From Health and Fitness

Delicate Covid Vaccines Slow Rollout — Leading to Shots Given Out of Turn or, Worse, Wasted

For Heather Suri, a registered nurse in Virginia, the race to vaccinate Americans against covid has thrown up some unprecedented obstacles.

The vaccines themselves are delicate and require a fair bit of focus over time. Consider Moderna’s instructions for preparing its doses: Select the number of shots that will be given. Thaw the vials for 2.5 hours in a refrigerator set between 36 and 46 degrees. Then rest them at room temperature for 15 minutes. Do not refreeze. Swirl gently between each withdrawal. Do not shake. Inspect each vial for particulate matter or discoloration. Store any unused vaccine in refrigeration.

And then there’s this: Once open, a vial is good for only six hours. As vaccines go, that’s not very long. Some flu vaccine keeps almost a month.

“This is very different, administering this vaccine. The process, it takes a whole lot longer than any mass vaccination event that I’ve been involved with,” said Suri, a member of the Loudoun Medical Reserve Corps who joined her first clinic Dec. 28, to vaccinate first responders.

Of the first two covid vaccines on the market, Moderna’s is considered more user-friendly. Pfizer-BioNTech’s shot must be stored in specialized freezers at 94 degrees below zero. Once out of deep freeze, it lasts just five days, compared with 30 days for Moderna’s.

One thing the shots have in common: They last a paltry six hours once the first dose is removed from a vial. That short shelf life raises the stakes for the largest vaccination effort in U.S. history by forcing clinicians to anticipate the exact number of doses they’ll need each day. If they don’t get it right, precious stores of vaccine may go to waste.

During one recent clinic over several hours, Suri estimated she gave “maybe 25” shots, many fewer than the number of flu shots she’s given during similar clinics over the years.

With covid, she said, “the vaccine itself slows things down.”

The slow rollout has frustrated people who at Thanksgiving imagined millions of vaccines in arms by Christmas. Promises that 20 million would be vaccinated by New Year’s fell well short: Just 2.8 million had the first of two required shots by the end of December, according to data from the Centers for Disease Control and Prevention.

Public health officials say many factors are at play, including a shortage of workers trained to administer shots, covid protocols that require physical distancing at clinics and vaccine allocation numbers from the federal government that fluctuate by the week.

And then there are the logistics of the first covid vaccines, which are complex and make hyper-vigilant practitioners wary of opening too many vials over the course of each day, for fear that anything unused will have to be tossed. Vaccine providers also report wasted or spoiled doses to public health authorities.

“If you get to the end of your clinic and every nurse has half a vial left, what are you going to do with that vaccine?” Suri said. “The clock is ticking. You don’t want to waste those doses.”

That impulse has led some health personnel to make dramatic decisions at the end of a day: calling non-front-line health workers or offering shots to whoever is at hand in, say, a grocery store, instead of scrambling to find the health workers and residents of nursing homes in the government’s first tier for injections.

“We jumped and ran and got the vaccine,” said Dr. Mark Hathaway, an OB-GYN in the District of Columbia who received the first dose of a Moderna vaccine on Dec. 26 along with his wife, a registered nurse specializing in nutrition. Both clinicians received vaccines faster than anticipated at a Unity Health Care clinic when there were extra doses because fewer front-line health care workers than expected showed up.

“Health care workers have been priority 1a, so our first attempt has always been our staff,” said Dr. Jessica Boyd, Unity Health Care’s chief medical officer. Since then, the community health center network has broadened its criteria for extra doses to include staff members or high-risk patients visiting a clinic, she said.

Health officials encourage using the doses to get as many Americans vaccinated as quickly as possible. Public health experts say the need to vaccinate people is especially urgent as a new and more contagious variant of the virus first detected in the United Kingdom is showing up in multiple states. Some states, including New York and California, have loosened their guidelines on who can get vaccinated after an outcry over health care providers throwing away doses that didn’t meet officials’ strict criteria.

The tiers “are simply recommendations, and they should never stand in the way of getting shots in arms instead of keeping vaccine in the freezer or wasting vaccine in the vial,” Health and Human Services Secretary Alex Azar said Jan. 6, referring to CDC guidelines saying health care workers and residents and staff of long-term care facilities should be first in line, then people at least 75 years old. The Trump administration this week also said it would make more shots available by releasing second doses and urged states to broaden rules to allow anyone 65 or older and any resident with a serious medical condition to get a shot.

Pfizer-BioNTech’s ultra-cold storage requirements have made it less ideal for local public health departments and rural areas.

Both of the available vaccines arrive in multidose vials — Pfizer-BioNTech’s contains about five doses, Moderna’s 10. Neither contains preservatives and they are viable for only six months frozen. By contrast, during the H1N1 pandemic roughly a decade ago, the swine flu vaccines lasted 18 weeks to 18 months, Sen. Chuck Grassley (R-Iowa) wrote in a May 2010 letter to then-HHS Secretary Kathleen Sebelius.

“We can’t get the vaccine out fast enough; we have people dying. But, at the same time, we have to get it right,” said Claire Hannan, executive director of the Association of Immunization Managers.

The added risk of losing doses due to quick expiration is another thing “causing angst,” Hannan said. “You can’t just draw it up and let it sit. It can’t just sit out like that.”

The Trump administration fell significantly short of its promise that 20 million Americans would be vaccinated by the end of December, partly the result of a disjointed and underfunded public health system that has received limited guidance from federal officials. As of Jan. 11, 25.5 million vaccine doses had been distributed nationwide but only 9 million administered, according to the CDC.

Federal officials have released sparse data about who is getting vaccinated, but state information has shown significant variation in vaccination rates depending on the facility. New York Gov. Andrew Cuomo on Jan. 4 said New York City’s public hospital system had used only 31% of its allocated vaccines, while private health systems NewYork-Presbyterian and Northwell Health had used 99% and 62%, respectively.

“When you target a priority group, it’s inefficient. When you open it up to a larger group, it’s efficient … but you’re not going to have enough supply,” Hannan said. “You still have the challenge of getting those health care workers vaccinated and no matter any way you slice it, you still have limited supply. You can’t please everyone.”

While Pfizer’s vaccine has largely been earmarked for large institutions like hospitals and nursing homes, Moderna’s has been more widely distributed to smaller sites like public health departments and clinics run by volunteers. State and local officials have begun or will soon vaccinate other priority populations, including police officers, teachers and other K-12 school employees, and seniors overall.

Unlike the covid vaccines, many flu vaccines come in prefilled syringes — each syringe’s cap is removed only when a shot is given, which speeds the process and eases some concerns about storage. However, relying on prefilled syringes during a pandemic has its own complications, according to Michael Watson, former president of Valera, a Moderna subsidiary: They take up more fridge space. They’re more expensive. And they can’t be used for frozen products, he said.

“For all these reasons, a vial was the best and only option,” he said.

In Ohio, Eric Zgodzinski, health commissioner for Toledo-Lucas County, said two-thirds of first responders the county surveyed said they would get the vaccine. Still, he said, his department has encountered situations in which a covid vaccine dose is left over in an open vial and officials have turned to a waiting list to find someone who can arrive within minutes to get a jab.

His department also has an internal running list of potential vaccine takers, including health department staffers, people in congregate care settings or those who had scheduled vaccination appointments for later on.

“We’re not going to open up a vial for one individual and figure out nine other people right away,” said Zgodzinski, whose department planned to distribute 2,200 doses of the Moderna vaccine the week of Jan. 4.

“If I have one dose left, who can I give it to?” he added. “A shot in the arm for anybody is better than it being wasted.”

San Francisco editor Arthur Allen and senior correspondent JoNel Aleccia contributed to this report.

Vaccination Disarray Leaves Seniors Confused About When They Can Get a Shot

For weeks, doctors’ phones have been ringing off the hook with anxious older patients on the other end of the line.

“When can I get a covid-19 vaccine?” these patients want to know. “And where?”

Frustration and confusion are rampant as states and counties begin to offer vaccines to all seniors after giving them first to front-line health care workers and nursing home residents — the groups initially given priority by state and federal authorities.

My 91-year-old mother-in-law, who lives in upstate New York, was one of those callers. She said her doctor’s office told her it could be several months before she can get her first shot.

That was before New York’s Gov. Andrew Cuomo announced on Friday that the state would begin offering vaccines to residents age 75 and older starting Monday. On Tuesday, the state changed vaccine policies again, this time making residents 65 and older eligible.

In this chaotic environment, with covid cases and deaths skyrocketing and distribution systems in a state of disarray, it’s difficult to get up-to-date, reliable information. Many older adults don’t know where to turn for help.

Since the holidays, I’ve heard from dozens of people frustrated by poorly informed staffers at physicians’ offices, difficult-to-navigate state and county websites, and burdensome or malfunctioning sign-up arrangements. Below are some questions they posed, with answers drawn from interviews with experts and other sources, that may prove helpful.

Keep in mind that states, counties and cities have varying policies, and this is a rapidly shifting landscape with many uncertainties. Foremost among them are questions regarding vaccine supply: how many doses will become available to states and when and how those will be allocated.

Q: How can I make an appointment to get a vaccine? — James Vanderhye, 77, Denver

Vanderhye is a throat cancer survivor who suffers from sarcoidosis of the lungs and heart — an inflammatory disease.

Colorado Gov. Jared Polis announced on Dec. 30 that residents 70 and older could start getting covid vaccines, but Vanderhye wasn’t sure whether he needed to sign up somewhere or whether he’d be contacted by his physicians — a common source of confusion.

UCHealth, the system where Vanderhye’s doctors practice, has created a registry of patients 70 and older and is randomly selecting them for appointments, Dr. Jean Kutner, its chief medical officer told me. It’s reaching out to patients through its electronic patient portal and is planning to notify those who don’t respond by phone down the line. Then, it’s up to patients to finalize arrangements.

Nearly 200,000 people 70 and older are patients at UCHealth’s hospitals and clinics in Colorado, Wyoming and Nebraska.

TIPS: Although some health systems such as UCHealth are contacting patients, don’t assume that will happen. In most cases, it appears, you will need to take the initiative.

Check with the physician’s office, hospital or medical clinic where you usually receive care. Many institutions (though not all) are posting information about covid vaccines on their websites. Some have set up phone lines.

Some health systems are willing to vaccinate anyone who signs up, not just their patients. Kaiser Permanente, which operates in California, Colorado, Georgia, Hawaii, Oregon, Washington, Washington, D.C., and parts of Virginia and Maryland, is among them, according to Dr. Craig Robbins, co-leader of its national covid vaccination program. (Within the next few weeks, it will post an online registration tool on plan websites.) Check with major hospitals or health systems in your area to see what they’re doing. (KHN is not affiliated with Kaiser Permanente.)

Most places are asking people to sign up online for appointments; some sites require multiple steps and their systems may seem hard to use. If you don’t have a computer or you aren’t comfortable using one, ask a younger family member, friend or neighbor for help. Similarly, ask for help if you aren’t fluent in English.

If you can’t figure out how to sign up online, call your local county health department, Area Agency on Aging or county department on aging and ask for assistance. Every state has a covid-19 hotline; see if the hotline can direct you to a call center that’s taking appointments. Be prepared for long waits; phone lines are jammed.

Q: My mother has stage 3 renal failure, high blood pressure and dementia. She’s unable to take care of herself or be left alone. When can I get her vaccinated with the COVID shot? — Wendy, 61, Chandler, Arizona

Wendy had checked Maricopa County’s website days before we talked on Jan. 5 and couldn’t figure out when her 84-year-old mother might get a vaccine appointment. The week before, her 90-year-old father died, alone, of renal failure complicated by pneumonia in a nursing home.

Three days after our conversation, Maricopa County announced that people 75 and older could start making appointments to be vaccinated on a “first-come, first-served” basis on Monday, Jan. 11. (The state’s appointment site is https://podvaccine.azdhs.gov/; callers should try 844-542-8201 or 211, according to information provided by the county.)

In Arizona, “it’s up to each county to come up and execute a plan for vaccine distribution,” said Dana Kennedy, state director of AARP Arizona.

Demand is high and vaccine supplies are limited, other places have found. For example, on Jan. 7, a 1,200-slot vaccine clinic in Oklahoma City for adults 65 and older filled up within four minutes, according to Molly Fleming, a public information officer at the Oklahoma City-County Health Department.

“Once we get more vaccine supplies coming more frequently, we will do more clinics,” Fleming said. “The challenge we have right now is, we need the vaccine and we don’t know when it’s coming in.”

TIPS: Consult AARP’s state-by-state covid vaccine guides, focused on older adults and updated daily. (To access, go to https://www.aarp.org/coronavirus/. In the right-hand column, click on “the vaccine in your state.”) More than 20 states are listed there now, but guides for all states should be available by the end of January.

Meanwhile, check local media and your county’s and state’s health department websites regularly for fresh information about covid vaccine distribution plans.

On Monday, for example, Washington, D.C., unveiled a new vaccination registration site for residents 65 and older and health care workers. The week before, Illinois announced it would extend vaccines to residents 65 and older when it moved into the next phase of its vaccination plan, and the city of Chicago followed suit. The timetable for those transitions remains unclear.

Be prepared to be patient as problems with distribution surface. States and counties around the country are learning from problems that have arisen in places such as Florida — crashed phone lines, long lines of older adults waiting outdoors, massive confusion. It may take some time, but vaccine rollouts should become smoother as more sites come online and supplies become more readily available.

Q: When can a 72-year-old male with chronic lymphocytic leukemia expect to be vaccinated at Kaiser Permanente in Southern California? — Barry

California last week announced that counties that have made significant progress and have adequate supplies can move toward offering vaccines to residents 75 and older.

How soon this will happen isn’t clear yet; it will vary by location. But even then, Barry wouldn’t qualify immediately since he’s only 72 and it could take several months for vaccines to become available to people in his age group (65 to 74), said Robbins, who’s helping lead Kaiser Permanente’s vaccination program.

Barry is at especially high risk of doing poorly if he develops covid because of the type of cancer he has — leukemia. But, for the most part, medical conditions are not being taken into account in the initial stages of vaccine distribution around the country.

An exception is the Mayo Clinic. It’s identifying patients at highest risk of getting severe infections, being hospitalized and dying from covid at the Mayo Clinic Health System, a network of physician practices, clinics and hospitals in Iowa, Minnesota and Wisconsin. When states allow older adults outside of long-term care institutions to start getting vaccines, it will offer them first to patients at highest risk, said Dr. Abinash Virk, co-chair for Mayo Clinic’s vaccine rollout.

