Tagged Public Health

KHN’s ‘What the Health?’: Health Care as Infrastructure


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Health care makes some surprising appearances in President Joe Biden’s $2 trillion infrastructure plan, even though more health proposals are expected in a second proposal later this month. The bill that would help rebuild roads, bridges and broadband capabilities also includes $400 billion to help pay for home and community-based care and boost the wages of those who do that very taxing work. An additional $50 billion is earmarked for replacing water service lines that still contain lead, an ongoing health hazard.

Meanwhile, more than half a million people have signed up for health insurance under the new open enrollment for the Affordable Care Act — and that was before the expanded subsidies passed by Congress in March were incorporated into the federal ACA website, healthcare.gov.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Tami Luhby of CNN and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

  • When announcing the new ACA marketplace insurance numbers, federal officials said the enrollment opportunity has been particularly popular with Black residents and lower-income customers.
  • As part of its effort to spur more enrollment, the administration dramatically increased funding for marketing and outreach, including commercials during the NCAA basketball tournament. The Trump administration had cut advertising by 90%.
  • The enrollment bump came even before the new, more generous subsidies were reflected on healthcare.gov, the federal website offering health plans. Biden’s covid relief plan boosted the federal tax credits for people eligible to buy marketplace insurance, especially to middle-income families and those closer to the federal poverty level.
  • In describing Biden’s plan to enhance home and community-based health care, administration officials describe it as a jobs measure because it will help raise wages for people doing the work and help others not have to leave their jobs to care for a loved one.
  • The need for more help caring for older people has often been overlooked because policymakers do not have an easy way to pay for such programs. But as Americans live longer, officials are grappling with the difficult transition from a health system based on acute disease to one that must handle chronic health issues, too.
  • Vaccine credentials are increasingly being required before people can be admitted to public gatherings, but the U.S. does not have a standardized record-keeping system for consumers. When vaccinated, most people get a white card with handwritten details about the date and type of vaccine. Although some health systems and states are keeping records of that, not every facility has an easy way for consumers to get a new record if they lose their card. So, experts are urging them to at least take photos of the card and store that photo electronically.
  • The White House has said it is not in favor of setting up a federal vaccine passport system, and the World Health Organization also said it does not want that now. In the U.S., much of the opposition is being raised by conservatives, who object to federal mandates on issues such as health. But the WHO’s concerns stem from fears raised by groups on the left over vaccine distribution: Because so many doses have gone to First World countries, residents of poorer nations would be disadvantaged by a passport system.

Also this week, Rovner interviews KFF’s Mollyann Brodie, who, in addition to serving as executive vice president and chief operating officer for KFF, leads the organization’s public opinion and survey research activities. Brodie discusses KFF’s COVID-19 Vaccine Monitor, which has been tracking Americans’ feelings and behavior regarding the vaccine.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The New Yorker’s “Sweden’s Pandemic Experiment,” by Mallory Pickett

Joanne Kenen: Slate.com’s “What the Hell Are You Supposed to Do With Your Vaccine Card?” by Elena Debré

Tami Luhby: KHN’s “Despite Covid, Many Wealthy Hospitals Had a Banner Year With Federal Bailout,” by Jordan Rau and Christine Spolar

Sarah Karlin-Smith: Stat’s “Troubling Podcast Puts JAMA, the ‘Voice of Medicine,’ Under Fire for Its Mishandling of Race,” by Usha Lee McFarling


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‘Go Ahead and Vote Me Out’: What Other Places Can Learn From Santa Rosa’s Tent City

SANTA ROSA, Calif. — They knew the neighborhood would revolt.

It was early May, and officials in this Northern California city known for its farm-to-table dining culture and pumped-up housing prices were frantically debating how to keep covid-19 from infiltrating the homeless camps proliferating in the region’s celebrated parks and trails. For years, the number of people living homeless in Santa Rosa and the verdant hills and valleys of broader Sonoma County had crept downward — and then surged, exacerbated by three punishing wildfire seasons that destroyed thousands of homes in four years.

Seemingly overnight, the city’s homeless crisis had burst into view. And with the onset of covid, it posed a devastating health threat to the hundreds of people living in shelters, tents and makeshift shanties, as well as the service providers and emergency responders trying to help them.

In the preceding weeks, as covid made its first advance through California, Gov. Gavin Newsom had called on cities and counties to persuade hotel operators to open their doors to people living on the streets whose age and health made them vulnerable. But in Santa Rosa, a town that thrives on tourist dollars, city leaders knew they would never find enough owners to volunteer their establishments. City Council member Tom Schwedhelm, then serving as mayor, settled on an idea to pitch dozens of tents in the parking lot of a gleaming community center in an affluent neighborhood known as Finley Park, a couple of miles west of Santa Rosa’s central business district.

Neighborhood residents weren’t keen on the idea of accepting homeless people into their enclave of tree-lined streets and sleepy cul-de-sacs. Yet in short order, thousands of residents and businesses received letters notifying them of the city’s plans to erect 70 tents that could shelter as many as 140 people at the Finley Community Center, a neighborhood jewel that draws scores of families and fitness enthusiasts to its manicured picnic grounds, sparkling pool and tennis courts.

The backlash was fierce. For three hours on a Thursday evening in mid-May, Santa Rosa officials defended their plans as hundreds of residents flooded the phone lines to register their discontent.

“Will there be a list of everybody who decided to do this to us and our park, in case we want to vote them out?” one resident barked.

“This is a family neighborhood,” another fumed.

“How can we feel safe using our park?” others pleaded.

In Santa Rosa, like so many other communities, strenuous neighborhood objections typically would drive a stake through a proposal for homeless housing and services. Not this time. Elected officials were not asking; they were telling. The project would move ahead.

“Go ahead and vote me out,” said Schwedhelm, recounting his mindset at the time. “You want to shout at me and get angry? Go ahead. It’s important for government to listen, but the reality is these are our neighbors, so let’s help them.”

Within days, the spacious parking lot at the Finley Community Center was cordoned off with green mesh fencing. Inside, spaced 12 feet apart, were 68 blue tents, each equipped with sleeping bags and storage bin. A neat row of portable toilets lined one side of the encampment, and it was fitted throughout with hand-washing stations and misters for the summer heat.


From May to November, Santa Rosa spent $680,000 to supply and manage a tent city at a popular neighborhood community center. The six-month experiment charted a new course for the Northern California city’s approach to homeless services. (Angela Hart/California Healthline)

The city contracted with Catholic Charities of Santa Rosa to manage the camp, and social workers fanned out to the city shelters and unsanctioned encampments, where they found dozens of takers. The first dozen residents were in their tents four days after the site was approved, and the population quickly swelled to nearly 70. In exchange for shelter, showers and three daily meals, camp residents agreed to an 8 p.m. curfew and a contract pledging to honor mask and physical-distancing requirements and act as good neighbors.

Santa Rosa’s tent city opened May 18. And, not too long after, something remarkable happened. Finley Park residents stopped protesting and started dropping off donations of goods — food, clothing, hand sanitizer. The tennis and pickleball courts, an afternoon favorite for retirees, were bustling again. Parents and kids once more crowded the nearby playground.

And inside that towering green perimeter, people started getting their lives together.

From May to late November, Santa Rosa would spend $680,000 to supply and manage the site, a six-month experiment that would chart a new course for the city’s approach to homeless services. As cities across California wrestle with a crisis of homelessness that has drawn international condemnation, the Santa Rosa experience suggests a way forward. Rather than engage in months of paralyzing discussion with neighborhood opponents before committing to a housing or shelter project, city officials decided their role was to lead and inform. They would identify project sites and drive forward, using neighborhood feedback to tailor improvements to a plan — but not to kill it.

It was a watershed moment of action that would echo across Sonoma County.

“We know we’re pissing off a lot of people — they’re rising up and saying, ‘Hell, no!’” said county Supervisor James Gore, president of the California State Association of Counties. “But we can’t just keep saying no. That’s been the failed housing policy of the last 30 to 40 years. Everybody wants a solution, but they don’t want to see that solution in their neighborhoods.”

‘Death by a Thousand Cuts’

About a quarter of the nation’s homeless reside in California, nearly 160,000 people living in cars, on borrowed couches, in temporary shelters or on the streets. The pandemic has exacerbated the crisis for a host of reasons, including covid-related job loss and prison releases and new capacity limits at homeless shelters.

From Los Angeles to Fresno to San Francisco and Sacramento, homeless encampments have multiplied. And without toilets or trash bins, unsanctioned encampments have become magnets for neighborhood complaints about seedy, unsanitary conditions. That leads to regular law enforcement sweeps that raze an encampment only to see it rise elsewhere.

California’s capital city offers a telling example of the dynamic. An estimated 6,000 people are living homeless in Sacramento, a population that has grown more visible since covid brought office life to a standstill. Tents and tarps crowd freeway underpasses throughout the downtown grid, accompanied by wafting piles of trash and clutter.


An estimated 6,000 people are homeless in Sacramento, a population that has grown more visible during the pandemic. The city razed this sprawling encampment on Stockton Boulevard in December in response to neighborhood complaints. (Angela Hart/California Healthline)

For five years, Donta Williams has rotated through a series of squalid homeless encampments in Sacramento. He is part of a lawsuit calling for an end to city sweeps of unsanctioned camps. “We’ve got nowhere to go,” Williams says. “We need housing. We need services like bathrooms and hand-washing stations.” (Angela Hart/California Healthline)

The mayor, Darrell Steinberg, is known as a champion on homelessness issues. During his years in the state legislature, he pushed through measures that exponentially increased funding to address homelessness and mental illness. But in more than four years as mayor he has struggled to muscle through a cohesive policy for moving people off the streets and into supportive housing.

“The problem with our approach,” Steinberg said earlier this year, “is that every time we seek to build a project, there is a neighborhood controversy. Our own constituents say, ‘Solve it, but please don’t solve it here,’ and we end up experiencing death by a thousand cuts.”

With community uproar building, he is leading the charge on a new initiative to build a continuum of city-sanctioned housing, including triage shelters, sanctioned campgrounds and permanent housing with social services. The city has allocated up to $1 million in an initial outlay for tiny homes and safe camping, but as of March had gotten consensus on just one site: a parking lot beneath a busy freeway where the city will install toilets and hand-washing stations and allow up to 150 people to set up camp.

Donta Williams, homeless the past five years, shakes his head at how long it’s taken the city to sanction a campsite. Priced out of the South Sacramento neighborhood he considers home, Williams has subsisted in a series of squalid lots, regularly packing up and moving from one to the next in response to law enforcement sweeps.

“We’ve got nowhere to go,” said Williams, 40, who is a plaintiff in a legal battle with the city over encampment sweeps. “We need housing. We need services like bathrooms and hand-washing stations. Or how about just some dumpsters so we can pick up the trash?”

A Real Job, a New Beginning

Like Sacramento, Sonoma County has battled unruly homeless encampments for years. Before the fires, the crisis was more hidden, with people sheltering in creek beds and wooded glens abutting hiking and biking trails. The wildfires of 2017, 2019 and 2020 brought many out of the backcountry. And the 5,300 homes decimated by flames meant even more people displaced.

Politicians in Sonoma County described their soul-searching over how to cut through the community gridlock when it comes to finding locations to provide housing and services.


Rosa Newman, homeless more than a decade, moved into Santa Rosa’s tent city in September. “I had nothing, but I had Finley Park,” she says. “That meant I had somewhere safe to sleep; I had food; I had my own little space.” (Rosa Newman)

“It’s fear and anger that you’re going to take something away from me if you build this housing — that’s a big part of it, and I saw that anger directed at me, too,” said Shirlee Zane, a vocal backer of homeless services who lost her reelection bid last year after 12 years on the county board of supervisors. “It’s a psychology we see here too often, a sense of entitlement from white middle-class people.”

In creating the Finley Park model, Santa Rosa leaders drew on a few basic tenets. Neighbors were worried about crime and drug use, so the city deployed police officers and security guards for 24/7 patrols. Neighbors worried about trash and disease; the city brought in hand-washing stations, showers and toilets. Catholic Charities enrolled dozens of camp residents in neighborhood beautification projects, giving them gift cards to stores like Target and Starbucks in exchange for picking up trash — usually $50 for a couple of hours of work.

A few times a week, a mobile clinic serviced the camp, dispensing basic health care and medications. Residents had access to virtual mental health treatment and were screened regularly for covid symptoms; only one person tested positive for the coronavirus during the 256 days the site was in operation.

“We were serious about providing access to care,” said Jennifer Ammons, a nurse practitioner who led the mobile clinic. “You can get them inhalers, take care of their cellulitis with antibiotics, get rid of their pneumonia or skin infections.”

Rosa Newman was among those who turned their lives around. Newman, 56, said she had sunk into homelessness and addiction after leaving an abusive partner years before. She moved into her designated tent in September and in a matter of days was enrolled in California’s version of Medicaid, connected to a doctor and receiving treatment for a painful bladder infection. After two months in the camp, she was able to get into subsidized housing and landed a job at a Catholic Charities homeless drop-in center.

“Before, I was so sick I didn’t have any hope. I didn’t have to show up for anything,” she said. “But now I have a real job, and it’s just the beginning.”

James Carver, 50, who for years slept in the doorway of a downtown Santa Rosa business with his wife, said he felt happy just to have a tent over his head. Channeling his energy into cleanup projects and odd jobs around camp, Carver said, his morale began to improve.

“It’s such a comfort; I’m looking for work again,” Carver, an unemployed construction worker, said in November while cleaning stacks of storage totes handed out to camp residents. “I don’t have to sleep with one eye open.”


Matt Roberts says he struggled to find full-time work in Santa Rosa as businesses shut down amid the pandemic. Having access to shelter, showers and laundry service at the Finley Park tent city provided enough stability that he has since landed a job as a retail clerk.(Angela Hart/California Healthline)

Jennielynn Holmes, who runs Catholic Charities’ homeless services in Northern California, said the Finley Park experiment helped in ways she didn’t expect.

“This taught us valuable lessons on how to keep the unsheltered population safe, but also we were able to get people signed up for health care and ready for housing faster because we knew where they were,” Holmes said. Of the 208 people served at the site, she said, 12 were moved into permanent housing and nearly five dozen placed in shelters while they await openings.

When Santa Rosa officials conceived of the Finley site, they sold it to the community as temporary, believing covid would run its course by winter. And though covid still raged, they kept that promise and closed the site Nov. 30, then held a community meeting to get feedback. “Only three or four people called in, and they all had positive things to say,” said David Gouin, who has since retired as director of housing and community services.

Several area residents said they changed their mind about the project because of the way the site was managed.

“I was amazed I never saw anything negative at all,” said Boyd Edwards, who plays pickleball at the Finley Community Center a few times a week.

“I thought they were going to be noisy and have crap all over the place. Now, they can have it all year round for all I care,” said his friend Joseph Gernhardt.

Of the 108 calls for police service, almost all were in response to other homeless people wanting to sleep at the site when it was at capacity, records show. And there was no violent behavior, said Police Chief Rainer Navarro.

With the Finley encampment closed, Santa Rosa has expanded its primary shelter while drafting plans to set up year-round managed camps in several neighborhoods, this time with hardened structures. County supervisors, meanwhile, are using $16 million in state grants to purchase and convert two hotels into housing, and have stood their ground in pushing through two Finley Park-style managed encampments, one on county property, the other at a mountain retreat center.

The time has come, they said, to stop debating and embrace solutions.

“We have estates that sell for $20 million, and then you walk by people sleeping in tents with no access to hot food or running water,” said Lynda Hopkins, chair of the county board of supervisors. “These tiny villages — they’re not perfect, but we’re trying to provide some dignity.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Calls Mount for Biden to Track US Health Care Worker Deaths from Covid

Calls are mounting for the Biden administration to set up a national tracking system of covid-19 deaths among front-line health care workers to honor the thousands of nurses, doctors and support staffers who have died and ensure that future generations are not forced to make the same ultimate — and, in many cases, needless — sacrifice.

Health policy experts and union leaders are pressing the White House to move quickly to fill the gaping hole left by the Trump administration through its failure to create an accurate count of covid deaths among front-line workers. The absence of reliable federal data exacerbated critical problems such as shortages of personal protective equipment that left many workers exposed, with fatal results.

In the absence of federal action, “Lost on the Frontline,” a joint project between The Guardian and KHN, has compiled the most comprehensive account of health care worker deaths in the nation. It has recorded 3,607 lost lives in the first year of the pandemic, with nurses, health care support staffers and doctors, as well as workers under 60 and people of color, affected in tragically high numbers.

The Guardian/KHN investigation, which involved more than 100 reporters, is drawing to a close this week. Pressure is now growing for the federal government to step into the breach.

Harvey Fineberg, a leading health policy expert who approved a recent National Academy of Sciences report that cited the “Frontline” project and recommended the formation of a national tracking system run by the federal government, backed the calls for change. He said his ideal solution would be a nationwide record.

“There would be a combination of a selective look backward to gain more accurate tabulations of the past burden, and a system of data-gathering looking forward to ensure more complete counts in [the] future,” he said.

Zenei Triunfo-Cortez, a president of National Nurses United, the largest body of registered nurses in the U.S., said it was unconscionable how many health care workers have died of covid-19. The KHN/Guardian interactive found that almost a third of those who died were nurses — the largest single occupation — followed by support staff members (20%) and physicians (17%).

