the right treatment for you. The Substance Abuse and Mental Health Services Administration at the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) also has an online treatment locator.
If you decide you want to maintain your sobriety long-term, understand that treatment plans may vary over time. “The same practices that helped you quit drinking might not keep you sober later on,” Ms. Whitaker said. Maybe you’ve unlocked a trauma along the way, maybe you’re going through a divorce or maybe you’re living in the midst of a pandemic.
You haven’t done anything wrong; you just need a fresh set of tools.
Dr. Murphy recommends continuing to keep a log of alcohol use. Apps like Drink Control and Drinks Meter can help, but even using a pen and paper, make note of any benefits you see, to keep your momentum going. When you backslide, make note of that — and how you feel about it.
It probably took a long time to develop your current relationship with alcohol. Changing that relationship, then, will require sustained effort — and it might take several attempts. If the first one doesn’t last, Dr. Koob said, don’t judge yourself harshly. Just try again.
Como médica de emergencias, la doctora Eugenia South fue parte del primer grupo de personas en recibir la vacuna contra covid. Tuvo su segunda dosis a principios de enero, incluso antes que el presidente electo Joe Biden.
Así y todo, South dice que no tiene apuro por dejar de usar máscara
“Honestamente, no creo que vuelva a estar sin máscara en el trabajo”, dijo South, quien es directora del Urban Health Lab de la Universidad de Pennsylvania en Philadelphia. “No creo que me sentiría segura”.
Aunque las vacunas contra covid son altamente efectivas, South planea seguir usando máscara dentro y fuera del hospital.
Expertos en salud dicen que hay buenas razones para seguir el ejemplo de esta doctora.
“El uso de máscaras y el distanciamiento social deberán continuar en el futuro, hasta que tengamos cierto nivel de inmunidad colectiva”, dijo el doctor Preeti Malani, oficial de salud jefe de la Universidad de Michigan. “Las máscaras y el distanciamiento están aquí para quedarse”.
Malani y otros expertos en salud explican cinco razones:
- Ninguna vacuna es 100% efectiva
Extensos ensayos clínicos hallaron que dos dosis de las vacunas de Moderna y Pfizer-BioNTech prevenían el 95% de las enfermedades causadas por el coronavirus. Si bien esos resultados son impresionantes, 1 de cada 20 personas queda desprotegida, dijo el doctor Tom Frieden, ex director de los Centros para el Control y Prevención de Enfermedades (CDC).
Malani señala que las vacunas se probaron en ensayos clínicos controlados, en los mejores centros médicos, en condiciones óptimas.
Pero en el mundo real, las vacunas suelen ser un poco menos efectivas. Los científicos usan términos específicos para describir el fenómeno. Se refieren a la protección que ofrecen las vacunas en los ensayos clínicos como “eficacia”, mientras que la inmunidad real que se obvserva en la población vacunada es “efectividad”.
La efectividad de las vacunas contra covid podría verse afectada por la forma en que se manipulan, observó Malani. El material genético utilizado en las vacunas elaboradas con ARN mensajero del coronavirus es tán frágil que debe almacenarse y transportarse con cuidado.
Cualquier variante que no siga la guía de manejo de vacunas de los CDC podría influir en su funcionamiento, explicó Malani.
- Las vacunas no brindan protección inmediata
Malani explicó que ninguna vacuna ofrece protección apenas la persona se vacuna. El sistema inmunológico tarda aproximadamente dos semanas en producir anticuerpos que bloquean las infecciones virales.
Las vacunas contra covid, sin embargo, tardarán un poco más que otras porque tanto la de Pfizer como la de Moderna, requieren de dos dosis. Las dosis de Pfizer se administran con tres semanas de diferencia, las de Moderna, con cuatro semanas.
Es decir que no habrá protección completa hasta cinco o seis semanas después de la primera dosis. Una persona que se vacunó el día de Año Nuevo no estará completamente protegida hasta el día de San Valentín.
- Es posible que las vacunas no impidan propagar el virus
Las vacunas pueden poporcionar dos niveles de protección. Por ejemplo, la vacuna contra el sarampión previene que el virus infecte un organismo, por lo que las personas vacunadas no transmiten la infección ni desarrollan síntomas.
La mayoría de las otras vacunas, como la de la gripe, evitan que las personas se enfermen pero no que se infecten o transmitan el virus a otros, explicó el doctor Paul Offit, asesor de los Institutos Nacionales de Salud (NIH) y de la Administración de Drogas y Alimentos (FDA) sobre las vacunas contra covid.
Si bien las vacunas contra covid claramente previenen la enfermedad, los científicos necesitan más tiempo para descubrir si también previenen la transmisión, dijo Saskia Popescu, epidemióloga con sede en Phoenix y profesora asistente en el programa de biodefensa de la Escuela Schar de Gobierno y Políticas de la Universidad George Mason.
“Todavía no sabemos si la vacuna protege contra la infección o solo contra la enfermedad”, dijo Frieden, quien ahora es director ejecutivo de Resolve to Save Lives, una iniciativa mundial de salud pública. “En otras palabras, una persona vacunada podría transmitir el virus, incluso si no se siente enferma”.
Hasta que los investigadores puedan responder esta pregunta, usar cubrebocas es la forma más segura para que las personas vacunadas protejan a quienes las rodean.
- Las máscaras protegen a personas con sistemas inmunitarios comprometidos
Las personas con cáncer tienen un riesgo particular de contraer covid. Estudios han mostrado que son más propensos a infectarse y a morir a causa del coronavirus. Y es posible que las vacunas no los protejan dijo el doctor Gary Lyman, profesor del Centro de Investigación del Cáncer Fred Hutchinson.
Los pacientes con cáncer son vulnerables en muchos aspectos. Las personas con cáncer de pulmón son menos capaces de combatir una neumonía, y los que están bajo quimioterapia o radioterapia tienen sistemas inmunes debilitados. La leucemia y el linfoma atacan directamente las células inmunitarias, lo que dificulta que los pacientes combatan el virus.
Lyman dijo que no se sabe cómo reaccionarán a la vacuna los pacientes oncológicos, porque fueron excluidos de los ensayos clínicos. A solo unos pocos participantes se les diagnóstico cáncer después de inscribirse. En este grupo, la protección de las vacunas solo fue del 76%.
“Por ahora, debemos asumir que los pacientes con cáncer pueden no experimentar el 95% de eficacia”, completó Lyman.
También hay algunas personas alérgicas que no pueden vacunarse.
Usar máscaras también ayuda a proteger a estos grupos más vulnerables.
- Las máscaras protegen contra cualquier cepa del coronavirus, la original y las nuevas mutaciones
Hasta ahora, los estudios sugieren que las vacunas protegerán contra estas cepas. Pero es claro, según explicó Frieden, que los cubrebocas, la distancia física y medidas como evitar multitudes protegen contra todas las formas del virus, y de otros virus respiratorios.
Por ejemplo, los casos de gripe bajaron dramáticamente en todo el mundo desde que se implementaron las cuarentenas y el uso de máscaras.
Lo ideal es combinar las vacunas con las máscaras y el distanciamiento, para poner fin a la pandemia, dijo Offit. “Los tres enfoques funcionan mejor en equipo”.
In the past 24 hours, President-elect Joe Biden has delivered two speeches focused on the nation’s covid response.
Thursday night, he laid out a $1.9 trillion-dollar plan to address what he’s calling the “twin crises” of the covid-19 pandemic and the economy.
Biden proposed, among other things, that Congress allocate funds for implementing a national vaccination program, reopening schools, sending $1,400 checks to Americans who need them, providing support for small businesses, and extending unemployment insurance. He also proposed increasing subsidies for Affordable Care Act insurance coverage, and providing more assistance for housing, nutrition and child care.
The plan is ambitious and will likely face some pushback in Congress. (Read PolitiFact’s analysis here.)
Friday afternoon he offered a more detailed take on his vaccine distribution plan.
On his first day in office, he said, he will instruct the Federal Emergency Management Agency to start setting up mass vaccination centers across the country. Biden promised to have 100 of these sites set up by the end of his first month in office.
He also said his administration will work with pharmacies across the country to distribute vaccine more effectively and employ the Defense Production Act to ensure adequate vaccine supplies. His administration will also launch a public education campaign to address vaccine hesitancy and ensure that marginalized communities will be reached.
Biden maintained during the speech that he intends to reach the goal of “100 million shots the first 100 days in office.” He also said he will stick with the Centers for Disease Control and Prevention’s latest recommendation to distribute covid vaccines to those who are 65 and older, as well as essential workers, to push states to allocate the supply quickly.
During his Thursday speech outlining what he’s dubbed the “American Rescue Plan,” Biden made several claims about the current response to the pandemic and how it’s affecting Americans. We fact-checked and gave context to a couple of the president-elect’s statements.
“The vaccine rollout in the United States has been a dismal failure thus far.”
The vaccine rollout is far short of what officials promised. According to a Centers for Disease Control and Prevention tracker, since mid-December, when vaccines first started being distributed, about 30 million doses have been sent out. But only about 11 million have actually been administered into the arms of Americans. The Department of Health and Human Services had initially issued a goal of administering 20 million doses by the end of December.
A key reason for the slow pace, experts said, is that many state and local health departments lack the funding and resources to execute such a mass vaccination campaign. Communication with the federal government has also been dicey. Many states have complained that they aren’t informed about how much vaccine they will receive and when — making logistical planning difficult. In addition, the outgoing Trump administration recently changed its recommendations for who should qualify, adding an additional layer of confusion.
Still, public health experts say part of the reason the initial rollout was slow was that it occurred during the December holidays, when many locations were understaffed. And since Congress approved a second covid stimulus bill, states will receive about $3 billion in funding, which will help efforts.
“One in 7 households in America — more than 1 in 5 Black and Latino households in America — report they don’t have enough food to eat.”
This is accurate. Estimates vary on the exact number of Americans who live in households that are food insecure, but Biden’s numbers match recent numbers from the U.S. Census Bureau. The numbers translate to about 14% of all households and 20% of Black and Latino households.
The Census Bureau estimates food insecurity throughout the pandemic in a weekly report. According to numbers from December, 14% of all adults in the country reported their households sometimes or often not having enough food to eat in the last seven days. The data from December also shows that 24% of Black households and 21% of Latino households did not have enough to eat.
A Northwestern University study estimates that at one point during the pandemic, nearly 23% of households experienced food insecurity.
“These crises are straining the budgets of states and cities and tribal communities that are forced to consider layoff and service restrictions of the most needed workers.”
This is accurate. State and local governments generally by law are required to balance their operating budgets, resulting in layoffs and reductions in services — though federal aid provided through covid relief helped. Late last year, the Brookings Institution projected state and local revenues would decline by $155 billion in 2020 and $167 billion in 2021. According to a report by the Center on Budget and Policy Priorities, states and localities had furloughed or laid off 1.2 million workers through October 2020. Brookings also noted that, because state and local governments “are at the forefront of the response to the pandemic” they “will likely need to increase their typical spending to provide crucial public health services and help communities adapt to social distancing guidelines.”
Additionally, news reports starting early last summer detail a high number of health care workers being laid off or losing their jobs during the pandemic. Public health workers have also been furloughed or had their hours cut, despite having to create covid testing sites, initiate contact tracing programs and now create mass vaccination campaigns.
“Over the last year alone, over 600,000 educators have lost their jobs in our cities and towns.”