TIPS: Even if vaccines aren’t available right away, production is increasing, new products are in the pipeline, and new ways of distributing vaccines — notably mass distribution sites — are being planned. If you have to wait several weeks or months, don’t give up. Persistence is worth the effort, given the vaccine’s benefits.

California Counties ‘Flying the Plane as We Build It’ in a Plodding Vaccine Rollout

In these first lumbering weeks of the largest vaccination campaign in U.S. history, Dr. Julie Vaishampayan has had a battlefront view of a daunting logistical operation.

Vaishampayan is the health officer in Stanislaus County, an almond-growing mecca in California’s Central Valley that has recorded about 40,000 cases of covid-19 and lost 700 people to the illness. Her charge is to see that potentially lifesaving covid shots make it into the arms of 550,000 residents.

And like her dozens of counterparts across the state, she is improvising as she goes.

From week to week, Vaishampayan has no idea how many new doses of covid vaccines will be delivered until just days before they arrive, complicating advance planning for mass inoculation clinics. The inoculation clinics themselves can be a bureaucratic slog, as county staffers verify the identities and occupations of people coming in for shots to ensure strict compliance with the state’s multitiered hierarchy of eligibility. In these early days, the county also has provided vaccines to some area hospitals so they can inoculate health care workers, but the state system for tracking whether and how those doses are administered has proven clumsy.

With relatively little help from the federal government, each state has built its own vaccination rollout plan. In California, where public health is largely a county-level operation, the same departments managing testing and contact tracing for an out-of-control epidemic are leading the effort. That puts an already beleaguered workforce at the helm of yet another time-consuming undertaking. A lack of resources and limited planning by the federal and state governments have made it that much harder to get operations up and running.

“We are flying the plane as we are building it,” said Jason Hoppin, a spokesperson for Santa Cruz County. ”All of these logistical pieces are just a huge puzzle to work out.”

It’s a massive enterprise. Counties must figure out who falls where in the state’s multitiered system for eligibility, locate vaccination sites, hire vaccinators, notify workforce groups when they are eligible, schedule appointments, verify identities, then track distribution and immunizations administered.

Some of that burden has been eased by a federal program that is contracting with major pharmacies Walgreens and CVS to vaccinate people living in nursing homes and long-term care facilities, as well as a California mechanism that allows some large multicounty health care providers to order vaccines directly. As of this week, some smaller clinics and doctors’ offices also can get vaccine directly from the state.

But much of the job falls on health departments, the only entities required by law to protect the health of every Californian. And they are doing it amid pressures from the state to prevent people from skipping the line and a public eager to know why the rollout isn’t happening faster.

As of Monday, only a third of the nearly 2.5 million doses allocated to California counties and health systems had been administered, according to the most recent state data available. Gov. Gavin Newsom has acknowledged the rollout has “gone too slowly.” Health directors counter it’s the best that could be expected given the short planning timeline, limited vaccine available and other strictures.

“I would not call this rollout slow,” said Kat DeBurgh, executive director of the Health Officers Association of California. “This isn’t the same as a flu vaccine clinic where all you have to do is roll up your sleeve and someone gives you a shot.”

It has been one month since the first vaccines arrived in California, and just over five weeks since the state first outlined priority groups for vaccinations, then passed the ball to counties to devise ways to execute the plan.

Like most states, California opened its rollout with strict rules about the order of distribution. The first phase prioritized nursing home residents and hospital staffs before expanding to other broad categories of health care workers. In the weeks after the vaccines first arrived, state officials made clear that providers could be penalized if they gave vaccinations to people not in those initial priority groups.

Multiple counties said there had been little in the way of line-skipping, but stray reports in the media or complaints sent directly to community officials need to be chased down, wasting precious public health resources. The same goes for reports of vaccine doses being thrown away. One of the vaccines in circulation, once removed from ultra-cold storage, must be used within five days or discarded.

State officials have since loosened their rules, telling counties and providers to do their best to adhere to the tiers, but not to waste doses. On Jan. 7, California officials told counties they could vaccinate anyone in “phase 1a,” expanding beyond the first priority group of nursing homes and hospitals to nearly everyone in a health-related job. Once that wide-ranging category is finished, counties were supposed to move to “phase 1b,” which unfolds with its own set of tiers, starting with people 75 and older, educators, child care workers, providers of emergency services, and food and agricultural workers before expanding to all people 65 and older.

Mariposa and San Francisco both said they would be vaccinating people in the first 1b categories this week. That means residents will start seeing inequities among counties, said DeBurgh, noting that some counties had not yet received enough vaccine doses to cover health care workers while others are nearly finished. Stanislaus County, for example, had received approximately 16,000 first doses as of Jan. 9, but estimates it has between 35,000 and 40,000 health care workers phase 1a.

And the orders are changing yet again, forcing counties to pivot. On Tuesday, U.S. Health and Human Services Secretary Alex Azar said the Trump administration would begin releasing more of its vaccine supply, holding onto fewer vials for second doses; and he encouraged states to open up vaccinations to everyone age 65 and older. In response, California officials said Wednesday that once counties are done with phase 1a, people 65 and older are in the next group eligible for vaccines.

Some local health directors expressed dismay at the prospect, saying they welcome the influx of vaccines but need to prioritize people 75 and older who represent the bulk of hospitalizations. They also noted that states already offering broader access have had their own challenges, including flooded health department phone lines, crashed websites and fragile seniors camping out overnight in hopes of securing their place in line.

While sensible in theory, California’s phased approach to the rollout has proved cumbersome when it comes to verifying that people showing up for shots fall under the umbrella groups deemed eligible. In Stanislaus, for example, 6,600 people qualify as in-home support workers. Someone from another county department has to sit with health department staffers to verify their eligibility, since the health department doesn’t have access to official data on who is a qualified member of the group.

Complicating matters, about half the county’s in-home workers are caring for a family member, and many are bringing that person with them to get vaccinated. The county is required to turn those family members away if they don’t meet the eligibility criteria, Vaishampayan said.

A range of other hiccups hampered the rollout. Across the state, uptake of vaccination slowed to a crawl from Christmas to New Year’s. Health workers, particularly those who do not work in hospitals, were on vacation and enjoying a few days off with family after a tough year, several county officials said. Many chose not to get vaccinated during that time.

Others are choosing not to get vaccinated at all. Across the state, health care workers are declining vaccinations in large numbers. The health officer for Riverside County has said 50% of hospital workers there have declined the vaccine.

And in Los Angeles and Sonoma, officials described software challenges that prevented them from quickly enrolling doctors’ offices to receive vaccines and perform injections.

Still, statewide, officials said they were confident that the pace would pick up in the coming days, as more doses arrive, data snags get sorted out and more vaccination sites come on board. Los Angeles County announced this week it would convert Dodger Stadium and a Veterans Affairs site from mass testing sites into mass vaccination clinics. Similar plans are underway at Petco Park in San Diego and the Disneyland Resort in Orange County. Officials hope Dodger Stadium alone can handle up to 12,000 people a day.

The move solves one problem, but potentially exacerbates another: The two Los Angeles sites have been testing 87,000 people a week, according to Dr. Christina Ghaly, Los Angeles County Department of Health Services director. That will put new constraints on testing, even as covid cases in the nation’s most populous county continue to rise and hospitals are beyond capacity.

In Search of a Baby, I Got Covid Instead

As a health care journalist in Los Angeles reporting on the pandemic, I knew exactly what I needed to do once I landed in the hospital with covid pneumonia: write my goodbye emails.

I’d seen coverage of some final covid messages during this terrible year. They were usually directed to spouses, but my No. 1 concern was how to explain my own death to my 3-year-old, Marigold, whom we call “Goldie.” How much of me would she remember, and how would she make peace with what happened to me, when I could barely believe it myself?

After the emergency room doctor confirmed pneumonia in both of my lungs on Dec. 17, I was whisked upstairs to the hospital’s covid unit, where I got a blood thinner injection, infusions of steroids and remdesivir, and continued on the supplemental oxygen they had started in the ER.

Immediately after the treatments, my mind was clearer and more focused than it had been in the nine days since my husband, daughter and I had all received positive covid results (and when my raging fevers began). As I lay in my hospital bed, my roommate’s TV blaring, I started thinking about my daughter’s understanding of death. A lapsed evangelical married to a Jewish man, I had adopted his family’s perspective on the afterlife — that discussing it wasn’t very important — but had also inadvertently abdicated the death discussion to Hollywood.

Goldie’s afterlife education began with the movie “Coco,” about the Mexican Day of the Dead, in which families put pictures of their ancestors on a home altar, or ofrenda. Then came “Over the Moon,” in 2020, about a little girl in China who loses her mom to illness and struggles to accept a new stepmother, all while her mom’s spirit visits her in the form of a crane.

That prompted her first question about my death.

“Are you going to die like Fei Fei’s mom did?” Goldie asked me in November, before I got sick. I told her at the time that no one knows when they’re going to die, but that I would love her with all of my heart for as long as I lived.

After that, Goldie would sometimes randomly declare, “I don’t think you’re going to die,” or she would ask if we could all die together, at the same time — to which I’d say, “Sure!”

My covid symptoms started Dec. 7, and we got our positive results back the next morning. Thankfully, my husband and daughter had almost no symptoms except stuffy noses and a day of low fever. But I started off with a fever that would burn me up to 104 degrees, over and over again. Tylenol and Advil could bring it down only to 100 or 101. I would cry as the painful fevers reached their peak and wondered if God had been preparing Goldie all along this year for my eventual death.

My breathing problems began eight days later. The scariest moment during that time was when I was in the middle of a shower (much needed after days of sweaty fevers) and realized I was gasping for air. I punched the shower curtains out of my way and ran to my bed, where I could lie on my stomach and get my oxygen levels up again. As I lay there, hyperventilating, soaking wet, with shampoo still in my hair, the pulse oximeter monitor registered 67, before inching back up to 92. I began thinking of what I wanted to say to Goldie in my final letter to her, but I was too weak to type it out.

This sped-up video shows Anna proning on a bean bag and pillows in order to keep her oxygen saturation levels in the 90s. Anna lived like this for two days before being hospitalized. (Simon Ganz)

How to explain hubris, or was it foolhardiness, to a toddler? That in our loving quest to give her a “forever friend,” a sibling to grow up with and play with and fight with and commiserate with, my husband and I had been like two moths circling a flame, ramping up our fertility treatments even as the pandemic picked up speed in Los Angeles?

But here was my thinking: I’m 35, I want a second child, we’re very infertile, and we don’t have time to waste. This was my secret driving force in 2020, even as my colleagues reported on how elective medical procedures were siphoning resources and PPE from the covid effort, and how patients were avoiding medical appointments of all kinds to avoid accidental exposure to the coronavirus.

I also thought that I should be using this pandemic year “productively.” And what could be more productive than reproduction? I wanted to use my time wisely by growing another human being while we were all stuck indoors and blessed with jobs we could perform from home.

In March, I had a procedure to remove some uterine polyps to prepare for an embryo transfer. Back then, covid cases weren’t being regularly reported.

Anna and Goldie on Mother’s Day. At that point in the year, Anna was undergoing fertility treatments to prepare for a future embryo transfer. (Simon Ganz)

Two more uterine procedures led to a successful embryo transfer, but a miscarriage put me in the ER on Oct. 8. By then, Los Angeles County had seen 278,665 cases and 6,726 deaths — horrifying numbers that I monitored and reported on as a health journalist, but data points I couldn’t, or wouldn’t, use to alter the decision-making in my own life.

With four miscarriages now under my belt and no more viable embryos left to use, my husband, Simon, and I decided we’d give in vitro fertilization one final try. I started my injections for an egg retrieval in late November, and by the time the procedure rolled around on Dec. 3, L.A. was well into its scary, almost vertical holiday season ascent, posting 7,854 new cases that day — up fivefold from a month earlier.

A close friend was supposed to start her IVF injections at the same time, but she decided to postpone at the last minute because covid cases were so high in our area. By that point, we were so driven in our pursuing of pregnancy that I was startled to hear her say that, as the thought had never even crossed my mind.

I have no way of knowing for sure if I was exposed to the virus sometime during this last fertility treatment. The surgical center is located on a large medical campus that also hosts a covid-19 testing drive-thru in the garage where we parked. We waited, masks on, for almost an hour outside the building, which we thought was a safer choice than the fertility clinic waiting room, but that actually put us in proximity to a lot of sick people waiting for rides home.

I also had to remove my mask just before the actual egg retrieval, because I was under anesthesia and the doctors needed quick access to my mouth in case I needed a breathing tube.

Five days after the egg retrieval, we found out we were covid-positive. I called the clinic right away to warn them; the fertility doctor told me a few days later that none of her staffers had gotten sick. And also that none of the eggs they retrieved from me had developed properly. We had no embryos to use.

Of course, as anyone who has done fertility treatments knows, all the dangers and risks we undertook would have been “worth it” if it had worked. Because it didn’t work for us, I felt defeated and foolish.

In sum, we wanted to give Goldie a sibling, but attempting to do so may have been what threatened her mother’s life. This thought haunts me and will stay with me forever, even though I’ll never know how exactly the virus entered our home.

Our nanny, who also experienced covid symptoms and tested positive three days before us, could have picked it up at the supermarket. We could have gotten it from her or while walking around our neighborhood or playing in the park. But the act of choosing, over and over again, to engage in fertility treatments as the pandemic raged on, fills me with doubt and remorse.

This was all too much to put in my goodbye letter to Goldie. Instead, this is some of what I wrote:

Around Halloween, you and I were eating breakfast together and I asked you how your life was going, and if there were any improvements I could make for you. You said, with absolute seriousness, “I’m afraid of ghosts.”

Now that I’m a ghost, I hope there’s less reason to be afraid.

Please put my picture on the ofrenda once a year. I’ll always be in your heart and in your memories. I will try to visit you too. But not in a spooky way, just a gentle way.

I will always love you. Thank you so much for being born to us. You made everything better.

After finishing my goodbye letter, I went to sleep. In the morning, I woke up, got a second infusion of steroids and remdesivir, and then was released home with oxygen tanks and an oxygen concentrator. I stayed in bed, on oxygen, for another week before my lungs were strong enough for me to stand and walk on my own. We had a wonderful Christmas morning together opening presents during a Zoom call with my family. Other than fatigue, I am now almost back to normal.

After the holidays, I sat down with Goldie for breakfast as we usually do. Feeling morose about how the year had turned out, I asked, dreading her response, if she would like to have a baby brother or sister one day.

Anna and Goldie on Aug. 27, 2020, about one month before the embryo transfer that ended in miscarriage. (Simon Ganz)
Simon Ganz, Goldie and Anna pose for a picture on New Year’s Eve. By then, Anna had been off oxygen for three days and was quickly regaining strength. (Simon Ganz)

She put her hand on my neck and pressed her forehead into mine, a face-to-face embrace that we call a “pumpkin hug.”