Triunfo-Cortez said the death toll was an unacceptable tragedy aggravated by the lack of federal data, which made identifying problem areas more difficult. “We as nurses do not deserve this — we signed up to take care of patients, we did not sign up to die,” she said.

Dr. Anthony Fauci, the nation’s top expert on infectious diseases, also sees a role for federal agencies in tracking mortality among front-line health care workers. In an interview with The Guardian, he expressed a desire for a definitive picture of the human toll.

“We certainly want to find an accurate count of the people who died,” he said. “That’s something that I think would fall under the auspices of the federal government, likely Health and Human Services.”

The lack of federal intelligence on deaths among front-line health care workers was one of the running failures of the Trump administration’s botched response to the crisis. The main health protection agency, the Centers for Disease Control and Prevention, does curate some information but has itself acknowledged that its own record of 1,527 health worker fatalities — more than 2,000 fewer than the joint Guardian/KHN tally — is an undercount based on limitations in its data collection.

Overall, health care workers were revealed to be singularly at risk from the pandemic. Some studies have shown they were more than three times as likely to contract covid as was the general population.

To date, there is no sign of the Biden administration taking active steps to set up a comprehensive data system. An HHS spokesperson said the department has no plans to launch a comprehensive count. However, Triunfo-Cortez said there is a new willingness on the part of the White House and key federal agencies to listen and engage.

“We have been working with the Biden administration and they have been receptive to the changes we are proposing,” Triunfo-Cortez said. “We are hopeful that they will start to mandate the reporting of deaths, because if we don’t have that data how can we know how effective we are being in stopping the pandemic?”

The responsiveness of the new administration is likely to be heightened by the fact that Biden’s chief of staff, Ron Klain, has a track record in fighting infectious disease outbreaks. In 2014, President Barack Obama appointed him “Ebola tsar.”

In an article in The Guardian last August, Klain drew on the findings of “Lost on the Frontline” to decry the ultimate price paid by health care workers: “Although America has applauded health workers, banged pots in their honor and offered grateful video tributes, we have consistently failed them where it mattered most.”

David Blumenthal, the national coordinator for health information technology under Obama, said a national tracking system is an important step in healing the wounds of the pandemic. “So many health care workers feel as though their devotion and sacrifice weren’t valued,” he said. “We must combat the widespread fatigue and disappointment.”

KHN senior correspondent Christina Jewett contributed to this report.

California Counties a Hodgepodge of Highs and Lows in Vaccinating Vulnerable Seniors

Even as California prepares to expand vaccine eligibility on April 15 to all residents age 16 and up, the state has managed to inoculate only about half its senior population — the 65-and-older target group deemed most vulnerable to death and serious illness in the pandemic.

Overall, nearly 56% of California seniors have received the full course of a covid vaccine, according to the latest data from the federal Centers for Disease Control and Prevention. That’s about average compared with other states — not nearly as high as places like South Dakota, where almost 74% of seniors are fully vaccinated, but also not as far behind as Hawaii, which has reached 44%. The data, current as of Tuesday, does not include seniors who have received only the first dose of the Pfizer-BioNTech or Moderna vaccine.

But California’s overall progress masks huge variations in senior vaccination rates among the state’s 58 counties, which largely are running their own vaccine rollouts with different eligibility rules and outreach protocols. The discrepancies notably break down by geographic region, with the state’s remote rural counties — generally conservative strongholds — in some cases struggling to give away available doses, while the more populous — and generally left-leaning — metropolitan areas often have far more demand than supply.

In San Francisco Bay Area counties like Marin and Contra Costa, for example, more than two-thirds of seniors are fully vaccinated. Meanwhile, in the far northern reaches of the state, encompassing some of California’s most dramatic and rugged terrain, rural counties like Tehama, Shasta and Del Norte have fully vaccinated only about a third of senior residents, according to the CDC data.

“We definitely share one thing in common and that is that we have a fairly high percentage of people who are vaccine hesitant. And that even spreads into the seniors,” Dr. Warren Rehwaldt, health officer for Del Norte County, said of the Northern California counties with relatively low vaccination rates. Del Norte, which is 62% white and voted solidly for Donald Trump in the 2020 election, has vaccinated 36.6% of residents age 65 and older.

The county, population 28,000, has spotty internet service, leaving the health department reliant on phone appointments for its twice-weekly clinics, which have the capacity to give out 300 doses in a day.

“I don’t think we have filled any of them completely, and they are tapering off,” Rehwaldt said. Often, 100 or more appointment slots go unused, even after the county expanded eligibility to age 50 and up. “We expected that, but we didn’t expect it this fast,” he said.

Every Thursday morning, Rehwaldt joins a local public radio broadcast to encourage people to get their shots, and the department regularly airs public service announcements. “But it’s a really high hurdle to overcome serious misgivings about the vaccine itself,” Rehwaldt said.

Asked what resources might help bolster vaccination rates, Rehwaldt said he’d opt for a mobile van to travel to remote areas of his county. But moments later, he sighed and said he wasn’t sure a van would help much after all. “What kind of resources are going to overcome hesitancy? It’s not a resource problem,” he said.

Shasta County, whose population is about 80% white and voted in even stronger numbers for Trump, is also struggling to reach the 65-plus group, with just 36.6% of seniors fully vaccinated. Public information officer Kerri Schuette acknowledged health workers were encountering some hesitancy among residents but said their efforts also were hampered by early supply issues.

On the other end of the spectrum are counties like Marin, a largely suburban and affluent stretch of communities just north of San Francisco where 71.4% of seniors are fully vaccinated.

“There’s a thread of privilege that does lead to ease of access to vaccines that needs to be acknowledged,” said county public health officer Dr. Matt Willis. Many seniors in the county have access to computers and cars, he said, and have been able to access vaccine appointments with relative ease.

Still, the county made an aggressive plan to vaccinate seniors even before the first doses arrived, he said. Rather than waiting for the federal government’s program that relied on pharmacies to vaccinate residents in long-term care facilities, for example, the health department sent in workers as soon as it had vaccines.

The county also kept its eligibility rules tightly focused on seniors age 75 and older through the middle of February, while other counties were expanding to younger age groups and a broad array of occupations. At one point, the county briefly expanded eligibility to teachers, but pulled back just one week later when doses grew scarce.

“We showed that a dose offered to someone 75 and older in Marin was 320 times more likely to save a life than a dose offered to someone younger than 50,” Willis said.

Contra Costa County, a more diverse area on the other side of San Francisco Bay, has done nearly as well: 70.9% of seniors are fully vaccinated. Add in those who have received at least one dose, and the numbers are far higher: 90% of people ages 65-74 and 97% of those 75 and older, according to the county’s vaccine tracker.

To reach vulnerable seniors, Dr. Ori Tzvieli, Contra Costa’s deputy health officer, said the county worked with nonprofit groups to make lists of residential care facilities and low-income senior housing, then sent mobile clinics to each one. “For people who were literally homebound, we send someone inside. Otherwise, we set up a station in the lobby or right outside,” he said.

The county also set up mobile clinics at farms and places of worship. It gave community health workers dedicated appointments to sign up older residents directly. And rather than have residents track down their own appointment slots online, the department had people fill out forms and then scheduled appointments for them, prioritizing those who lived in low-income ZIP codes with high rates of disease.

With a population of just over 1 million, Contra Costa now is able to vaccinate 100,000 people a week, Tzvieli said, and has recently opened eligibility to everyone over 16. But even within the county, inequalities remain. In Bay Point, for example, a largely working-class Latino community, vaccination rates are still just half of those of some wealthier communities, Tzvieli said.

Farther south, in California’s agricultural Central Valley, Fresno County falls somewhere in the middle on vaccination rates. About 54% of seniors 65-plus are fully vaccinated, just under the state average. Just more than half the county’s residents are Latino, many of them farmworkers. And about a fifth of the population lives in poverty, which presents its own hurdles to a vaccination campaign.

“Poverty immobilizes, physically and mentally,” said Joe Prado, community health division manager in Fresno County. “For a wealthier population, going 3 to 5 miles away [to a vaccine clinic] is simple; you hop in the car and go. But if you’re living in poverty, that’s a big barrier.”

There are community pockets that have not engaged with the county health system, meaning health officials are coming up against vaccine hesitancy and distrust, Prado added. “Our health literacy is nowhere near where it should be, and now there’s a digital literacy problem, too,” he said. “We’re trying to deal with all this in the middle of a pandemic.”

At this point in the campaign, Prado said, most seniors eager for the vaccine have received at least an initial dose: “The final 25% is going to be the most resource-intensive, the most difficult to reach.”

Dr. William Schaffner, an infectious-disease specialist at Vanderbilt University, calls this public health’s “low-hanging fruit phenomenon.” As the proportion of people who are vaccinated grows, he said, “we’ll have to work proportionally harder to keep advancing these numbers, because the eager beavers go first.” In rural counties from California to Tennessee, he added, supply is already outpacing demand.

So far, just more than 75% of seniors in the U.S. have received at least one dose of vaccine, according to the CDC.

“You can look at that as the glass is half-empty or half-full,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, during a recent episode of his weekly podcast. That still leaves more than 13 million seniors unprotected despite facing the highest risk of death; 8 in 10 deaths from covid reported in the U.S. have been among adults 65 and older.

It is crucial, Osterholm said, that states continue to direct efforts toward reaching and vaccinating vulnerable seniors who are homebound or hesitant.

“When we say we’re going to open up eligibility to everybody 16 or 18 years and older, that seems like a victory,” he said. “In many states, that is an admission of defeat.”

Doctor Survived Cambodia’s Killing Fields, but Not Covid

Linath Lim’s life was shaped by starvation.

She was not yet 13 when the Khmer Rouge seized power in Cambodia and ripped her family apart. The totalitarian regime sent her and four siblings to work camps, where they planted rice and dug irrigation canals from sunrise to sunset — each surviving on two ladles of rice gruel a day. One disappeared, never to be found.

Just a few months before the Khmer Rouge fell in January 1979, Lim’s father starved to death, among the nearly one-quarter of Cambodians who perished from execution, forced labor, starvation or disease in less than four years.

For Lim, the indelible stamp of childhood anguish drove two of her life’s passions: serving people as a physician and cooking lavish feasts for friends and family — both of which she did until she died of covid-19 in January.

Within the week before her death at age 58, she treated dozens of patients who flooded the hospital during the deadly winter covid surge, while bringing home-cooked meals to the hospital for her fellow health care workers to enjoy during breaks.

“These experiences during the war made her humble and empathetic toward the people around her,” said Dr. Vidushi Sharma, who worked with Lim at Community Regional Medical Center in Fresno, California. “She always wanted to help them.”

Lim’s story is one of suffering and triumph.

During the Khmer Rouge’s brutal reign and the Cambodian civil war before it, Lim and her nine siblings attended school sporadically. The ravages of war forced the family first from its small town to the capital, Phnom Penh, and then into the countryside when the Khmer Rouge took power in 1975. As part of its vision to create a classless agrarian society, the communist group split families and relocated residents to rural labor camps.

Lim survived the work camps because she was smart and resourceful, said her youngest brother, Rithy Lim, who also lives in Fresno. She dug ditches, hauled clay-like dirt on her back, built earthen dams in the middle of a river during monsoons — all with little food or rest, he said.

She also became a skillful hunter and fisher, and learned to identify plants that were safe to eat.

“You cannot imagine the horrible conditions,” he said. “Think of it as a place that you live like wild animals, and people tell you to work. There’s no paper, no pens. You sleep on the ground. We witnessed death of all sorts.”

Vietnamese troops liberated Cambodia from the Khmer Rouge in 1979. Later that year, Lim, her mother and siblings sneaked into Thailand. “The whole family walked through minefields,” Rithy Lim recalled. There, they waited and worked in refugee camps. At one camp, they met a dentist from California’s Central Valley who was on a medical mission.

When Lim and her family arrived in the U.S. in 1982, they landed in Georgia. But she and an older brother soon moved to the small town of Taft, California, about 45 minutes west of Bakersfield, at the invitation of the dentist they’d befriended at the Thai refugee camp.

When she hit the ground, the 4-foot-11 dynamo, then 19, was driven by “pure determination,” Rithy Lim said.

Within two years, Linath Lim learned English, earned her GED and graduated from Taft College — “boom, boom, boom,” her brother recalled. (She learned to make traditional, middle-America Thanksgiving dinners when she worked at the community college’s cafeteria, which she would later cook for scores of friends and family.)

She went on to attend Fresno State and then the Medical College of Pennsylvania, sleeping on friends’ couches, borrowing money from other Cambodian refugees and scraping by.

“Imagine not having any money, studying alone, sleeping in someone else’s living room,” Rithy Lim said.

Lim became an internal medicine doctor “because she always wanted to be really involved with a lot of patients,” Rithy Lim said. After her residency, she returned to the Central Valley to practice in hospitals and clinics in underserved communities, including Porterville and Stockton, where some of her patients were farmworkers and Cambodian refugees.

California has the largest Cambodian population in the country, with roughly 89,000 people of Cambodian descent in 2019, according to a Public Policy Institute of California analysis of American Community Survey data.

Twice, Lim joined the Cambodian Health Professionals Association of America on weeklong volunteer trips to Cambodia, where she and other doctors treated hundreds of patients a day, said Dr. Song Tan, a Long Beach, California, pediatrician and founder of CHPAA.

“She was a kindhearted, very gentle person,” recalled Tan, who said he was the only member of his family to survive the Khmer Rouge. “She went beyond the call of duty to do special things for patients.”

Most recently, Lim worked the swing shift, 1 p.m. to 1 a.m., at Community Regional Medical Center. She admitted patients through the emergency room, where she was exposed to countless people with covid. She worked extra shifts during the pandemic, volunteering when the hospital was short-staffed, said Dr. Nahlla Dolle, an internist who also worked with Lim.

“She told me there were so many patients every day, and that they didn’t have enough beds and the patients had to wait in the hallway,” Tan said.

Colleagues said she was aware of the risks but loved her job. Lim, who was single and didn’t have kids, drew happiness from celebrating others’ joys. After getting home from work in the small hours, she slept for a bit, then got up to cook. Her specialties were Cambodian, Thai, Vietnamese and Italian food. She sometimes ordered a whole roasted pig that she transported to the hospital. Her memorable Thanksgiving dinners served 70 or more people.

“For any occasion that comes up — if it’s a birthday, if it’s a baby shower, if it’s Thanksgiving — she would cook, she would order food and bring everybody together,” Dolle said. “She loved to feed people because she experienced famine and lack of food.”

The week before she died, Lim cooked for her colleagues almost every day, and threw a baby shower for Sharma, complete with chicken calzones and blueberry cake.

“Every day, we were having lunch together,” Sharma said. “She did the shower, and then she’s gone.”

Lim, who had health problems including diabetes, had not been vaccinated.  Family and friends had urged her to take care of herself, and to check her blood sugar and take her medications. “She would care about everyone but herself,” Sharma said.

On Jan. 15, Lim told friends by phone that she was exhausted, achy and having trouble breathing. But she said that she would be fine, that she just needed to rest. Then she stopped responding to calls and texts.

When she didn’t show up for work a few days later, her brother went to check on her at home and found her on the couch, where she had died.

Now her brother and colleagues are haunted by what-ifs over the loss of a remarkable woman and doctor: What if I had checked on her sooner? What if she had been vaccinated? What if she had gotten care when she started feeling ill?

“To have someone who has been through all that in her childhood and then flourish as a physician, a human being, coming to a new country, learning English, going to school and college without having much financial support, it’s phenomenal,” Sharma said. “It’s unbelievable.”

This story is part of “Lost on the Frontline,” a project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Para este enfermero de cuidados paliativos, la vacuna de covid llegó demasiado tarde

Antonio Espinoza amaba a los Dodgers de Los Angeles. Los quería tanto que para su velatorio lo vistieron con su camiseta del equipo. Su familia y amigos, incluido su hijo de 3 años, también usaron remeras, y gorras de béisbol azul y blancas, en su honor.

Espinoza murió de covid a los 36 años, apenas unos días después de recibir la primera dosis de una de las vacunas contra el virus. Era un enfermero de cuidados paliativos, que arriesgó la vida para ayudar a los pacientes de covid, y a muchas otras personas, a morir en paz.

Cuando estalló la pandemia, a su familia no le sorprendió que este “gigante gentil”, como le llamaban sus amigos y familiares, diera un paso al frente.

“Su actitud era: ‘No, no voy a tener miedo’”, contó Nancy Espinoza, su esposa desde hacía 10 años. “Este es nuestro momento”, le había dicho a su esposa. “Esta es la razón por la que me hice enfermero”.

Como enfermero de cuidados paliativos y jefe de enfermería de Calstro Hospice en Montclair, California, Espinoza habitualmente hacía visitas a domicilio, iba a centros de vida asistida y realizaba citas de defunción, cuando un enfermero especializado declara la muerte de un paciente.

Los trabajadores de los hospicios no son sólo médicos y profesionales de enfermería: hay asistentes de salud en el hogar, trabajadores sociales, capellanes y consejeros. En el último año, han frecuentado algunos de los entornos de mayor riesgo sanitario, como residencias de adultos mayores, centros de vida asistida y las propias casas de los pacientes.

Los cuidados paliativos exigen una atención íntima del paciente, y los requisitos de seguridad adicionales y la necesidad de equipos de protección personal lo vuelven complicado, explicó Alicia Murray, presidenta de la junta directiva de la Hospice and Palliative Nurses Association.