This is a softened version of a previous claim about laid-off “teachers” that we rated Mostly False. This number likely refers to Bureau of Labor Statistics data that shows the number of local government education jobs declined from March to October by 666,000.
But that number doesn’t refer only to layoffs. Rather, it notes a net decrease in jobs. Reports show that, during the pandemic, some educators have quit, retired or taken a leave of absence.
It’s also not clear what type of educators Biden is referring to, and though the BLS does track layoff data by industry, it lumps state and local education data together, which means public college staff numbers are included. The BLS data shows that from March to October 39,000 state and local educators were laid off or discharged.
Associated Press, “Teacher Departures Leave Schools Scrambling for Substitutes,” Sept. 13, 2020
Becker’s Hospital Review, “Record Number of Healthcare Workers Laid Off, Furloughed During Pandemic,” June 5, 2020
The Brookings Institution, “How Much Is COVID-19 Hurting State and Local Revenues?” Sept. 24, 2020
Bureau of Labor Statistics, Employment, Hours, and Earnings from the Current Employment Statistics Survey (National), accessed Jan. 15, 2021
Bureau of Labor Statistics, Job Openings and Labor Turnover Survey, accessed Jan. 15, 2021
Centers for Disease Control and Prevention, COVID Data Tracker – Vaccinations, accessed Jan. 15, 2021
Center on Budget and Policy Priorities, “Tracking the COVID-19 Recession’s Effect on Food, Housing, and Employment Hardships,” Jan. 8, 2021 (updated Jan. 15)
Center on Budget and Policy Priorities, “Pandemic’s Impact on State Revenues Less Than Earlier Expected But Still Severe,” Oct. 30, 2020
U.S. Census Bureau, Household Pulse Survey Data Tables, accessed Jan. 15, 2021
Kaiser Health News and Associated Press, “Hollowed-Out Public Health System Faces More Cuts Amid Virus,” July 1, 2020
Northwestern University, “How Much Has Food Insecurity Risen? Evidence from the Census Household Pulse Survey,” June 10, 2020
PolitiFact, “Biden Mischaracterizes Teacher Layoffs From Pandemic,” Nov. 20, 2020
Rev.com, “Joe Biden Speech Transcript on COVID-19 Economic Recovery Plan,” accessed Jan. 15, 2021
The effort to vaccinate some of the country’s most vulnerable residents against covid-19 has been slowed by a federal program that sends retail pharmacists into nursing homes — accompanied by layers of bureaucracy and logistical snafus.
As of Thursday, more than 4.7 million doses of the Pfizer-BioNTech and Moderna covid vaccines had been allocated to the federal pharmacy partnership, which has deputized pharmacy teams from Walgreens and CVS to vaccinate nursing home residents and workers. Since the program started in some states on Dec. 21, however, they have administered about one-quarter of the doses, according to the Centers for Disease Control and Prevention.
Across the country, some nursing home directors and health care officials say the partnership is actually hampering the vaccination process by imposing paperwork and cumbersome corporate policies on facilities that are thinly staffed and reeling from the devastating effects of the coronavirus. They argue that nursing homes are unique medical facilities that would be better served by medical workers who already understand how they operate.
Mississippi’s state health officer, Dr. Thomas Dobbs, said the partnership “has been a fiasco.”
The state has committed 90,000 vaccine doses to the effort, but the pharmacies had administered only 5% of those shots as of Thursday, Dobbs said. Pharmacy officials told him they’re having trouble finding enough people to staff the program.
Dobbs pointed to neighboring Alabama and Louisiana, which he says are vaccinating long-term care residents at four times the rate of Mississippi.
“We’re getting a lot of angry people because it’s going so slowly, and we’re unhappy too,” he said.
Many of the nursing homes that have successfully vaccinated willing residents and staff members are doing so without federal help.
For instance, Los Angeles Jewish Home, with roughly 1,650 staff members and 1,100 residents on four campuses, started vaccinating Dec. 30. By Jan. 11, the home’s medical staff had administered its 1,640th dose. Even the facility’s chief medical director, Noah Marco, helped vaccinate.
The home is in Los Angeles County, which declined to participate in the CVS/Walgreens program. Instead, it has tasked nursing homes with administering vaccines themselves, and is using only Moderna’s easier-to-handle product, which doesn’t need to be stored at ultracold temperatures, like the Pfizer vaccine. (Both vaccines require two doses to offer full protection, spaced 21 to 28 days apart.)
By contrast, Mariner Health Central, which operates 20 nursing homes in California, is relying on the federal partnership for its homes outside of L.A. County. One of them won’t be getting its first doses until next week.
“It’s been so much worse than anybody expected,” said the chain’s chief medical officer, Dr. Karl Steinberg. “That light at the end of the tunnel is dim.”
Nursing homes have experienced some of the worst outbreaks of the pandemic. Though they house less than 1% of the nation’s population, nursing homes have accounted for 37% of deaths, according to the COVID Tracking Project.
Facilities participating in the federal partnership typically schedule three vaccine clinics over the course of nine to 12 weeks. Ideally, those who are eligible and want a vaccine will get the first dose at the first clinic and the second dose three to four weeks later. The third clinic is considered a makeup day for anyone who missed the others. Before administering the vaccines, the pharmacies require the nursing homes to obtain consent from residents and staffers.
Despite the complaints of a slow rollout, CVS and Walgreens said they’re on track to finish giving the first doses by Jan. 25, as promised.
“Everything has gone as planned, save for a few instances where we’ve been challenged or had difficulties making contact with long-term care facilities to schedule clinics,” said Joe Goode, a spokesperson for CVS Health.
Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, acknowledged some delays through the partnership, but said that’s to be expected because this kind of effort has never before been attempted.
“There’s a feeling they’ll get up to speed with it and it will be helpful, as health departments are pretty overstretched,” Plescia said.
But any delay puts lives at risk, said Dr. Michael Wasserman, the immediate past president of the California Association of Long Term Care Medicine.
“I’m about to go nuclear on this,” he said. “There should never be an excuse about people not getting vaccinated. There’s no excuse for delays.”
Bringing in Vaccinators
Nursing homes are equipped with resources that could have helped the vaccination effort — but often aren’t being used.
Most already work with specialized pharmacists who understand the needs of nursing homes and administer medications and yearly vaccinations. These pharmacists know the patients and their medical histories, and are familiar with the apparatus of nursing homes, said Linda Taetz, chief compliance officer for Mariner Health Central.
“It’s not that they aren’t capable,” Taetz said of the retail pharmacists. “They just aren’t embedded in our buildings.”
If a facility participates in the federal program, it can’t use these or any other pharmacists or staffers to vaccinate, said Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties.
But many nursing homes would like the flexibility to do so because they believe it would speed the process, help build trust and get more people to say yes to the vaccine, she said.
Howell pointed to West Virginia, which relied primarily on local, independent pharmacies instead of the federal program to vaccinate its nursing home residents.
The state opted against the partnership largely because CVS/Walgreens would have taken weeks to begin shots and Republican Gov. Jim Justice wanted them to start immediately, said Marty Wright, CEO of the West Virginia Health Care Association, which represents the state’s long-term care facilities.
The bulk of the work is being done by more than 60 pharmacies, giving the state greater control over how the doses were distributed, Wright said. The pharmacies were joined by Walgreens in the second week, he said, though not as part of the federal partnership.
“We had more interest from local pharmacies than facilities we could partner them up with,” Wright said. Preliminary estimates show that more than 80% of residents and 60% of staffers in more than 200 homes got a first dose by the end of December, he said.
Goode from CVS said his company’s participation in the program is being led by its long-term care division, which has deep experience with nursing homes. He noted that tens of thousands of nursing homes — about 85% nationally, according to the CDC — have found that reassuring enough to participate.
“That underscores the trust the long-term care community has in CVS and Walgreens,” he said.
Vaccine recipients don’t pay anything out-of-pocket for the shots. The costs of purchasing and administering them are covered by the federal government and health insurance, which means CVS and Walgreens stand to make a lot of money: Medicare is reimbursing $16.94 for the first shot and $28.39 for the second.
Technically, federal law doesn’t require nursing homes to obtain written consent for vaccinations.
But CVS and Walgreens require them to get verbal or written consent from residents or family members, which must be documented on forms supplied by the pharmacies.
Goode said consent hasn’t been an impediment so far, but many people on the ground disagree. The requirements have slowed the process as nursing homes collect paper forms and Medicare numbers from residents, said Tracy Greene Mintz, a social worker who owns Senior Care Training, which trains and deploys social workers in more than 100 facilities around California.
In some cases, social workers have mailed paper consent forms to families and waited to get them back, she said.
“The facilities are busy trying to keep residents alive,” Greene Mintz said. “If you want to get paid from Medicare, do your own paperwork,” she suggested to CVS and Walgreens.
Scheduling has also been a challenge for some nursing homes, partly because people who are actively sick with covid shouldn’t be vaccinated, the CDC advises.
“If something comes up — say, an entire building becomes covid-positive — you don’t want the pharmacists coming because nobody is going to get the vaccine,” said Taetz of Mariner Health.
Both pharmacy companies say they work with facilities to reschedule when necessary. That happened at Windsor Chico Creek Care and Rehabilitation in Chico, California, where a clinic was pushed back a day because the facility was awaiting covid test results for residents. Melissa Cabrera, who manages the facility’s infection control, described the process as streamlined and professional.
In Illinois, about 12,000 of the state’s roughly 55,000 nursing home residents had received their first dose by Sunday, mostly through the CVS/Walgreens partnership, said Matt Hartman, executive director of the Illinois Health Care Association.
While Hartman hopes the pharmacies will finish administering the first round by the end of the month, he noted that there’s a lot of “headache” around scheduling the clinics, especially when homes have outbreaks.
“Are we happy that we haven’t gotten through round one and West Virginia is done?” he asked. “Absolutely not.”
KHN correspondent Rachana Pradhan contributed to this report.
This article is part of our new series, Currents, which examines how rapid advances in technology are transforming our lives.
In the first joint replacement surgery in 1890, the German surgeon Themistocles Gluck implanted “carved and machined pieces of ivory” into joints diseased by tuberculosis — starting with a knee replacement for a 17-year-old girl, according to the medical historian and author Dr. David Schneider.
The implants used today, as well as those doing the implanting, are radically different from those in the days of Themistocles Gluck.
In thousands of such procedures, robots are now assisting surgeons to ensure an optimum fit of the new joint. Although many doctors still perform the procedures successfully without their assistance, the robots’ ability to help achieve more precise implant positioning — often determined through 3-D computerized modeling of the patient’s joint before the actual procedure — makes their role likely to grow over the next decade as the implants become more individualized, and such technologies as augmented reality are integrated into the operating room.
And the replacements themselves have changed. Over the past century, they have evolved to include metal, plastic and ceramics, and are now made of titanium, cobalt chrome and specially reinforced plastics. (Gone are the metal-on-metal replacements that caused problems in hip replacements in the past).
But something else important has also changed: the psychology of the patients, specifically, baby boomers. Now in their late 50s, 60s and 70s, they represent about half of the patients for the most common, knee and hip replacements.
“This is the first generation that is trying to stay active on an aging frame,” said Dr. Nicholas DiNubile, an orthopedic surgeon in Havertown, Pa. “My parents weren’t active at all. If they went out and did something and were sore afterwards, they’d never do it again. But baby boomers stay active, in droves.”
Dr. DiNubile, 67, author of several books on the subject, coined the term “boomeritis” to describe the wave of sports-related injuries he has been seeing in his practice among his cohort. “I’m still trying to play tennis at a high level,” he said. “My knees hurt sometimes, but I’m not stopping.”