“No, Mom,” she said. “I want it to be just you and me, forever.”

I took a deep breath, and then sighed with relief.

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At Home Newsletter

What Art Does for Us

And why we should support it.

Credit…Invisible Creature

  • Jan. 13, 2021, 4:00 p.m. ET

Welcome. When I was 22, I was a factotum at a nonprofit theater in New York City. I made fundraising calls and addressed envelopes. The job was pretty humdrum, but it had one massive perk: I’d frequently get free tickets to shows I’d never be able to afford otherwise: Cherry Jones in “Pride’s Crossing”; “Art,” with Alan Alda, Victor Garber and Alfred Molina; musicals like “Ragtime” and “The Lion King.”

I thought about that era of constant theatergoing — of sitting in the dark of the audience, overwhelmed by the grandness of the spectacle onstage and my luck at getting to experience it — while reading the critic Jason Farago’s suggestions for what the Biden administration can do to provide relief for the arts. He argues that the country is in urgent need of Aristotelian catharsis — of art, music, drama and the emotions they summon:

You go to the theater, you listen to a symphony, you look at a painting, you watch a ballet. You laugh, you cry. You feel pity, fear. You see in others’ lives a reflection of your own. And the catharsis comes: a cleansing, a clarity, a feeling of relief and understanding that you carry with you out of the theater or the concert hall. Art, music, drama — here is a point worth recalling in a pandemic — are instruments of psychic and social health.

Farago advises Biden to create a new Works Progress Administration-style program treating artists as essential workers, and to make it easier for artists to receive unemployment benefits, among other recommendations.

We’re all waiting for things to open up so we can resume what we think of as normal life. Considering what that will take is daunting, but it makes the promise of going to a play, hearing live music or standing awed before a painting that much more exciting to anticipate.

In the shorter term, I’m anticipating “A Swim in a Pond in the Rain,” George Saunders’s close reading of Chekhov. Parul Sehgal wrote, in her review of it, that Saunders “offers one of the most accurate and beautiful depictions of what it is like to be inside the mind of the writer that I’ve ever read.” Who could resist?

There’s also a new Sally Rooney novel coming in September. (Rooney’s last novel, “Normal People,” which was adapted into a popular Hulu series last year, gets more attention, but I’m partial to her first book, “Conversations with Friends.”)

And if it’s sunny where you are, or even if it’s not, you might find it thrilling, as I did, to take a stroll and listen to this episode of the podcast “Grounded with Louis Theroux,” in which Theroux interviews his friend and rival, the writer and filmmaker Jon Ronson.

Tell us.

When was the last time you had a strong emotional response to a play or film? The last time a book or painting freed you from “the feeling that there’s only one way to live, or only one way to go about your day,” as the writer Ben Lerner put it? Write to us: athome@nytimes.com. We’re At Home. We’ll read every letter sent. More ideas for leading a full and cultured life at home appear below.

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Were you forwarded this newsletter? Sign up to receive it yourself! You can always find much more to read, watch and do every day on At Home. And let us know what you think!

Vitamins C and E Tied to Lower Risk for Parkinson’s Disease

Vitamins C and E Tied to Lower Risk for Parkinson’s Disease

Consuming foods high in vitamins C and E may help protect against the onset of Parkinson’s later in life, a Swedish study suggests.

Nicholas Bakalar

  • Jan. 13, 2021, 2:51 p.m. ET

People who consume a diet rich in vitamins C and E may be at reduced risk for Parkinson’s disease.

Researchers followed 41,058 Swedish men and women for an average of 18 years, gathering data on their health and diet. They assessed intake of vitamins C and E as well as beta-carotene and a measure called NEAC, which takes into account all antioxidants from food and their interactions with each other.

Over the course of the study, published in Neurology, there were 465 cases of Parkinson’s disease.

After adjusting for age, sex, B.M.I., education, smoking, alcohol consumption and other characteristics, they found that compared with the one-third of people with the lowest intake of vitamin C or E, the one-third with the highest intake had a 32 percent reduced risk for Parkinson’s disease. Those in the highest one-third in consumption of both vitamins together had a 38 percent reduced risk. There was no effect for beta-carotene or the NEAC measure.

The lead author, Essi Hantikainen, who was a researcher at the University of Milano-Bicocca when the work was done, that more research needs to be done before drawing definitive conclusions or offering advice about diet or supplement use and the risk of Parkinson’s.

Still, she said, “Implementation of a diet that includes foods rich in vitamins C and E might help protect against the development of Parkinson’s later in life. In any case, it’s never wrong to implement a healthy diet.”

How to Reset (or at Least Lower) Your Stress in 5 Minutes

How to Reset (or at Least Lower) Your Stress in 5 Minutes

Jenny Taitz

Jenny TaitzDe-stressing in Los Angeles 💆‍♀️

This year has already proved to be the emotional equivalent of an ultramarathon. To help you hit the reset button, it’s key to know some quick, efficient stress-reducing strategies.

Here are a few ideas from an assistant clinical professor in psychiatry

Kids and Covid Tests: What You Need to Know

So You Think Your Kid Needs a Covid Test

Here’s everything you need to know about when to get it and what to expect.

Credit…Sonia Pulido
Christina Caron

  • Jan. 13, 2021, 6:00 a.m. ET

My 4-year-old daughter is pretty tough when it comes to medical procedures. The flu shot? Not even a flinch. Stitches in her forehead? No big deal. Years earlier, she calmly watched as a nurse pricked her finger and squeezed the blood, drop by drop, into a tiny vial to test it for lead.

But the Covid test was different.

In early September, just before her preschool reopened, she began sneezing and had a sore throat. When her congestion worsened, we knew that she needed to get a coronavirus test. But as the nurse approached her, holding a long stick with a brush on the end resembling a pipe cleaner, she covered her face and backed away. In the end, two people had to hold her down. She screamed as the swab activated her lacrimal reflex, bringing tears to her eyes. It was over quickly, but she cried for half an hour afterward and insisted that she would never visit another doctor again. She now refers to that probe as “the needle.”

In late December she needed another test for her preschool, but this time she wasn’t sick. With the memory of her last experience still fresh in my mind, I immediately started researching. Were there less invasive tests to consider? If so, how would we find one? Would it be accurate enough? And was there an ideal way to prepare a squeamish young child who was averse to getting tested?

As it turned out, none of these questions had simple answers. So I consulted with five doctors and two of the largest urgent care providers in the United States to learn more.

How do I know if my child needs a test?

There are four main reasons a child might need to be tested:

  • They have symptoms

  • They have been exposed to someone infected with the virus

  • Their school, day care or a hospital requires it

  • They need it as a precaution before and after traveling

If your child has any symptoms of Covid — even mild ones like a runny nose or a sore throat — it’s a good idea for them to get tested and stay home, said Dr. Stanley Spinner, chief medical officer and vice president of Texas Children’s Pediatrics, the largest pediatric primary care group in the country, and Texas Children’s Urgent Care.

“We have seen, time and time again, kids with very mild symptoms with no known exposures who get tested with our very accurate PCR and sure enough, they come back positive,” Dr. Spinner said.

If your child has been in close contact with someone who tested positive for Covid-19 — even if your child does not have any symptoms — they should get tested, the experts said. The Centers for Disease Control and Prevention define close contact as spending at least 15 minutes within six feet of someone who has the coronavirus, or having any type of direct physical contact with an infected person, including kissing or hugging.

If your child is in school or day care, those institutions may have rules on when they must be tested, and how.

It’s safest to stay home, but if you and your children must travel, the C.D.C. recommends getting tested one to three days before your trip and then again three to five days after your trip.

If you’re still unsure if your child needs a test, call their pediatrician, said Dr. Kristin Moffitt, an infectious disease specialist at Boston Children’s Hospital. You can also take the C.D.C.’s clinical assessment tool, which can be used for any family member, including children.

Which types of tests are available for kids?

Virus testing for children is, for the most part, the same as it is for adults. The Food and Drug Administration has authorized the emergency use of two basic categories of diagnostic test. The most sensitive ones are the molecular PCR tests, which detect the genetic material of the virus and can take days to deliver results (some locations offer results in as little as a day). The second type of test, the antigen test, hunts for fragments of proteins that are found on or within the coronavirus. Antigen tests typically yield results quickly, within 15 minutes, but can be less sensitive than the molecular tests.

The way your provider collects your sample can vary. For instance, regardless of whether you get a PCR test or an antigen test, the collection method could be any of the following: nasopharyngeal swab (the long swab with a brush at the end that reaches all the way up the nose toward the throat); a shorter swab that is inserted about an inch into the nostrils; a long swab of the tonsils at the back of the throat; or a short swab swizzled on the gums and cheeks. The new saliva tests, which are still being vetted, require you to drool into a sterilized container, which could be difficult for young children.

FastMed Urgent Care, which has a network of more than 100 clinics in Arizona, North Carolina and Texas, currently uses a long swab to perform the rapid antigen test and a short swab for the PCR test, said Dr. Lane Tassin, one of the company’s chief medical officers. But MedExpress, a different urgent care group with clinics in 16 states, tests all patients with the shorter nasal swab when doing either PCR or antigen tests at its nearly 200 urgent care centers, said Jane Trombetta, the company’s chief clinical officer.

Which diagnostic test should my child get?

The type of test that your child gets will largely depend on what is available in your area, how long it takes to get the results back and why the child needs it, the experts said.

Some day care centers and schools will only accept PCR results for clearance to return to school, so it is best to double check their rules beforehand.

The long-swab molecular test is considered the “gold standard,” but other less-invasive testing methods are also reliable. For routine testing, Dr. Jay K. Varma, senior advisor for public health at the Office of the Mayor of New York City, said the shorter swab “performs basically as well as the longer, deeper swab does. That’s true in both adults and children.” In fact, he added, New York City’s public hospital testing sites began switching from the long swab to the short swab during the summer.

Dr. Jennifer Lighter, a pediatric infectious disease specialist at NYU Langone Health, said she likes the antigen tests because they can quickly identify Covid-positive kids when they are contagious. Antigen tests are most accurate when the amount of virus in the sample is highest — typically around the day that symptoms start.

If you have a preference on which test you’d like your child to get, call your pediatrician’s office first and ask what kinds of tests they perform and how they collect the samples. Clarify whether they use the shallow (anterior) swab or the long (nasopharyngeal) swab. If you want the more comfortable, shallow PCR test but your pediatrician’s office does not offer it, try other testing centers in your area, including pediatric urgent care centers.

Some tests are now available for home use. But if you’re using a home test, check the label. Some aren’t indicated for children.

Are there any downsides to getting my kid tested? Is it safe?

Many testing sites offer drive-through services where you don’t need to leave your car. But if you must walk into a clinic, the experts I spoke with said that the risk of getting Covid while you’re there is low.

“In my experience, everyone that is delivering health care now is being incredibly careful with infection control,” said Dr. Sean O’Leary, the vice chairman of the American Academy of Pediatrics’ committee on infectious diseases. “The risk of going into a health care facility is probably pretty low relative to a lot of the other things people are currently engaging in in the U.S.”

Testing facilities require people to wear masks and to maintain physical distancing, he added.

The experts also said that the tests themselves are not harmful for young children, including infants, even if done repeatedly. The long swab may produce discomfort for a brief period — Dr. O’Leary jokingly calls it the “brain biopsy” — but he is not aware of any long-term risk to the nose or throat.

How can I prepare my child for the test?

To avoid any surprises, ask your provider about which types of tests they offer and how they collect the samples ahead of time.

It’s usually best to be straightforward with your kid about what to expect. For short nasal swabs, explain that a doctor will tickle the inside of their nose with a cotton swab to collect their boogers, and that it won’t hurt.

For the long swab, you may want to prepare your child by explaining that the swab might feel a little uncomfortable, but that it will be over quickly. You can also share that kids of all ages are getting the test, even babies.

Over all, convey that it’s no big deal and it’s something that simply needs to get done, Dr. Lighter said.

“Kids are only as anxious as the information that’s coming to them,” she added.

If your child might be intimidated by the protective gowns, masks and face shields that health providers wear, explain that they wear that clothing to stay safe — kind of like how people wear cloth masks when they go outside.

Some hospitals have created videos like this one from the Children’s Hospital Colorado that show how the Covid test works and what families can expect. If your child is old enough to understand, it might be helpful to watch a video like this together and then talk about it afterward.

Try to find out how long you might need to wait. Many areas have long lines at testing sites, so consider bringing water, snacks and entertainment (crayons, storybooks) for your kids.

If your child’s pediatrician is administering Covid tests, it might be reassuring for your child to have the test performed by someone they are already familiar with. But if not, “try and go somewhere that has experience working with children,” Dr. O’Leary said. Doctors and nurses who test children regularly will most likely know what to do if your child is nervous or scared.

An 11-Minute Body-Weight Workout With Proven Fitness Benefits

Phys Ed

An 11-Minute Body-Weight Workout With Proven Fitness Benefits

Five minutes of burpees, jump squats and other calisthenics, alternating with rest, improved aerobic endurance in out-of-shape men and women.

Credit…Getty Images
Gretchen Reynolds

  • Jan. 13, 2021, 5:00 a.m. ET

Five minutes of burpees, jump squats and other calisthenics significantly improve aerobic endurance, according to one of the first randomized, controlled trials to test the effects of brief body-weight workouts. The study’s findings are predictable but reassuring, at a time when many of us are relying on short exercise sessions in our homes to gain or retain our fitness. They provide scientific assurance that these simple workouts will work, physiologically, and our burpees will not be in vain.

Last year, when the pandemic curtailed traditional gym hours and left many people hesitant to exercise outside on crowded sidewalks or paths, quite a few of us moved our workouts indoors, into our living rooms or basements, altering how we exercise. Some of us purchased stationary bicycles and started intense spin classes or turned to online personal trainers and yoga classes. But many of us started practicing some version of a body-weight routine, using calisthenics and other simple strength-training exercises that rely on our body weight to provide resistance.

Body-weight training has been a staple of exercise since almost time immemorial, of course. Usually organized as multiple, familiar calisthenics performed one after another, this type of exercise has gone by various names, from Swedish Exercises a century ago to the Royal Canadian Air Force’s Five Basic Exercises (5BX) program in the 1960s, to today’s Scientific 7-Minute Workout and its variations.

In general, one of the hallmarks of these programs is that you perform the exercises consecutively but not continuously; that is, you complete multiple repetitions of one exercise, pause and recover, then move on to the next. This approach makes the workouts a form of interval training, with bursts of intense exertion followed by brief periods of rest.