Pero dijo que los trabajadores de los hospicios asumieron el reto, sabiendo que podían ser las únicas personas que acompañarían a los pacientes terminales, cuando a los familiares no se les permitía visitar los centros médicos y de cuidados de largo plazo.

“Cuidan a personas que están muriendo y, en particular, a los moribundos de covid que pueden estar propagando el virus”, señaló el doctor Karl Steinberg, geriatra y especialista en cuidados paliativos que es director médico de Hospice by the Sea, en Solana Beach, California, y de varias residencias de mayores.

A los pocos meses de la pandemia, cuando Calstro Hospice empezó a atender a pacientes con covid, Espinoza ayudó a crear una unidad de covid. Parte de su trabajo consistía en asegurarse de que el personal tuviera suficiente equipo de protección, incluido él mismo.

“A algunos les costaba conseguir el equipo de protección personal, pero su oficina contaba con el equipo adecuado”, aseguró su esposa y añadió que, justo antes de enfermar, recibió con entusiasmo un gran cargamento de batas, mascarillas N95, escarpines y protectores faciales del condado de San Bernardino.

Espinoza cayó enfermo unos días después de su primera dosis de la vacuna de covid, el 5 de enero, pero fue a trabajar pensando que era una reacción a la vacuna. “Tenía dolor de garganta y se sentía un poco indispuesto, pero nada importante”, dijo Nancy Espinoza. Los síntomas se convirtieron en fiebre y escalofríos, y el 10 de enero dio positivo para covid.

Otros siete miembros del personal de Calstro Hospice también se contagiaron de covid durante la pandemia, apuntó Jennifer Arrington, directora de servicios de atención al paciente de Calstro Hospice.

Espinoza fue una víctima de las circunstancias, según la doctora Lucy Horton, especialista en enfermedades infecciosas y profesora de la Escuela de Medicina de la Universidad de California-San Diego.

El período de incubación del virus es de cinco a siete días promedio. “Si el resultado es positivo unos días después de la vacuna, lo más probable es que te hayas expuesto antes de recibir la primera dosis”, explicó Horton.

Horton dijo que las personas no están completamente vacunadas hasta al menos 14 días después de la segunda dosis de una vacuna de dos dosis, o la primera dosis de una versión de una dosis. Y agregó que, inmediatamente después de la primera dosis, los beneficios de la vacuna todavía no están funcionando a pleno.

“Incluso después de estar completamente vacunado, sigue habiendo un riesgo remanente”, advirtió Horton, coautora de una carta al New England Journal of Medicine sobre las tasas de infección post-vacunación entre los trabajadores de la salud en California. “Aunque sea mucho menor, sigue estando presente”.

Espinoza sabía que quería cuidar de los demás y dedicarse a la atención de salud desde que estaba en la preparatoria, y se dio cuenta de que la comunidad hispana necesitaba enfermeros latinos de cuidados paliativos, dijo su mujer. “Se propuso ayudar a la comunidad hispana a entender el mundo de los cuidados paliativos y a no tenerle miedo”, señaló.

El 15 de enero, Nancy Espinoza y el hijo pequeño de la pareja, Ezekiel, hablaron por teléfono con Antonio por última vez. “Te quiero” fueron las últimas palabras que escuchó decir a su marido.

Le permitieron visitarlo justo antes de morir, el 25 de enero. Estaba intubado con un nivel de oxígeno del 25%.

Nancy Espinoza estuvo en la habitación a solas con su marido por última vez. “Sólo quería sostener su mano y rezar por él”, dijo. “Quería que supiera que no estaba solo”.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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Colleges and Universities Plan for Normal-ish Campus Life in the Fall

Dr. Sarah Van Orman treads carefully around the word “normal” when she describes what the fall 2021 term will look like at the University of Southern California in Los Angeles and other colleges nationwide.

In the era of covid, the word conjures up images of campus life that university administrators know won’t exist again for quite some time. As much as they want to move in that direction, Van Orman said, these first steps may be halting.

“We believe that higher education generally will be able to resume a kind of normal activity in the fall of ’21, and by that I mean students in classrooms and in the residence halls, others on campus, and things generally open,” said Van Orman, USC’s chief health officer. “But it will not look like the fall of 2019, before the pandemic. That will take a while.”

Interviews with campus officials and health administrators around the country reveal similar thinking. Almost every official who spoke with KHN said universities will open their classrooms and their dorms this fall. In many cases, they no longer can afford not to. But controlling those environments and limiting viral spread loom among the largest challenges in many schools’ histories — and the notion of what constitutes normalcy is again being adjusted in real time.

The university officials predicted significantly increased on-campus activity, but with limits. Most of the schools expect to have students living on campus but attending only some classes in person or attending only on selected days — one way to stagger the head count and to limit classroom exposure. And all plan to have vaccines and plenty of testing available.

“We’re going to be using face coverings,” Van Orman said. “We’re going to be lowering densities of people in certain areas. We’re going to be offering vaccinations on campus, and we need tracking mechanisms so that we can perform contact tracing when it’s called for.”

With three vaccines being administered nationally so far, the chances that college faculty and staff members could be partially or fully inoculated against covid by fall are improving. Students generally fall well down on the priority list to receive covid vaccines, so schools are left to hope that vaccination of adults will keep covid rates too low to cause major campus outbreaks. It may take months to test that assumption, depending on vaccination and disease rates, the duration of vaccine-induced immunity and the X-factor of variants and their resistance to existing vaccines.

And most colleges are interpreting federal law as prohibiting them from requiring staffers or students to be vaccinated, because the shots have been granted only emergency use authorization and are not yet licensed by the Food and Drug Administration.

Regardless, many schools are powering forward. The University of Houston recently announced it would return to full pre-pandemic levels of campus activity, as did the University of Minnesota. Boston University president Robert Brown said students will return this fall to classrooms, studios and laboratories “without the social distancing protocols that have been in place since last September.” No hybrid classes will be offered, he said, nor will “workplace adjustments” be made for faculty and staff.

The University of South Carolina plans to return residence halls to normal occupancy, with face-to-face classes and the resumption of other operations at the 35,000-student main campus, Debbie Beck, the school’s chief health officer, announced last month.

At some of the largest state institutions, however, it’s clear that a campus-by-campus decision-making process remains in play. In December, the California State University system, a behemoth that enrolls nearly half a million students, announced plans for “primarily in-person” instruction this fall, only to be contradicted by officials at one of its 23 campuses.

The 17,000-student Chico State campus plans to offer about a quarter of its fall course sections either fully in person or blended, president Gayle Hutchinson wrote to the campus community in February. “There is no easy explanation of what this means for students,” she said. “It could mean a fully online schedule, or one that is both in-person and online.”

The 285,000-student University of California system in January declared a return to primarily in-person instruction for fall, but said specific plans and protocols would be announced by each of its 10 campuses. Places like UCLA, in Los Angeles County, which was ravaged by sky-high infection rates for months, could wind up with far fewer in-person classes than UC campuses in Merced or Santa Cruz.

There’s no getting around the financial component of schools’ decisions for the fall. After most of the more than 4,000 colleges and universities in the U.S. went into full or nearly full physical shutdown late last spring, overall enrollment fell 2.5% and freshman enrollment decreased by more than 13%. And the real pain was felt in empty dormitories and cafeterias. For many schools, room and board make up the profit margin for the year.

According to research by the College Board, room and board costs rose faster than tuition and fees at public two- and four-year institutions over the past five years. In 2017, the Urban Institute found that room and board costs had more than doubled since 1980 in inflation-adjusted dollars. When those dollars dry up, as they have during the pandemic, budgets can be severely strained.

In mid-March, Mills College, a 169-year-old women’s liberal arts school in Oakland, announced it would no longer admit first-year undergrads and would instead become an institute promoting women’s leadership. Mills is among a number of schools in financial distress that the pandemic pushed over the edge.

In an October letter to Congress seeking enhanced financial support, the American Council on Education estimated a collective $120 billion in pandemic-related losses by the nation’s colleges and universities. The Chronicle of Higher Education in February revised that estimate to a staggering $183 billion, “the biggest losses our financial sector has ever faced.”

There are no easy solutions. The hybrid class model, with professors simultaneously teaching some students in person and others online, “is a heavy lift for both institutions and faculty,” said Sue Lorenson, vice dean for undergraduate education at Georgetown University. But although instructors generally loathe it, that model almost certainly will be in place at most schools this fall to keep enrollments as high as possible.

Clearly, the preference at any school is to have those students back on campus. And university health officials would rather see them living in dorms. As long as infection rates are low in communities around campus, “the schools really have a great ability to keep those kids in the residential halls very safe,” Van Orman said. “We’ve got the ability to test them regularly and mitigate with mask-wearing, distancing, disinfecting and other things.”

One of USC’s biggest viral outbreaks, in fact, occurred off campus last summer, when more than 40 people became infected in the “fraternity row” area, a couple of blocks away from the university.

On campuses across the country, officials say, the fall term will again be marked by adjustments all around. And as for the return to a true normal?

“I don’t think, reasonably, that this will happen before September of ’22, and I truly believe we’ll probably be looking at ’23,” Antonio Calcado, chief operating officer at Rutgers, New Jersey’s 70,000-student state university, said during a campus presentation. “It was easy bringing the university to a standstill. It’ll be difficult bringing it back up to where we need to be.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

An Indie Artist’s Plea to Look Beyond Algorithms and Curated Playlists

When the pandemic hit, Debórah Bond, like many artists, was caught off guard. “I thought I’d be juggling gigs and touring,” said the independent R&B/soul musician.

A full-time artist, Bond, 44, made a living through a patchwork of vocal gigs — performing live at weddings, bars and theaters, recording jingles, teaching vocal lessons and hosting events.

But the coronavirus pandemic found her burning through her savings and struggling to make ends meet in a tiny rental accessory dwelling unit above the tree-lined garage of a home in Hyattsville, Maryland. According to a 2020 report from the Rand Corp., artists were more likely than others to have lost their main source of income — music-related or not — due to the pandemic.

So with few other obvious options, and the world at a standstill for the foreseeable future, she set out to write her first solo album in the small rental she fondly referred to as her “treehouse.”

But cut off from family, friends and other nearby musicians, she devised a way to bring together out-of-work musicians from around the world, people who felt just as abandoned and stuck as she did. What resulted is an extraordinary transnational album — “compass: I,” released March 5 — that connected her with a far broader musical community and buoyed their collective spirits during a year of isolation.

The new album is a pandemic-fueled collaboration of musicians such as Chelsey Green, PhD. a violinist and acting chair of the strings department at Berklee College of Music in Boston; two-time Grammy-nominated drummer Nate Smith in Nashville; and a percussionist from the British acid jazz band Incognito, who sent in his recordings from London. “Everyone jumped on board from wherever they were,” Bond said. And most, she said, “didn’t even stress me for money. We all wanted to create.” She was even able to work with Gordon Chambers, a songwriter who has written for several artists from Beyoncé to Anita Baker and likely would not have been accessible to her or available pre-pandemic.


In the small rental dwelling she calls her “treehouse,” Debórah Bond created a home-recording studio with mics, speakers, her MacBook ­­–– and the help of music engineers over video conferences. (David Hicks for KHN)

They were up against the challenges of not just a pandemic, but also a music industry that has come to rely heavily on curated playlists like Apple Music’s “New Music” or “From Our Editors” to promote new releases. Mainstream artists who have released music during the pandemic have teams of industry professionals ensuring their tunes end up on the most highly trafficked playlists.

Some music-streaming platforms like Apple Music don’t allow third-party playlist curation. So, without a direct connection to their editorial team or partners, landing a spot on these lists isn’t likely. Without being able to perform live at clubs and events this past year, Bond says, some independent artists may feel financial pressure to focus less on the quality of their music and more on finding ways to go viral on social media to tip the scales.

How does an independent artist find new listeners at a time when performing for a crowd isn’t allowed, and they’re battling against more than 50 million and 60 million songs already on Spotify and Apple Music, respectively?

Bond was not naïve about how the music world works, having been a performer for decades. She and her band, Third Logic, had been performing together since they were in their early 20s, but as time passed and adulthood — marriage, children, increased work responsibilities — set in, finding the time to write music together became nearly impossible. They hadn’t released a new album since “Madam Palindrome” in 2011. Time and distance from her bandmates meant that gigs were few. So, in 2019, she decided to embark on a solo career. Then covid hit.

At first, she despaired about how she would be able to pay for things like rent and food without the hope of recurring live gigs. “The pandemic relief money was really helpful,” she said, because independent artists can sometimes go weeks without making any money even without a global pandemic. Between her stimulus check and unemployment, Bond budgeted $600 a week to live on. She had affordable health insurance through Kaiser Permanente, “thanks to Obamacare,” she said. She cut expenses, stuck to her budget and received modest payments from booking a few covid-friendly, livestreamed events for Washington, D.C.’s Kennedy Center and the Music Center at Strathmore in North Bethesda, Maryland.

She was able to improvise a home-recording studio with mics, speakers, her MacBook and ProTools software and the help of music engineering friends over video conferences. Bond writes song lyrics and performs but doesn’t herself compose music. So, she put out a call to the musicians in her network and found many of them were also at home tinkering with new tunes and willing to share. Bond would “wait until late at night, turn on colored bulbs, blast things through my monitors and write,” she said.

After a rough draft of the album was completed in September, she and independent producer Brandon Lane put out a broader call for help for more live instrumentation. Their pleas circulated and produced a village of talent, as musicians from all over the world sent the singer their high-quality home recordings. “It showed me how many musicians were in the same boat,” Bond said.


“It showed me how many musicians were in the same boat,” Bond says.(David Hicks for KHN)

Lane, who lived nearby and became part of Bond’s pandemic bubble, would come to her home studio — fully masked-up — as technical support and to co-produce the album. The title “compass: I” reflects an appreciation of the importance of trusting your own internal compass, she explained. The project showed Bond “who has my back,” she said, and that in a time of global crisis musicians — many of whom Bond considers friends — would come together to co-create with her.

Bond, who describes herself as having an eclectic Bohemian style and devil-may-care attitude, said she doesn’t want to change herself to jockey for a spot on the Billboard charts or playlists — even in the post-pandemic world.

The music industry is notoriously youth-obsessed and male-dominated, she said. The third annual report on the industry, “Inclusion in the Recording Studio?” from professor Stacy Smith and the USC Annenberg Inclusion Initiative found that in evaluating gender across eight years of Grammy nominations for Record of the Year, Album of the Year, Song of the Year, Producer of the Year and Best New Artist, 21.7% — or about 1 in 5 artists — were women.

“This is who the f*** I am,” she said. “I’m not 18, but I’m not ‘old’ either.” She wants listeners to have the chance to discover diverse musical options for female entertainers, at different ages, with different sounds and styles to match. By dint of necessity, the pandemic opened new types of doors for performers like her — through which she hopes new types of music will continue to be heard.

“You have to be smart,” she said. “It’s not hard to find new music.” Manually searching streaming apps like SoundCloud and Spotify take no more effort than scrolling through Instagram, she said. Bond hopes that listeners will take a break from the algorithms that sneakily sway our musical interests toward those artists pushed to the top of the charts and follow their own compass.

For This Hospice Nurse, the Covid Shot Came Too Late

CORONA, Calif. — Antonio Espinoza loved the Los Angeles Dodgers. He loved them so much that he was laid to rest in his favorite Dodgers jersey. His family and friends, including his 3-year-old son, donned a sea of blue-and-white baseball shirts and caps in his honor.

Espinoza died at age 36 of covid-19, just days after he got his first dose of a covid vaccine. He was a hospice nurse who put his life in danger to help covid patients and others have a peaceful death.

When covid hit, it was no surprise to his family that this “gentle giant,” as friends and family called him, stepped up to the plate.


Antonio Espinoza with his son, Ezekiel (Nancy Espinoza)

“His attitude was like, ‘No, I’m not going to be scared,’” said Nancy Espinoza, his wife of 10 years. “This is our time to shine,” he told her. “I became a nurse for a reason.”

As a hospice nurse and chief nursing officer for Calstro Hospice in Montclair, California, Espinoza routinely made house calls, visited assisted living facilities and performed death visits — during which hospice nurses pronounce patients dead.

Hospice workers aren’t just doctors and nurses, but also include home health aides, social workers, chaplains and counselors. In the past year, they have frequented some of the highest-risk environments, such as nursing homes, assisted living facilities and patients’ homes.

Hospice requires intimate patient care, and the additional safety requirements and need for personal protective equipment made it challenging, said Alicia Murray, board president of the Hospice and Palliative Nurses Association. But hospice workers adapted, she said, knowing they might be the only people who could comfort dying patients when family members were not allowed to visit medical and long-term care facilities.

“They’re taking care of dying people and, in particular, people dying of covid who may be spewing out the virus,” said Dr. Karl Steinberg, a geriatrician and palliative care specialist who is the medical director of Hospice by the Sea in Solana Beach, California, and several nursing homes.

A few months into the pandemic, when Calstro Hospice began caring for covid patients, Espinoza helped develop a covid unit. Part of his job was to make sure staff members had sufficient personal protective gear, including himself.


Ezekiel Espinoza holds a photograph of his first Los Angeles Dodgers game with his dad, Antonio.(Heidi de Marco / KHN)

“Some people had a hard time getting a hold of all the PPE gear, but his office had adequate equipment,” his wife said. Right before he got sick, he was excited to receive a big shipment of gowns, N95 masks, booties and face shields from San Bernardino County, she said.