This change in attitude is a striking difference in the patient population, and some say it has helped drive the advances in orthopedic surgery.
“When I started practice 30 years ago, if someone had hip pain, we’d take an X-ray and even if they had arthritis, and were in their 40s, we’d tell them to modify their activity and wait,” said Dr. William Maloney, professor of orthopedic surgery at Stanford University.
No longer. “The technology caught up with our patients’ desire to stay active,” he said.
One of the biggest innovations came in the late 1990s and early 2000s — just in time for the marathon-running, tennis-playing boomers to start showing signs of wear and tear.
“The industry figured out a way to make the implants better,” said Robert Cohen, president of digital, robotics and enabling technologies for Stryker’s Orthopedic joint replacement division in Mahwah, N.J. “We used the exact same plastic — relatively soft, but durable — and put it through a post process, of heat and radiation, that made it even stronger.”
The “highly cross-linked polyethylene” implants significantly reduced the need for revision surgery. “One of the main reasons for revision was the polyethylene breaking down in the replacement joint,” he said.
Thanks to the advent of the stronger, more durable material, he says, “we’ve pretty much eliminated that.”
The new implants also helped lead to faster recovery times.
“When I was a resident, people were admitted to the hospital for 10 days after a total hip or knee,” said Dr. Dorothy Scarpinato, in Melville, N.Y. “Now they get them out after a day or two.” As a result, she added, “people aren’t as afraid of this surgery as they used to be.”
The factors contributing to the shorter hospital stays, Dr. Maloney said, include less invasive surgery, accelerated rehabilitation protocols, better pain management methods and the use of regional as opposed to general anesthesia.
But, Dr. Maloney cautions, despite the fact that many replacements are now done on an outpatient basis, it’s still major surgery. “People are getting kind of cavalier about it,” he said. The primary risks — infection and blood clot — he notes, are “rare, but if it happens to you, it’s a major complication.” The use of antibiotics and blood thinners — not to mention surgical hoods and air filtration systems in the operating room — help ensure a good outcome for the vast majority of patients, according to Dr. Maloney.
In a 2018 study, published in The Journal of Bone and Joint Surgery, researchers projected that the annual numbers of total hip replacements would grow to 635,000 by 2030 (an increase of 71 percent) and of total knee replacements to 1.26 million in (an increase of 85 percent).
Of course, numbers may drop this year, as joint replacements, like many other forms of elective surgery, were delayed at many hospitals because of the coronavirus pandemic.
At Stanford University Medical Center, Dr. Maloney said, “we didn’t do any elective joint replacements between March 13 and May 5.” A backlog followed, he said, although recent pandemic-related restrictions in his state meant that many of those who were waiting, postponed their procedures yet again.
Moreover, he noted, recreational sports activities — the source of wear and tear for many a joint — have been severely curtailed during the lockdowns. “There are no weekend warriors right now,” he said.
But over the past 20 years, they have provided the impetus behind the growth in these procedures. The Hospital for Special Surgery in Manhattan — which performs more replacements than any in the country (according to the Department of Health’s Centers for Medicare and Medicaid) — has tracked a nearly threefold rise in hip and knee replacements, from about 3,500 performed in 2000 to 11,000 in 2019.
Dr. Matthew Sloan at the University of Pennsylvania, the lead author of the 2018 study, said that “among the older patients, the big driver is the desire to stay active.”
And that’s not just active as in being able to shuffle around the block, or play with the grandchildren without pain.
Dorene Schneider of Heathrow, Fla., 65, had both hips replaced in the early 2000s. Already active, Ms. Schneider not only refused to cut back on her exercise but also increased it after surgery. In 2011, she ran her first marathon — seven years after her second hip replacement.
She went on to complete a number of races, including the Antarctica Half Marathon in 2014 and the 2016 New York City Marathon.
Ms. Schneider initially ran to raise money for charity. While her pace has slowed as she’s gotten older — now, she says, her running “is more like fast walking” — she has discovered many health benefits.
“I used to have blood pressure issues, but not anymore,” Ms. Schneider said. “My cholesterol numbers are good, and I feel great. Being active has a lot to do with it.”
Even if her continued high level of activity might mean she will need revision surgery? “That’s the price I’m willing to pay,” she said.
If Ms. Schneider does eventually need new replacements, she will be entering an operating theater very different from the one in which her first ones were implanted. Today, Mr. Cohen says, models of a bone implant can be superimposed on a 3-D model of a patient’s joint.
“This information is imported directly into the robot in the O.R.,” he said, which then “executes the procedure with a level of accuracy and precision that we have never seen.”
About 1,000 robots manufactured by his company, Mr. Cohen says, are now helping to perform about 15,000 joint replacement procedures a month in over 850 hospitals worldwide. That number is expected to increase.
Also, as opposed to Dr. Gluck’s contributions (at the time, the surgeon’s new procedure was dismissed by the German medical establishment), the value and durability of joint replacements today is well recognized. Dr. DiNubile predicts that gradual improvements in the design, components, technologies and techniques of joint replacement will make for even more precise surgeries — demand for which is likely to remain unabated.
“I think arthritis and joint deterioration are here to stay,” he said.
Russell Lee spat a wad of snuff into a Planters peanuts can. We sat at a picnic table in his backyard, next to the railroad tracks. He jackhammered the ground with his right leg.
“Your mom’s having an affair,” said Russ, my mother’s husband.
“What’re you talking about?” I stared at his face — grayed muttonchops against skin bronzed from working under the Texas sun. Hummingbirds buzzed past us, sucking sugar water from the cherry-red feeder. I wanted to crush them.
Russ struggled against tears. “And she has AIDS. I have proof.”
His accusation rang false, but adults held secrets. Then 21, I had mine.
I had met Russell Lee even before my mom did. When I was 5, my uncle took me to visit one of his ailing relatives. In walked a brawny guy carrying a motorcycle helmet and wearing purple pants. His thinning black hair was long and curly.
I wondered if he was a hippie. I’d seen ones on TV but never in real life.
When I was 6, my father, a suit-and-tie-wearing principal, descended into psychosis from abusing alcohol and speed. My mother, Nelda, a petite blonde schoolteacher, escaped with me when the death threats became body blows and a brandished .38.
Mom filed for divorce. The court forbade my father from future contact. We never saw him again.
Three months later, my mom’s sister arranged a blind date with one of her in-laws. He turned out to be Russell Lee, the man in the purple pants.
Mom loved that Russ had overcome life obstacles. One-quarter Cherokee, he was the last of 12 kids in an evangelical family of sharecroppers in the Ozarks. His mother died when he was 7. At 14, Russ quit middle school. He married four years later, had two kids, and by 45 had been divorced for a decade.
Within six weeks, he and my mom married. We moved from a middle-class life in conservative San Antonio to a duplex covered in psychedelic posters in liberal Austin.
My mother told me that Russ was my father now, so I should call him Dad.
I was a first grader and did as told but felt like a liar. Russell and I had met only four times.
He was an avid outdoorsman. I loved books and music. Scrawny, blond and asthmatic, I embodied my stepfather’s opposite, an albino salamander next to a grizzly bear.
Mom wanted me to be more like normal boys. She and her husband decided to remold me.
Cub Scouts was first. I kept offering to make the troop cupcakes.
They redoubled their efforts.
Every boy should know how to hunt and fish, Russ said. I wanted to play Scrabble, but he took me fishing. I threw the pole into the water. He had me shoot a rifle at a coffee can. I missed. “The only ones who’ll be safe are the deer,” he said, shaking his head.
Over time, the relationship with my stepdad became more contentious. Russ grew irate when I was elected student council president my junior year, saying the position interfered with my J.C. Penney janitor job.
He wanted me to quit, but I argued that the position might help me with college scholarships. Nelda and Russ had no money. I negotiated a compromise. “I won’t run again next year.”
But my plan was to run for senior class officer.
The next fall, we went to dinner at a relative’s house. Our hostess hugged me. “The ladies at church say you were elected class president. Congratulations!”
My stepdad smacked his fist against his thigh. “You promised me!” He didn’t look at me during the meal.
“You lied! Now you gotta quit,” he yelled, later in the car.
I startled myself when I said “no.”
He wanted me to move out, but my mother begged for me to be able to stay. I avoided him, going into their home just to sleep.
Each semester of high school, Russ insisted I take an auto repair class. I always stalled, promising “later.”
Every man should know how to work on his car, he said.
Before my last semester, Russell brought up the mechanics’ course again.
The only way I could fit it into my schedule was by dropping calculus, physics and AP English, so I refused.
“Don’t you disrespect—”
“I’m not meant for manual labor, like you!” I shouted. “I have a brain!”
I stuffed my backpack.
“School ends soon. Let him stay until then,” mom pleaded.
Russ acquiesced, but skipped my graduation.
I moved out. When Russell and I saw each other at family events, we’d shake hands for show but keep our distance.
In my junior year of college, Russ was diagnosed with lung cancer. After he’d recovered from surgery, Nelda moved into a motel. My stepfather stayed at the house by the railroad tracks.
When my mom asked me to go see him, I agreed — as a favor to her.
It was during that visit he announced that my mother had AIDS, and that she had been cheating on him with the train engineers.
“When the horn blows, it’s a signal.” He believed my mother was meeting the railroad staff for trysts in a nearby abandoned shack.
“The tracks bend there,” I said, pointing. “The horns are warnings.”
He didn’t believe me. “There’s proof she has AIDS in the shack,” he said.
I crossed the tracks and went inside. “Nelda has AIDS” was spray-painted on a wall. But I recognized Russ’s handwriting. His capital “I” looked like a tadpole swallowing its tail.
When I called my mom, she cried. “He kept accusing me of grotesque sexual infidelity. I couldn’t take it.”
Because of our history of emotional distance, I wasn’t wounded by Russ’s break with reality. He’d been diagnosed with paranoid schizophrenia when I was in my teens. But mom hid the depth of his mental illness from me.
After his lung surgery, he’d stopped taking his meds. Mental illness made his greatest fear appear true: Nelda didn’t love him.
Witnessing the extent of his disorder made me kinder. I started visiting my stepdad on weekends. We convinced him to visit his psychiatrist, who recalibrated his medications. Nelda and Russ reconciled.
Though I’d come to understand him, it took me the better part of a decade to allow myself to trust him — and my mother — with my secret. At 30, I told them I was gay.
“Never made any difference to me,” Russ said.
My jaw hit the floor.
“He’s known since you were 16,” Nelda said. “A boy telephoned. Russ went to get you. You fainted.” I remembered the phone call, but hadn’t realized they did, too. A guy from Nebraska I had a crush on had called long-distance. We’d met at student council camp and I’d been desperate for him to like me.
She paused. “It was hard for me, but he says you were born this way.”
So, Russell Lee had been my secret ally all along.
When I was 45, he fractured a hip, had a heart attack and went into a coma. That night, the nurses told Nelda she had to leave. She hugged Russ. Though he was unconscious, his arm pulled her closer.
I flew back to Texas from New York. “There’s little chance for recovery,” a doctor said. We signed the papers to unplug the respirator.
The morning of his funeral, I walked outside. A hummingbird hovered near my face.
“If I could choose anyone in the world as my dad, I’d choose you,” I whispered. The tiny creature floated a moment longer. Then, it darted away.
Court Stroud lives in New York City, where he’s working on a book.