Traditional interval training has plenty of scientific backing, with piles of research showing that a few minutes — or even seconds — of strenuous intervals, repeated several times, can raise aerobic fitness substantially. But the exercise in these studies usually has involved stationary cycling or running.

Few experiments have examined the effects of brief body-weight workouts on endurance and strength, and those few had drawbacks. Most focused on people who already were fit, and almost none met the scientific gold standard of being randomized and including an inactive control group. Consequently, our faith in the benefits of short body-weight training may have been understandable, but evidence was lacking.

So, for the new study, which was published this month in the International Journal of Exercise Science, researchers at McMaster University in Hamilton, Ontario, and the Mayo Clinic in Rochester, Minn., decided to develop and test a basic body-weight routine. They modeled their version on the well-known 5BX program, which once had been used to train members of the Canadian military in remote posts. But the researchers swapped out elements from the original, which had included exercises like old-fashioned situps that are not considered particularly good for the back or effective in building endurance.

They wound up with a program that alternated one minute of calisthenics, including modified burpees (omitting the push-ups that some enthusiasts tack onto the move) and running in place, with a minute of walking, also in place. The routine required no equipment, little space and a grand total of 11 minutes, including a minute for warming up and cooling down.

They then recruited 20 healthy but out-of-shape young men and women, measured their current fitness, leg power and handgrip strength and randomly assigned half to start practicing the new program three times a week, while the others continued with their normal lives, as a control.

The exercisers were asked to “challenge” themselves during the calisthenics, completing as many of each exercise as they could in a minute, before walking in place, and then moving to the next exercise.

After six weeks, all of the volunteers returned to the lab for follow-up testing. And, to no one’s surprise, the exercisers were more fit, having upped their endurance by about 7 percent, on average. Their leg power also had grown slightly. The control group’s fitness and strength remained unchanged.

“It was good to see our expectations confirmed,” says Martin Gibala, a professor of kinesiology at McMaster University, who oversaw the new study and, with various collaborators, has published influential studies of intense interval training in the past.

“It seemed obvious” that this kind of training should be effective, he says. But “we now have evidence” that brief, basic body-weight training “can make a meaningful difference” in fitness, he says.

The study was small and quite short-term, though, and looked at the effects only among healthy young people who are capable of performing burpees and jump squats. “Some people may need to substitute” some of the exercises, Dr. Gibala says, especially anyone who has problems with joint pain or balance. (See the Standing 7-Minute Workout for examples of appropriate replacements, in that case.)

But whatever mix of calisthenics you settle on, “the key is to push yourself a bit” during each one-minute interval, he says.

Here is the full 11-minute workout used in the study, with video links of each exercise by Linda Archila, a researcher who led the experiment while a student at McMaster University.

  • 1 minute of easy jumping jacks, to warm up

  • 1 minute of modified burpees (without push-ups)

  • 1 minute of walking in place

  • 1 minute of high-knee running in place

  • 1 minute of walking in place

  • 1 minute of split squat jumps (starting and ending in the lunge position, while alternating which leg lands forward)

  • 1 minute of walking in place

  • 1 minute of high-knee running in place

  • 1 minute of walking in place

  • 1 minute of squat jumps

  • 1 minute of walking in place, to cool down

Are You Old Enough to Get Vaccinated? In Tennessee, They’re Using the Honor System

In December, all states began vaccinating only health care workers and residents and staffers of nursing homes in the “phase 1A” priority group. But, since the new year began, some states have also started giving shots to — or booking appointments for — other categories of seniors and essential workers.

As states widen eligibility requirements for who can get a covid-19 vaccine, health officials are often taking people’s word that they qualify, thereby prioritizing efficiency over strict adherence to distribution plans.

“We are doing everything possible to vaccinate only those ‘in phase,’ but we won’t turn away someone who has scheduled their vaccine appointment and tells us that they are in phase if they do not have proof or ID,” said Bill Christian, spokesperson for the Tennessee Department of Health.

Among the states pivoting to vaccinating all seniors, timelines and strategies vary. Tennessee started offering shots to people 75 and older on Jan. 1. So, Frank Bargatze of Murfreesboro, Tennessee, snagged an appointment online for his father — and then went ahead and put his own name in, though he’s only 63.

“He’s 88,” Bargatze said, pointing to his father in the passenger seat after they both received their initial shots at a drive-thru vaccination site in Murfreesboro, a large city outside Nashville. “I jumped on his bandwagon,” he added with a laugh. “I’m going to blame it on him.”

Bargatze does work a few days a week with people in recovery from addiction, he added, so in a way, he might qualify as a health care worker.

Some departments are trying more than others, but overwhelmed public health departments don’t have time to do much vetting.

Dr. Lorraine MacDonald is the medical examiner in Rutherford County, Tennessee, where she’s been staffing the vaccination site. If people seeking the vaccine make it through the sign-up process online, MacDonald said, and show up for their appointment, health officials are not going to ask any more questions — as long as they’re on the list from the online sign-up.

“That’s a difficult one,” MacDonald acknowledged, when asked about people just under the age cutoff joining with older family members and putting themselves down for a dose, too. “It’s pretty much the honor system.”

People getting vaccinated in several Tennessee counties told a reporter they did not have to show ID or proof of qualifying employment when they arrived at a vaccination site. Tennessee’s health departments are generally erring on the side of simply giving the shot, even if the person is not a local resident or is not in the country legally.

The loose enforcement of the distribution phases extends to other parts of the country, including Los Angeles. In response, New York’s governor is considering making line-skipping a punishable offense.

Still, many people who don’t qualify on paper believe they might need the vaccine as much as those who do qualify in the initial phases.

Gayle Boyd of Murfreesboro is 74, meaning she didn’t quite make the cutoff in Tennessee, which is 75. But she’s also in remission from lung cancer, and so eager to get the vaccine and start getting back to a more normal life, that she joined her slightly older husband at the Murfreesboro vaccination site this week.

“Nobody’s really challenged me on it,” she said, noting she made sure to tell vaccination staffers about her medical issues. “Everybody’s been exceptionally nice.”

Technically, in the state’s current vaccine plan, having a respiratory risk factor like lung cancer doesn’t leapfrog anyone who doesn’t otherwise qualify. But in some neighboring states such as Georgia, where the minimum age limit is 65, Boyd would qualify.

Even for those who sympathize with such situations, anecdotes about line-skipping enrage many trying to wait their turn.

“We try to be responsible,” said 57-year-old Gina Kay Reid of Eagleville, Tennessee.

Reid was also at the Murfreesboro vaccination site, sitting in the back seat as she accompanied her older husband and her mother. She said she didn’t think about trying to join them in getting their first doses of vaccine. “If you take one and don’t necessarily need it, you’re knocking out somebody else that is in that higher-risk group.”

But there is a way for younger, healthier people to get the vaccine sooner than later — and not take a dose away from anyone more deserving.

A growing number of jurisdictions are realizing they have leftover doses at the end of every day. And the shots can’t be stored overnight once they’re thawed. So some pharmacists, such as some in Washington, D.C., are offering them to anyone nearby.

Jackson, Tennesse, has established a “rapid response” list for anyone willing to make it down to the health department within 30 minutes. Dr. Lisa Piercey, the state’s health commissioner, said her own aunt and uncle received a call at 8 p.m. and rushed to the county vaccination site to get their doses.

Piercey called it a “best practice” that she hopes other jurisdictions will adopt, offering a way for people eager for the vaccine to get it, while also helping states avoid wasting precious doses.

This story is part of a partnership that include WPLN, NPR and Kaiser Health News.

Hospitals’ Rocky Rollout of Covid Vaccine Sparks Questions of Fairness

Last week, after finishing inoculations of some front-line hospital staff, Jupiter Medical Center was left with 40 doses of precious covid vaccine. So, officials offered shots to the South Florida hospital’s board of directors and their spouses over age 65.

But that decision sparked outrage among workers left unvaccinated, including those at one of the hospital’s urgent care clinics, or who believe the hospital was currying favor with wealthy insiders before getting all its staffers protected, according to a hospital employee who spoke on the condition of not being named.

The move also prompted dozens of calls from donors looking to get vaccinated.

The hospital received 1,000 doses of the Moderna vaccine two days before Christmas, fewer than half of what it requested from the state to cover its workforce. Officials prioritized delivering the vaccine to front-line medical workers who requested it, performing inoculations on Christmas Eve or the holiday weekends.

Patti Patrick, a hospital vice president, said the hospital acted appropriately in its offerings of the vaccine, which has a short shelf life once vials are opened. Neither she nor other administrators who don’t work directly with patients were included in this first round of shots.

“This was a simple way to move 40 doses very quickly” before it spoiled, she said.

She added that all front-line staff from the health system, including the clinics, were given the opportunity to get the shots.

Jupiter is not the only hospital in the nation facing questions about its handling of the vaccines. The initial rollout — aimed at health care workers and nursing home residents — has been uneven at best because of a lack of a federal strategy on how it should work, with states, hospitals, nursing homes and pharmacies often making decisions on their own about who gets vaccinated and when.

In some hospitals, administrators and other personnel who have no contact with patients or face no risk at work from the virus are getting shots, while patients — and even front-line staff — who are at heightened risk for covid complications are being passed by. Some administrators who have been working remotely throughout the pandemic have been vaccinated, especially at hospitals that decided to allocate doses by age group rather than exposure risk.

Although states and federal health groups laid out broad guidelines on how to prioritize who gets the vaccine, in practice what’s mattered most was who controlled the vaccine and where the vaccine distribution was handled.

Stanford Health Care in California was forced to rework its priority list after protests from front-line doctors in training who said they had been unfairly overlooked while the vaccine was given to faculty who don’t regularly see patients. (Age was the important factor in the university’s algorithm.)

Members of Congress have called for an investigation following media reports that MorseLife Health System, a nonprofit that operates a nursing home and assisted living facility in West Palm Beach, Florida, vaccinated donors and members of a country club who donated thousands of dollars to the health company.

At least three other South Florida hospital systems — Jackson Health, Mount Sinai Medical Center and Baptist Health — have offered vaccines to donors in advance of the general public, while administering the shots to front-line employees, The Miami Herald reported.

Like Jupiter Medical, the hospitals insist that those offered shots were 65 and older, as prioritized by state officials.

Staffing Problems at Hospitals

An advisory board to the Centers for Disease Control and Prevention designated hospitals and nursing homes to get covid vaccines first because their workers and residents were considered at highest risk, and most states have followed that recommendation. But in many cases, the health institutions have found demand from staffers, some of whom are leery of the voluntary shot, is less than anticipated.

In addition, the arrival of promised shipments has been unpredictable. While the federal government approved the first covid vaccine on Dec. 14, some hospitals did not receive allotments until after Christmas.

That was the case at Hendry Regional Medical Center in Clewiston, Florida, which got 300 doses from the state. The hospital vaccinated 30 of its 285 employees between Dec. 28 and Jan. 5, said R.D. Williams, its chief executive officer. Some employees preferred to wait until after New Year’s weekend out of concern about side effects, he said.

The vaccine has been reported to commonly cause pain at the injection site and sometimes produce fever, lethargy or headache. The reactions generally last no more than a few days.

“I’m happy with how it’s going so far,” Williams said. “I know many of our employees want to be vaccinated, but I don’t see it as a panacea that they have to have it today,” he said, noting that staffers already have masks and gloves to protect themselves from the virus.

The hospital is also trying to coordinate vaccination schedules so 10 people at a time get the shot to ensure none of the medication is wasted after the multidose vials are thawed. Once vaccine is thawed, it must be used within hours to retain its effectiveness.

As of Jan. 6, Howard University Hospital in Washington, D.C., had vaccinated slightly more than 900 health workers since its first doses arrived Dec. 14. It has received 3,000 doses.

Success has been limited by reluctance among workers to get a vaccine and a lack of personnel trained to administer it, CEO Anita Jenkins said.

“We still have a hospital to run and have patients in the hospital with heart attacks and other conditions, and we don’t have additional staff to run the vaccine clinics,” she said.

While some hospitals offer the vaccine only to front-line workers who interact with patients, Howard makes it available to everyone, including public relations staff, cafeteria workers and administrators. Jenkins defended the move because, she said, it’s the best way to protect the entire hospital.

She noted such employees as information technology personnel who don’t see patients may be around doctors and nurses who do. “Working in a hospital, almost everyone runs into patients just walking down the hallway,” she said.

At Eisenhower Health, a nonprofit hospital based in Rancho Mirage, California, 2,300 of the 5,000 employees have been vaccinated.

“Our greatest challenge has been managing the current patient surge and staffing demands in our acute and critical care areas while also trying to ensure we have adequate staffing resources to operate the vaccine clinics,” said spokesperson Lee Rice.

A Non-System of Inequitable Distribution

Arthur Caplan, a bioethicist at NYU Langone Medical Center in New York City, said hospitals should not be inoculating board members ahead of hospital workers unless those people have a crucial role in running the hospital.

“That seems, to me, jostling to the head of the line and trying to reward those who may be potential donors,” he said. But he acknowledged that the hospitals’ vaccination systems are not always rational or equitable.

Covid vaccines need to get out as quickly as possible, he added, but hospitals can give them only to people they are connected with.

Caplan noted he was vaccinated at an NYU outpatient site last week, even though his primary care doctor hadn’t yet gotten the vaccine because his clinic had not received any doses.

Feeling Left Out: Private Practice Doctors, Patients Wonder When It’s Their Turn for Vaccine

Dr. Andrew Carroll — a family doctor in Chandler, Arizona — wants to help his patients get immunized against covid, so he paid more than $4,000 to buy an ultra-low-temperature freezer from eBay needed to store the Pfizer vaccine.

But he’s not sure he’ll get a chance to use it, given health officials have so far not said when private doctor’s offices will get vaccine.

“I’m really angry,” said Carroll.

Not only are doctors having trouble getting vaccine for patients, but many of the community-based physicians and medical staff that aren’t employed by hospitals or health systems also report mixed results in getting inoculated. Some have had their shots, yet others are still waiting, even though health workers providing direct care to patients are in the Centers for Disease Control and Prevention’s top-priority group.

Many of these doctors say they don’t know when — or if — they will get doses for their patients, which will soon become a bigger issue as states attempt to vaccinate more people.

“The reason that’s important is patients trust their doctors when it comes to the vaccine,” said Carroll, who has complained on social media that his county hasn’t yet released plans on how primary care doctors will be brought into the loop.

Collectively, physicians in the county could vaccinate thousands of patients a day, he said, and might draw some who would otherwise be hesitant if they had to go to a large hospital, a fairground or another central site.