Espinoza fell ill a few days after his first dose of covid vaccine on Jan. 5, but went to work thinking it was vaccine-related. “He had kind of a sore throat and felt a little bit under the weather, but nothing major,” said Nancy Espinoza. His symptoms progressed to a fever and chills and he tested positive for covid on Jan. 10.

Seven other Calstro Hospice staff members also got covid during the pandemic, said Jennifer Arrington, Calstro Hospice’s director of patient care services.


Nancy holds her son, 3-year-old Ezekiel. A licensed vocational nurse, she stopped working after he was born. Her husband was the main breadwinner, and she is now trying to figure out how she will care for their young son. (Heidi de Marco / KHN)

Espinoza was a victim of bad timing, according to Dr. Lucy Horton, infectious disease specialist and associate professor at the University of California-San Diego School of Medicine.

The virus’s incubation period averages five to seven days, she explained. “If you test positive a few days after the vaccine, chances are you actually got exposed before you even got your first dose,” she said.

Horton said people aren’t fully vaccinated until at least 14 days after their second dose of a two-dose vaccine, or their first dose of a one-dose version. Early after the first dose, people don’t reap the benefit of the vaccine yet, she said.

“Even after you’re fully vaccinated, there still is a remaining risk,” said Horton, co-author of a letter to the New England Journal of Medicine about post-vaccination infection rates among health care workers in California. “Even if it’s so much lower, it’s still present.”


Nancy and Ezekiel, visit Antonio’s grave at Forest Lawn in Long Beach, California. (Heidi de Marco / KHN)

Nancy and Ezekiel, visit Antonio’s grave at Forest Lawn in Long Beach, California.(Heidi de Marco / KHN)

Nancy and Ezekiel, visit Antonio’s grave at Forest Lawn in Long Beach, California. (Heidi de Marco / KHN)

Espinoza knew he wanted to care for others and go into health care since he was in high school, and realized the Hispanic community needed Latino nurses in hospice care, his wife said. “He made it his purpose to help the Hispanic community understand hospice care and not be afraid of it,” she said.

On Jan. 15, Nancy Espinoza and the couple’s toddler, Ezekiel, spoke to Antonio over the phone for the last time. “I love you” were the last words she heard her husband say.

She was allowed to visit him right before he died on Jan. 25. He was intubated with an oxygen level of 25%.

Nancy Espinoza stood in the room alone with her husband for the last time. “I just wanted to be able to hold his hand and pray for him,” she said. “I wanted him to know that he wasn’t alone.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Despite Covid, Many Wealthy Hospitals Had a Banner Year With Federal Bailout

Last May, Baylor Scott & White Health, the largest nonprofit hospital system in Texas, laid off 1,200 employees and furloughed others as it braced for the then-novel coronavirus to spread. The cancellation of lucrative elective procedures as the hospital pivoted to treat a new and less profitable infectious disease presaged financial distress, if not ruin. The federal government rushed $454 million in relief funds to help shore up its operations.

But Baylor not only weathered the crisis, it thrived. By the end of 2020, Baylor had accumulated an $815 million surplus, $20 million more than it had in 2019, creating a 7.5% operating margin that would be the envy of most other hospitals in the flushest of eras, a KHN examination of financial statements shows.

Like Baylor, some of the nation’s richest hospitals and health systems recorded hundreds of millions of dollars in surpluses after accepting the lion’s share of the federal health care bailout grants, their records show. Those included the Mayo Clinic, Pittsburgh’s UPMC and NYU Langone Health. But poorer hospitals — many serving rural and minority populations — got a tinier slice of the pie and limped through the year with deficits, downgrades of their bond ratings and bleak fiscal futures.

“A lot of the funding helped the wealthy hospitals at a time, especially in New York, when safety-net hospitals were hemorrhaging,” said Colleen Grogan, a health policy professor at the University of Chicago. “We could have tailored it to hospitals we knew were really suffering and taking on a disproportionate amount of the burden.”

In Baylor’s case, the system, which runs Baylor University Medical Center in Dallas and 51 other hospitals, said it spent $257 million last year on pandemic-related costs, including protective clothing for employees and patients and creating isolation rooms. Baylor has $197 million in unspent federal relief funds to use this year to cover costs of battling the virus and refrigerating vaccines, it said.

“Our covid-19-related expenses and lost revenue continue to exceed the funding we have received to date,” Baylor said in a statement to KHN.

Other well-heeled hospitals or large systems faced bigger problems. Both NewYork-Presbyterian Hospital and CommonSpirit Health, a 140-hospital Catholic system that operates in 21 states, lost money despite federal grants in the vicinity of a billion dollars each. A few systems, including the for-profit chain HCA Healthcare, returned federal funds when they saw they had skirted their worst-case scenarios. But most spent the aid and held onto any leftover money and new grants to cover anticipated pandemic costs this year because hospital executives fear more case spikes.

Much of the lopsided distribution was caused by the way the Department of Health and Human Services based the allotment of the initial bailout funds on hospitals’ past revenue. That favored institutions with well-off patients who have private health plans over those that rely on lower-paying government insurance, which is what many poor people use.

HHS distribution formulas did not take into account which hospitals had enough assets to survive.

Baylor, for instance, began 2020 with $5.4 billion in cash and investments, enough to keep it running for 238 days, the financial disclosures show.

Hospitals that ended the year with profits were entitled to federal aid because of the extraordinary latitude Congress and HHS set in how hospitals could classify their pandemic costs.

Last fall, when HHS attempted to limit how much aid hospitals could keep based on their profits — so the money could be redirected to struggling hospitals — the effort was swiftly beaten back by the industry and Congress. HHS officials declined requests for an interview but noted in a statement that Congress had ordered it to revert to its “broader definition of permissible use of PRF funds.”

“The Biden Administration continues to review programs and policies including considerations for the unallocated funding under the PRF program and the $8.5 billion recently appropriated under the recently signed American Rescue Plan Act,” the statement said.

Avoiding a Drawdown of Reserves

The bailouts were initiated last spring to help health care providers ride out a once-in-a-century public health calamity. The money designated to hospitals and other health care providers from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and subsequent legislation totaled $178 billion.

It was intended to offset all costs of treating infected patients, including purchasing ventilators, masks, gowns and other personal protective equipment. Congress further authorized hospitals to use the money to compensate for a drop in revenue when they shut down elective surgeries and non-emergency treatments to prepare for the anticipated deluge of covid-19 patients.

The money, referred to as the Provider Relief Fund, helped many poorer hospitals avert cash crunches, layoffs and bond rating downgrades. A survey by the consulting firm Kaufman Hall found that the median hospital gain during 2020 would have been 0.3% without the federal support. With it, half of hospitals posted gains of 2.7% or more, below the 2019 median margin of 3.1%, according to the firm, which also produces analytic work for the American Hospital Association.

In February, the association urged Congress to replenish the nearly empty relief fund, saying, “hospitals have never experienced such a widespread, national health crisis.”

Some hospitals’ finances deteriorated significantly during the pandemic. From the end of March through December, the rating agency Moody’s downgraded 28 hospitals, primarily because of weaknesses such as higher debt or more competition, said Lisa Goldstein, associate managing director at Moody’s.

Others suffered worse fates, like Williamson Memorial Hospital, which shut down last April. The hospital, in West Virginia’s coal country, had been trying to climb out of bankruptcy protection, but “unfortunately, the decline in volumes experienced from the current pandemic were to[o] sudden and severe for us to sustain operations,” its CEO wrote on Facebook.

Conversely, many prosperous health systems emerged unscathed from the moratoriums of last spring, often due to the federal aid. “It gave them an ability to not have to draw down on their reserves to make up for the loss in revenue,” said Suzie Desai, a senior director at S&P Global Ratings.

Systems saw patient visits return to near normal as the year wore on. In some cases, business in the latter half of 2020 was even higher than in the same period in 2019 because of pent-up demand for treatments postponed from the spring, financial records show.

“We saw volumes spring back” in every area except emergency room visits, said Kevin Holloran, a senior director at Fitch Ratings. Major hospital systems also reported that cases tended to be more complex than normal, leading to higher insurance payments.

UPMC accepted $460 million in bailout funds while collecting $2.5 billion more in revenue in 2020 than in 2019. The nonprofit system ended the year with an $836 million operating surplus — providing a 3.6% margin that was triple the prior year’s — in part due to the growth of the health insurance plan the system owns.

Other hospitals that sold insurance, including Baylor, persevered because the cause of their financial troubles — fewer surgeries and doctors’ visits — meant the health plans paid fewer claims.

UPMC’s strong finances went unmentioned in a recent fundraising pitch announcing the launch of its “Health Care Heroes” campaign. “During the past year, health care workers have carried the weight of the world on their shoulders, risking their own health and safety to ensure ours as we navigated the covid-19 pandemic,” the email said. “Now it’s our turn to recognize their hard work. … By making a donation, you will help provide training, recognition, and support for our staff initiatives.”

Donald Yealy, a senior vice president of UPMC and the chief medical officer of UPMC Health Services, said the fundraising appeal was a way to allow people in the community to show their appreciation.

“The intent of the request and the letter were clear. People are free to ignore or to have an opinion. I don’t begrudge that at all. I respect people having a different opinion,” he said.

Hospitals can hold on to unspent relief funds until the end of July to defray any further pandemic-related costs. After that, any unspent money must be returned to the U.S. Treasury. UPMC retains $80 million in unspent relief funds, which the health system said it expects to use. “We’re still in the process of incurring significant costs related to covid,” said Edward Karlovich, UPMC executive vice president and chief financial officer.

‘A Shot in the Arm’ Sometimes Unneeded

In April 2020, the Mayo Clinic in Rochester, Minnesota, forecast up to $3 billion in lost revenue because of the pandemic. Instead, Mayo, which received $338 million in federal relief funds, ended the year with revenue that was $202 million higher than in 2019. Mayo recorded a $728 million surplus, which equaled a 5.2% margin.

“It gave us a shot in the arm when we needed it,” said Dennis Dahlen, Mayo’s chief financial officer. Later, when it seemed likely Mayo would run a surplus, executives debated what to do with the federal funds.

“Honestly, we considered dropping the margin,” Dahlen said. After weighing their options, Mayo “landed in a middle-of-the-road decision” by returning $156 million to the federal government.

“We considered it with what everyone else was doing … and we thought about what was good for society,” Dahlen said. “’Nonprofit’ doesn’t really mean no profit. It means tax-exempt. We still have to create earnings so we can reinvest in ourselves.”

Mayo ended the year with $14 billion in investments, $3 billion more than it had in 2019, a 29% increase.

The funds were, indeed, a lifesaver for some. Marvin O’Quinn, president and chief operating officer of CommonSpirit Health, said “there was never a thought of turning back the money.”

Despite receiving $1.3 billion in relief funds, CommonSpirit, based in Chicago, ended last year with a $75 million deficit, which translated to a 0.2% loss.

“We have been set back by a year,” O’Quinn said. “All the things we wanted to do — to renovate, to building new facilities, to expand our service — we’ve had to slow up to get through the crisis.”

Scattershot Relief

The first $50 billion in relief funds “was sent out indiscriminately as a life support,” said Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health. HHS tried to target subsequent distributions. It sent $22 billion to 1,090 hospitals with large numbers of covid patients. It sprinkled an additional $16 billion among hospitals that serve poor populations, Native American tribes, people in rural areas and children.

But even with the targeted aid, recipients included well-endowed academic medical centers and major urban hospitals. Only $14 billion took profitability into consideration, HHS documents show. HHS restricted those payments to hospitals with 3% or lower profit margins.

Wealthy hospitals also benefited because HHS used a broad definition of lost revenue. If a hospital earned less than in the year before, or simply less revenue than it had budgeted for, it could chalk up that difference to the pandemic and apply the relief funds to it. The implications garnered little attention at the time as they were overshadowed by the concerns about how HHS was doling out the money rather than how it could be used.

In September, HHS attempted to tighten its overall limits on how much money the hospitals could keep by basing it on the difference from the previous year’s net income rather than overall revenue — a number that in many cases would be much lower. The goal, the department said, was to “prohibit most providers from using PRF [Provider Relief Fund] payments to become more profitable than they were pre-pandemic, to conserve resources to allocate to providers who were less profitable.”

The American Hospital Association complained that would punish hospitals that had behaved responsibly by cutting costs and be an “administrative and accounting disaster,” as many hospitals had already spent the grant money.

HHS backed down a month later, citing “significant attention and opposition from many stakeholders and Members of Congress.” Not fully satisfied, Congress cemented the rollback in a December law.

Some hospital executives attributed their surpluses to their aggressive cost-cutting measures.

NYU Langone Health, for instance, received $461 million in relief funds, which covered about a third of its pandemic-related losses, said Daniel Widawsky, chief financial officer. Another third of Langone’s losses was absorbed by the record-high financial performance in the months before the pandemic, he said, and prompt cost control addressed the rest.

Widawsky said that at the beginning of March Langone canceled travel, froze hiring, paused construction and stopped discretionary purchases. “The first three days in March, we locked down spending,” he said. “If they wanted to buy a pencil, they had to call me.” Langone ended its fiscal year in August with $208 million in net income, and recorded a $136 million surplus in the final quarter of 2020, or 5.5%. Earlier this year, two credit agencies upgraded their outlook on Langone from stable to positive.

Despite accepting $942 million in bailout funds, NewYork-Presbyterian Hospital had a $457 million operating deficit, a 7% loss, at the end of September. It was a sharp turn from September 2019, when the system recorded a $166 million surplus, a 2.5% gain.

The system, which declined to comment, has not yet released its financial metrics for the final three months of 2020, but Fitch projected it would remain in the red. Still, NewYork-Presbyterian remains fiscally solid: Its most recent disclosure reported $3.8 billion in cash and short-term investments, enough to keep operating for more than a year.

Montana Sticks to Its Patchwork Covid Vaccine Rollout as Eligibility Expands

MISSOULA, Mont. — Montana’s covid-19 vaccine distribution is among the most efficient in the nation, but closer examination reveals a patchwork of systems among counties and tribal governments that will be put to the test as the state opens vaccine eligibility to all people 16 and older starting this month.

KHN, Montana Free Press and the University of Montana School of Journalism surveyed all 56 counties and eight tribal governments to find out how vaccine distribution has worked over the past four months and what residents might expect when the floodgates open.

Montana’s rate of covid vaccines given is in the top tier in the nation, according to the Centers for Disease Control and Prevention. More than 186,500 people — roughly 17% of the state’s population — had been fully vaccinated by the end of March. But that progress papers over a disjointed rollout that’s been left to individual public health departments that are already overstretched. An increasing number of employees have resigned after working long hours while being harassed and blamed for enforcing covid restrictions such as mask mandates. At least 10 counties have lost their top health official in the past year, though many more public health workers have left jobs.

The pressure remains as larger shipments of vaccines arrive and highly contagious variants of the coronavirus spread in Montana. More pharmacies are coming online to administer doses, which is expected to help in the race to vaccinate Montanans. But the task of ensuring everyone who wants a shot gets that chance will likely continue to fall on local health officials.


Empty bottles of the Pfizer-BioNTech vaccine during the KwaTaqNuk Resort vaccination clinic.(Tailyr Irvine for KHN)

For those seeking vaccines, the process can be bewildering. In Missoula County, Dennis Klemp qualified early on for the shot as an 81-year-old with kidney disease. Klemp, who doesn’t have a computer, put the county’s health department on his phone’s speed dial and called daily, but he was unable to secure a spot in vaccination clinics that filled within minutes.

“I was pretty despondent,” Klemp said. “There was mass confusion, and I’ve got a lot of friends who were just as confused as I was.”

After spending more than a month trying to book an appointment, Klemp called his local television station for help in February. NBC Montana reporter Maritsa Georgiou said she managed to book an appointment for him over the phone, and she estimated she similarly helped at least 30 others register for vaccines.

There are multiple ways to get a vaccine in Montana. Tribal governments are getting doses to Native Americans and some are also vaccinating non-Natives either through the state or the federal Indian Health Service program. The U.S. Department of Veterans Affairs is a source for veterans, their spouses and caregivers. Federally contracted pharmacies are giving vaccines to the general public after distributing shots in assisted living centers.


Kipp helps Reaves through the vaccination questionnaire before her vaccine.(Tailyr Irvine for KHN)

For counties and tribes that participate in the state program, a mishmash of strategies has resulted in the absence of a detailed state plan to sign up people for doses. Montana’s patchwork approach is no accident. State leaders deliberately left it up to local governments with few rollout guidelines because they said local leaders know best how to reach their residents.

Some states have set up one-stop vaccine registration systems to bring order to the scramble of the largest vaccine effort in history. But Jim Murphy, head of Montana’s Communicable Disease Control and Prevention Bureau, said that a pandemic wasn’t the time to force a new system on local governments, and that Montana’s approach is working.

“Most of our major providers already have those systems built, so we weren’t going to say, ‘Well, here’s another big road you can take,’” Murphy said. “Just didn’t seem like it would be worth that effort.”


A nurse prepares the Pfizer-BioNTech vaccine during a Confederated Salish and Kootenai tribal vaccination clinic on March 30.(Tailyr Irvine for KHN)

Nicholas Stewart, a senior research scientist at the international health data nonprofit Surgo Ventures, said Montana’s high national ranking, despite its lack of a unified system, has been a surprise.