A few weeks before the U.S. presidential election, Zulema Hormaeche, a tarot reader in Los Angeles, chose a card to reflect the state of the nation. It was the one that depicts a tall building struck by lightning, with flames bursting from the top and occupants leaping to their deaths.
“The Tower,” she said, “is the end of a system as we know it, the end of an era as we know it.”
Ms. Hormaeche has an intimate understanding of the ways this year upended people’s lives and sapped their optimism. She has peered into a huge number of homes during virtual consultations. Her clients tell her they are eating and drinking more, and that they feel desperately lonely. And sometimes they mention even more troubling details. One client, she said, described a dream in which they harmed their children.
“All of us are feeling the fear of everybody,” Ms. Hormaeche said, and that fear, coupled with uncertainty about when it might abate, has caused demand for spiritual guidance to soar. According to data from Yelp, interest in businesses in the somewhat niche “Supernatural Readings” category more than doubled in April. Keen, an online marketplace for psychics, has reported a steep rise in customers.
These consultations function almost as armchair counseling sessions: clients can open up and have their thoughts reflected back at them through a nonscientific — even mystical — lens. And while there is good reason to doubt the material of psychic readings (the mystical realm being inherently unknowable, or at least, endlessly interpretable), these consultations provide comfort for some.
James Alcock, a professor of psychology at York University in Canada, who has spent his career looking at belief systems and debunking scientific studies of the paranormal, said he is unsurprised (albeit concerned) by the appeal of such services. “If you look throughout history, whenever there has been some sort of upheaval or some sort of collective anxiety in society, interest in psychics has shot up,” he said.
“The reason is simple,” Mr. Alcock continued. “People experience a lack of control and anxiety. We’d all like the pandemic to end.” And without definitive answers from scientists, physicians or elected officials, people are turning to more spurious sources for reassurance.
A Growing Online Market
Online psychic marketplaces have been around for decades, though many of the businesses that host them didn’t begin with overt ties to the occult. Purple Ocean, which opened in 2016, was a spinoff of a site originally intended for nutritionists; Keen opened in 1999 as an online marketplace for live advice. As they grew larger, those sites began to embrace psychic services.
Warren Heffelfinger, who has worked in operations in many industries, joined Ingenio, Keen’s parent company, as C.E.O. seven years ago. The site offers clients more than a glimpse of the future, he said: “They come for prediction, but stay for ongoing counseling and therapy.”
Lynn Bufka, the associate executive director for practice research and policy at the American Psychological Association, said that trained therapists were better equipped to talk to clients about mental health. “We have a license to uphold the health and well-being and safety of the individuals that we serve,” she said. “And there’s an accountability.”
But Mr. Heffelfinger isn’t concerned; he sees the trend of consulting psychics as part of a broader secular movement. In recent decades, institutional religion has declined; more than a quarter of U.S. adults now say they think of themselves as spiritual but not religious.
And a surprising number of people say they’ve consulted fortune tellers: 1 in 5 Americans, according to a YouGov survey published in 2017. People go to psychics for all kinds of fanciful services, like palm and aura readings, astrological consultations, cartomancy, mediumship and animal communication. In 2019, the market research firm IBISWorld reported that those businesses had a combined revenue of $2.2 billion.
Even before the pandemic, the business, like so many others, was shifting online. In 2019, consumers spent nearly $40 million on the top 10 U.S. psychic and astrology apps, compared to $24 million the previous year, according to the app research firm Sensor Tower. And demand for services that support emotional well-being (such as counseling and wellness apps) has grown over a year of profound loss and collective anxiety.
“All of this opens up a tremendous amount of new business,” Mr. Heffelfinger said. Nine of Keen’s 10 highest revenue days during its 20-year history happened during the pandemic.
The Upsides of Remote Readings …
For many, performing readings by phone or computer has been a boon. Nicole Bowman, a psychic in Miami who charges $4.49 a minute on Keen, initially honed her skills in shops and bookstores, but she gets the appeal of anonymous platforms.
She prefers the telephone for technical reasons: “Phone sessions allow me to get into a more meditative state.” Its also works better for clients who feel “fidgety” or “nervous” during the session. She said that in her consultations, “the bulk of what I do is empowerment.”
Michael Wamback and Krista Schwimmer, who perform readings in Venice, Calif., are nearing 60 and take the risks of the coronavirus seriously. “I don’t want to end up dying just to do a reading,” Mr. Wamback, 58, said.
These days, they can schedule readings between running errands and looking after their birds, Lily, a crow, and Sister Claire, a dove. (They often swoop across the screen during consultations.) Mr. Wamback has enjoyed using virtual tarot decks; physical decks can lose their uniformity over time, and he worries he might subconsciously choose one card over another. (“I think you can cheat,” he said.)
Before the pandemic, the couple had been thinking of going digital. Not only did they want the freedom to travel, but the Mystic Journey Bookstore in Santa Monica, where they had worked for 20 years, was cutting shifts. The bookshop had more than $1 million in revenue in 2018, said the shop’s owner, Jeffrey Segal, but the rent was rising and they needed to downsize.
Covid-19 forced the couple’s hand. “In the long run, it will be very beneficial,” Mr. Wamback said. “In the short term, it’s a little chaotic.” The clients are fewer, but the readings often last longer. “They’re a bit bored and lonely and just want someone to talk to,” he said. Otherwise, their clients don’t follow a type: “Everyone and anyone — the janitor to the C.E.O., and everyone in between, therapists, strippers.”
Despite the overwhelming number of shared challenges of this year, “the questions really haven’t changed a lot,” Mr. Wamback said of those who consult him. Love and relationships dominate, though they’re filtered through the lens of social distancing. Clients have been asking about their jobs, but it doesn’t compare to 2008. “People felt more hopeless during the recession,” Mr. Wamback said. “They sort of see the virus as just a short-term complication.”
… and the Downsides
Thomas Rabeyron, a professor of clinical psychology and psychopathology at the University of Lorraine in France, recently published the results of a study on a group of 60,000 students during lockdown, where he found marked increases in depression, anxiety and post traumatic symptoms. He compared it to the aftermath of 9/11: the constant warnings of an invisible threat have wreaked havoc on mental health.
Though he is a scientist first, Mr. Rabeyron also conducts research on the paranormal. “Psychics are barometers of social anxiety,” he said.
While consultations can feel very therapeutic, he said, these online marketplaces are full of fraudsters, looking to trick vulnerable clients out of their money. “These people are dangerous,” Mr. Rabeyron said. “Anyone can be a psychic, it’s expensive, it’s the industrialization of clairvoyance.” He thinks limits on how much clients can spend should be mandatory on these sites.
Though Mr. Heffelfinger, of Keen, insists safety is a priority, he declined to say how exactly the site vets its psychics. “I’d love to share with you,” he said, “but maybe if I did, the bad guys would figure out how to get on our platform.”
Fraud and scams are undoubtedly a danger, particularly now. In September, the A.A.R.P.’s Helpline reported receiving at least one or two weekly calls from victims of psychic fraudsters compared to one complaint every couple of months in the past.
Even Mr. Wamback, who relies on videoconferencing technology to work, is critical of the platforms, which he refers to as “psychic sweatshops.” Ms. Bowman, on the other hand, is more skeptical of psychics who haunt the neon signs and small storefronts of New York City. (She’s not the only one; in New York, performing a psychic reading under pretenses other than entertainment is a class B misdemeanor, and those convicted of fraud can face multiple years in prison.)
“All you need is a handful of desperate people,” she said.
Bridging the Counseling Gap
In recent years technology has opened up new possibilities for counseling, in addition to traditional talk therapy. Apps that feature consultations with professionals and self-guided thought exercises have reached a wider population, and the evolving view that mental health is simply health has reduced some of the stigma around seeking help. The pandemic has only caused demand for such services to rise.
But instead of seeking out mental health professionals, some sufferers have looked to psychics. Mr. Alcock, the psychology professor, is worried they are using these sessions to make important life decisions. “People ask specific questions sometimes,” he said. “This gets really serious when people ask for medical advice.”
Indeed, equating therapists and psychics places a global mental health crisis in the hands of people with no training. And while many different kinds of counselors — religious, spiritual and mystical among them — may be able to help with temporary bouts of anxiety and depression, only health care professionals have the adequate qualifications to treat chronic conditions and more dangerous disorders like schizophrenia.
Dr. Bufka emphasized that people experiencing distress should reach out to professionals: “Whether it’s going to be a psychologist or other kind of mental health professional, social worker, counselor, primary care provider or a psychiatrist — somebody who has training in mental health concerns and understands what those are, and has expertise in how to best treat and address those problems.”
Mr. Rabeyron believes there are some benefits to nonpsychological consultations, like helping people carry out mourning rites in a new way, or simply listening. He said that clients may decide to consult a professional after talking to a reader.
“When it goes well, it can be an entry point into a process of self-examination,” Mr. Rabeyron said.
Therapy can appear daunting at the outset. The need for multiple sessions can also be a deterrent, along with the possibility of diagnosis or medicalization. “Some people are less frightened of psychics than doctors or psychologists,” Mr. Rabeyron said.
Still, there’s no match for a trained professional. Ms. Hormaeche, who also works as a nurse’s assistant, is used to dealing with vulnerable people, but she is receiving calls that are beyond her expertise. (The uptick could be due to the immense stress of the moment, but there have also been reports of a small number of Covid-19 patients experiencing psychotic symptoms, hearing voices and developing paranoia.)
She mentioned a new client who said he was hearing voices that were encouraging violence. She told him only a doctor could help him; she has not heard from the young man since.
“I hope to God he got some help, but that made the hair on my neck go up,” she said.
California Healthline senior correspondent Anna Maria Barry-Jester discussed public health backlash on WABE’s “Did You Wash Your Hands?” on Jan. 5.
KHN Colorado correspondent Rae Ellen Bichell dissected how covid-19 exacerbates tensions between counties in Colorado on NPR’s “Weekend Edition” on Jan. 9.
KHN chief Washington correspondent Julie Rovner talked about mental health care and the pandemic on WAMU/NPR’s “1A” on Jan. 11.
An 11-minute program of calisthenics and rest, done three times a week for six weeeks, had this effect on out-of-shape young men and women:
It increased their fitness levels
It improved their endurance by 7 percent
It increased their leg power slightly
All of the above
Which statement about body temperatures is not true?
Worldwide, average body temperatures seem to be decreasing
Body temperatures tend to rise during and after exercise
Older people tend to have lower body temperatures than younger people
Body temperature tends to be higher in the morning than in the evening
Health authorities are investigating the death of a 56-year-old doctor in Florida who developed this blood clotting disorder days after receiving the Covid vaccine:
Acute immune thrombocytopenia
Creutzfeldt-Jakob disease, sometimes called mad cow disease, is thought to be caused by this type of infectious organism:
Which statement about throat cancers is not true?
Most throat cancers are caused by human papillomavirus, or HPV
Having oral sex at a young age increases the risk of developing throat cancer
HPV-associated throat cancers are more common in women than men
HPV-associated throat cancers are more common in whites than in African-Americans
Being overweight during pregnancy was tied to this fertility issue, Danish researchers report:
Mothers who are overweight during their first pregnancy are at increased risk of fertility problems during subsequent pregnancies
Daughters born to overweight mothers were at increased risk of having fertility problems
Sons born to overweight mothers were at increased risk of being infertile
All of the above
Diets rich in this vitamin were tied to a lower risk of developing Parkinson’s disease:
Vitamins C and E
Dr. Monte Junker, an Oregon dentist, is waiting for his turn to get vaccinated for covid even though he considers himself a front-line health worker.