His concern comes as, nationally, the rollout of the vaccine is off to a slower start than expected, lagging far behind the initial goal of giving 20 million doses before the new year.

But Dr. Jen Brull, a family practice doctor in Plainville, Kansas, said her rural area has made good progress on the first phase of vaccinations, crediting close working relationships formed well before the pandemic.

This fall, before any doses became available, the local hospital, the health department and physician offices coordinated a sign-up list for medical workers who wanted the vaccine. So, when their county, with a population of 5,000, got its first 70 doses, they were ready to go. Another 80 doses came a week later.

“We’ll be able to vaccinate almost all the health care-associated folks who wanted it in the county” Brull said recently

Gaps in the Rollout

But that’s not the case everywhere.

Dr. Jason Goldman, a family doctor in Coral Gables, Florida, said he was able to get vaccinated at a local hospital that received the bulk of vaccines in his county and oversaw distribution.

In the weeks since, however, he said several of his front-line staff members still “don’t have access to the vaccine.”

Additionally, “a tremendous number” of patients are calling his office because Florida has relaxed distribution guidelines to include anyone over age 65, Goldman said, asking when they can get the vaccine. He’s applied to officials about distributing the vaccines through his practice but has heard nothing back.

Patients “are frustrated that they do not have clear answers and that I am not being given clear answers to provide them,” he said. “We have no choice but to direct them to the health department and some of the hospital systems.”

Another troubling point for Goldman, who served as a liaison between the American Academy of Family Physicians and the expert panel drawing up the CDC distribution guidelines, is the tremendous variation in how those recommendations are being implemented in the states.

The CDC recommends several phases, with front-line health care workers and nursing home residents and staff in the initial group. Then, in the second part of that phase, come people over 75 and non-health care front-line workers, which could include first responders, teachers and other designated essential workers.

States have the flexibility to design their own rollout schedule and priority groups. Florida, for example, is offering doses to anyone 65 and up. In some counties, older folks were told vaccines were available on a first-come, first-served basis, a move that has resulted in long lines.

“To say right now, 65-plus, when you haven’t even appropriately vaccinated all the health care workers, is negating the phasing,” said Goldman. “There needs to be a national standard. We have those guidelines. We need to come up with some oversight.”

On Thursday, the American Hospital Association echoed that concern in a letter to Health and Human Services Secretary Alex Azar. Hospitals — along with health departments and large pharmacy chains — are doing the bulk of the vaccinations.

Calling for additional coordination by federal officials, the letter outlined what it would take to reach the goal of vaccinating 75% of Americans by the end of May: 1.8 million vaccinations every day. Noting there are 64 different rollout plans from states, cities and other jurisdictions, the letter asked whether HHS has “assessed whether these plans, taken as a whole, are capable of achieving this level of vaccination?”

Making It Work

Lack of direct national support or strategy means each county is essentially on its own, with success or failure affected by available resources and the experience of local officials. Most state and local health departments are underfunded and are under intense pressure because of the surging pandemic.

Still, the success of vaccination efforts depends on planning, preparation and clear communication.

In Lorain County, Ohio, population 310,000, local officials started practicing in October, said Mark Adams, deputy health commissioner. They set up mass vaccination clinics for influenza to study what would be needed for a covid vaccination effort. How many staff? What would the traffic flow be like? Could patients be kept 6 feet apart?

“That gave us an idea of what is good, what is bad and what needs to change,” said Adams, who has had previous experience coordinating mass vaccination efforts at a county level.

So, when the county got its first shipment of 500 doses Dec. 21, Adams had his plan ready. He called the fire chiefs to invite all emergency medical technicians and affiliated personnel to an ad hoc vaccination center set up at a large entertainment venue staffed by his health department. Upon arrival, people were greeted at the door and directed to spaced-apart “lanes” where they would get their shots, then to a monitoring area where they could wait for 15 minutes to make sure they didn’t have a reaction.

Right after Christmas, another 400 doses arrived — and the makeshift clinic opened again. This time, doses went to community-based physicians, dentists and other hands-on medical practitioners, 600 of whom had previously signed up. (Hospital workers and nursing home staff and residents are getting their vaccinations through their own institutions.)

As they move into the next phase — recipients include residents over 80, people with developmental disorders and school staff — the challenges will grow, he said. The county plans a multipronged approach to notify people when it’s their turn, including use of a website, the local media, churches, other organizations and word-of-mouth.

Adams shares the concerns of medical providers nationwide: He gets only two days’ notice of how many doses he’s going to receive and, at the current pace of 400 or 500 doses a week, it’s going to take a while before most residents in the county have a chance to get a shot, including the estimated 33,000 people 65 and older.

With 10 nurses, his clinic can inject about 1,200 people a day. But many other health professionals have volunteered to administer the shots if he gets more doses.

“If I were to run three clinics, five days a week, I could do 15,000 vaccinations a week,” Adams said. “With all the volunteers, I could do almost six clinics, or 30,000 a week.”

Still, for those in the last public group, those age 18 and up without underlying medical conditions, “it could be summer,” Adams said.

One Mask Is Good. Would Two Would Be Better?

One Mask Is Good. Would Two Would Be Better?

Health experts double down on their advice for slowing the spread of the coronavirus.

A double-mask wearer in New York City in April.
A double-mask wearer in New York City in April.Credit…Kena Betancur/Getty Images
Katherine J. Wu

  • Jan. 12, 2021, 12:51 p.m. ET

Football coaches do it. President-elects do it. Even science-savvy senators do it. As cases of the coronavirus continue to surge on a global scale, some of the nation’s most prominent people have begun to double up on masks — a move that researchers say is increasingly being backed up by data.

Double-masking isn’t necessary for everyone. But for people with thin or flimsy face coverings, “if you combine multiple layers, you start achieving pretty high efficiencies” of blocking viruses from exiting and entering the airway, said Linsey Marr, an expert in virus transmission at Virginia Tech and an author on a recent commentary laying out the science behind mask-wearing.

Of course, there’s a trade-off: At some point, “we run the risk of making it too hard to breathe,” she said. But there is plenty of breathing room before mask-wearing approaches that extreme.

A year into the Covid-19 pandemic, the world looks very different. More than 90 million confirmed coronavirus infections have been documented worldwide, leaving millions dead and countless others with lingering symptoms, amid ongoing economic hardships and shuttered schools and businesses. New variants of the virus have emerged, carrying genetic changes that appear to enhance their ability to spread from person to person.

And while several vaccines have now cleared regulatory hurdles, the rollout of injections has been sputtering and slow — and there is not yet definitive evidence to show that shots will have a substantial impact on how fast, and from whom, the virus will spread.

Through all that change, researchers have held the line on masks. “Americans will not need to be wearing masks forever,” said Dr. Monica Gandhi, an infectious disease physician at the University of California, San Francisco, and an author on the new commentary. But for now, they will need to stay on, delivering protection both to mask-wearers and to the people around them.

The arguments for masking span several fields of science, including epidemiology and physics. A bevy of observational studies have suggested that widespread mask-wearing can curb infections and deaths on an impressive scale, in settings as small as hair salons and at the level of entire countries. One study, which tracked state policies mandating face coverings in public, found that known Covid cases waxed and waned in near-lockstep with mask-wearing rules. Another, which followed coronavirus infections among health care workers in Boston, noted a drastic drop in the number of positive test results after masks became a universal fixture among staff. And a study in Beijing found that face masks were 79 percent effective at blocking transmission from infected people to their close contacts.

Recent work by researchers like Dr. Marr is now pinning down the basis of these links on a microscopic scale. The science, she said, is fairly intuitive: Respiratory viruses like the coronavirus, which move between people in blobs of spittle and spray, need a clear conduit to enter the airway, which is crowded with the types of cells the viruses infect. Masks that cloak the nose and mouth inhibit that invasion.

The point is not to make a mask airtight, Dr. Marr said. Instead, the fibers that comprise masks create a haphazard obstacle course through which air — and any infectious cargo — must navigate.

“The air has to follow this tortuous path,” Dr. Marr said. “The big things it’s carrying are not going to be able to follow those twists and turns.”

Experiments testing the extent to which masks can waylay inbound and outbound spray have shown that even fairly basic materials, like cloth coverings and surgical masks, can be at least 50 percent effective in either direction.

Several studies have reaffirmed the notion that masks seem to be better at guarding people around the mask-wearer than mask-wearers themselves. “That’s because you’re stopping it right at the source,” Dr. Marr said. But, motivated by recent research, the Centers for Disease Control and Prevention has noted that there are big benefits for those who don masks as well.

Masks awaiting disinfecting at the Battelle N95 decontamination site in Somerville, Mass.
Masks awaiting disinfecting at the Battelle N95 decontamination site in Somerville, Mass.Credit…Michael Dwyer/Associated Press

The best masks remain N95s, which are designed with ultrahigh filtration efficiency. But they remain in short supply for health workers, who need them to safely treat patients.

Layering two less specialized masks on top of each other can provide comparable protection. Dr. Marr recommended wearing face-hugging cloth masks over surgical masks, which tend to be made with more filter-friendly materials but fit more loosely. An alternative is to wear a cloth mask with a pocket that can be stuffed with filter material, like the kind found in vacuum bags.

But wearing more than two masks, or layering up on masks that are already very good at filtering, will quickly bring diminishing returns and make it much harder to breathe normally.

Other tweaks can enhance a mask’s fit, such as ties that secure the fabric around the back of the head, instead of relying on ear loops that allow masks to hang and gape. Nose bridges, which can help the top of a mask to fit more snugly, offer a protective boost as well.

Achieving superb fit and filtration “is really simple,” Dr. Gandhi said. “It doesn’t need to involve anything fancy.”

No mask is perfect, and wearing one does not obviate other public health measures like physical distancing and good hygiene. “We have to be honest that the best response is one that requires multiple interventions,” said Jennifer Nuzzo, a public health expert at Johns Hopkins University.

Mask-wearing remains uncommon in some parts of the country, in part because of politicization of the practice. But experts noted that model behavior by the nation’s leaders might help to turn the tide. In December, President-elect Joseph R. Biden Jr. implored Americans to wear masks for his first 100 days in office, and said he would make doing so a requirement in federal buildings and on planes, trains and buses that cross state lines.

A large review on the evidence behind masking, published this month in the journal PNAS, concluded that masks are a key tool for reducing community transmission, and is “most effective at reducing spread of the virus when compliance is high.”

Part of the messaging might also require more empathy, open communication and vocal acknowledgment that “people don’t enjoy wearing masks,” Dr. Nuzzo said. Without more patience and compassion, simply doubling down on restrictions to “fix” poor compliance will backfire: “No policy is going to work if no one is going to adhere.”

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How to Pretend You’re in Tunis Tonight

Panorama La Medina, a rooftop cafe in Tunis, offers some of the best views of the old city.
Panorama La Medina, a rooftop cafe in Tunis, offers some of the best views of the old city.Credit…Sebastian Modak/The New York Times

How to Pretend You’re in Tunis Tonight

The Tunisian capital beckons with white-sand beaches, the medina, cafe districts and Roman ruins that speak to its place in history. Luckily, there are ways to capture its spirit at home.

Panorama La Medina, a rooftop cafe in Tunis, offers some of the best views of the old city.Credit…Sebastian Modak/The New York Times

Sebastian Modak

  • Jan. 12, 2021, 5:00 a.m. ET

While your travel plans may be on hold, you can pretend you’re somewhere new for the night. Around the World at Home invites you to channel the spirit of a new place each week with recommendations on how to explore the culture, all from the comfort of your home.

There are worse places to be lost than the old medina of Tunis, a dizzying labyrinth of ancient alleyways. As I discovered on my visit to the Tunisian capital, there is so much to look at: the vendors doling out spices, the cats watching the afternoon pass from sun-soaked stoops, the groups of friends sitting around crowded tables and sipping mint tea. You might pass the open window of a traditional music school and hear snippets of a haunting song hundreds of years old or, out of another storefront, the thump of techno music accompanying an experimental art exhibition.

From left: Shopping in the old medina of Tunis, swimming at a Carthage beach, and the ruins of ancient Carthage.
From left: Shopping in the old medina of Tunis, swimming at a Carthage beach, and the ruins of ancient Carthage.Credit… Andy Haslam for The New York Times (left and far right); Mohamed Messara/EPA, via Shutterstock (center)

It is hard to believe that all of this exists in just one corner of a sprawling, cosmopolitan and complex city on the tip of North Africa. Elsewhere, there are nightclubs that spill out onto white-sand beaches, cafe districts that wouldn’t be out of place in southern Europe, and Roman ruins that speak to its place in history as a gateway to Africa and a center of Mediterranean commerce. It is a lot to take in over a single visit, and I am looking forward to my next one. In the meantime, I will be following these tips to make it feel as if I am back in Tunis, even if just for a night.

Cook with harissa

Tunisian cuisine is sometimes hearty, other times delicate. It can be spicy, but is not afraid of a little sweetness. It is also brimming with history. Arabs, Romans, Sicilians, Byzantines, Berbers and more have all, at one point or another, called this land on the Mediterranean home, and that is all on display come mealtime. Rafram Chaddad, an artist and food researcher, spends much of his time tracing that history, with a special interest in the food culture of Tunisian Jews like his own family. He consulted multiple old recipes to come up with this one, for a pan-fried sea bass with dried rose petals and harissa, a ubiquitous hot chile paste. Featured in Yotam Ottolenghi and Sami Tamimi’s “Jerusalem,” a collection of recipes from around the world that converge in that city, Mr. Chaddad’s recipe highlights the importance of seafood to Tunis’s food scene.

A Tunisian woman preparing harissa.Credit…Mohamed Messara/EPA, via Shutterstock

“Fish in the Tunisian sea are special,” said Mr. Chaddad, who grew up in Jerusalem and recently returned to Tunis, pointing out that the hot temperatures and shallow depths make for a special flavor. “The seafood here is kissed by the sun.” While you might not be able to get your hands on bona fide Tunisian sea bass, the flavors — the way the spiciness of the harissa plays with the perfumes of the rose petals — are evocative enough of the city’s cuisine.

Make sure the egg is runny

For a snack, Mr. Chaddad recommends brik a l’oeuf, a deep-fried cousin to the dumpling, filled with some combination of tuna, potatoes, onions, capers, harissa (because of course), and, the star, a runny egg yolk that will drip all over your plate at the very first bite. His recipe, also included in “Jerusalem,” was featured in a write-up from the travel website Roads and Kingdoms, alongside an iteration from a Tunisian grandmother. Sarah Souli, a journalist whose associations with Tunisia’s capital are closely linked to visits with her grandmother, told me that she wouldn’t dare try it on her own, even if she encourages others who want a taste of Tunis to do so.