Montana’s success may be partly due to officials’ familiarity with the inherent challenges that come with delivering health care in the fourth-largest state by land, yet eighth-smallest state by population. Public health workers have long worked to reach isolated people and spot hurdles to accessing care, such as a lack of internet access.

Ideally, states would test different scenarios before expanding vaccine eligibility, but needs have rapidly shifted. “What we have constantly been seeing is decisions are being made on the fly,” Stewart said.

In Carter County, in the southeastern corner of the state, early vaccine efforts faltered because nobody was on hand to administer the shots. The area’s health officer resigned in mid-December and the county had been without a public health nurse since summer. In January, residents eligible for a shot had to drive to neighboring Fallon County, where Carter County had sent its allotment of vaccines to prevent wasting doses.

Trish Loughlin, Carter County’s interim public health nurse, has led the vaccine effort part time since late January. Despite the initial lag, Loughlin said, the county is catching up and everyone who wants a dose should be able to get one by early April.

“The collaboration of a neighboring county is what helped; it’s the only way we did that,” Loughlin said.


A Confederated Salish and Kootenai tribal vaccination clinic at the KwaTaqNuk Resort in Polson, Montana, on March 30. (Tailyr Irvine for KHN)

A nurse administers the Pfizer-BioNTech vaccine. (Tailyr Irvine for KHN)

Fallon County’s health director also resigned in December. Mindi Murnion, Fallon County’s public health specialist, said residents angry about pandemic-related rules drove out the health director before the county got its first supply of covid vaccines.

“There was a little bit of panic,” Murnion said. “But after we got through that first clinic, now we whip it out like clockwork.”

She said she’s relieved the state let Fallon create its own vaccine plan, which includes calling people already in its system to book appointments and working with other counties to move doses based on need.

“It might not be the way everybody else does stuff, but it’s the way we do stuff,” Murnion said.


Kaelen Wall administers a vaccine during a Confederated Salish and Kootenai tribal vaccination clinic on March 30.(Tailyr Irvine for KHN)

In larger counties, a major hurdle is making sure all residents can navigate systems in which they’re competing with thousands for appointments.

Despite Klemp’s difficulty making an appointment by phone, Missoula County set aside 20% of available vaccine appointments for seniors without internet access, according to Adriane Beck, Missoula County’s emergency management director. The county also held an outreach campaign using nonprofit agencies, utility bill inserts and ads run by newspapers and radio and television stations to prod people to make appointments by phone.

But, to the dismay of some, the county doesn’t offer a vaccine waitlist for people struggling to book an appointment.

“From a logistical and just a management perspective, we were not going to be successful and we were not going to meet people’s expectations,” Beck said.

She said making vaccines available to all people over 16 may complicate access for more vulnerable groups until supplies increase. An effort is underway, she said, to reach “stragglers” and homebound residents.

The Flathead Nation’s Confederated Salish and Kootenai Tribes have outpaced many Montana counties when it comes to vaccine distribution, despite what Health Director Chelsea Kleinmeyer described as a low initial allocation by the state to the tribes. Weeks before the state’s April 1 expansion of eligibility to the general population, tribal health officials were offering shots to all adult tribal members along with descendants and other Native Americans.


Vaccine recipients wait the designated 15 minutes after receiving their dose of covid vaccine during a Confederated Salish and Kootenai tribal vaccination clinic.(Tailyr Irvine for KHN)

Kleinmeyer said tribal health officials relied heavily on community health representatives to identify and contact vulnerable elders. Health officials eventually worked their way to anyone living in an American Indian household along with tribal and nontribal teachers and employees. The Salish and Kootenai Tribes had planned to vaccinate approximately 12,000 people.

“We feel like maybe we hit this saturation point with tribal people on the reservation,” Kleinmeyer said, adding the tribe is now preparing to help nearby counties.

Silver Bow County is using its civic center ticketing system, usually used for concerts and sporting events, as one way to schedule vaccine appointments.

“We thought, if you could get a ticket to go to a basketball game, why couldn’t we do that here? And it worked,” said Karen Sullivan, health officer for Butte-Silver Bow County.

Sullivan said the overall joy that people exhibit at vaccine clinics has been a bright spot during a difficult period. The past year has been one of threats and verbal attacks against her and her staffers for implementing covid restrictions. Sullivan, 62, said she’s considering early retirement after seeing the vaccine rollout through.

“I’m not gonna leave in the middle of this,” Sullivan said. “When we get to the point where we have a great percentage of our people vaccinated, I’ll give retirement some serious thought. I need the rest.”


Eric Dietrich and Chris Aadland of Montana Free Press and Andrea Halland, Antonio Ibarra Olivares, Aidan Morton and Addie Slanger of the University of Montana School of Journalism contributed to this report.

Vermont Is 1st State to Give Blacks and Other Minority Residents Vaccine Priority

States have tried with limited success to get covid vaccines to people of color, who have been disproportionately killed and hospitalized by the virus.

Starting Thursday, Vermont explicitly gave Black adults and people from other minority communities priority status for vaccinations. Although other states have made efforts to get vaccine to people of color, Vermont is the first to offer them priority status, said Jen Kates, director of global health and HIV policy at KFF. (KHN is an editorially independent program of KFF.)

All Black, Indigenous residents and other people of color who are permanent Vermont residents and 16 or older are eligible for the vaccine.

It will be a short-term advantage, since Vermont opens covid inoculations to all adults April 19.

Still, Vermont health officials say they hope the change will lower the risk for people of color, who are nearly twice as likely as whites to end up in the hospital with covid-19. “It is unacceptable that this disparity remains for this population,” Dr. Mark Levine, Vermont’s health commissioner, said at a recent news conference.

But providing priority may not be enough to get more minority residents vaccinated — and could send the wrong message, some health experts say.

“Giving people of color priority eligibility may assuage liberal guilt, but it doesn’t address the real barriers to vaccination,” said Dr. Céline Gounder, an infectious diseases specialist at NYU Langone Health and a former member of President Joe Biden’s covid advisory board. “The reason for lower vaccination coverage in communities of color isn’t just because of where they are ‘in line’ for the vaccine. It’s also very much a question of access.”

Vaccination sites need to be more convenient to where these targeted populations live and work, and more education efforts are necessary so people know the shots are free and safe, she said.

“Explicitly giving people of color priority for vaccination could backfire,” Gounder said. “It could give some the impression that the vaccine is being rolled out to them first as a test. It could reinforce the fear that people of color are being used as guinea pigs for something new.”

Dr. Georges Benjamin, executive director of the American Public Health Association, said that’s why he has opposed using race as a risk factor to determine covid vaccine eligibility.

But he sees signs that vaccine hesitancy is improving nationally and called Vermont’s new approach “admirable.” Still, he said, states should continue to use a range of options to get vaccines to minority communities, such as providing vaccination sites in Black neighborhoods and places that residents trust, like churches.

No state is achieving equity in its vaccine distribution, said KFF’s Kates.

“People of color, whether they be Black or brown, are being vaccinated at lower rates compared to their representation among covid cases and deaths, and often their population overall,” she said.

Blacks make up about 2% of Vermont’s population and 4% of its covid infections, but they have received 1% of the state’s vaccines, according to KFF.

“Since states are really not doing well on equity, other strategies are welcome at this point,” said Kates.

Yet, there’s another reason public health officials have balked at explicitly giving people of color vaccine priority. “It could be politically sensitive,” she said.

Vermont to Give Minority Residents Vaccine Priority

[UPDATED at 5 p.m. ET]

States have tried with limited success to get covid vaccines to people of color, who have been disproportionately killed and hospitalized by the virus.

Starting Thursday, Vermont explicitly gave Black adults and people from other minority communities priority status for vaccinations. It follows Montana, which in January announced that Native Americans and other people of color, because they are at higher risk of complications from covid-19, would be allowed to receive the vaccine.

All Black, Indigenous residents and other people of color who are permanent Vermont residents and 16 or older are eligible for the vaccine.

It will be a short-term advantage, since Vermont opens covid inoculations to all adults April 19.

Still, Vermont health officials say they hope the change will lower the risk for people of color, who are nearly twice as likely as whites to end up in the hospital with covid-19. “It is unacceptable that this disparity remains for this population,” Dr. Mark Levine, Vermont’s health commissioner, said at a recent news conference.

But providing priority may not be enough to get more minority residents vaccinated — and could send the wrong message, some health experts say.

“Giving people of color priority eligibility may assuage liberal guilt, but it doesn’t address the real barriers to vaccination,” said Dr. Céline Gounder, an infectious diseases specialist at NYU Langone Health and a former member of President Joe Biden’s covid advisory board. “The reason for lower vaccination coverage in communities of color isn’t just because of where they are ‘in line’ for the vaccine. It’s also very much a question of access.”

Vaccination sites need to be more convenient to where these targeted populations live and work, and more education efforts are necessary so people know the shots are free and safe, she said.

“Explicitly giving people of color priority for vaccination could backfire,” Gounder said. “It could give some the impression that the vaccine is being rolled out to them first as a test. It could reinforce the fear that people of color are being used as guinea pigs for something new.”

Dr. Georges Benjamin, executive director of the American Public Health Association, said that’s why he has opposed using race as a risk factor to determine covid vaccine eligibility.

But he sees signs that vaccine hesitancy is improving nationally and called Vermont’s new approach “admirable.” Still, he said, states should continue to use a range of options to get vaccines to minority communities, such as providing vaccination sites in Black neighborhoods and places that residents trust, like churches.

No state is achieving equity in its vaccine distribution, said Jen Kates, director of global health and HIV policy at KFF. (KHN is an editorially independent program of KFF.)

“People of color, whether they be Black or brown, are being vaccinated at lower rates compared to their representation among covid cases and deaths, and often their population overall,” she said.

Blacks make up about 2% of Vermont’s population and 4% of its covid infections, but they have received 1% of the state’s vaccines, according to KFF.

“Since states are really not doing well on equity, other strategies are welcome at this point,” said Kates.

Yet, there’s another reason public health officials have balked at explicitly giving people of color vaccine priority. “It could be politically sensitive,” she said.

[CORRECTION: This story was corrected on April 5, 2021, at 5:08 p.m. ET to note that Montana had also initiated a program earlier this year saying that “Native Americans and other persons of color who may be at elevated risk for COVID-19 complications are eligible to receive the vaccine.”]

Journalists Dive Deep Into Roots of Vaccine Distrust in Prisons and Covid’s Toll on Public Health

Reporter Eric Berger discussed vaccine hesitancy among inmates at a Missouri correctional center with Newsy on Thursday.


KHN Editor-in-Chief Elisabeth Rosenthal discussed how the U.S. has focused on international terrorism at the expense of public health with the Los Angeles Times’ “Second Opinion” on March 28. She also joined North Carolina Public Radio’s “The People’s Pharmacy” radio program on March 25 to discuss how covid-19 has impacted the U.S. health system.

Beating the Pavement to Vaccinate the Underrepresented — And Protect Everyone

Leonor Garcia held her clipboard close to her chest and rapped on the car window with her knuckles. The driver was in one of dozens of cars lined up on a quiet stretch of road in Adelanto, California, a small city near the southwestern edge of the Mojave Desert. He was waiting for the food bank line to start moving and lowered the passenger window just enough to hear what Garcia wanted. Then she launched into her pitch.

“Good morning! We’re here to talk about covid-19 today! Do you have a minute?” she said in Spanish.

After a brief conversation, Garcia learned the man had no internet connection or phone of his own but was 66 years old and wanted to get the covid vaccine. He had tried to visit a pharmacy in person, but the shots were all out for the day. Garcia took down his name and the phone number of a friend, so she could reach the driver later about a mobile vaccine clinic that her organization, El Sol Neighborhood Educational Center, was putting together for the remote desert city sometime in April.

Then it was on to the next car. And the next. As the line started moving, she and fellow health worker Erika Marroquin jogged up and down the sidewalk, taking down names, phone numbers and preexisting conditions. It was the first mild, sunny day the High Desert region had seen in weeks, and the exercise made them sweat.


El Sol community health worker Leonor Garcia speaks to a driver waiting in line for a church food bank in Adelanto, California, on March 17. In addition to letting people know about the covid vaccines, she and her colleagues also ask whether people need help with mental health care, food or rent.(Anna Almendrala / KHN)

After 90 minutes, the food bank was done for the day, and Garcia and Marroquin had spoken to people in 54 cars. They had found six people eager for the covid vaccine and eligible for it immediately. Ten more wanted to be put on a waiting list for leftover doses.

The rollout of vaccinations in California, as in many states, has been slow and chaotic. More than 5 million of the 24 million adults in the nation’s most populous state have been at least partially vaccinated, while an additional 5.6 million are fully vaccinated. Come April 15, all adults in California will be eligible to sign up for a vaccine, and by early summer the goal is to have plenty of vaccine for any adult who wants it.

But the country needs to get the vaccination rate to about 75% to keep the virus from easily spreading — a level called herd immunity by experts on infectious diseases. But even that figure assumes the population is homogenous in terms of vaccination. That’s why the state’s ability to stave off another covid surge may rely on people like Garcia and Marroquin — community health workers and organizers doing time-intensive, laborious work — to prevent pockets of the population with low vaccination rates in remote or isolated communities from becoming a tinderbox for a new covid surge.

“When you have geographical or social pockets of unvaccinated people, it really messes up herd immunity,” said Daniel Salmon, director at the Institute for Vaccine Safety at Johns Hopkins University’s Bloomberg School of Public Health.

U.S. measles outbreaks in recent years provide a sobering example. State and national vaccine coverage is quite high, “but then you’d have these communities where a lot of people would refuse vaccines, and then measles would be imported and create an outbreak,” Salmon said. Outbreaks have hit certain Orthodox Jewish communities in New York, Somali immigrants in Minnesota and affluent pockets of Southern California where anti-vaccine parents lived.


Residents of California’s High Desert region line up at the Centro Cristiano Luz y Esperanza church in Adelanto to receive their second doses of covid vaccine at El Sol’s March 19 vaccination event. In line on the left are those who got their first shot at an event the previous month. The line on the right is full of people hoping for leftover doses. (Anna Almendrala / KHN)

The coronavirus is still circulating widely in California, though at much lower levels than two months ago. The virus, especially an increasingly common, more contagious variant, could easily rip through vulnerable communities with low levels of immunity. In Adelanto, where 29% of residents live in poverty, less than 6% of the adult population had been fully vaccinated by March 20.

As of March 26, most of the more than 15.9 million vaccine doses distributed since December had gone to the healthiest, wealthiest places in the state. Community-based organizations like nonprofits and churches are clamoring for more funding — and trust — to carry the vaccine the final mile to the people they’ve been serving for years.

El Sol’s success in getting Black, Latino and other underrepresented populations vaccinated debunks the idea that these groups won’t get the shot, said Juan Carlos Belliard, assistant vice president for community partnerships at Loma Linda University Health in San Bernardino County. Loma Linda is collaborating with El Sol to staff and provide doses for clinics. The people who show up are ready for their vaccine, though some are a bit hesitant, he said.

“They’re not like our middle-class folks who are literally crying for the vaccine,” Belliard said. “These folks are still nervous about it, but you’ve removed almost all of these other barriers for them.”


Staff members and students from Loma Linda University Health in San Bernardino County guide people into the church hall for vaccinations at El Sol’s pop-up event. Special paper forms were created so people wouldn’t have to enter their information into a computer to make an appointment. After the event is over, the hospital’s clinical team manually uploads all the data.(Anna Almendrala / KHN)

El Sol’s community workers were funded by a $52.7 million combined effort from state and philanthropic funding that provided grants to 337 organizations considered “trusted messengers” in their communities. The money was pushed out to groups like El Sol that had proven track records of shoe-leather canvassing for voter registration or census surveys.

El Sol received $120,000 from the public-private initiative to support its general outreach and educational efforts for covid vaccination. But the group was in the dark about whether it would get any reimbursement for the mobile vaccination events it has organized in San Bernardino County, said executive director Alex Fajardo.

El Sol held a pop-up vaccination event Feb. 17 at Centro Cristiano Luz y Esperanza, a church located off a two-lane expressway in Adelanto, surrounded by desert scrub. Medical staffers, students and vaccines arrived from Loma Linda University Health, about an hour away, to vaccinate 250 people, and returned a month later to give people their second doses.

Patricia Perez, 47, and Rosa Hernandez, 69, a mother-daughter pair, were among those who got their vaccines at Centro Cristiano.


Rosa Hernandez (left) and daughter Patricia Perez received their second doses of a covid vaccine at El Sol’s March 19 clinic, and were waiting the requisite 15 minutes before heading home to Hesperia, California. Hernandez is a cancer survivor, and her husband struggled with a severe case of covid in June. Thankfully, no one else in their seven-member household got sick.(Anna Almendrala / KHN)

Perez’s father, who works in a supermarket dairy department, fell ill with covid in June and was unable to return to work for six months. No one else in the seven-member household ended up testing positive, but Rosa Hernandez is a cancer survivor and her daughter was worried about her.

Despite multiple calls to a county phone line, Perez had been unable to line up a vaccine for her mom. The family’s internet connection, in the nearby town of Hesperia, was spotty, and Perez couldn’t really navigate the websites or find any information in Spanish, the language she’s most comfortable with.

She jumped at the chance when she heard about El Sol’s pop-up event through someone at her church. Perez also managed to snag an additional dose for herself after someone didn’t show up for their appointment. Now she and her mom are fully vaccinated, Perez said, and it wouldn’t have happened without El Sol.