“If they offered it to me today, I would be there,” he said.
In December, just before the first vaccines were cleared for emergency use, the Centers for Disease Control and Prevention immunization advisory board recommended that health care workers — as well as nursing home residents and staff members — be the first to be inoculated because of their high risks of infection.
But Oregon is one of a handful of states, including Colorado, North Carolina and Texas, that have put dentists lower in priority order than other health professionals who treat patients — even though they have their hands in people’s mouths and are exposed to aerosols that spray germs in their faces during procedures.
As a result, dentists in those states must wait while many of their peers got their shots in December.
Dr. Tam Le, president of the Connecticut State Dental Association, was vaccinated in December along with employees at his practice in Cheshire. He said he lobbied the state to include dentists with other front-line hospital and health workers.
“In Connecticut, we are doing really well,” he said, noting that the state set up an online registration system for eligible health workers and then contacted them about when and where they could get the vaccine. Le said he and his staff went to a nearby community health center for their shots.
Dentists gained goodwill from state officials last spring by donating gloves and masks to hospitals, Le said. They also offered to help administer the shots since they have experience with that.
States are increasingly diverging from CDC guidance in their vaccination plans, according to an analysis by KFF. “Timelines vary significantly across states, regardless of priority group, resulting in a vaccine rollout labyrinth across the country,” the report said. (KHN is an editorially independent program of KFF.)
The American Dental Association said it’s aware that the lack of a national immunization strategy has meant that dentists and their staffs are not being treated equally across the country.
The CDC advisory board included dentists when it recommended that front-line health workers get priority.
“Each state government’s approach to vaccination will be different based on populations and need, but all dental team members should be prioritized in the first-tier distribution as the vaccines roll out by the different state and county public health departments,” said Daniel Klemmedson, the ADA president. An oral surgeon in Arizona, he has been vaccinated.
In Florida, dentists and their staffs are included among front-line workers eligible for vaccines in the first wave, but a lack of supply has hindered some from getting their shots, according to Drew Eason, CEO of the Florida Dental Association. Some county health departments have also incorrectly turned dentists away, he added.
Dr. Cindy Roark, a Boca Raton dentist and chief clinical officer of Sage Dental, which has 15 offices in Florida and Georgia, said she has no idea when she’ll get vaccinated. She said Georgia dentists in her company have been vaccinated, while those in Florida must wait. The only exceptions appear to be the relatively few dentists affiliated with hospitals. “We are equally vulnerable,” she said.
Still, Roark said she is not upset. “I know I can protect myself,” she said, adding that her office staffers wear N95 masks, face shields and gloves to protect themselves and patients. “Most dentists feel completely safe running their practice and preventing transmission.”
Junker, regional dental director at Advantage Dental in The Dalles, Oregon, said he understands that intensive care staff members, emergency department workers and the elderly in nursing homes need the vaccine first.
“But we are definitely up there for the copious quantities of aerosol in our faces each day,” he said. “The atmosphere is highly concentrated” with virus.
He’s upset at the poor planning and coordination between states and the federal government to make dentists a priority.
In cases where hospital staffers are declining the vaccine because they don’t trust it, Junker said, hospitals should offer shots to dentists and others who are eager for them.
“I don’t think it’s fair for them to sit on the vaccine for a month or two. It needs to get used, and if the hospital workers later decide to get vaccinated, they can get back in line,” he said.
Dr. Stan Hardesty, a Raleigh, North Carolina, dentist and president of the state dental society, said it’s disappointing to see dentists in other states get the vaccine while he and his colleagues have been told to wait.
“We have been advocating on behalf of our members to have dentists and our team members included in phase 1a as recommended by the CDC,” he said. “Unfortunately, the decision-makers [in the state government] have decided to utilize a different prioritization in their vaccine implementation.”
North Carolina dentists will be in “phase 1b,” which includes adults 75 and older, essential workers such as police officers and firefighters.
On Sundays, Bishop Bruce Davis preached love. Through his Pentecostal ministry, he organized youth parades and gave computers, bicycles and food to families in need.
During the week, Bruce practiced what he preached, caring for prisoners at a Georgia hospital. On March 27 he began coughing, and on April 1 he was hospitalized. He’d tested positive for covid-19. The virus swept through his household, infecting his wife and daughter and hospitalizing their disabled son. Ten days after landing in the hospital, Bruce died.
But when Gwendolyn Davis received her husband’s death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.
“He wouldn’t have had kidney failure if he didn’t have covid,” Gwendolyn said.
After Bruce died, his wife applied to two pandemic relief programs seeking help with $1,500 in missed payments on a truck and an electricity bill. But, she said, she was denied because his death certificate didn’t mention covid-19.
“I think it’s wrong,” Gwendolyn said. “It’s almost like we didn’t count.”
The count has profound implications for families and the country. Omitting covid-19 on death certificates threatens to undercount the toll of the pandemic nationwide. For Davis’ family and others, it can pile financial hardship onto emotional despair, as death benefits and other covid-19 relief programs are withheld. Interviews with families across the U.S. shed light on reasons covid deaths are being undercounted — and the consequences loved ones have endured.
When covid patients die, the “immediate” cause of death is always something else, such as respiratory failure or cardiac arrest. Residents, doctors, medical examiners and coroners make the call on whether covid was an underlying factor, or “contributory cause.” If so, the diagnosis should be included on the death certificate, according to the Centers for Disease Control and Prevention.
Even beyond the pandemic, there is wide variation in how certifiers describe causes of death: “There’s just no such thing as an objective measure of cause of death,” said Lee Anne Flagg, a statistician at the CDC’s National Center for Health Statistics.
Partly because of a lack of training in how to fill them out, “the quality of the death certificates is not good,” said Dr. James Gill, vice president of the National Association of Medical Examiners. And in cases in which people had other chronic conditions, it can be difficult to determine whether covid was a contributing cause of death, he said. That was especially true early on, when reliable testing was not widely available.
Since early in the pandemic, the CDC has encouraged certifiers who suspect covid as a cause of death to list it on the death certificate as “probable” or “likely.”
Still, some clinicians are “reluctant to certify a death as a covid death without a test in hand,” Gill said.
It’s not clear how Bruce Davis’ case slipped under the radar. His death was certified by William Ken Garland, deputy coroner in Baldwin County. Reached by phone, Garland said the causes of death were provided by Dr. Joseph Coppiano, a medical resident who pronounced Davis dead at Augusta University Medical Center, about 90 miles away. No autopsy was done.
“I did certify the record, but that’s about all I did,” Garland said.
Hospital spokesperson Danielle Harris declined to comment on the case, citing patient privacy. She said the hospital follows Georgia Department of Public Health guidelines.
In the absence of certainty, the CDC has encouraged coroners to document the virus. “We’re not worried that we’re overcounting the number of [covid-19] deaths,” Farida Ahmad, epidemiologist and mortality surveillance team leader at NCHS, said in April.
Missed cases are one reason that experts agree covid deaths are being undercounted nationwide. As evidence for that, they point to the vast number of excess deaths — additional deaths compared to what would be expected based on prior-year numbers and demographic trends.
Over the past year, the U.S. had endured up to 431,792 excess deaths as of Jan. 6, with 68% directly attributed to covid, according to the CDC.
These excess deaths “tend to track pretty closely with covid cases, trailing by a couple of weeks,” said Daniel Weinberger, an epidemiologist at Yale School of Public Health who has published on this topic. “This strongly suggests that a large proportion of these uncounted deaths are due to covid but not recorded as such.”
We may never know how many covid deaths went uncounted: Postmortem tests can detect the virus, but it’s “unlikely that this type of testing will be performed at a [sufficient] scale,” Weinberger said. Early in the pandemic, especially in the Northeast, many of those who were treated clinically for covid and then died were not tested for the virus — so they never made it into the statistics.
Testing Troubles Affect Lawsuits, Hospital Bills
Inaccurate death certificates can make it harder to pursue a lawsuit or win a workers’ compensation case when a loved one dies after contracting covid on the job. Gwendolyn Davis did win workers’ compensation death benefits from Bruce’s employer, a state psychiatric facility in Milledgeville, by providing medical records. But problems with covid testing can complicate the process.
Bruce’s supervisor at work, Mark DeLong, also died after contracting covid, but it did not appear on his death certificate with the other causes: cardiopulmonary arrest, respiratory failure and diabetes.
The omission on DeLong’s certificate seemed to stem from a delay in test results: His covid-positive results didn’t arrive until three days after he died, according to his widow, Jan DeLong. She has asked the local coroner to correct the record.
In New Jersey, attorney Paul da Costa represents 75 family members who lost loved ones at veterans homes in Menlo Park and Paramus in April and May. He said he knows of at least five patients whose death certificates did not list covid-19 despite evidence suggesting it killed them.
The root problem, he said, was a “complete dearth of testing.” Patients were transferred to hospitals, or dying in the veterans facilities, without ever being tested, he said.
The gap between excess deaths and confirmed covid deaths has “narrowed over time as testing has increased,” Weinberger said.
Early testing inaccuracy may also have led to undercounting, which creates a different burden: hospital bills. Without a diagnosis, families can be on the hook for thousands of dollars in charges that otherwise would have been covered under the CARES Act.
Correcting the Record
In some cases, families have sought to have death certificates changed to reflect covid. Dorothy Payton, 95, who lived in the ManorCare nursing home in Denver, first showed covid symptoms April 5. Five days later, Payton — known as “Nana Dee” — tested positive for it. And on April 13, her husband, Edward Benjamin, received a call that she had died.
The death certificate offered a litany of causes: vascular dementia, atrial fibrillation, congestive heart failure, gait instability, difficulty swallowing and “failure to thrive.”
But not covid-19. So it “seemed logical to fight for listing her cause of death under her cause of death,” Benjamin said.
After a few calls, her husband was able to get the certificate amended. ManorCare could not be reached for comment.
For Benjamin, it wasn’t about public health statistics or financial considerations. It simply offers a sense of closure.
“I want her life and death remembered the way it was, and I’m glad we set the record straight,” he said. “It’s the first step towards moving on.”
This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.
As an emergency physician, Dr. Eugenia South was in the first group of people to receive a covid vaccine. She received her second dose last week — even before President-elect Joe Biden.
Yet South said she’s in no rush to throw away her face mask.
“I honestly don’t think I’ll ever go without a mask at work again,” said South, faculty director of the Urban Health Lab at the University of Pennsylvania in Philadelphia. “I don’t think I’ll ever feel safe doing that.”
And although covid vaccines are highly effective, South plans to continue wearing her mask outside the hospital as well.
Health experts say there are good reasons to follow her example.
“Masks and social distancing will need to continue into the foreseeable future — until we have some level of herd immunity,” said Dr. Preeti Malani, chief health officer at the University of Michigan. “Masks and distancing are here to stay.”
Malani and other health experts explained five reasons Americans should hold on to their masks:
1. No vaccine is 100% effective.
Large clinical trials found that two doses of the Moderna and Pfizer-BioNTech vaccines prevented 95% of illnesses caused by the coronavirus. While those results are impressive, 1 in 20 people are left unprotected, said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention.
Malani notes that vaccines were tested in controlled clinical trials at top medical centers, under optimal conditions.