“I don’t cook brik at home because I think longing is an important part of loving,” Ms. Souli said. “I’ll wait till I can go back to Tunis and Memeti, my grandmother, makes me one.”

From left: Tastes of Tunis, including a traditionally prepared couscous dish, fish at a market and sweets.Credit…Photographs by Fethi Belaid/Agence France-Presse — Getty Images

Or put in an order

If the thought of cooking up your own Tunisian pastries is too daunting and you happen to be in the United States, you can order a box of them. Layla’s Delicacies, based in New Jersey, ships boxes of pastries across the country to Tunisians who miss the taste of home.

“Traditionally made by hand at home, Tunisian pastries are made with the noblest ingredients, and take an incredible amount of time and attention to detail,” said Rim Ben Amara, the company’s founder.

While the pastries are most common at gatherings, there’s no shame in digging into a box on your own. For something that you would come across in Tunis, try kaak warka, a doughnut-shaped treat filled with almond paste and rose water, or samsa, a triangle-shaped sweet pastry encrusted with pistachios and filled with almonds and hazelnuts.

The Bardo Museum, a converted mansion, houses one of the largest collections of Roman murals in the world.Credit…Sebastian Modak/The New York Times

Take a museum tour

Tunis is brimming with history: the mausoleums of the medina that have remained unchanged for centuries; the Roman ruins at the original site of Carthage, in the city’s northeastern suburbs; and the Bardo Museum, a sprawling 19th-century palace that is home to one of the largest collections of Roman mosaics in the world. While there is nothing like seeing them in person, you can get a sense of the scale and craftsmanship of the ancient artwork through a virtual tour that allows you to roam the palace’s halls at your own pace.

But don’t forget the contemporary art scene

You also should get a sense of the contemporary art scene, which can be found in art galleries and pop-up events across the city. Dora Dalila Cheffi, a Finnish-Tunisian artist, paints brightly-colored tableaus, often inspired by the city she now calls home. Some of her work can be viewed online. Scenes from across the city are interspersed with more esoteric interpretations of Tunisian life.

“The slow pace of life, light and general atmosphere are great for the type of work I do,” she said, describing how her work has evolved over time. “There is less scenery now, but that doesn’t mean that the work doesn’t talk about life in Tunisia. If anything, it does so even more.”

Ms. Cheffi also recommends transporting yourself to the city through the work of a street art duo, ST4 the project. Their work can be seen not only in Tunis but also in other cities around the world, as they weave homegrown influences into their work to create connections across borders. “They use Arabic lettering and, as the work evolves, the letters transform more and more into an abstract and universal language,” Ms. Cheffi said.

Sidi Bou Said, a scenic town on the outskirts of Tunis, is popular with tourists for its white and blue buildings and views of the Mediterranean. Credit…Andy Haslam for The New York Times

Get cozy

While the fouta, a handwoven towel, has its roots in the hammam, or public bathhouses, and are commonplace today along Tunisia’s beaches, they’re just as useful as a cozy throw at home. Fouta Harissa works with artisans who spend hours spinning the cotton towels on looms that have been passed down through generations.

“I always pack a few when I travel — to give as gifts (along with a jar of harissa), and also as my one-and-done accessory,” said Fouta Harissa’s co-founder, Lamia Hatira. “It’s a wrap, a sarong, a beach towel or a blanket depending on my destination.” It’s a versatile accessory — even when that destination is your living room couch.

From left: The old British Embassy in Tunis, which has been converted into a hotel, the Royal Victoria; the rapper 4lLFA performing in Gammarth, a suburb; and the Tunis medina.Credit…Andy Haslam for The New York Times (left); Sebastian Modak/The New York Times (center and far right)

Wind down with some music

Finally, it is time to unplug with the sounds of Tunis. For an introduction to Tunisian music, check out this radio broadcast, featuring a wide survey of traditional genres and an interview with a Tunisian percussionist. If it is current sounds you are after, Emily Sarsam, a cultural programmer in Tunis and one of the hosts of the aforementioned radio show, recommends “Lila Fi Tounes” by Deena Abdelwahed, an experimental and electronic rendition of the jazz standard “A Night in Tunisia.”

Ms. Sarsam, along with Ms. Cheffi, also recommends the work of Souhayl Guesmi, a composer who releases music under the name Ratchopper. A frequent collaborator with some of Tunisia’s biggest rappers, his solo albums are ethereal and full of barely contained energy — much like the city of Tunis itself.


How are you going to channel the spirit of Tunis in your home? Share your ideas in the comments.

To keep up with upcoming articles in this series, sign up for our At Home newsletter or follow New York Times Travel on Instagram, Twitter and Facebook. See more Around the World at Home guides here.

When I Was Labeled a ‘Troubled’ Teen, I Obliged

The author in the Adirondack Mountains of upstate New York in 2007, during his second stay in a wilderness therapy program. 
The author in the Adirondack Mountains of upstate New York in 2007, during his second stay in a wilderness therapy program. Credit…via Kenneth R. Rosen

Voices

When I Was Labeled a ‘Troubled’ Teen, I Obliged

I was sent to three “tough love” programs meant to redirect me. Trying to run away from one made me feel that I had no choice but to become what I had been told I was.

The author in the Adirondack Mountains of upstate New York in 2007, during his second stay in a wilderness therapy program. Credit…via Kenneth R. Rosen

Kenneth R. Rosen

  • Jan. 12, 2021, 5:00 a.m. ET

All I heard was rain, my thumping heart harmonizing with the tempo of the tempest outside. I waited for the night watchman’s light to sweep over my bunk. He disappeared into the hallway, into the next room of clients who he noted to himself were present and asleep and so moved to the next room.

When he entered another room, I hurried behind him, crouching, to the central alcove, from where I made my escape. My plan included a list — backpack, peanut butter, headlight, rain gear, stolen MapQuest printouts, knife — and a destination, Boston. I’d run to an unfamiliar city, across a state to which I’d been taken against my will, to meet a future I could not be certain was any better. The rain seemed less like a portent, more an encouragement, as if each wind gust carried with its rivulets the words, It’s your time. They’ll never find you. Go now.

They were the escorts. Transporters. Redirection specialists. They, usually two men who take unsuspecting teenagers in the middle of the night to therapeutic programs across the country, went by different names. I was certain they were coming for me. They had come for me several months before the night of my escape, in late winter 2007, at the request of my parents who saw no other way to set me straight. My mom and dad hired the men, after consulting with school officials, psychologists and an education consultant, to take me from my bed and to deliver me like a wasted soul to an experiential therapy program in the Adirondack Mountains in upstate New York. They believed they were practicing “tough love,” making the difficult choice to send their child away to forge a better future away from home.

Some of the gear the group carried through remote stretches of New York State. 
Some of the gear the group carried through remote stretches of New York State. Credit…Kenneth R. Rosen

From New York I’d go on to a program in Massachusetts. I did not know it then, but I’d become one of the tens of thousands of “troubled” or “at-risk” teenagers carted off to these unregulated, private industries each year.

The years leading up to my being taken and the eventual break out is now a blur of misanthropy. I was reckless, taking my mom’s car out for joy rides without permission, skipping class, distrusting authority figures like the high school principal and local municipal authorities sent to curb my behavior, to put me back on a path more, how should we say, normal.

In the nearly 12 months I’d spend between the experiential wilderness therapy program (twice), a therapeutic boarding school in Massachusetts and a residential treatment center on a ranch in Utah, I lived up to the designation of a troubled teen. The programs were what the media called part of a tough love movement, which flourished in the early aughts but still exists today.

The Academy at Swift River, a former therapeutic boarding school for troubled children, in Cummington, Mass., in spring 2007. The author spent months here before trying to escape, after which he was sent to a remote ranch in Southern Utah.Credit…Kenneth R. Rosen

I’d return that type of love to my parents, ignoring their written letters, our only form of communication, vetted and censored by my “therapists.” I felt betrayed and discarded. They pleaded with me to accept the programs and to do my best to succeed in them. It felt like they wanted me gone. Really, I was being groomed for institutionalization. The juvenile and criminal justice systems the programs ventured to save me from instead prepared me for adult incarceration. By the end of my time away I recognized a bliss associated with handcuffs. Lockup and lockdown meant the familiarity of strip searches, drug tests, isolation cells and men who handled me like I was worthless: hallmarks of the programs that became synonymous with the word homebound.

But losing any self-actualization and inner-direction came later. On the night of my escape, I still believed I held some agency over my future, shrouded in uncertainty though it was. What would I do in Boston? I didn’t care. How would I earn money? Where would I stay? I would figure it out once I was far away from this place.

My parents were no longer trustworthy. They were part of the growing number of my adversaries working to keep me from personal liberties. At the program I was restricted access to food. I was allowed only communication with my parents, not my friends back home. If I chose not to respond to my parents, I would also be cut off from my peers in the programs. Either way, I’d lose.

The night the author tried to run away from the Academy at Swift River, he started from this alcove.Credit…Kenneth R. Rosen

I was given prescription medication to ease my anxiety and depression, which left me hollow and numb. I was made to answer questions about my life and emotions until, I was told, I got them right, framing things in a way the program and therapists felt more accurately told a story about my deviance that I then internalized. My journals were confiscated, their private contents used against me in “therapy sessions.”

I wasn’t troubled or bad. I was alone, all the angst and hormonal shifts of adolescence compounded and weaponized against me. I was backed into a corner and told to change, made to think I’d become reproachable and unwanted. What they wanted from me — to be happy, well-adjusted, open to therapy and the mind-numbing boredom I associated with schooling — seemed a betrayal of the very thing they wanted me to be: myself.

Meanwhile, I had broken a number of rules at the school — “cheeking” medication, drinking hand sanitizer, fraternizing with girls. I was certain then, by the fourth month at the program, that I was doomed for another “transport.” Then one night they came.

I’d been waiting, staring deep into the white ceiling overhead, my inability to sleep soundly forever cemented. Before I could jump down from the top bunk bed, the escorts announced that they were there for a different boy, my roommate. He stood from his bed, his head hanging. He pulled a pre-packed suitcase from underneath his bed (we all had our own type of go-bag), gave a weak smile, shrugged, told me he’d see me again, however unlikely, and left with the men flanking him out the door, choosing to go, as they called it, the “easy way.” He had already gone the “hard way.”

Picked off. Kidnapped. Taken. Call it what you wish, but trying to sleep each night with the notion that a pair of strangers could come to lift you from your bed, whether your actions were deserving of this treatment or not, haunts me, haunts thousands. Having watched my roommate get taken was surreal. It made real for the first time what had happened to me, brought into context that it was happening to others, and eventually sold me on my own desire to flee. I would not wait to be taken. I had to get out. No one would take me. I would lead myself away.

Now, standing outside the central alcove with my back to the doorways of the program, I stared into the fields of the Berkshire mountains, another expanse of seclusion and remove, the rain washing over me in blinding sheets. I bent into the storm, leaning into the wind that soon turned, pushed at my back, leading me away from this place into the deep, heaving thicket at the far end of the program’s property.

The author’s room at the academy in spring 2007. Sometimes the boys played Monopoly at night in the bathroom, seeking a rare opportunity for unsupervised recreation. Credit…Kenneth R. Rosen

I vaulted a fence and tore my rain pants. Water and a cold breeze swept into the tear. I began to shiver. Boston seemed farther than ever, the return to my previous life an impossibility. My mother once told me “to strive, to seek, to find, and never to yield,” cribbed from the Tennyson poem. But yield I would, turning around and greeting my future and any hope I had for making it my own. I was told I was troubled and believed it and ran because that’s what bad kids did.

I unceremoniously turned myself in to the night watchman because I had lost all strength to continue being bad. I wanted to be good, loved. It was as much a desire to get away that drove me from the program as it was a display of disapprobation and the final displacement of my waning emotional strength. I would fold into the programs, accepting that if I were to change it would be by a force better accepted than rejected, one that had overpowered and broken me into a shell of my former self.

Those programs are now a distant memory, but the contours of those inescapable feelings of rejection and dismissal, of living up to the expectations held by others and not myself, follow me. When I find the energy to keep those memories from chaining me to a different person, a different time, I do my best never to yield.

Kenneth R. Rosen is the author, most recently, of “Troubled: The Failed Promise of America’s Behavioral Treatment Programs.”

Well, So Much for Dry January

Noted

So Much for Dry January?

It’s been an intense and distressing month in America.

This you?
This you?Credit…Getty Images
Alex Williams

  • Jan. 12, 2021, 5:00 a.m. ET

Well, that was quick.

Dry January, the social-media fueled month of voluntary sobriety, became Damp January in under a week for many temporary teetotalers. Many were horrified enough by the assault on the U.S. Capitol and the ensuing protracted situation to break their vow and reach for the bottle, as evidenced by jokes, confessions and memes ricocheting around Twitter and Instagram.

Among bandwagoneers, the should-I-or-shouldn’t-I conversation was happening offline, too, as many attempting four weeks as non-tipplers decided that a national crisis was bigger than a 31-day health kick.

Dry January at least seemed like a sensible way to start fresh in 2021, said Nina McConigley, an assistant honors professor at the University of Wyoming in Laramie who swore off her extended pandemic cocktail kick.

But as she and her husband watched the tragedy unfold on television, feeling “sad and useless,” a nice dinner and a bottle of tempranillo seemed like the only balm, Ms. McConigley, 45, said: “I am of color, watching the Confederate flag being paraded in the Capitol, it was the worst. The act of a hot warm dinner and nice wine, it felt self-preserving.”

After five days of lemon detox tea, for example, Emily Titelman, an event producer in Los Angeles, detoured to tequila and orange juice on Wednesday, to ease her nerves after witnessing a mob send elected officials, their staff and media into hiding for their lives.

“As someone who is very politically engaged, I felt morally obligated to return to the news,” Ms. Titelman, 35, said. The drink, she added, “absolutely took the edge off my very real anger.”

People surround the U.S. Capitol on Jan. 6.
People surround the U.S. Capitol on Jan. 6.Credit…Jason Andrew for The New York Times

A year of quarantine had converted Adam Roberts, 41, the creator of Amateur Gourmet, a food blog, from social drinker to a regular home drinker, he said. It got to the point that he had vowed that very day, on a walk with his husband, the film director Craig Johnson, and their dog in the Atwater Village neighborhood of Los Angeles, to cut out drinking on weekdays during January.

“But when we got home and saw the images of a guy in a Camp Auschwitz sweatshirt storming the U.S. Capitol, I said, ‘I changed my mind. Make me a Oaxacanite,” he said.