The group plans to do three more vaccination pop-ups in the High Desert area. But future support for its clinics, vaccine outreach and education are murky, said Fajardo.

“What is going to happen after?” he said. “When we need you, we pay you. When we don’t need you, ‘Bye-bye.’”

“That’s a very fair assessment,” said Susan Watson, program director for the Together Toward Health initiative of the Public Health Institute, the philanthropic funder behind some of El Sol’s work. “There’s an opportunity here for people to be thinking about the future, and how we do things that doesn’t necessarily leave community groups permanently on the outside, only tapped into when there’s an emergency.”

Community Coalition, a South Los Angeles nonprofit founded in 1990, also received grants from the public-private partnership to raise awareness about covid vaccines, but no additional funding to deliver vaccines to the people. Still, it mobilized staff to knock on doors, text and email eligible people to turn out for a two-week pop-up vaccination event at a neighborhood park in early March — providing 4,487 people with their first vaccine dose, said the group’s chief operating officer, Corey Matthews.


Dr. Marx Genovez injects Guadalupe Neri with a covid-19 vaccine.(Anna Almendrala / KHN)

Dr. Mark Ghaly, the state’s secretary for health and human services, promised to provide more money for groups that are getting their communities vaccinated. “This is not a volunteer job,” he told KHN at a news briefing. “This is real work, and I want to be part of the team that makes that a reality for all of them.”

Los Angeles County department of public health Director Barbara Ferrer echoed that sentiment. “They were there before the pandemic started, they’ve been there the entire time during the pandemic, and they’ll be here long after the pandemic,” she said.

Whether or not those promises hold up, community groups say, they want to be part of the vaccination effort.

“Even if they don’t give us money, we’ll keep doing the work,” said Fajardo.

Battle Brews Over Neutral Zone Where Border-Crossing Parties Rendezvous, Risking Detection and Infection

BLAINE, Wash. — In the shadows of covid travel restrictions, a 42-acre park on the far western edge of the U.S.-Canadian dividing line has become a popular opening in an otherwise closed border, a place where Americans and Canadians can gather without needing permission to go through an official border crossing.

What is known as Peace Arch Park has lush green lawns, gardens and a 67-foot-tall white concrete arch erected in 1921 that spans the border. It’s an often muddy, sometimes idyllic place. But the pandemic has transformed this patch of historically neutral ground into a playing field for some fundamental public health questions.

Should people from Canada, which has a lower incidence of covid-19, risk mingling with people from the U.S.? Should families who’ve masked and distanced be able to reunite for a day without quarantining? Who decides?

On a recent sunny weekend, couples and groups of up to 15 people spaced themselves across a large central lawn and filled a dozen or so picnic tables. Some kept their distance of several feet, others huddled closely. Some wore masks, others didn’t. Sounds of laughter came from kids on the large playground. And all was quiet on the eastern edge of the park, where visitors had pitched dozens of tents, rumored to facilitate conjugal visits.

An American park ranger periodically made rounds and asked groups to stay physically distant from one another. Though dozens of surveillance cameras on tall poles kept watch throughout the parking lot, no police were in sight.

Canada closed its land borders a year ago to all but some select groups, and its side of the park has stayed shut since late June. Even so, Canadians can freely hop across a small grass ditch that runs along 0 Avenue in Surrey, British Columbia, and Washington state’s side remains open after a brief closure earlier in the pandemic.

Royal Canadian Mounted Police officers stationed outside every few houses along 0 Avenue demand proof of citizenship as parkgoers exit, then suggest that returning Canadians quarantine.

That’s far different from the conventional passage through an immigration site like the one near the park, where anyone driving into Canada must sign up for a strictly enforced 14-day quarantine.

And most Americans need to be in an exempted group and have a negative covid test. Those who claim “family relationships” must be able to prove it to a border official. And, even then, they have that 14-day quarantine.

Immigration lawyer Len Saunders, who lives in Blaine, Washington, comes to the park most days to see his clients. “For many people, it’s a lifeline,” he said. “Without the park, people would be effectively separated from their spouses, fiancés and partners.”

He has two clients in that situation: Canadian Katrina Gurr, 29, and American Alexis Gurr, 32. They each live within an easy drive to the border and met online last March. “We just started talking, and then couldn’t stop,” said Alexis.

They married in July and today sometimes talk in unison.


The Zuidmeer family used to meet regularly at Peace Arch Park. Bill Zuidmeer was diagnosed in December with terminal kidney cancer. Bill and his grandson (above) had a final visit together before Bill passed away 12 days later.(Peter Zuidmeer)

The rules for travel are complex and changing, laxer for entering the U.S. and for air travel into Canada but still daunting. The Gurrs have visited each other for weeks-long stretches, but have spent most of their first year as newlyweds apart. Katrina has applied for a green card that would allow her to live and work in the U.S., a process she expects will take about a year.

In the meantime, Katrina walks across the ditch one day most weekends. Alexis brings a tent and a small propane tank.

“During football season, we watch the football game,” Alexis said.

“And we nap a lot, actually,” said Katrina, finishing her wife’s sentence.

For the Zuidmeer family, Peace Arch Park was a place to reunite. Father Bill and mother Denise traveled there many times in the past few months from their home 7 miles south to see their son, Peter, and his wife and child, who live north of the park. The visits became particularly important after Bill was diagnosed in December with terminal kidney cancer.

But what became Bill’s last visit to the park was nearly a failure. The rules in Canada had changed — the Mounties warned Peter that to return to Canada he’d need to show his real passport, not just the photo on his phone. The round trip to retrieve it would take an hour and a half. His father was already exhausted from the trip, and Denise needed to return the specialized medical vehicle known as a cabulance she’d rented to get him there.

Denise begged the Mounties for dispensation. For her, this was all about her husband having a chance to have what might be a final reunion, safe because it was outdoors and all involved had been careful about physical distancing. “This isn’t tourism,” she said later. “It’s families.”

The Mounties ultimately allowed Peter across for a brief and emotional hug, and Peter’s 3-year-old got to sit on his grandfather’s lap for the last time.

Bill died at home 12 days later, on March 11, after his son made one last visit the formal way involving a strict 14-day quarantine on his return.


Katrina (left) and Alexis Gurr stand outside their tent on the American side of Peace Arch Park in Blaine, Washington. Katrina is Canadian. Alexis is American. They met online last spring and married in July. (Joanne Silberner)

Most of the park reunions are happier. Saunders, the immigration lawyer, said he’s seen a lot of weddings.

Some of the Canadians who live on 0 Avenue or thereabouts object to the gatherings. Canadian John Kageorge is concerned mostly about security issues, people smuggling things like guns or drugs. In addition, he said, “people need to follow public health guidelines, and they are not doing that at the park.”

Fear of covid is prevalent in Canada, so much so that “covid shaming” — social media outing and threatening of covid-positive people — has become fervent, according to The New York Times. And Americans are often blamed. “There’s a big stigma in Canada that you guys aren’t the best,” said Katrina Gurr.

The U.S. has an appreciably higher rate of covid infections and deaths — more than 92,000 cases per million people compared with Canada’s 26,000 per million as of Wednesday. But whether SARS-CoV-2 is being spread outdoors or in the tents of Peace Arch Park is anybody’s guess. After the issue was raised by the Canadian media in February, the British Columbia premier responded that his chief health official had told him no outbreaks were attributable to the park.

The Public Health Agency of Canada attributes just 0.3% of March covid cases to international travel. But that estimate is likely to be low, said Kelley Lee and Anne-Marie Nicol, global health policy experts at Simon Fraser University. In an essay in The Conversation, an online news site, they note that only air travelers are monitored. That leaves out the people in Peace Arch Park and essential workers like truckers and health care workers who regularly drive across the border.

“Essential travelers remain untested so we cannot know what risk they pose,” Lee wrote in an email.


Tents abound on the eastern side of Peace Arch Park, even though park rules clearly state that no tents are allowed. (Joanne Silberner)

In the absence of clear information about spread, the fight over the park remains a political one. Two Liberal Party of Canada members of the provincial legislature have pressed British Columbia’s premier, a member of the New Democratic Party, to ask Washington Gov. Jay Inslee, a Democrat, to close the American side. But the premier turned them down, saying that international borders were an issue for the federal government in Ottawa.

Inslee spokesperson Mike Faulk said Washington discourages people from gathering but did not indicate any action was imminent. Last October, Prime Minister Justin Trudeau said the border closures would last “as long as we feel that they need to last.”

The Canadian side of the arch says: “Brethren Dwelling Together in Unity.” For now, at least, that’s true in the park, but not along the rest of the 4,000 miles of border between the Atlantic and Pacific oceans. Saunders, the Gurrs and Zuidmeers plus many other border watchers are not expecting any changes soon.

Backed by Millions in Public and Private Cash, Rapid Covid Tests Are Coming to Stores Near You

Scientists and lawmakers agree that over-the-counter covid tests could allow desk workers to settle back into their cubicles and make it easier to reopen schools and travel.

But even as entrepreneurs race their products to market, armed with millions of dollars in venture capital and government investment, the demand for covid testing has waned. Manufacturing and bureaucratic delays have also kept rapid tests from hitting store shelves in large numbers, though the industry was energized by the Food and Drug Administration’s greenlighting of two more over-the-counter tests Wednesday.

Corporate giants and startups alike plan to offer a dizzying array of test options, most costing between $10 and $110. Their screening accuracy varies, as does the way consumers get results: collection kits mailed back to a lab, devices synced with artificial intelligence-enabled apps on a smartphone that spit out results within 15 minutes, and credit card-sized tests with strips of paper that must be dipped into a chemical substance.

“At-home tests are one of the key steps to getting back to normal life,” said Andy Slavitt, a member of the White House COVID-19 Response Team, during a February briefing.

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The Biden administration announced in March it will allocate $10 billion from the recently passed stimulus package for covid testing to expedite school reopenings, and earlier said it would invoke the Defense Production Act to manufacture more at-home tests. Separately, the federal government has already sent millions of Abbott Laboratories’ BinaxNOW rapid tests to states, and California, for instance, is giving 3 million of them to its most disadvantaged school districts for free.

Large employers, like Google, sports leagues and the federal government, have already shelled out millions to regularly test their workers. Amazon just received emergency use authorization from the FDA for its own covid test and home collection kit, which it intends to use for its employee screening program.

Individuals who want to buy over-the-counter tests can bill their health insurance plans, which are required by the federal government in most cases to fully cover covid tests that have been authorized by the FDA.

Everlywell, based in Austin, Texas, is an at-home diagnostic company that already sells its collection kit to consumers through its website and Walgreens, and will soon offer same-day delivery via DoorDash in a dozen cities. Dr. Marisa Cruz, Everlywell’s executive vice president of regulatory and clinical affairs, said buyers can seek reimbursement from their insurance plans for the kit’s $109 cost. The tests are also eligible for purchase with pretax dollars from health savings or flexible spending accounts, she said.

Even with vaccines, epidemiologists say, rapid tests are desperately needed because more testing, along with mask-wearing and physical distancing, will get people back in offices and classrooms and help catch cases that go undetected. A report by the Centers for Disease Control and Prevention found that, of people with active infections, 44% reported no symptoms.

But the market for over-the-counter tests is risky. Demand for testing has plunged dramatically since the height of the winter surge and may not rebound as more people are vaccinated.

“You clearly are at risk of missing the market,” said Michael Greeley, co-founder and general partner at Flare Capital Partners, a venture capital firm focused on health care technology.

But Douglas Bryant, president and CEO of Quidel Corp., remains unfazed, even after the diagnostics manufacturer’s testing demand dropped by about one-third in the past two months.

“The level of testing for people with symptoms and the ‘worried well,’ who see others getting tested and think they should, too, is subsiding,” Bryant said. “But once we start to get more people vaccinated, the government will move from campaigning to get people vaccinated to saying, ‘Please test yourself regularly so we can get back to work.’”

Quidel, headquartered in San Diego, recently unveiled its latest test, the QuickVue At-Home COVID-19 Test, which takes 10 minutes to detect the coronavirus by homing in on specific proteins, called antigens. The FDA authorized the test for over-the-counter use Wednesday, and Quidel plans to announce retail partners in the coming weeks.

The FDA said in mid-March it would speed the pipeline for “screening testing,” including at-home covid tests that don’t require consumers to have symptoms or a prescription.

In February, the Biden administration cut a $232 million deal with Ellume, whose rapid antigen test was authorized by the FDA in December. Paired with an app, the test takes 15 minutes to analyze after a nose swab.

The Australian company currently ships hundreds of thousands of test kits a week to the U.S. from its factory in Brisbane to large companies and the Department of Defense. It plans to be on the shelves of multiple pharmacies by the second half of the year and in one major retailer in April, said Dr. Sean Parsons, the company’s founder and CEO.

“We are going as fast as we can possibly go,” he said.

The main holdup for Ellume has been getting enough swabs for its production line. The company is building a factory in the U.S. to reduce international shipping costs and increase production.

Abbott, which dominates the rapid-test market, said in January it expects to sell 120 million BinaxNOW antigen tests to consumers in the first half of the year. People who take the test now must do so under observation by telemedicine platform eMed. But Abbott received authorization from the FDA this week for an over-the-counter version that won’t require remote observation or a prescription. The test will be available in U.S. stores in the coming weeks, the company said.

Throughout the pandemic, the government has depended heavily on medical device behemoth Abbott’s testing options. The company’s rapid-diagnostics arm alone has snared $673 million in federal contracts to combat the coronavirus, according to a ProPublica database. This includes bulk purchases made by the Defense Department, the national prison system, Immigration and Customs Enforcement, the State Department and former President Donald Trump’s office.

But antigen tests sometimes report false negatives, particularly among people without symptoms, noted Dr. Jac Dinnes, who co-authored a review of 64 covid test studies. By comparison, polymerase chain reaction (PCR) tests — generally employed by commercial labs — are more sensitive. PCR tests search for the virus’s genetic material over multiple testing cycles, which magnifies what’s in the swab sample, requiring a much smaller viral load for detection.

Antigen tests are the basis for most at-home screening, but the FDA has also authorized two at-home options — made by Lucira Health and Cue Health — that use molecular processes similar to a PCR test.

Still, many experts support the widespread distribution of cheap, rapid tests, even if they aren’t as sensitive as lab-run alternatives, and see a demand. In Germany, the supermarket chain Aldi began selling rapid tests in early March, roughly $30 for a five-pack, and sold out within hours. One recent study found that if a pack of tests was mailed to every household in the U.S. — even assuming that up to 75% would go into the garbage — they would save thousands of lives and avert millions of infections.

“Don’t let perfect be the enemy of good,” said study co-author and Yale University professor A. David Paltiel. “This doesn’t have to work perfectly to make a huge difference.”

Some companies are working on rapid-testing options that more precisely read samples, such as Gauss.

The Menlo Park, California, health tech company, which before the pandemic created an artificial intelligence-based app to measure surgical blood loss in real time, aims to harness its expertise to improve on the basic antigen test. It took about a week for CEO Siddarth Satish to raise $30 million of venture capital last October.

Its covid-testing app uses facial recognition software to confirm that test-takers correctly swab their noses. The app provides step-by-step instructions and timers. After 15 minutes, an algorithm based on thousands of sample tests interprets the result — which displays as a colored line, as with a pregnancy test — using the phone’s camera.

Gauss and Cellex, which manufactures the Gauss tests, await FDA authorization. In the meantime, they have produced more than 1.5 million kits and struck deals with supermarket chain Kroger and e-pharmacy site Truepill to sell them for about $30.

“A huge part of the accuracy issue with rapid tests is that you have to visually interpret them,” Satish said. “Sometimes you get really faint lines, just like with a pregnancy strip, and there’s some guesswork.”

Lucira Health, based in Emeryville, California, uses something called loop-mediated isothermal amplification technology, which is similar to PCR tests in precision. In February, the company went public, raising $153 million largely to fund the manufacturing of its all-in-one testing kit, currently prescribed by doctors across the country. The kit comes with a nose swab and a vial of chemicals analyzed by a hand-held device — taking up to 30 minutes for results.

Kelly Lewis Brezoczky, Lucira’s executive vice president, envisions the test kit on the shelf in local pharmacies, perched next to the NyQuil. “I always like to tell people that it is as easy to use as toothpaste,” she said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

‘It Didn’t Really Stick With Me’: Understanding the Rural Shrug Over Covid and Vaccines

At 70, Linda Findley has long been active in her small town of Fort Scott, Kansas, which sits more than an hour away from any major city.

Findley, whose husband died in an accident just after the local hospital closed, helps with the Elks and fundraising, and — like many people in this part of the country — doesn’t think covid-19 is that dangerous.

“I don’t even know what I think about it,” Findley said recently. “I don’t know if I trust the testing because it’s so messed up or … I’ve had nieces and nephews, that’ve had it. I’ve lost good friends to it, or supposedly it’s to that.”

Findley said she just isn’t sure that every case reported as the coronavirus really is the virus: “Everything seems to be coronavirus. I mean, it’s just … no matter what somebody has, it’s coronavirus. I don’t know whether it is or isn’t.”

Fort Scott is one of nearly 140 rural communities that have lost a hospital in the past decade. Mercy Hospital Fort Scott closed in December 2018.

Even though critically ill patients now must travel to hospitals farther away, Fort Scott residents haven’t seen that as a pandemic-related problem. Rather, not having a hospital doesn’t really come up when people here talk about covid.