In the real world, vaccines are usually slightly less effective. Scientists use specific terms to describe the phenomenon. They refer to the protection offered by vaccines in clinical trials as “efficacy,” while the actual immunity seen in a vaccinated population is “effectiveness.”
The effectiveness of covid vaccines could be affected by the way they’re handled, Malani said. The genetic material used in mRNA vaccines — made with messenger RNA from the coronavirus — is so fragile that it has to be carefully stored and transported.
Any variation from the CDC’s strict guidance could influence how well vaccines work, Malani said.
2. Vaccines don’t provide immediate protection.
No vaccine is effective right away, Malani said. It takes about two weeks for the immune system to make the antibodies that block viral infections.
Covid vaccines will take a little longer than other inoculations, such as the flu shot, because both the Moderna and Pfizer products require two doses. The Pfizer shots are given three weeks apart; the Moderna shots, four weeks apart.
In other words, full protection won’t arrive until five or six weeks after the first shot. So, a person vaccinated on New Year’s Day won’t be fully protected until Valentine’s Day.
3. Covid vaccines may not prevent you from spreading the virus.
Vaccines can provide two levels of protection. The measles vaccine prevents viruses from causing infection, so vaccinated people don’t spread the infection or develop symptoms.
Most other vaccines — including flu shots — prevent people from becoming sick but not from becoming infected or passing the virus to others, said Dr. Paul Offit, who advises the National Institutes of Health and Food and Drug Administration on covid vaccines.
While covid vaccines clearly prevent illness, researchers need more time to figure out whether they prevent transmission, too, said Phoenix-based epidemiologist Saskia Popescu, an assistant professor in the biodefense program at George Mason University’s Schar School of Policy and Government.
“We don’t yet know if the vaccine protects against infection, or only against illness,” said Frieden, now CEO of Resolve to Save Lives, a global public health initiative. “In other words, a vaccinated person might still be able to spread the virus, even if they don’t feel sick.”
Until researchers can answer that question, Frieden said, wearing masks is the safest way for vaccinated people to protect those around them.
4. Masks protect people with compromised immune systems.
People with cancer are at particular risk from covid. Studies show they’re more likely than others to become infected and die from the virus, but may not be protected by vaccines, said Dr. Gary Lyman, a professor at Fred Hutchinson Cancer Research Center.
Cancer patients are vulnerable in multiple ways. People with lung cancer are less able to fight off pneumonia, while those undergoing chemotherapy or radiation treatment have weakened immune systems. Leukemia and lymphoma attack immune cells directly, which makes it harder for patients to fight off the virus.
Doctors don’t know much about how people with cancer will respond to vaccines, because they were excluded from randomized trials, Lyman said. Only a handful of study participants were diagnosed with cancer after enrolling. Among those people, covid vaccines protected only 76%.
Although the vaccines appear safe, “prior studies with other vaccines raise concerns that immunosuppressed patients, including cancer patients, may not mount as great an immune response as healthy patients,” Lyman said. “For now, we should assume that patients with cancer may not experience the 95% efficacy.”
Some people aren’t able to be vaccinated.
While most people with allergies can receive covid vaccines safely, the CDC advises those who have had severe allergic reactions to vaccine ingredients, including polyethylene glycol, to avoid vaccination. The agency also warns people who have had dangerous allergic reactions to a first vaccine dose to skip the second.
Lyman encourages people to continue wearing masks to protect those with cancer and others who won’t be fully protected.
5. Masks protect against any strain of the coronavirus, in spite of genetic mutations.
So far, studies suggest vaccines will still work against these new strains.
One thing is clear: Public health measures — such as avoiding crowds, physical distancing and masks — reduce the risk of contracting all strains of the coronavirus, as well as other respiratory diseases, Frieden said. For example, the number of flu cases worldwide has been dramatically lower since countries began asking citizens to stay home and wear masks.
“Masks will remain effective,” Malani said. “But careful and consistent use will be essential.”
The best hope for ending the pandemic isn’t to choose between masks, physical distancing and vaccines, Offit said, but to combine them. “The three approaches work best as a team,” he said.
Our two-year-old marriage was already struggling before the pandemic sent France into lockdown. Now here we were, stuck in our Paris apartment with my two teenage sons. “Le confinement,” as the French lyrically call it.
My husband, two decades younger than me, sought refuge from all the forced togetherness by barricading himself in the guest room, shoving the heavy sofa bed — normally used by my ex-husband when he comes to visit his sons — against the door.
I hated sleeping apart but rationalized our growing distance by telling myself that his snoring and my tossing made it difficult for us to get a good night’s rest. (Never mind that those things hadn’t been issues before.)
Besides, what couple doesn’t need space from time to time? Especially when the French government permitted only one hour of outside exercise per day, within one kilometer of home. To leave the house, we had to fill out a form and carry ID. Police were checking paperwork and issuing fines.
This was the flip side of having fallen madly in love with a man born the year I finished college. In the early days of our courtship, in Cairo, I was so caught up in the post-divorce, risk-laden thrill of stealing illicit kisses on poorly lit street corners — public displays of affection can land you in jail in Egypt — that I scarcely noticed the age difference.
Love may be blind, but lust is both blind and idiotic.
As a mother, I had often felt the need to choose between the demands of parenthood and my sexual desires. That duality became even more stark when I met my second husband, who helped me rediscover the sensuality lying dormant during the 20 years I was married to the father of my children.
When I started letting him spend the night in the Cairo villa I shared with my sons, I was choosing the erotic version of myself over the maternal version. The boys must have thought I had been body snatched.
They would have been right. Sexual empowerment reanimated me. When my new lover and I met, he was exactly the same age I had been when I first got married. Choosing him felt like both a do-over and an escape from the invisibility of midlife. Not only did he see me as desirable, but our being together suddenly made me a source of envy. Women his age who admired his good looks would try to figure out our relationship. It was exactly the kind of validation I craved after a marriage in which the erotic flame had been doused long before we ended it.
I liked that our May-September romance was unconventional. Bucking the norms I had hewed to out of a sense of duty felt as validating as it did challenging.
My husband had to confront the alienation of his Tunisian family, who refused to acknowledge my existence, even after our wedding. Yes, we had fallen deeply in love, but choosing to marry was also an act of rebellion for each of us, a rejection of what society and friends and family expected. It felt like setting out into uncharted territory. It was exhilarating.
But marriage was also a necessity for our relationship’s survival. When I moved to Paris with my sons, my lover’s Tunisian passport made it nearly impossible for him to spend time with me here. We fixed our problem by flying to California and tying the knot.
Alas, thrill-seeking and passion can only take a marriage so far and, now that we were living as a family, reality had set in. Gone was the Middle Eastern backdrop, the inexpensive four-bedroom house with the verdant garden. The City of Lights is as romantic as ever, but Paris, for me, represented a return to the responsibilities of adult life with its endless loads of laundry and the drudgery of putting dinner on the table every night.
Since my husband’s arrival, I had been bumping up against the uncomfortable understanding that the way I wanted to live as a woman in my 50s was starkly different from how he thought life in his late 20s should look. My middle-aged friends bored him. My insistence on living in a clean and orderly house was, to him, senseless. And the hours he lost to Facebook, to watching European football, seemed pointless to me.
We sought out couples’ therapy, twice, but were no more able to communicate past our language and cultural barriers than we had been before. We still didn’t have the tools to address the imbalance of power that resulted from his being dependent on me for financial and visa support. He resented being reliant on me and, truthfully, I resented it too. I wanted an equal partner, someone I could depend on, someone who would share the load.
As wonderful a diversion as our love had been, I simply could not turn back the clock and be a suitable spouse to someone as young as my husband. I couldn’t pretend I hadn’t matured over the previous 22 years. I couldn’t unlearn what experience had taught me, nor did I want to. I love being 54. Falling in love with a younger man had rejuvenated me. I looked and felt better than ever. But surface is no substitute for depth.
As the days wore on, my husband’s self-isolation grew to feel less benign. Before long, we were not engaging in even monosyllabic exchanges. His main form of communication became the missives he left on strategically placed Post-it notes. I might wake up in the morning to find “I scrubbed this” on a pot that wasn’t getting clean or return from my run and discover “please refill after use” on the Brita pitcher.
I could hear the thump, thump of the weights he lifted for hours, but I hardly ever saw him. I never knew when he might burst out of the guest room to cook himself a meal or zip out to the grocery store.
Mostly, I wanted to protect my boys from seeing my pain. I felt guilty enough for letting them watch me fall to pieces when my marriage to their father collapsed, and here I was, forcing them into front-row seats to witness the failure of yet another relationship.
One day, when sifting through the cupboard and trying to find something he could eat that hadn’t been claimed by a Post-it with my husband’s initials, my 19-year-old turned to me in exasperation. “I can’t take it anymore,” he said.
I broke through the couch barricade to the guest room and told my husband we needed to talk. We were over, I said. We couldn’t go on like this. We were all suffering too much. And then, with nothing to lose, we allowed ourselves to say all the things we hadn’t been able to.
He told me how overwhelming the previous few years had been. Between estrangement from his family, fruitless job hunting, living in the land of his country’s former colonizer, the pressures of sharing a house with me and my teenagers, and never speaking his native Tunisian, he hadn’t been able to let his guard down for a minute. He loved me, but he had never wanted to be a stepfather.
For him, “le confinement” had allowed him to catch his breath. He hadn’t been stewing in anger in the spare room, as I had thought. Solitude had been a respite.
I heard his anguish. I felt his suffering. I managed to move past my anger and disappointment at my feelings of failure and having been failed. For a beautiful moment, we each saw the other. The love that we shared in that room briefly eclipsed the pain we had inflicted on one another. We vowed to do better.
I think, even then, we knew the futility of our promises. Confinement had both locked us down and birthed an unavoidable truth: We loved each other, but love wasn’t enough.
By choosing a man nearly half my age, I had not chosen the sexually empowered iteration of myself, but rather the mother. As I watched him unburden himself, I saw a beautiful man who was too young, too inexperienced to be my partner. If I wanted to fully embody the woman I had become, I had to release both him and the 25-year-old self I was trying to reinhabit.
When confinement finally lifted, and we were once again allowed to move freely through the city, my husband signed the lease on a sun-filled studio astride the Canal Saint Martin, where young hipsters hang out drinking craft beers.
Grabbing a black suitcase crammed full of clothes, he walked out of his self-imposed exile and into his new life. As I watched him leave, I cried. Of course I cried. But with confinement over, I could already feel the first flutters of my own rebirth.
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It wasn’t until last fall that many parents started to breathe easier, as it became clear that elementary schools, at least, were not cesspools of infection with the coronavirus. But the alarming news of a more contagious version of the virus, first identified in Britain, revived those concerns.
Initial reports were tinged with worry that children might be just as susceptible as adults, fueling speculation that schools might need to pre-emptively close to limit the variant’s spread. But recent research from Public Health England may put those fears to rest.
Based on detailed contact-tracing of about 20,000 people infected with the new variant — including nearly 3,000 children under 10 — the report showed that young children were about half as likely as adults to transmit the variant to others. That was true of the previous iteration of the virus, as well.
“There was a lot of speculation at the beginning suggesting that children spread this variant more,” said Muge Cevik, an infectious disease expert at the University of St. Andrews in Scotland and a scientific adviser to the British government. “That’s really not the case.”
But the variant does spread more easily among children, just as it does among adults. The report estimated that the new variant is about 30 percent to 50 percent more contagious than its predecessors — less than the 70 percent researchers had initially estimated, but high enough that the variant is expected to pummel the United States and other countries, as it did Britain.