Others who had pledged a month of sobriety managed to stay dry through the crisis, if barely.

Hitha Palepu, a pharmaceuticals executive in New York, leaned on more than 20 Dry January accountability groups she had started on Instagram to convince her to to boil a kettle for tea (albeit, with a drop or two of CBD,) rather than uncork a bottle of pinot noir.

“I had spent the past four years numbing the feelings that the news brought me with wine,” Ms. Palepu, 36, said. “This time, I chose to fully feel these feelings and find a new way to process them. It was my own little act of resistance for my present and future self, against my past self.”

The vision of the president of the United States goading his supporters against Congress, the Senate and his own vice president proved to be a shocking test for Frauke Weston, who is German and a marketing manager in Brooklyn. She was wondering if she could stick with her alcohol-free month she began, as she awaits her final interview to gain citizenship later this month.

“I keep getting messages from German and American friends alike, jokingly asking ‘Are you sure you want to sign up for this?’” Ms. Weston said.

For those who signed on to Dry January as a wellness experiment, like a juice cleanse, it seemed all in good fun to ditch their resolve after a few days and post jokey memes on Twitter, like the oft-quoted line from the 1980 comedy film “Airplane” — “Looks like I picked the wrong week to stop sniffing glue.”

But for many with addiction issues, the crisis of Jan. 6 was a graver matter, particularly after a wearying 2020 that seemed like a stress-ridden version of the movie “Groundhog Day,” said Dr. Joseph Lee, the medical director of Hazelden Betty Ford Foundation in Minneapolis.

“You’re seeing the intersection of pandemic stress, economic stress, political and social strife, and all those things have added together and predictably have increased the consumption of various substances by high-risk people,” Dr. Lee said in an email.

A lot of people, he said, were posting messages on social media like, “‘We made it five days, then everything went dumpster-fire-emoji,’” he said. “But on a serious level, when people are isolated and already over-interpreting the news, worrying too much, and losing confidence in our sense of democracy, all these things can be tipping points for people at risk.”

For those with the luxury of experimenting with sobriety by choice, however, the evenings of hot tea with lemon will last only through a month, even if the political chaos does not.

A day after breaking her Dry January vow, Ms. McConigley was back on the wagon, intent to last through the month. Well, most of the month, anyway.

“My one exception for the month has always been Jan 20,” she said. “We have a special bottle of champagne we are saving for Inauguration Day.”

How Our Sex Habits May Affect Our HPV and Cancer Risk

How Our Sex Habits May Affect Our HPV and Cancer Risk

Certain sex practices, at certain ages, increased the risk of throat cancers related to human papillomavirus.

Credit…Getty Images
Nicholas Bakalar

  • Jan. 12, 2021, 5:00 a.m. ET

Human papillomavirus, or HPV, is a leading cause of throat cancer, and it is sexually transmitted. But how the timing, number and types of sexual behaviors affect the risk, and why some people develop cancer and others don’t, are still open questions. Researchers are beginning to suggest some possible answers.

HPV causes about 70 percent of oropharyngeal cancers — tumors of the back of the throat, the base of the tongue and the tonsils. According to the Centers for Disease Control and Prevention, there are about 3,500 new cases of HPV-associated oropharyngeal cancers diagnosed in women and 16,200 in men every year in the United States. These cancers are more common among white people than among African-Americans, Asian-Americans, Hispanics, or American Indians and Native Alaskans.

There are many types of HPV, only some of which cause cancer. In addition to throat cancer, HPV is a cause of cervical, vaginal, vulvar, penile and anal cancers. It can take years, even decades, after infection for cancer to develop.

To try to sort out the risk factors for HPV-associated throat cancer, researchers compared 163 patients with cancer with 345 cancer-free controls. Patients and controls ranged in age from 18 to 89, but more than 95 percent of them were over 40. At the start of the study, all of the participants provided a blood sample, and the scientists obtained tumor samples from the patients with cancer. None of the participants had had the HPV vaccine, which was introduced in the United States in 2006 and recommended primarily for preadolescents, teenagers and young adults.

Using a self-interview administered on a computer, the participants also answered detailed questions on lifetime and recent sexual behavior, including number of partners, age of sexual initiation, types of sexual acts, extramarital sex and the use of alcohol and recreational drugs during sex. The scientists also had data on income, education, sexual orientation, and any history of sexually transmitted and other diseases. The study is in the journal Cancer.

Taken together, the various cancers caused by HPV are slightly more common in women, but HPV-associated oropharyngeal cancers are almost five times as common in men. Exactly why is unclear.

“There is some evidence that cunnilingus is more infective than fellatio,” said the senior author, Gypsyamber D’Souza, a professor of epidemiology at Johns Hopkins. “But that’s a surrogate for more nuanced behavior. Many patients have not engaged in high-risk sex behavior and are unlucky enough to still get this. It’s not just sexual partners, but the timing, the kind of practice, the nature of the partners and other factors, plus aspects of our own immunological response that are all involved in this.”

The cancer patients in the study were about 80 percent more likely than those without cancer to have ever performed oral sex on a partner. They were also younger when they first did so — 37 percent of patients were younger than 18 the first time they performed oral sex, compared with 23 percent of controls — and they were more likely to have performed oral sex at their sexual debut.

Why having oral sex at a first sexual encounter would raise the risk is unknown. Is there a different immune response if a person has had other forms of sex before having oral sex? Does the initial site of exposure affect your risk? “We don’t have good answers yet,” Dr. D’Souza said.

Almost 45 percent of patients had had more than 10 sexual partners during their lifetimes, compared with 19 percent of the cancer-free controls. People under 23 who had a sexual partner at least 10 years older were more likely to be infected, possibly because older people have had longer exposure to the virus.

Deep kissing was also associated with increased risk. Those who had 10 or more deep-kissing partners were more than twice as likely to have an HPV-related cancer as those who had none or one.

People who reported that their partners had extramarital affairs, and those who even suspected that their partners had had affairs, also had an increased risk of HPV-associated throat cancer. There was no association of HPV-related throat cancer with smoking, alcohol consumption or substance use.

The study had limitations. It depended on self-reports, which are not always reliable, and because more than 95 percent of the participants described themselves as heterosexual, there was not enough data to draw conclusions about the effects of sexual orientation on HPV and cancer risk. But the analysis had carefully matched controls, HPV tumor data, and a confidential questionnaire, all of which contribute to its strengths.

Dr. Jason D. Wright, an associate professor of gynecologic oncology at Columbia who was not involved in the research, believes the work could be useful in clinical practice. “This is one of the first studies to provide in-depth details for patients about how specific practices influence your long-term risk,” he said. “A higher exposure, more partners, oral sex early on — these are all risk factors. These are important things to think about in talking to patients.”

The lead author, Dr. Virginia E. Drake, a resident physician at Johns Hopkins, said that explaining the infection to patients can be difficult. “If people get this infection, they’re going to ask, ‘Why me?’” she said. “How this information will change things clinically, we don’t know. But we can give patients a better understanding of the disease process and how someone gets it.”

Still, she said, “It’s complex, more complex that just the number of sexual partners. We don’t have the exact answers on this, and we’re still figuring out the complete picture.”

California Budget Reflects ‘Pandemic-Induced Reality,’ Governor Says

SACRAMENTO, Calif. — The coronavirus pandemic doomed Gov. Gavin Newsom’s ambitious plans last year to combat homelessness, expand behavioral health services and create a state agency to control soaring health care costs.

But even as the pandemic continues to rage, California’s Democratic governor said Friday he plans to push forward with those goals in the coming year, due to a rosier budget forecast buoyed by higher tax revenue from wealthy Californians who have fared relatively well during the crisis.

Newsom’s $227.2 billion budget blueprint also prioritizes billions to safely reopen K-12 schools shuttered by the pandemic, $600 payments for nearly 4 million low-income Californians — in addition to federal stimulus payments — and coronavirus relief grants and tax credits for hard-hit small businesses.

However, his 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California’s pandemic response, which have been chronically underfunded. He vowed to support cities and counties by boosting state testing and contact tracing capacity, speeding vaccination efforts and funding state-run surge hospitals that take overflow patients.

Newsom said Friday his budget reflects a “pandemic-induced reality” with investments aimed at spurring California’s economic recovery by helping businesses and people living in poverty. Wealth and income disparities, he added, “must be addressed.”

But Democrats in control of the state legislature, county leaders and social justice groups say that will be difficult to achieve because Newsom’s spending plan does not sufficiently fund health and social safety-net programs.

And without additional public health money, local leaders worry California will not be able to adequately control the spread of the virus.

“County public health is drowning,” said Graham Knaus, executive director of the California State Association of Counties. “We are triaging right now between testing, contact tracing and vaccination, and it’s impacting the response to the pandemic.”

Newsom’s budget proposal is the first step in a months-long negotiation process with the Democratic-controlled legislature, which has until June 15 to adopt the state budget that takes effect July 1. Lawmakers have become increasingly frustrated with the governor’s response to the pandemic, including his unilateral spending decisions in response to the emergency. Newsom is also facing a burgeoning recall effort, backed by heavyweight Republicans such as former San Diego Mayor Kevin Faulconer, who is considering challenging Newsom in the 2022 California gubernatorial election.

Newsom said he expects to make some tough calls on spending even though the state anticipates a $15 billion budget surplus for the coming fiscal year, largely because a state fiscal analysis projected deficits in subsequent years.

“While we are enjoying the fruits of a lot of one-time energy and surplus, it’s not permanent and we have to be mindful of over-committing,” Newsom said, explaining why he didn’t include funding to expand Medicaid to more unauthorized immigrants.

Some lawmakers say they will nonetheless press Newsom to use higher-than-expected revenues — and perhaps seek new taxes — to expand health coverage to more Californians.

The following health care proposals factor heavily into Newsom’s 2021-22 budget proposal.

Covid Relief

Newsom committed $4.4 billion in his budget to vaccine distribution, increased testing, contact tracing and other short-term pandemic expenses. Because that spending is related to the public health emergency, the state expects at least 75% to be reimbursed by the federal government and insurance payments.

He also proposed $52 million to fund costs at state-run surge hospitals, including support staff. And he is asking lawmakers to sign off on a covid relief package that would provide funding before the start of the fiscal year in July. It would include $2 billion to help school districts reopen classrooms to in-person instruction beginning in February by paying for protective equipment, ventilation systems and adequate testing. It would also commit billions to economic recovery, such as stimulus payments for individuals, and grants and tax credits for struggling small businesses.

Newsom also wants to increase the budget for the Department of Industrial Relations by $23 million to fund up to 113 additional workplace inspectors at the California Division of Occupational Safety and Health to police health order violations at businesses and enforce workplace safety laws.

Transforming Medi-Cal

Spending for Medi-Cal, the state’s Medicaid program for low-income residents, is expected to grow in the coming year because of the economic impact of the pandemic — as is its enrollment. The program has roughly 13 million enrollees, or about one-third of the state population.

In the coming year, Newsom will also press forward with a major overhaul of Medi-Cal, through a project called CalAIM, to provide new benefits emphasizing mental health care and substance use treatment, and pay for some nontraditional costs such as housing assistance. The hope is the program would divert homeless and other vulnerable people away from expensive emergency room care and keep them out of jail.

State Medi-Cal officials estimate the program would cost $1.1 billion for the first year. The state is working with the federal Centers for Medicare & Medicaid Services to obtain approval for the program.

Newsom also wants to expand Medi-Cal benefits to cover over-the-counter cold medicine and blood glucose monitors for people with diabetes. His budget includes $95 million for a major expansion of telehealth services that would permanently provide higher payments for virtual doctor visits.

Controlling Health Care Costs

Newsom is proposing a new state agency, the Office of Health Care Affordability, which he said would help control health care costs. He budgeted $63 million over the next three years for the office, which would set health care cost targets for the health care industry — along with financial penalties for failing to meet future targets.

Powerful health industry groups said they are still assessing whether they will support the proposal. But some expressed concern last year when Newsom floated the idea. Doctors and hospitals routinely fight proposals in Sacramento that might limit their revenue.

Newsom acknowledged Friday the task would be “tough.”

Battling Homelessness and Food Insecurity

Newsom is proposing a one-time infusion of $1.75 billion to battle homelessness.

Of that, Newsom said, $750 million would help counties purchase hotels and transform them into permanent housing for chronically homeless people. Another $750 million would allow counties to purchase facilities to treat people with mental illness or substance use disorders. And $250 million would help counties purchase and renovate homes for low-income older people.

Newsom’s budget also includes $30 million to help overwhelmed food banks and emergency food assistance programs.

Lawmakers said they plan to negotiate for even more funding for homelessness and safety-net programs.

“We absolutely need to significantly increase our investment to address homelessness because the need is so intense,” said Assembly member David Chiu (D-San Francisco). “And I don’t think there’s a single legislator who isn’t incredibly concerned about the food insecurity we’re seeing: lines around the block for food banks in what should be the wealthiest state in the country.”

Expanding Health Coverage

Newsom did not include money in his proposed budget to expand Medi-Cal to unauthorized immigrants age 65 and older. He had previously promised to fund the proposal, estimated to cost $350 million per year once fully implemented, but he said Friday the state cannot afford to commit to ongoing costs with a projected budget deficit starting in fiscal year 2022-23. California already offers full Medicaid benefits for income-eligible unauthorized immigrants up to age 26.

Some lawmakers and health care advocates countered that providing health insurance for undocumented immigrants would save lives and reduce costs, especially during the pandemic, and vowed to continue to fight for the expansion.

“To say we are disappointed is describing it very lightly,” said Orville Thomas, a lobbyist with the California Immigrant Policy Center. “These are Californians dying and getting sick at disproportionate rates during covid.”

Health Workers Unions See Surge in Interest Amid Covid

The nurses at Mission Hospital in Asheville, North Carolina, declared on March 6 — by filing the official paperwork — that they were ready to vote on the prospect of joining a national union. At the time, they were motivated by the desire for more nurses and support staff, and to have a voice in hospital decisions.

A week later, as the covid-19 pandemic bore down on the state, the effort was put on hold, and everyone scrambled to respond to the coronavirus. But the nurses’ long-standing concerns only became heightened during the crisis, and new issues they’d never considered suddenly became urgent problems.

Staffers struggled to find masks and other protective equipment, said nurses interviewed for this story. The hospital discouraged them from wearing masks one day and required masks 10 days later. The staff wasn’t consistently tested for covid and often not even notified when exposed to covid-positive patients. According to the nurses and a review of safety complaints made to federal regulators, the concerns persisted for months. And some nurses said the situation fueled doubts about whether hospital executives were prioritizing staff and patients, or the bottom line.