Dave Martin, the former city manager, is pretty sure he caught covid at work last August.

“You know, when I got it, I was in good health and it did take me a while to recover,” Martin said. “I do remember waking up one of my bad nights and thinking, when I was running a temperature and not feeling very well. And I’m thinking, ‘Oh, wow, this could kill me.’”

But Martin also thought that any number of unpredictable events could end a person’s life. “So it didn’t really stick with me,” he said.

After recovering, the 62-year-old Martin went ahead with his retirement. He took his wife to Disney World and then they hiked Yellowstone National Park.

That casual attitude toward the dangers of covid worries health care leaders in Fort Scott. Jason Wesco helps lead the regional health center that took over primary care services when the hospital closed. One clinic occupies part of the same building that used to be Mercy Hospital.

Wesco said his family is careful about wearing masks and not gathering in groups, and he believes they are in the minority in the area.

“I think most people just keep going. They have maybe modified a little bit. Maybe they put on a mask in public,” Wesco said. “I think life here has changed a lot less than it’s changed in D.C. And I think we’re seeing the impact of that, right?”

The pandemic hit the area hard in the fall, peaking in late December.

One in 11 people in Bourbon County, where Fort Scott is the largest community, has been infected by covid, according to national analysis.

Two dozen of the county’s 14,000 residents have died of covid. And most people know someone who had the virus and survived — but residents just seem tired of talking about it.

Community volunteer Findley said she won’t get a vaccine.

“How did they come up with a vaccine that quickly? And how do they even know for sure it’s even working?” Findley wondered.

The three vaccines approved by federal regulators in the U.S. are being given out to millions, and their efficacy has been shown through massive clinical trials in the U.S. and globally.

But Findley’s skepticism is fairly common in southeastern Kansas and across rural America. Nationwide, a smaller share of rural residents say they will definitely get a covid shot compared with their more urban counterparts. More than a third, 35%, of those who live outside big-city borders said they would probably not or definitely not get vaccinated, compared with about a quarter of suburban and urban residents, according to a poll by KFF. (KHN is an editorially independent program of the foundation.) An NPR/PBS NewsHour/Marist Poll found that 47% of Trump supporters said they would not get a vaccine; 75% of Bourbon County residents voted for Trump in 2020.

Factors such as age and occupation also play a role in attitudes toward the vaccines. And — as Findley and others in Fort Scott noted — rural Americans are more likely to think of getting a vaccine as a personal choice and believe the seriousness of covid is exaggerated in the news.

Findley said she believes that there is a very bad virus, but also that the media have brainwashed people. The news has “everybody running scared,” she said. “I don’t know why they want to do that, but that’s what I feel like.”

About 50% of rural residents say the seriousness of the coronavirus is generally exaggerated in the news, according to the KFF poll. And 62% see getting the vaccine as a personal choice — rather than a necessary social obligation.

Wesco, executive vice president of the Community Health Center of Southeast Kansas, said he has hope more area residents will begin to see the vaccines as necessary.

“There’s hesitancy,” Wesco said, adding that he believes hesitancy is declining as vaccines become more abundant.

When residents are directly provided the opportunity to get a vaccine, they consider it more seriously, he said. And the more people they know who have gotten a vaccine, the more likely they will be to get a shot.

The Community Health Center, like other health centers nationwide, is receiving direct federal shipments of vaccines. Currently, the clinic has a waitlist and is giving out as many doses as it can get its hands on.

Sarah Jane Tribble is reporter and host of “Where It Hurts,” a narrative podcast created by KHN and St. Louis Public Radio about the people of Fort Scott and how their health care transformed after the hospital closed. “Where It Hurts” is available wherever you get your podcasts.

In California, Blue Shield’s Vaccination Takeover Fixes What Wasn’t Broken

In California’s Mendocino County, public health officials and community clinics say they have hit their vaccination stride.

Despite the county’s remoteness and its largely rural population spread among wooded mountains, rugged coastline and idyllic vineyards, about 40% of eligible adults have received at least one dose of a covid-19 vaccine.

But now they face renewed turbulence as health insurer Blue Shield of California takes over the state’s vaccine program with the mission of speeding up vaccinations.

Instead of tracking down the most vulnerable of the county’s roughly 68,000 eligible residents, community clinics and health care workers will be learning data systems. Instead of administering vaccines, they’ll be navigating new software. And instead of strengthening collaborations with the county that have helped get vaccines into arms, they’ll be forging relationships with the insurance company.

“I’m not quite sure what issue the state was trying to fix when they moved to this contract,” said Mendocino County CEO Carmel Angelo.

What’s happening in Mendocino echoes the frustrations, successes and stumbles felt by counties and clinics across the state during this turbulent transition.

Counties had been receiving vaccines from the state before turning around and distributing them to clinics in their areas. In March, the state started transferring that responsibility to Blue Shield, which will supply doses to most providers directly beginning this week as part of its $15 million no-bid contract with the state.

Counties will continue to receive doses for their own vaccination sites and will be able to share some with community clinics. But they will no longer be orchestrating how to allocate doses to clinics countywide. That is now Blue Shield’s responsibility.

That crazy-quilt system makes it more complicated for clinics and counties, not simpler. “We’ve been very nimble in terms of giving certain amounts to certain people,” said Mendocino County Public Health Officer Dr. Andrew Coren. Now, “it’s going to be hard for us to manage where there’s more need, or less.”

Before Blue Shield took over, county public health officials began holding Friday meetings with local providers, including hospitals and community health centers, something that didn’t occur before the pandemic.

The cooperation helped providers vaccinate people in hard-to-reach pockets of the county because clinics could discuss which ones had extra doses and which ones needed more, said Scott McFarland, CEO of MCHC Health Centers, which operates three clinics in Mendocino County and one in Lake County.

“It’s why we have seen success,” McFarland said.

Of the six community health center organizations in the county, all have signed on with Blue Shield or are in talks with the insurer.

Chloë Guazzone-Rugebregt, executive director of Anderson Valley Health Center in the inland town of Boonville, said the doses administered in Mendocino County have been hard-won, the result of hours of personal outreach to vulnerable and eligible communities.

Guazzone-Rugebregt said she is reluctantly starting over with Blue Shield because she feels she has no choice. She received the contract on a Friday night in mid-March and was told to sign by the following Tuesday if she didn’t want to lose her allocation — though she still has no idea how many doses are promised.

Erika Conner, a Blue Shield spokesperson, said the insurer is trying to enroll as many providers as possible into the state’s vaccination system, and work with them once they join.

“Our goal is to build a network that reaches every corner of our state, especially those communities that have been disproportionately affected by this pandemic,” she wrote via email.

McFarland said he looks forward to the streamlined process he hopes Blue Shield will bring. He isn’t worried about his allocation because his large clinics have been working with Adventist Health Ukiah Valley to set up weekly mass vaccination events that have administered up to 2,000 doses a day.

He sees no reason why his collaboration with the hospital can’t continue.

“It may take a week, it may take two weeks, but in the end, I think it’s going to be a better system,” McFarland said.

Darrel Ng, a spokesperson for the California Department of Public Health, said the the Blue Shield project has already improved vaccination distribution statewide, especially in communities that are most vulnerable to the virus. For instance, he said, vaccines in those communities went up by 30% from Feb. 20 to March 20.

“That’s evidence that the state’s actions are not just working, but helping to promote equity,” Ng said.

The biggest change on the horizon, and the one that has the potential to cause the most disruption for clinics, is the compulsory use of My Turn, the state’s centralized vaccine website. It’s meant to serve as an online hub where patients can find appointments and providers can order doses and set up clinics, all while seamlessly feeding data back to the state.

Mendocino County was one of the first rural counties to test it out, Coren said. Right away, there were problems.

For instance, Mendocino expanded vaccine eligibility to people with certain health conditions on March 1, two weeks before the state guidelines did the same. That was within the county’s authority, but My Turn couldn’t make sense of the conflicting eligibility categories.

So, for two weeks, providers logged patients into My Turn under a different category. That means someone who became eligible because they had cancer may have been coded as an agricultural worker, teacher or some other eligible profession.

But using tricks to get around the website’s quirks wastes time and skews county and state vaccination data, which could lead to future doses going to the wrong places or people, problems My Turn was specifically designed to prevent.

“It represents a big IT bureaucracy, so there can be major screw-ups, where, in the past, there were small screw-ups,” Coren said. “So it’s not perfect, it’s not going to be perfect, but I think we’re seeing that it’s improving.”

Ng said issues like that will stop once every county is using My Turn and vaccinating by the same eligibility rules this week. On Thursday, everyone 50 and older becomes eligible, regardless of their job or health status.

Focusing on data entry and website problems leaves clinics with less time to address the looming challenge of getting everyone vaccinated — not just the first wave of enthusiastic takers, Coren said.

“The problem is that it does take our eyes and our attention from some of the local issues,” like reaching vulnerable groups or overcoming language barriers, he said.

In the county’s grape-growing areas, many farmworkers don’t speak English, don’t have legal status, can’t access high-speed internet — or all three.

The way Guazzone-Rugebregt’s clinic has been able to reach them, and other vulnerable populations, is by being patient, flexible — and putting in the time, she said.

For instance, instead of relying on the population to find appointments online and provide all the right documentation, she’s been working directly with employers in the area, getting rosters of agricultural workers or other eligible professions to work from.

Lucresha Renteria, executive director of Mendocino Coast Clinics, serves 10,000 people spread across 52 miles of coastline and 20 miles inland.

Getting people vaccinated requires personal connections, not sending them to a scheduling website or statewide hotline, she said.

“People need to trust who they’re interacting with in order to put themselves in a position to get this vaccine,” Renteria said. “Using their known medical providers, a name people already trust, is a great way to do that in a small rural community.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Dramática baja de enfermedades por virus comunes… ¿significa máscaras para siempre?

Las máscaras y el distanciamiento físico están demostrando tener importantes beneficios extra, evitando que las personas contraigan todo tipo de enfermedades, no solo covid-19.

Pero no está claro si los protocolos valdrán la pena a largo plazo.

Maestros de la Academia New Hope en Franklin, Tennessee, estaban charlando sobre el tema. La escuela cristiana privada ha permanecido presencial durante gran parte de la pandemia, requiriendo máscaras y tratando de mantener a los alumnos separados, en la medida en que es posible con niños pequeños.

Nicole Grayson, quien enseña en cuarto grado, dijo que se dieron cuenta de algo peculiar.

“No conocemos a nadie que se haya engripado”, dijo. “A ningún estudiante que haya contraído faringitis estreptocócica”.

Y no se trata solo de algo anecdótico.

Un estudio publicado este marzo en el Journal of Hospital Medicine, dirigido por investigadores del Centro Médico de la Universidad de Vanderbilt, encontró que en 44 hospitales infantiles, el número de pacientes pediátricos hospitalizados por enfermedades respiratorias se redujo en un 62%.

Las muertes también han disminuido drásticamente en comparación con los últimos 10 años: el número de muertes por influenza en niños suele estar entre 100 y 200 por año, pero hasta ahora solo un niño ha muerto a causa de la enfermedad en el país durante la temporada de influenza 2020-21.

Los adultos tampoco se están enfermando. Las muertes por influenza esta temporada se medirán en cientos en lugar de miles. En 2018-19, una temporada de gripe moderada, se estima que murieron 34,200 estadounidenses.

Combo eficaz

No son solo las máscaras y el distanciamiento físico lo que está frenando las enfermedades transmisibles, dijo la doctora Amy Vehec, pediatra de Mercy Community Healthcare, una clínica de Tennessee que recibe fondos federales.

Que un niño tenga fiebre ahora es algo serio, los padres no están mandando a sus hijos enfermos a la escuela, agregó.

“Están quedándose en casa cuando están enfermos”, dijo Vehec. Eso incluye a los adultos que pueden sentirse enfermos.

Este aislamiento cuando alguien se siente mal podría mantenerse después de la pandemia. Pero el aislamiento, la distancia y las máscaras no funcionan para muchos niños, explicó Vehec.

Por ejemplo, los que tienen problemas del habla no ven la boca de su maestro para aprender a hablar correctamente.

“Creo que ha sido un mal necesario por la pandemia, y lo he apoyado por completo, pero ha tenido sus consecuencias”, dijo.

Y dado que las vacunas contra covid no estarán disponibles para los niños por un tiempo, puede ser otro año de cubrebocas en las escuelas.

Algunos expertos, como los investigadores que intentan mejorar las máscaras, argumentan que más sociedades deberían adoptarlas, como lo han hecho algunos países asiáticos. Pero incluso los expertos en enfermedades infecciosas como el doctor Ricardo Franco de la Universidad de Alabama-Birmingham dudan de que sea práctico.

“Soy un poco escéptico de que esta crisis sea suficiente para un cambio cultural generalizado, dado lo difícil que ha sido lograr un cambio cultural razonable en los meses anteriores”, analizó Franco.

El escenario más realista para un cambio duradero puede ser dentro de la propia atención médica.

Los médicos y enfermeras no solían usar máscaras antes de covid. El doctor Duane Harrison, quien dirige el departamento de emergencias de un hospital de HCA en las afueras de Nashville, mencionó a un colega médico que ha usado máscara desde que salió de la escuela de medicina.

“Solíamos bromear sobre esto”, dijo Harrison. “Hasta la pandemia”.

Ahora que todos usan máscaras, el departamento de Harrison ha descubierto lo mismo que muchos otros lugares de trabajo: los empleados no están diciendo que están enfermos, a menos que sea covid.

“Cuando covid termine, ésta es una práctica que la mayoría de nosotros probablemente continuaremos”, dijo Harrison. “Porque no tendremos que preocuparnos por los niños con secreción nasal y las personas mayores que no saben que están estornudando en tu cara”.

Algunos sistemas hospitalarios, incluido Nebraska Medicine, han comenzado a relajar los requisitos de uso universal de máscara para su personal. Pero incluso el personal vacunado todavía tiene que usar cubreboca cuando están con pacientes.

Intermountain Healthcare, en Utah, ha dicho que seguirá requiriendo máscara cuando se levante el mandato estatal en abril.

Pero incluso los que creen en la eficacia de las máscaras tienen dudas de que la comunidad médica las adopte en forma permanente.

“La pregunta más importante es: ¿Todos van a necesitar un descanso?”, se preguntó el doctor Joshua Barocas, quien estudia enfermedades infecciosas en la Universidad de Boston.

Funcionarios de salud pública dicen que, independientemente de lo que depare el futuro, aún no ha llegado el momento de eliminar los requisitos de las mascarillas, porque todavía hay mucha gente que vacunar contra covid.

Pero eventualmente, incluso los médicos y las enfermeras están listos para volver a mostrar sus caras sonrientes.

Esta historia es parte de una asociación que incluye Nashville Public Radio, NPR y KHN.

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Noticias En Español Public Health States



Durango’s Covid ‘Cowboy’ Rounds Up Spring Break Scofflaws, Lines ’Em Up for Shots

Bartenders were pouring Old-Fashioneds at a bar with a bullet hole straight through the wood. Servers in corsets and fishnet stockings roamed the room, passing an old piano that, twice a week, fills the building with ragtime tunes.

It was a Friday evening at the Diamond Belle Saloon on the main drag in Durango, Colorado. Outside, a man in boots, a cowboy hat and a button-down vest adorned with a U.S. marshal badge patrolled the block, eyes scanning the streets for trouble. If trouble were to appear, it would likely take the form of errant Texans.

“You can’t throw a stone around here without hitting a Texan,” recalled Scott Perez, the man in the marshal get-up.

This was the Wild West, after all: spring break 2021. And leaders of this city of about 19,000 are eager to hold covid-19 at bay with a bit of old-time law and order on mask mandates — and even a little modern vaccine science.

Perez is very familiar with this block, having staged his death several times outside the saloon during summertime gunfight performances. The former cowboy and current actor, stuntman and history buff also pretended to rob the steam train that takes tourists to the former mining town of Silverton. Now, a consortium that includes local businesses and the tourism office has hired him and a few other actors for a very specific task: to get people to obey the city’s mandate to wear their dang masks.


Dressed in Old West attire, Cathy Roberts (left) and Scott Perez (right) mix it up with locals and visitors while on a mission in Durango, Colorado: to encourage mask use during the pandemic. They give out free masks and sometimes stand for a quick photo opportunity with tourists.(Jeremy Wade Shockley / for KHN)

Scott Perez and Cathy Roberts make the rounds at the Diamond Belle Saloon in Durango, Colorado, on March 21, to make sure everyone is masked up and to offer complimentary masks. (Jeremy Wade Shockley / for KHN)

Old West actor Cathy Roberts hands out complimentary masks to diners at the Diamond Belle Saloon in Durango, Colorado, on March 21. (Jeremy Wade Shockley / for KHN)

Early in the pandemic, some mountain towns and counties shut out visitors. These days, they’re welcoming tourists with open arms — and, in some cases, a shot in the arm.

The health department that serves Durango’s La Plata County is among those offering covid vaccines to outsiders. In neighboring San Juan County, where the sheriff was threatening to fine and tow cars with out-of-county license plates a year ago, officials are now telling visitors, “If you’re here and with us now, let’s get you vaccinated if you’re eligible,” county spokesperson DeAnne Gallegos said. Andrew Sandstrom, a spokesperson for the Gunnison County covid response, said his county is doing the same but officials are just asking that visitors receive both doses in the same place.