Prime Minister Boris Johnson of Britain had promised last year to do all he could to keep schools open. But he changed course in the face of soaring infections and buckling hospital systems, and ordered schools and colleges to move to remote learning. Other European countries put a premium on opening schools in September and have worked to keep them open, though the variant already has forced some to close.
In the United States, the mutant virus has been spotted only in a handful of states but is expected to spread swiftly, becoming the predominant source of infections by March. If community prevalence rises to unmanageable levels — a likely proposition, given the surge in most states — even elementary schools may be forced to close.
But that should be a last resort, after closures of indoor restaurants, bars, bowling alleys and malls, several experts said.
“I still say exactly what many people have said for the past few months — that schools should be the last thing to close,” said Helen Jenkins, an infectious disease expert at Boston University. Keeping schools open carries some risk, but “I think it can be reduced substantially with all the mitigations in place,” she said.
Reports of the new variant first surfaced in early December, and some researchers initially suggested that unlike with previous versions of the virus, children might be just as susceptible to the new variant as adults.
Researchers at P.H.E. looked at how efficiently people of various ages transmitted the variant to others. They found that children under 10 were roughly half as likely as adults to spread the variant.
Adolescents and teenagers between ages 10 and 19 were more likely than younger children to spread the variant, but not as likely as adults. (The range for the older group in the study is too broad to be useful for drawing conclusions, Dr. Cevik said. Biologically, a 10-year-old is very different from a 19-year-old.)
Over all, though, the variant was more contagious in each age group than previous versions of the virus. The mutant virus will result in more infections in children unless schools shore up their precautions, experts said.
“The variant is not necessarily affecting children particularly, but we know that it’s adding on more transmissibility to all age groups,” Dr. Cevik said. “We need to find ways to return these kids back to school as soon as possible; we need to use this time period to prepare.”
In Germany, Chancellor Angela Merkel had vowed that schools would be the last thing to close during the second lockdown that began in November. Schools went to great lengths to keep in-person classes in session, requiring children to wear masks and opening windows to ensure better ventilation even as temperatures plummeted.
But fear of the variant’s spread prompted Ms. Merkel to keep schools closed following the holiday break at least through the end of January.
In France, where the new variant has not resulted in a surge of infections so far, schools reopened earlier this month after the winter break. France was not dealing with a particularly difficult epidemic, and health protocols put in place last September limited transmission in schools, Jean-Michel Blanquer, France’s education minister, has said.
The Italian government, too, has allowed not just elementary schools to open but also high schools, albeit at half capacity. Still, local leaders have implemented tighter restrictions, with some high schools slated to stay closed until the end of the month.
In the United States, the variant has only been spotted in a handful of states, and still accounts for less than 0.5 percent of infections. Schools remain open in New York City and many other parts of the country, but some have had to shut down because of rising virus infections in the community.
“Obviously, we don’t want to get to a point where it seems like we closed schools too late,” said Dr. Uché Blackstock, an urgent care physician in Brooklyn and founder of Advancing Health Equity, a health care advocacy group. “But at the same time, I think that we should try to keep our young children in school for as long as possible for in-person learning.”
The latest on how the pandemic is reshaping education.
- Chicago’s mayor and its teachers’ union are locked in a bitter fight over whether to reopen classrooms in the nation’s third-largest district.
- Singapore’s three major universities have reported zero coronavirus cases. Their secret: technology, tough penalties and students willing to comply.
- New York City’s teachers’ union wants schools to shut again if the rate of positive virus tests keeps rising. The city is determined to keep them open.
- Class of 2025: It’s been a year like never before. How did you write about it?
It’s been clear for months what measures are necessary, Dr. Blackstock and other experts said: requiring masks for all children and staff; ensuring adequate ventilation in schools, even if just by opening windows or teaching outdoors; maintaining distance between students, perhaps by adopting hybrid schedules; and hand hygiene.
The new variant, while more contagious, is still thwarted by these measures. But only a few schools in Britain implemented them.
“When we look at what’s happened in the U.K. and think about this new variant, and we see all the case numbers going up, we have to remember it in the context of schools being open with virtually no modification at all,” Dr. Jenkins said. “I would like to see a real-life example of that kind of country or state or location, which has managed to control things in schools.”
There are some examples within the United States.
Erin Bromage, an immunologist at the University of Massachusetts Dartmouth, advised the governor of Rhode Island, as well as schools in southern Massachusetts, on preventive measures needed to turn back the coronavirus. The schools that closely adhered to the guidelines have not seen many infections, even when the virus was circulating at high levels in the community, Dr. Bromage said.
“When the system is designed correctly and we’re bringing children into school, they are as safe, if not safer, than they would be in a hybrid or remote system,” he said.
The school Dr. Bromage’s children attend took additional precautions. For example, administrators closed the school a few days before Thanksgiving to lower the risk at family gatherings, and operated remotely the week following the holiday.
Officials tested the nearly 300 students and staff at the end of that week, found only two cases, and decided to reopen.
“That gave us the confidence that our population was not representative of what we were seeing in the wider community,” he said. “We were using data to determine coming back together.”
The tests cost $61 per child, but schools that cannot afford it could consider testing only teachers, he added, because the data suggest the virus is “more likely to move from teacher to teacher than it is from student to teacher.”
In New York City, students and teachers are randomly tested, and have so far shown remarkably low rates of transmission within schools.
Dr. Blackstock has two children at an elementary school in Brooklyn, and said her son has not been tested all year. Even if the new variant brings a spike in cases, the city’s policy of closing a school if it has two unrelated infections is “too conservative,” she said.
If the number of cases skyrockets and the schools shut down more often, “then I would probably say, ‘This doesn’t feel right, let’s keep them home,’” she said. “But they’re going to be in school as long as I can possibly keep them.”
Emma Bubola contributed reporting from Milan, Melissa Eddy from Berlin, Constant Méheut from Paris and Benjamin Mueller from London.
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The reverberations from the Jan. 6 storming of the U.S. Capitol by supporters of President Donald Trump continue. A broad array of business groups, including many from the health industry, are halting contributions to Republicans in the House and Senate who voted against certifying the victory of President-elect Joe Biden. Meanwhile, Republicans in the House who have refused to wear masks or insisted on carrying weapons are being subjected to greater enforcement, including significant fines.
Away from the Capitol, the Trump administration has granted a first-in-the-nation waiver to Tennessee to turn its Medicaid program into a block grant, which would give the state potentially less federal money but more flexibility to structure the federal-state health program for those with low incomes. And in its waning days, the administration is moving to make its last-minute policies harder for Biden to undo.
This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Kimberly Leonard of Business Insider.
Among the takeaways from this week’s podcast:
- The decision by industry groups to cut their political contributions to some Republican lawmakers could reshape businesses’ relationships on Capitol Hill. But it’s still not clear if this announcement will affect the vast sums of political contributions that come through PACs and other unnamed sources, as well as individual contributions from corporate officials.
- The slow start of the covid vaccination campaign points to the tension between the need to steer the vaccine to people at high risk of contracting the disease and the concerns about wasting the precious medicine. Because the vaccines that have been approved for emergency use have a relatively short shelf life, some doses may go to waste if they are reserved for specific populations.
- The response to the vaccine among health care workers varies widely. In some areas, staffers are eager to get the shots, while in other places, some workers have been hesitant and the shots are going unused. And the federal government has not provided a strong public messaging campaign about the vaccines.
- The Trump administration’s announcement last week that it would move to convert Tennessee’s Medicaid program to a block grant program is raising concerns among advocates for the poor, who fear that the flexibility the state is gaining could lead to enrollees getting less care, especially since the state will get a hefty portion of any savings it finds in running the program.
- It may not be easy for the Biden administration to change this decision. Federal officials in recent weeks have been sending states, including Tennessee, letters to sign that could protect the Medicaid waivers they have received from the Trump administration and could serve as a legal guarantee that would require a long, difficult process to unwind.
- Mental health care may be a casualty of the coronavirus pandemic. As states look to balance their budgets after a year in which revenues were slashed, they may turn to cutting mental health care services provided through Medicaid and other programs.
Also this week, Rovner interviews KHN’s Victoria Knight, who wrote the latest KHN-NPR “Bill of the Month” feature — about an unusually large bill for in-network care. If you have an outrageous medical bill you’d like to share with us, you can do that here.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week that they think you should read too:
Julie Rovner: The Washington Post’s “Young ER doctors Risk Their Lives on the Pandemic’s Front Line. But They Struggle to Find Jobs,” by Ben Guarino
Margot Sanger-Katz: The New York Times’ “Why You’re Probably Not So Great at Risk Assessment,” by AC Shilton
Joanne Kenen: The Atlantic’s “Why Aren’t We Wearing Better Masks?” by Zeynep Tufekci and Jeremy Howard
Kimberly Leonard: Business Insider’s “I Was Offered a Covid Vaccine Even Though I’m Young and Healthy. Here’s How I Did It,” by Kimberly Leonard
To hear all our podcasts, click here.
Beginning Jan. 26, international travelers bound for the United States must show negative coronavirus test results before boarding their flights. Here’s what you need to know.
My sister is married to a great guy with a successful military career. He has supported her through diagnoses of mental illness and cancer. But my sister does many frustrating things: She hoards food, feeds her kids junk (they’re obese) and allowed her son to fail a grade in school by letting him stay home and play video games all day while his father was deployed. If anyone talks to my sister in a way she finds remotely critical, she stonewalls that person for days. Her husband is morally opposed to divorce, but I worry about his happiness. In order to maintain a relationship with my sister, I have to pretend everything she does is OK. Please help!
You have been fairly meticulous about cataloging your sister’s failures and flaws. But I don’t see a word about your efforts to support her — only a concern for her husband’s happiness as your sister struggles. If her husband is home again, he bears as much as responsibility as your sister for raising their children. And if he is still deployed, she could probably use a hand.
What you fail to acknowledge here is that many mental illnesses and cancer treatments are debilitating and exhausting. Trying to manage them while raising children may be pushing your sister to the brink. The last thing she needs from you is any criticism.
Instead, organize a circle of supportive friends and relatives to lift her up. Offer to shop and make dinner for the family occasionally. Give the kids a ride to school or help with their homework. With a more manageable load, your sister she may be open to tackling the issues you raise in your letter — perhaps with the help of a therapist.
My fiancé and I had a New Year’s Eve party with a small pod of friends we’ve seen frequently during the pandemic. It was a great night and all the more special because we hosted it at our new house. The morning after, though, we discovered our new off-white sofa was covered in clothing dye. After some investigation, we are certain it was from a friend’s black dress. We hired an upholstery cleaner, but the dye is still visible. Fortunately, there is another solution: For $800, we can buy three new sofa cushion covers. Would it be rude to ask our friend to cover this cost?
One of the few certainties in giving parties is that accidents can happen. So, let me offer a script for mishaps-while-hosting that you may find unfair at first, but that has served me well for many years.
Call your friend to let her know what happened. Along with her apologies and a possible vow to retire that dress, she may offer to cover your cleaning costs. (Don’t mention the failed cleaning attempt or imminent cushion replacement.) Thank her for her kind offer, but refuse it. If she insists, use my mother’s effective line: “It would hurt me for you to pay me.” That should settle the issue.
True hospitality — making friends comfortable in our homes — often requires shrugging off accidental damage. That’s what makes it so hard and precious. (On a practical note: Before you replace your white cushion covers, get an estimate for having some made in a nice indoor/outdoor fabric. It’s more durable and often stain resistant.)