By the time the nurses held their election in September — six months after they had filed paperwork to do so — 70% voted to unionize. In a historically anti-union state with right-to-work laws and the second-least unionized workforce in the country, that margin of victory is a significant feat, said academic experts who study labor movements.

That it occurred during the pandemic is no coincidence.

For months now, front-line health workers across the country have faced a perpetual lack of personal protective equipment, or PPE, and inconsistent safety measures. Studies show they’re more likely to be infected by the coronavirus than the general population, and hundreds have died, according to reporting by KHN and The Guardian.

Many workers say employers and government systems that are meant to protect them have failed.

Research shows that health facilities with unions have better patient outcomes and are more likely to have inspections that can find and correct workplace hazards. One study found New York nursing homes with unionized workers had lower covid mortality rates, as well as better access to PPE and stronger infection control measures, than nonunion facilities.

Recognizing that, some workers — like the nurses at Mission Hospital — are forming new unions or thinking about organizing for the first time. Others, who already belong to a union, are taking more active leadership roles, voting to strike, launching public information campaigns and filing lawsuits against employers.

“The urgency and desperation we’ve heard from workers is at a pitch I haven’t experienced before in 20 years of this work,” said Cass Gualvez, organizing director for Service Employees International Union-United Healthcare Workers West in California. “We’ve talked to workers who said, ‘I was dead set against a union five years ago, but covid has changed that.’”

In response to union actions, many hospitals across the country have said worker safety is already their top priority, and unions are taking advantage of a difficult situation to divide staff and management, rather than working together.

Labor experts say it’s too soon to know if the outrage over working conditions will translate into an increase in union membership, but early indications suggest a small uptick. Of the approximately 1,500 petitions for union representation posted on the National Labor Relations Board website in 2020, 16% appear related to the health care field, up from 14% the previous year.

In Colorado, SEIU Local 105 health care organizing director Stephanie Felix-Sowy said her team is fielding dozens of calls a month from nonunion workers interested in joining. Not only are nurses and respiratory therapists reaching out, but dietary workers and cleaning staff are as well, including several from rural parts of the state where union representation has traditionally been low.

“The pandemic didn’t create most of the root problems they’re concerned about,” she said. “But it amplified them and the need to address them.”

A nurse for 30 years, Amy Waters had always been aware of a mostly unspoken but widespread sentiment that talking about unions could endanger her job. But after HCA Healthcare took over Mission Health in 2019, she saw nurses and support staff members being cut and she worried about the effect on patient care. Joining National Nurses United could help, she thought. During the pandemic, her fears only worsened. At times, nurses cared for seven patients at once, despite research indicating four is a reasonable number.

Members of the Union of American Physicians and Dentists went on a two-day strike in November asking for more N95 masks. MultiCare found another vendor for N95s and said it would provide them by mid-December. (Marisa Powell)

In a statement, Mission Health said it has adequate staffing and is aggressively recruiting nurses. “We have the beds, staffing, PPE supplies and equipment we need at this time and we are well-equipped to handle any potential surge,” spokesperson Nancy Lindell wrote. The hospital has required universal masking since March and requires staff members who test positive to stay home, she added.

Although the nurses didn’t vote to unionize until September, Waters said, they began acting collectively from the early days of the pandemic. They drafted a petition and sent a letter to administrators together. When the hospital agreed to provide advanced training on how to use PPE to protect against covid transmission, it was a small but significant victory, Waters said.

“Seeing that change brought a fair number of nurses who had still been undecided about the union to feel like, ‘Yeah, if we work together, we can make change,’” she said.

Old Concerns Heightened, New Issues Arise

Even as union membership in most industries has declined in recent years, health workers unions have remained relatively stable. Experts say it’s partly because of the focus on patient care issues, like safe staffing ratios, which resonate widely and have only grown during the pandemic.

At St. Mary Medical Center outside Philadelphia, short staffing led nurses to strike in November. Donna Halpern, a nurse on the cardiovascular and critical care unit, said staffing had been a point of negotiation with the hospital since the nurses joined the Pennsylvania Association of Staff Nurses and Allied Professionals in 2019. But with another surge of covid cases approaching, the nurses decided not to wait any longer to take action, she said.

A month later, officials with Trinity Health Mid-Atlantic, which owns the hospital, announced a tentative labor agreement with the union. The contract “gives nurses a voice in discussions on staffing while preserving the hospital’s right and authority to make all staffing decisions,” the hospital said in a statement.

In Colorado, where state inspection reports show understaffing led to a patient death at a suburban Denver hospital, SEIU Local 105 has launched a media campaign about unsafe practices by the hospital’s parent company, HealthOne. The union doesn’t represent HealthOne employees, but union leaders said they felt compelled to act after repeatedly hearing concerns.

In a statement, HealthOne said staffing levels are appropriate across its hospitals and it is continuing to recruit and hire staff members.

Covid is also raising entirely new issues for workers to organize around. At the forefront is the lack of PPE, which was noted in one-third of the health worker deaths catalogued by KHN and The Guardian.

Nurses at Albany Medical Center in New York picketed on Dec. 1 with signs demanding PPE and spoke about having to reuse N95 masks up to 20 times.

The hospital told KHN it follows federal guidelines for reprocessing masks, but intensive care nurse Jennifer Bejo said it feels unsafe.

At MultiCare Indigo Urgent Care clinics in Washington state, staff members were provided only surgical masks and face shields for months, even when performing covid tests and seeing covid patients, said Dr. Brian Fox, who works at the clinics and is a member of the Union of American Physicians and Dentists. The company agreed to provide N95 masks after staffers went on a two-day strike in November.

MultiCare said it found another vendor for N95s in early December and is in the process of distributing them.

PPE has also become a rallying point for nonunion workers. At a November event handing out PPE in El Paso, Texas, more than 60 workers showed up in the first hour, said SEIU Texas President Elsa Caballero. Many were not union members, she said, but by the end of the day, dozens had signed membership cards to join.

Nurses at Albany Medical Center picketed on Dec.1, asking for more personal protective equipment. They say they’re having to reuse N95 masks up to 20 times. (Hans Pennink)
Members of the Union of American Physicians and Dentists went on a two-day strike in November asking for more N95 masks. MultiCare found another vendor for N95s and said it would provide them by mid-December. (Marisa Powell)

Small Successes, Gradual Movement

Organized labor is not a panacea, union officials admit. Their members have faced PPE shortages and high infection rates throughout the pandemic, too. But collective action can help workers push for and achieve change, they said.

National Nurses United and the National Union of Healthcare Workers said they’ve each seen an influx in calls from nonmembers, but whether that results in more union elections is yet to be seen.

David Zonderman, an expert in labor history at North Carolina State University, said safety concerns like factory fires and mine collapses have often galvanized collective action in the past, as workers felt their lives were endangered. But labor laws can make it difficult to organize, he said, and many efforts to unionize are unsuccessful.

Health care employers, in particular, are known to launch aggressive and well-funded anti-union campaigns, said Rebecca Givan, a labor studies expert at Rutgers university. Still, workers might be more motivated by what they witnessed during the pandemic, she said.

“An experience like treating patients in this pandemic will change a health care worker forever,” Givan said, “and will have an impact on their willingness to speak out, to go on strike and to unionize if needed.”

Only a Smokescreen? Big Tobacco Stands Down as Colorado and Oregon Hike Cigarette Taxes

Big Tobacco did something unusual in Marlboro Country last fall: It stood aside while Colorado voters approved the state’s first tobacco tax hike in 16 years.

The industry, led by Altria Group, one of the world’s largest tobacco companies, has spent exorbitantly in the past to kill similar state ballot initiatives. In 2018, Altria’s lobbying arm spent more than $17 million to help defeat Montana’s tobacco tax ballot initiative. That same year, it spent around $6 million to help defeat South Dakota’s similar measure.

And four years ago, Altria was the leading funder in a successful $16 million campaign to quash Colorado’s previous proposed tobacco tax increase.

In November, by contrast, Altria didn’t spend a penny in opposition and Colorado voters overwhelmingly approved the tax with two-thirds support. Likewise, in Oregon, Big Tobacco stayed on the sidelines while a tax hike passed there.

The tax measures are major wins for anti-smoking advocates after a string of defeats but, in an example of how politics makes strange bedfellows, Colorado’s tax might not have been possible without Altria’s help. And, advocates said, the way those measures passed could provide a blueprint for states to follow in future elections.

In Colorado, Altria, the parent company of Marlboro cigarette maker Philip Morris, insisted that a minimum price be included in the proposal, according to The Colorado Sun, citing emails between political consultants and Gov. Jared Polis’ office. So while supporters see an increased tobacco tax as more revenue for the state, a disincentive for kids to smoke and a win for public health, the measure could also allow America’s premium tobacco companies to gain market share.

The Colorado measure will increase the total state-levied tax from 84 cents to eventually $2.64 per pack by 2027. The tax rate on vaping products, not currently taxed, will be 30% of the manufacturer’s list price in 2021, gradually increasing to 62% by 2027. The proposition also set the minimum price per pack of cigarettes at $7 as of Jan. 1 and that floor rises to $7.50 in 2024. The change could effectively help premium cigarette companies corner the market, since discount cigarettes would rise to at least $7.

Discount cigarette companies Liggett Group, Vector Tobacco and Xcaliber International — which funded opposition to the tax initiative, Proposition EE — tried to sue the state over the minimum tax provision, alleging “Philip Morris will reap huge benefits from the new legislation” and the changes will “destroy their ability to compete in Colorado.” In December, a federal judge rejected the company’s request for a preliminary injunction. A spokesperson for Liggett said the company plans to appeal.

“When it came to entities like Altria and other stakeholders that we engaged in the legislative process, I think that they saw the writing on the wall,” said Jake Williams, executive director of Healthier Colorado and one of the key organizers behind Proposition EE. “And it helped us get through the legislative process, not just with Democratic votes, but Republican votes to refer the measure to the ballot.”

Altria officials said in a statement that their tobacco companies oppose excise tax increases, but they did not say whether they had worked with Colorado lawmakers.

“Altria did not advocate for or against Proposition EE, and after evaluating the content and intent of this measure, Colorado voters decided to vote in favor of it, some aspects of which were focused on tobacco harm reduction and may help transition adult smokers to a non-combustible future,” the statement said.

Polis’ office did not respond to a request for comment. The Colorado Attorney General’s Office said it would not comment on matters under active litigation. State Democratic Sen. Dominick Moreno and Rep. Julie McCluskie, both state sponsors for the legislation, declined to comment for the same reason. Fellow Democrats Rep. Yadira Caraveo and Sen. Rhonda Fields, also state sponsors for the legislation, did not respond to requests for comment.

Colorado campaign finance records show Altria and Altria’s lobbying arm in 2020 contributed to funds that support both Democratic and Republican candidates in the state — a pattern playing out nationally.

Williams said Altria’s absence of public opposition wasn’t the only factor in the initiative’s success. The tax revenue will initially fund revenue lost during the covid-19 pandemic, then fund tobacco use prevention and eventually preschool education.

The American Lung Association, which supported the Colorado measure, said it believes tobacco taxes are among the most effective ways to reduce tobacco use, especially among youths, who are more sensitive to changes in price. The organization cites studies that found every 10% increase in the price of cigarettes reduces consumption by about 4% for adults and 7% for teens.

“Without tobacco industry opposition, it’s very popular among the public,” Thomas Carr, the association’s director of national policy, said of the tax increase. “We’ve long seen it in polling on the subject.”

There was no major industry opposition to the Oregon increase, either. Its tobacco tax increase — Measure 108 — also got a resounding two-thirds of support. But Oregon didn’t negotiate with Altria lobbyists or set a minimum price provision, according to Elisabeth Shepard, campaign manager for Yes for a Healthy Future.

“I don’t know what the [Colorado] deal was,” Shepard said. “All I know is that before it even made it to the ballot, Altria indicated that they were not going to oppose the measure and stuck with their word.”

While Shepard worried until Election Day whether Big Tobacco would swoop in with opposition in Oregon, it didn’t. She believes her campaign worked because the effort had early resources and money, the tax was targeted to fund the Oregon Health Plan (the state’s Medicaid), and her campaign’s coalition had 300 endorsers, including those in health and business communities.

“We had the left, we had the right, we had the far-right, we had the far-left,” Shepard said.

Her campaign paid its advisory committee members, including representatives from affected communities such as Indigenous Oregonian tribes. At least 30% of American Indian and Alaska Native adults in the state smoke cigarettes. Oregon’s measure increases tobacco taxes $2 per pack, from $1.33 to $3.33, as well as creates a new tax for e-cigarettes. The revenues will help fund an estimated $300 million for the state’s health plan.

Altria did not respond to a request for comment about Oregon tobacco taxes, but the company has previously said it opposed Oregon’s measure.

Shepard believes her campaign model could work in other states. Other anti-smoking advocates took note of the 2020 election.

“We certainly support establishing minimum prices for all tobacco products in conjunction with tobacco tax increases, as we know increasing the price of tobacco products is one of the most effective ways to reduce tobacco use,” said Cathy Callaway, director of state and local campaigns for the American Cancer Society Cancer Action Network.

It could just come down to a state’s voters and its politics, according to Mark Mickelson, a former Republican in South Dakota’s legislature. Mickelson was behind creating his state’s failed 2018 tobacco tax ballot initiative.

“We just got beat,” Mickelson said. The opposition “got ahead of us on the message. They had a lot more money and had just played on doubts that the [tax revenue] money would go to tech ed.”

The average state cigarette tax is $1.88 per pack, but it varies across the country — as high as $4.35 in New York but only 44 cents in North Dakota, where a 2016 ballot initiative to increase that to $2.20 was defeated.

Tax increases can translate into hundreds of millions of dollars in new revenue for states, said Richard Auxier, senior policy associate at the nonpartisan Urban-Brookings Tax Policy Center.

“It’s a little easier to pass a tax on someone else, which is often how this is seen — passing this tax on smokers, rather than passing it on all working people, [compared to] if you were to increase income tax or … a sales tax.”

But not all voters get a say.

In Kentucky, which isn’t a referendum state, Republican state Rep. Jerry Miller said there’s not a lot of sympathy for tobacco companies anymore.

“The agriculture community, which used to be on the same page with cigarette companies, are now always in opposition because the cigarette companies are always trying to tweak their formula to use cheaper tobacco,” he said.

Miller’s recent vaping tax bill failed in the state legislature, but he’s working on a new one.

“We don’t have that tradition or the mechanism that somebody collects 10,000 signatures and they get a referendum on a ballot,” he said. “That’s why things like this have to go through the legislature — and so it really just depends on the state [government].”