Liane Jollon, executive director of the health department that spans La Plata and Archuleta counties, said more than 30% of residents have gotten at least one vaccine dose, putting the counties ahead of the curve. They aren’t advertising their vaccine supply as a lure for tourists, but as long as visitors fit Colorado’s vaccine eligibility criteria, Jollon said, they aren’t turning anyone away.

The state told vaccine providers not to ask for IDs or proof of residency, to avoid creating barriers for immigrants or homeless people, said Brian Spencer, with the Colorado State Joint Information Center. By extension, though, that means spring break tourists or second-home visitors also can partake.

“While it can feel like a difficult burden to vaccinate more individuals in your jurisdiction, it also helps keep our entire community safe,” Jollon said. “We’ve had people drive up for the day from New Mexico to get a vaccine.”

Typically this time of year, visitors come in spring break waves from Texas, Oklahoma, New Mexico and Arizona. Oklahoma’s governor has refused to impose a statewide mask mandate, and the governor of Texas lifted that state’s mandate and fully reopened businesses shortly before spring break tourists began arriving in Colorado.

In La Plata County, cellphone data analyzed by the health department shows that, from the first week of March to the third, mobile devices belonging to nonresidents shot from 15% of the total to 40%, with most coming from Texas and Oklahoma.

Some of the influx started even earlier. Gunnison County, which banned visitors during last year’s spring break, has seen tourism more than rebound in the past few months. It had a jump of at least 30% in tax revenue from short-term lodging in December and January compared with the same months before the pandemic.

Coloradans fear what the visitors may leave behind.

“In many of our mountain towns, we’re starting to see a new uptick,” said Jollon. “We’re really concerned that after spring break we could see an uptick that would hurt our schools’ ability to continue to offer in-person learning options.”

Around this time 102 years ago, Durango was closing its schools and opening an emergency hospital — again — to deal with a resurgence of the 1918 flu pandemic. People were fumigating their houses with formaldehyde, and kids were jumping rope to the song “I had a little bird. Its name was Enza. I opened the window, and in-flu-Enza.”


In the midst of the covid pandemic, local officials and businesses in Durango, Colorado, have hired actors Cathy Roberts and Scott Perez, among others, for a specific task: to get people to wear their darn masks.(Jeremy Wade Shockley / for KHN)

“It was definitely bad here,” said Perez. “They had bodies stacked up, particularly the ones that died in the winter because they couldn’t dig to bury them. They couldn’t find the mortician. He was laying amongst the bodies because he died. … A lot of the ladies of the evening became nurses.”

So this time, the community wants to prevent a resurgence, but also keep the tourism dollars flowing.

Durango, which usually attracts an estimated 1.5 million visitors each year with its brick buildings, steam train and bluffs crumbling into the Animas River, initially planned to hire a private security firm to persuade out-of-towners to don masks. That’s what the town of Breckenridge did. But then Rachel Brown, executive director of Visit Durango, jokingly proposed Old West actors instead.

“I have been told that the fun and theatrical approach of the Mask Marshal program is being very well received,” Brown said. “We are glad that we chose this option over private security.”

The need for mask police puzzles Perez. “I can’t figure it out at all,” he said. “I mean, there’s so much evidence about how this helps and yet somehow it became political.”

His right-hand woman in mask compliance is Cathy Roberts, a fellow reenactor, plus an animal advocate and military veteran. She wears a red-and-black cancan dress and goes by “Miss Kitty,” after the saloon owner in the TV and radio series “Gunsmoke.”

“She can disarm anybody with charm,” said Perez. “The goal is that I disarm them with some humor.” But he’s also clear they have a second option if things go sour: a direct line to the Durango Police Department.

“And the third option is not pretty,” said Perez. To be clear, the only heat he’s packing is two rounds of Pfizer.


Businesses and officials in Durango, Colorado, have hired Old West actors Scott Perez and Cathy Roberts to tackle a current problem: the Wild West of spring break, in which visitors from states like Texas and Oklahoma flock to the city. The actors’ job is to cajole tourists into wearing masks. Durango doesn’t require people to wear masks outdoors but does when people enter any businesses or public buildings.(Jeremy Wade Shockley / for KHN)

As the pair entered the saloon Friday night, Roberts recounted, a waitress gave her what she calls “the look.”

“That’s all they gotta do,” said Roberts, who quickly spotted the problem by the door: four people who clearly were not familiar with Durango’s mask rules. People are required to wear masks indoors, even in a bar or restaurant, unless they’re seated and eating or drinking. The women had on masks, but their noses weren’t covered. The men didn’t have masks at all.

Roberts walked up cheerfully in her red dress, greeted them, welcomed them to Durango, and offered masks that said “I [heart] Durango.” One man accepted it, she said, and put it on. The other sulked, zipping his coat up over his mouth. “I’m like, ‘Sorry, sir, it’s not over your nose,’ and he pulled it up even higher,” she recalled.

Perez hung back behind her, silent beneath his bandanna and white mustache. Technically speaking, all noses had been covered, so the pair moved on.

“Mask compliance actually is really, really high,” said Perez. “There’s a lot of people wearing masks even out on the sidewalks, where they don’t have to.”

The past few weekends, he’s mostly found himself greeting people, welcoming them to Durango, chatting about local history and then slipping in the rules about masks.

“And 99.9% of the time, that’s well received,” he said, even among the Texans, who may also go home vaccinated.


Dressed in Old West attire, Cathy Roberts (left) and Scott Perez (right) are on a mission in Durango, Colorado: to encourage mask use during the pandemic. (Jeremy Wade Shockley / for KHN)

Dramatic Drop in Common Viruses Raises Question: Masks Forever?

Masks and physical distancing are proving to have major fringe benefits, keeping people from getting all kinds of illnesses — not just covid-19. But it’s unclear whether the protocols will be worth the pain in the long run.

The teachers at New Hope Academy in Franklin, Tennessee, were chatting the other day. The private Christian school has met in person throughout much of the pandemic — requiring masks and trying to keep kids apart, to the degree it is possible with young children. And Nicole Grayson, who teaches fourth grade, said they realized something peculiar.

“We don’t know anybody that has gotten the flu,” she said. “I don’t know of a student that has gotten strep throat.”

It’s not just an anecdote.

A study released this month in the Journal of Hospital Medicine, led by researchers from Vanderbilt University Medical Center, found that across 44 children’s hospitals the number of pediatric patients hospitalized for respiratory illnesses is down 62%. The number of kids in the U.S. who have died of the flu this season remains in the single digits. Deaths have dropped dramatically, too, compared with the past 10 years: The number of flu deaths among children is usually between 100 and 200 per year, but so far only one child has died from the disease in the U.S. during the 2020-21 flu season.

Adults aren’t getting sick either. U.S. flu deaths this season will be measured in the hundreds instead of thousands. In 2018-19, a moderate flu season, an estimated 34,200 Americans died.

Effective Combo

It’s not just the masks and physical distancing that are tamping down communicable disease, said Dr. Amy Vehec, a pediatrician at Mercy Community Healthcare, a Tennessee clinic that gets federal funding. It’s become a serious societal faux pas to go anywhere with a fever — so parents don’t send their ailing kids to school, she said.

“They are doing a better job of staying home when they’re sick,” Vehec said. That includes adults who may feel ill.

Isolating when feeling bad could be kept up after the pandemic. But the isolation, the distance and the masks are not working for many kids, Vehec said.

Children with speech trouble aren’t seeing their teacher’s mouth to learn how to speak correctly, for instance.

“I think it has been a necessary evil because of the pandemic, and I have completely supported it, but it has had prices. It’s had consequences,” she said. “Kids’ education is suffering, among other things.”

And with covid vaccines unavailable to children for a while yet, it may be another year of masks in schools.

Some experts, like researchers trying to improve masks, argue that more societies should embrace masking — as some Asian countries have. But even infectious-disease experts like Dr. Ricardo Franco of the University of Alabama-Birmingham doubt that’s practical.

“I’m a little skeptical that this crisis will be enough for a widespread culture change, given how difficult it’s been to achieve a reasonable culture shift in the previous months,” Franco said.

The most realistic setting for lasting change may be within health care itself.

Doctors and nurses didn’t usually wear masks before covid. Dr. Duane Harrison, who directs an emergency department for an HCA hospital outside Nashville, mentioned a physician colleague who has worn a mask since he got out of medical school.

“We used to joke and clown with him about this,” Harrison said. “Until this.”

Now that everyone wears masks, Harrison’s department has found the same thing many other workplaces have: Employees aren’t calling out sick, unless it’s covid.

“When covid’s done, this is a practice that most of us will probably continue,” Harrison said. “Because we won’t be worried about runny-nose kids and elderly people who don’t know they’re sneezing in your face.”

Some hospital systems, including Nebraska Medicine, have started to relax universal masking requirements for their staffs. But even vaccinated staffers still have to wear a mask when seeing patients. Intermountain Healthcare in Utah has signaled masks will continue to be required when a statewide mandate lifts in April.

‘Is Everyone Going to Need a Break?’

But even believers in the effectiveness of masks have their doubts about the medical community keeping it up.

“The larger question is: Is everyone going to need a break?” asked Dr. Joshua Barocas, who studies infectious diseases at Boston University.

Whatever the future holds, public health officials say, the time has not yet come to drop mask requirements as the U.S. waits for more people to get a covid vaccine. But eventually, even doctors and nurses are ready to see smiling faces again.

“I know I’m going to need to retire my masks at some point in the future,” Barocas said, “for a little bit.”

This story is part of a partnership that includes Nashville Public RadioNPR and KHN.

Web Event: The Crucial Role of Home Health Workers, Unsung Heroes of the Pandemic

Even as the pandemic took a devastating toll on health care workers and older adults in the United States, many home care workers reported to work and provided vital care to vulnerable people despite the health risks to themselves and their families.

KHN and The John A. Hartford Foundation held an interactive web event to examine the crucial roles these workers have played for families during the pandemic, as well as the challenging economics of the industry for providers and consumers alike. KHN Editor-in-Chief Elisabeth Rosenthal served as moderator of the event.

Ask KHN-PolitiFact: How Can Covid Vaccines Be Safe When They Were Developed So Fast?

The development of the first covid vaccines may have seemed to occur at a dizzying pace. After all, scientists identified a new virus and created vaccines to protect against its most severe effects within a year.

But the research underpinning these vaccines isn’t that new at all, vaccine experts say. Some of it is decades old. This foundation, combined with technical expertise, urgency and financial resources, enabled scientists to pull off the medical marvel.

“The reason it was so fast is money and work,” said Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.

Leveraging mRNA: A Technique as Old as Millennials

Covid mRNA vaccines use the human body’s natural immune response to its advantage. The shot contains the recipe for making the molecule known as the spike protein, which the covid virus uses to bind to cells. Once the cell receives these instructions, it creates the protein and displays it on its surface. The immune system then spots the unknown protein and makes antibodies to fight it.

The vaccines made by the companies Pfizer-BioNTech and Moderna use this technology, which stems from research that began in the early ’90s, said Dr. Drew Weissman, a professor of medicine at the University of Pennsylvania. It has been tested against other viruses like influenza. Scientists learned from previous clinical trials and have since worked to perfect the use of mRNA, he said. Previous work on related coronaviruses like SARS helped speed the process.

Weissman and his colleague Katalin Karikó, a senior vice president of BioNTech, are credited with the breakthrough discovery that enabled these vaccines to be safe and highly effective.

“This isn’t new technology,” Weissman said.

Viral Vector Vaccines: A Health Emergency Veteran

The third vaccine being distributed in the United States to protect against severe covid-19 uses viral vector technology to generate an immune response. It contains a weakened form of a different virus that carries instructions for cells to make the spike protein found on SARS-CoV-2, the virus that causes covid. The protein appears on the cell’s surface, and the immune system creates antibodies against it.

Like the mRNA vaccines, this technology carries the code for making the spike protein to the cell, said Dr. Ruth Karron, director of the Center for Immunization Research at Johns Hopkins University.

“The truck is different,” she said, “but what’s being delivered is very similar.”

Viral vector technology has been studied since the 1970s. These vaccines have been approved for use around the world to immunize people against Japanese encephalitis. Johnson & Johnson, which uses this platform for its covid shot, also created a viral vector vaccine for Ebola after a massive outbreak of the disease in 2019 in the Democratic Republic of the Congo.

Are They Safe?

In addition to existing research, generous resources were allocated to quickly create the covid vaccines, experts said. As of Dec. 2020, the federal government spent $12.4 billion alone on Operation Warp Speed to hasten vaccine development. Drug companies partnered with the National Institutes of Health to tap into its expertise and quickly enroll trial participants.

Perhaps most important, the final clinical trials for the covid vaccines enrolled between 30,000 and nearly 45,000 participants.

“These studies are so much bigger than the studies we do for many licensed vaccines,” Karron said. Some trials for previously approved vaccines have included as few as 3,000 participants, she added.

Dr. Scott Ratzan, who runs a covid-19 vaccine communications initiative called CONVINCE USA at the City University of New York, said pushing certain information has helped assuage fears among the vaccine hesitant. These include highlighting the reality of the virus, comparing the shot’s side effects to other vaccines and showing the vaccines’ effectiveness in millions of people.

Waiting for others to get the shot first was “a fair thing” when they first rolled out, Offit said. However, after nearly 90 million people in the United States have received at least one vaccine dose with no sign of safety issues, he said, the skepticism should be fading away.

“You have your proof in terms of efficacy and safety,” Offit said. If you are still refusing, “then that’s because you’re not a skeptic anymore. You’re a cynic.”

Covid Vaccine Hesitancy Drops Among All Americans, New Survey Shows

A new poll of attitudes toward covid vaccinations shows Americans are growing more enthusiastic about being vaccinated, with the most positive change in the past month occurring among Black Americans.

About 55% of Black adults said they had been vaccinated or plan to be soon, up 14 percentage points from February, according to a poll released Tuesday by KFF. The rate now approaches that of Hispanics, at 61%, and whites at 64%. (Asian Americans were not polled in sufficient numbers to compare their responses with other racial and ethnic groups.)

But the poll found that 13% of respondents overall said they will “definitely not” be vaccinated, signaling that significant hurdles remain in the nation’s vaccination campaign. (KHN is the editorially independent newsroom of KFF, an endowed nonprofit organization providing national information on health issues.)

Among all groups, Republicans and white evangelical Christians were the most likely to say they will not get vaccinated, with almost 30% of each group saying they will “definitely not” get a shot.

And while the poll indicated that some arguments are effective at persuading hesitant people — such as sharing that the vaccines are nearly 100% effective at preventing hospitalization and death — those messages do almost nothing to change the minds of people who have decided not to be vaccinated.

Last week, President Joe Biden announced that the United States has administered more than 100 million vaccine doses and doubled his goal, to 200 million doses, by early May. According to KFF’s poll, 32% said they had already received at least one dose, and 30% said they planned to get it as soon as possible.

The poll also showed fewer people waiting to see how others respond to the vaccines before deciding to get vaccinated themselves, with 17% saying they fall into that “wait and see” group this month — a drop from 22% in February and 31% in January.

Young adults, ages 18-29, and Black adults were most likely to be in this “wait and see” group, at 25% and 24%, respectively.

Twenty-seven percent of Republicans and 35% of white evangelical Christians said they had already received at least one dose, the poll showed. Forty-two percent of Democrats said they have been vaccinated.

But Republicans and white evangelical Christians, along with 21% of essential workers in non-health fields and 20% of rural residents, were the most likely to say they will “definitely not” get vaccinated. One in 5 Republicans said they would be more likely to get vaccinated if former President Donald Trump strongly urged them to do so.

People who said they would “definitely not” receive a vaccine were asked to identify the main reason for their decision. The most common reason, at 17%, was that the vaccines are too new and not enough information is known about their long-term effects.

But informing people in the “definitely not” camp that scientists have been working on the technology used in the vaccines for about 20 years, among other arguments, did little to change their minds. Only about 6% said hearing that argument made them more likely to get the vaccine.

The poll found that some arguments were persuasive to those who had yet to make up their minds, though. Forty-one percent said they were more likely to get the vaccine after hearing that the vaccines are nearly 100% effective at preventing hospitalization and death from covid — the most effective message KFF tested.

Some indicated they would be more likely to get vaccinated if it were easier to do while going about their daily lives — or made going about their daily lives easier.

Of those in the “wait and see” group, half said they would be more likely to get vaccinated if it were offered to them during a routine medical appointment. And 37% said they would be more likely if their employer arranged for on-site vaccinations at their workplace. Thirty-eight percent said they would be more likely if their employer offered to pay them an extra $200 to be vaccinated.

Of those who were not already vaccinated or planning to be soon, the poll showed travel restrictions could prove persuasive. About 3 in 10 said they would be more likely to get vaccinated if airlines required passengers to be vaccinated, or if the Centers for Disease Control and Prevention said vaccinated people could travel freely and, in most cases, would not need to wear masks.

Still, 7% of those who said they would “definitely not” be vaccinated said they would be more likely to do so if airlines and the CDC were to make those policy changes.

The poll also showed that, for the first time, most of those who had not been vaccinated said they have enough information to know where and when to get a vaccine. However, problems remain: About 3 in 10 said they did not know whether they were eligible in their state. Most likely to respond that way were Hispanic adults and those under age 30, making less than $40,000 annually or who do not have a college degree.

The survey was conducted March 15-22 among 1,862 adults and has a margin of error of +/-3 percentage points.