My husband and I are hoping to have a child soon. I am politically liberal, and he is conservative. We are both tolerant. But we have some family and friends who are right-wing conspiracy theorists. After learning that many of them still hold their extreme views after the events in Washington, D.C., on Jan. 6, I would be more comfortable if my child were never exposed to them. How do I tell these people they will not meet my child because of their views?
Listen, I get revenge fantasies as well as the next person. (And the assault on our democracy has been frightening to watch.) But you’re asking about blocking access to a child who doesn’t exist yet because of political views that may change over time. I suggest choreographing your rejections later.
For now, make sure that you and your husband agree on the principles that will govern your future child’s world. As long as you two are on the same page, working out how to deal with extended family will be a challenge you can manage together.
Not Even a ‘Happy Birthday’?
Because of the pandemic, my 19-year-old son stayed on his college campus for winter break. He forgot my birthday, which upset me more than I would have thought. It’s not like I expected a gift, just an acknowledgment. Would it be too much of a guilt trip to say something?
Nineteen is old enough to understand the hurt that carelessness can cause. Say, “Honey, you forgot my birthday, and it hurt my feelings. Will you try to remember next year? A call or card would mean a lot to me.” I bet he will — especially if you tell him to put the date in his calendar.
For help with your awkward situation, send a question to SocialQ@nytimes.com, to Philip Galanes on Facebook or @SocialQPhilip on Twitter.
When my 80-year-old father recently died, coronavirus restrictions meant that our family, like many others, could not safely gather for a funeral. My mother, brother and sister-in-law in New York, along with me in Berkeley, Calif., hastily organized a memorial service on Zoom.
What could have been a disaster or fodder for an episode of “Curb Your Enthusiasm” ended up being incredibly moving. Rather than diminishing the experience or getting in the way, videoconferencing facilitated an event filled with emotion, humor and love. During a difficult time for our family — in a devastating year for the entire world — that was an unexpected blessing.
Despite our fatigue with remote work meetings, we all were struck by how well-suited it turned out to be for a memorial.
Families who are opting for video memorials are probably doing so because of pandemic restrictions limiting the number of people who can attend an indoor gathering. Since you can join a virtual event from anywhere — and with minimal planning — more people are likely to attend than if they needed to travel to an in-person event.
In our case, the immediate family was on both coasts, one grandchild was in Scottsdale, Ariz., and the rabbi, Jeff Salkin of Temple Israel West Palm Beach, a longtime friend and former student of my dad, was in Florida.
With a videoconferencing service, you can style your memorial as you like. While we did not include photos, videos or music, nothing prevents you from doing so. In addition, a virtual memorial costs much less than an in-person event, where you’d have to pay for the brick-and-mortar venue and perhaps catered food. And you can easily record the event to share and save for posterity.
A virtual memorial also might accommodate more speakers than an in-person event. Ours began with moving eulogies by Rabbi Salkin, followed by my brother and me, then morphed into an impromptu shiva, as numerous guests offered wonderful remembrances and reflections about my dad. The event lasted two and a half hours; many people remained the entire time.
My father’s was not Rabbi Salkin’s first Zoom memorial service. He was skeptical before he led a Zoom gathering after his stepmother died of Covid-19 in April.
“I feared that such funerals would be alienating,” he said. “I was wrong. Wi-Fi carries the love quite effectively. In person, you can hold people’s hands and embrace them. On Zoom, it’s more about holding people’s eyes and simply being with them, in every way that matters.”
At the beginning of lockdown, Zoom ran into security issues. As the technology writer Brian X. Chen detailed in a column in April, weak privacy protections resulted in uninvited “Zoombombers” crashing meetings in embarrassing fashion.
That happened when my kids’ school district started distance learning: A nude man entered a virtual class and used racial slurs. It was a lesson for our family to be sure our event was password protected.
Even Jonathan Leitschuh, a software engineer and security researcher who identified flaws in Zoom’s security protocols that allowed hackers to take over Mac users’ webcams in 2019, turned to Zoom to plan a funeral for his mother who died in April.
“I went in terrified about a Zoombombing,” Mr. Leitschuh said. “I’d seen the same media coverage everyone else did.” But he said: “For this use case, I wasn’t aware of a better platform.”
Funeral homes are also offering livestreamed services, in conjunction with limited in-person memorials. Chris Robinson, a fourth-generation funeral director in Easley, S.C., and spokesman for the National Funeral Directors Association, said his funeral home has been livestreaming services via its website, allowing anyone to attend without the need to download software or register for a videoconferencing platform.
“It’s important to go ahead and put together a virtual service,” he said, “rather than wait until the pandemic is over, because it could be a long time, and delaying indefinitely can be an ongoing trauma.”
In my family’s case, we were truly impressed by how videoconferencing, which can be so enervating in our daily work lives, enabled us to celebrate my dad’s full life in a beautiful and moving way.
If you have to arrange a memorial service on a video platform, here are some tips.
We purchased a one-month subscription to Zoom Pro (right now it’s $14.99 a month and you can cancel at any time). It allows for up to 100 participants (other plans allow for more, at additional cost), with unlimited meeting time, and stores a recording in the cloud. We’re glad we did. If we had had to limit the time of the event, we would have missed many moving contributions from participants.
Identify Someone to Handle Logistics
Because I created the account, I was the de facto meeting host. In hindsight I wish I had handed the role to my 17-year-old daughter, a digital native. Responsibilities include admitting people from the waiting room; muting all mics as appropriate; unmuting the officiant or other speakers; troubleshooting technical issues; providing assistance to guests; and passing messages along to family members in the chat box. Introduce the tech host at the beginning of the service, so people know whom to contact for help.
Familiarize Yourself With Platform Settings
The back end of video platforms have settings that can be tricky if you are new to them, especially if it is an emotional event. The host can go through the “toggle” switches in advance to figure out how to mute people upon entry or enable the waiting room, a security feature that keeps guests in a queue until the host admits them.
Who Will Lead?
Our virtual memorial succeeded, in part, because the rabbi wasn’t thrown off by the difficulties inexperienced Zoomers had muting themselves at the start. When the service segued into the shiva, my mother moderated — greeting people and making sure everyone who wanted to offer a remembrance had the chance to do so.
Plan a Dry Run to Anticipate Issues
Schedule one or more short practice sessions to work out kinks and make sure you’re on the same page about various roles. Some participants at our event were complete Zoom novices, fearful of missing the eulogy, and self-conscious about holding up the program as they attempted to mute as requested. We recommend offering tips to guests about logging on and off; muting and unmuting; switching screen views; and using the chat function — either along with the invitation, or on request ahead of the event. Don’t assume that everyone will be joining with up-to-date devices.
We sent an email to notify friends and relatives of my dad’s death and of the Zoom event, including a link and password. Each of our family members compiled and distributed our own lists. You can also use Zoom to send email invitations.
You’re on TV (Sort of)
Without being obsessive, think about your on-screen appearance, makeup, lighting, camera height and angle and backdrop.
Beware of Tech Gremlins
While we were spared technical disruptions, the specter lurked in our minds. Many parts of the country experienced power outages this summer, and we’ve all had our internet connections go down or struggled with microphones and screens that freeze at just the wrong time. Although impossible to predict, be mindful of what could go wrong and how you’d handle it.
Ultimately, you want to make sure the virtual event accomplishes the same things an in-person funeral or memorial service would, honoring the life of the deceased and comforting the survivors. As it turned out, many more of my parents’ circle — friends and family in their 70s and 80s — were able to attend the funeral than would have been able to, even without Covid restrictions. Likewise, more people spoke than would have stepped to the lectern at an in-person funeral service. And the video we have is a blessing, which will enable my family to keep my father’s memory alive and hold on to vivid memories of those who so loved him.
Steven Birenbaum is senior communications officer at the California Health Care Foundation in Oakland, Calif.
“I’ve known you since 2003,” my patient reminded me, after I had entered the examination room and took my usual seat a few feet away from her. She was sitting next to her husband, just as she had been at her first visit 17 years earlier, and both wore winter jackets to withstand the sleet that Cleveland had decided to dump on us in late October. “That was when I first learned I had leukemia,” she added. He nodded dutifully, remembering the day.
I was freshly out of my fellowship training in hematology-oncology back then, and still nervous every time I wrote a prescription for chemotherapy on my own, without an attending’s co-signature. In her case, it was for the drug imatinib, which had been on the market only a couple of years.
At the time, a study had just reported that 95 percent of patients who had her type of leukemia and who were treated with the drug imatinib achieved a remission. But on average, patients in that study had been followed for just a year and a half, so I couldn’t predict for her how long the drug might work in her case.
Seventeen years later, she was still in a remission. During that time, she had retired from her job as a nurse, undergone a couple of knee replacements, and had a cardiac procedure to treat her atrial fibrillation.
“You had a toddler at home,” she reminded me. That son was now in college. “And then your daughter was born the next year. And you had another boy, right?”
I nodded, and in turn reminded her of the grandchildren she had welcomed into the world during the same time. We had grown older together. Then we sat quietly, staring at each other and enjoying the shared memories.
“I can’t believe you’re leaving me,” she said softly.
When I decided to take a new job in Miami, I knew how difficult it would be to tell the other doctors, nurses, pharmacists and social workers I work with, the team from whom I had learned so much and relied upon so heavily for years.
I didn’t anticipate how hard it would be to tell my patients.
For some with longstanding, chronic cancers, it was like saying goodbye to a beloved friend or a comrade-in-arms, as if we were reflecting on having faced down an unforgiving foe together, and had lived to tell about it.
For others, still receiving therapy for a leukemia that had not yet receded, I felt as if I were betraying them in medias res. I spent a lot of time reviewing their treatment plans and reinforcing how I would transition their care to another doctor, probably more to reassure myself than my patients, that they would be OK.
A few were angry. Unbeknownst to me, my hospital, ever efficient, had sent out a letter informing patients of my departure and offering the option to choose any one of eight other doctors who could assume their care — even before I had a chance to tell some of them in person. How were they expected to choose, and why hadn’t I told them I was leaving, they demanded indignantly.
I felt the same way as my patients, and quickly sent out my own follow-up letter offering to select a specialist for their specific types of cancer, and telling my patients I would miss them.
I then spent weeks apologizing, in person, for the first letter.
And though I always tell my patients the best gift I could ever hope for is their good health, many brought presents or cards.
One man in his 60s had just received another round of chemotherapy for a leukemia that kept coming back. I think we both knew that the next time the leukemia returned, it would be here to stay. When I entered his examination room, he greeted me where my other patient had left off.
“I can’t believe you’re leaving me.”
Before I could even take a seat, he handed me a plain brown bag with some white tissue paper poking out of the top and urged me to remove its contents.
Inside was a drawing of the steel truss arches of Cleveland’s I-90 Innerbelt bridge, with the city skyline rising above it.
“It’s beautiful,” I told him. “I don’t know what to say.”
“You can hang this on your office wall in Miami,” he suggested, starting to cry. “So you’ll always remember Cleveland.” And then, Covid-19 precautions be damned, he walked over and gave me a huge bear hug. After a few seconds we separated.
“No,” I said, tearing up. “I’ll hang up the picture and always remember you.”
Mikkael Sekeres (@mikkaelsekeres), formerly the director of the leukemia program at the Cleveland Clinic, is the chief of the Division of Hematology, Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine and author of “When Blood Breaks Down: Life Lessons From Leukemia.”