A woman with DD living in a state home was raped and had a baby. A task force was made to come up with changes to protect people like her. Most of those changes have not happened yet.
This article was published on Wednesday, January 20, 2021 in ProPublica.
In 2018, a crime happened in Arizona. A woman was raped. Raped means someone had sex with her when she did not want to.
The woman lives in a long-term care facility. She can not walk or talk. Staff help care for her. She was 29 when she was raped.
She got pregnant from the rape. She had a baby on New Year’s Eve in 2018. No one knew she was pregnant.
The place where this happened was Hacienda HealthCare in Phoenix. Many people across the USA were very angry this woman got hurt this way.
Arizona is known for being a good place to live if you have a developmental disability (DD) like this woman. The state wanted to change so bad things like this wouldn’t happen again.
The governor of Arizona is named Doug Ducey. He made a task force to help protect people like the woman who was raped. This group is made up of leaders from across the state. They include:
Leaders of government programs
People working in health care
People running group homes
Advocates
They are called the Governor’s Abuse and Neglect Prevention Task Force.
Abuse means to hurt someone you are supposed to care for. Neglect means to not take care of them.
This group made a list of ideas to better protect people with DD. They gave this list to the government more than a year ago. Most of their ideas were supposed to happen in 2020.
The group had 30 ideas for changes. Only about 10 changes have been made. It could take months or years for all the changes to happen.
Here are some examples of the changes they suggested:
Make a single list with all the people in Arizona who have abused:
Children
Adults who need extra help
People with DD
Give training to staff and family about how to know if someone they care about has been abused.
These changes have not happened yet.
One member of the task force is Jon Meyers. He runs The Arc of Arizona. That is a group that speaks up for people with DD. He said many people are frustrated that the changes have not all happened yet.
Many of the changes cost money. One change would be to pay staff more. They would stay at their jobs longer and have more training if the job paid more. The group also wants to pay more to the people who check to see if abuse happened.
But the government has not asked for more money to pay for these things.
Jon said, “That’s so obviously not going to happen it’s a wonder we could include it with a straight face.”
The government program in charge of helping people with DD in Arizona is called the Division of Developmental Disabilities. It’s also called DDD.
People on the task force said DDD ignored their ideas. They want DDD to be:
Transparent: That means making it easier for everyone to know what they are doing.
Accountable: That means taking responsibility for what happens to people with DD in Arizona.
DDD made a website with some new info. It is about safety at places like group homes. It only has basic facts.
Another government program is Adult Protective Services (APS). Its job is to check to see if people with DD have been abused. It changed its website too. Its new website still does not have a lot of info. For example, you can’t see if a group home has had problems with abuse in the past.
A worker for the government said DDD and APS are not allowed to share more info. But other people think they could be sharing more. Other programs can give more info about places like hospitals and nursing homes.
Will Humble is in charge of the Arizona Public Health Association. He has a son with Down syndrome. He said, “At a real practical level, a family member who is considering a group home environment should be able to look at all the complaints that have been filed and the resolutions to get the compliance history for that individual home and that individual provider.”
This means he thinks people should know if there have been problems at group homes. That way they can decide if it is a good choice to live there.
The task force has reached some of its goals. Arizona’s Medicaid agency has a new rule. Group homes must have signs telling people how to report abuse. The signs are for:
People with DD
Their loved ones
Staff
The signs are not done yet. DDD made some signs but self-advocates with DD said they were hard to understand. DDD is making new ones now.
People who work for the government said changes are happening. They said half are done or being done now.
Jami Snyder is in charge of the Arizona Health Care Cost Containment System. That is the government program that is taking the lead on making these changes. Jami said: “I actually am really proud of the work that the task force has done. I think the agencies have done a lot of really phenomenal work since that time. I think we have more work to do.”
Christina Corieri works for the governor of Arizona. She is happy with the task force. She said: “We have implemented many of [the changes]. We are committed to implementing all of them.”
The Department of Economic Security is in charge of DDD. They wrote a statement that said they are “committed to ensuring the health and safety of vulnerable individuals.”
It also said, “We support the work and recommendations of the Task Force and have strong collaboration across state agencies and with stakeholders in the joint commitment to improve the quality of life for vulnerable Arizonans.”
The Wheels of Government
DDD gave out instructions this year for staff. They show staff how to:
Know if someone is being abused
Make sure they don’t hurt someone who has been abused even more
Share about abuse where they work
There is no money to give this training to staff. That will make it hard to do.
This is what Gina Griffiths said. Gina works for Opportunity Tree. They run group homes and programs in Phoenix. Gina is on the task force.
She said: “I don’t know why any of this has taken as long as it’s taken. The wheels of government really do turn slowly.”
The task force wants workers at APS to have better training too. This training would help them notice when people with DD are being abused. APS said they will have this training done by June 2021.
There are some problems the task force did not have ideas for. One problem is support coordinators. These are workers at DDD who help make sure people with DD have what they need. Some of the problems are:
They do not make a lot of money.
They quit their jobs a lot.
They don’t have much training.
These problems were not mentioned by the task force.
Diedra Freedman is part of a group that helped the task force. She is also part of an independent oversight committee. That group makes sure DDD is doing what it is supposed to do. Her son has autism.
Diedra said, “In two years of work, the bureaucracy has created a flowchart that explains the system, but they have not in any way improved the system.”
Pandemic Problems
Some changes have been slow because of COVID-19.
Erica McFadden runs the Arizona Developmental Disabilities Planning Council. She is on the task force. She said the changes should happen faster because of COVID-19.
She thinks abuse could happen more now. Places like group homes can’t have visitors because of the virus.
Erica said Arizona should learn from what happened at Hacienda. If they took it seriously, they “would have ensured how to proactively react to members at this time.”
She said, “This should not be a fight.”
One thing that makes changing things harder is that some people in the government left their jobs. This includes the people in charge of:
DDD
APS
The Department of Economic Security
It is hard when people leave because new leaders have to learn how things work.
Some people on the task force are not interested in it anymore. They think they can’t make a difference.
G’Kyshia Hughes is part of a group that helped the task force. She works in social services. She takes care of her brother with autism.
G’Kyshia stopped going to meetings. She thinks they can’t make changes if they don’t have money.
She said, “What’s the point of putting these things together if you don’t know for sure that the Legislature is going to give you funding for it? It’s just a document with no teeth.”
Dana Kennedy is also on the task force. She runs AARP Arizona. She thinks the Arizona government doesn’t think protecting people with DD is very important. She thinks it won’t be a big issue when they meet to make new laws for Arizona in 2021.
She said: “It’s just maddening to me because we already had a Hacienda. We didn’t get anything done through the Legislature. And now here we are starting another legislative session and ... nobody's talking about it.”
A Healthy Child
The woman who was raped at Hacienda had a baby two years ago. The little boy turns 2 on Dec. 31.
He lives with his grandparents. They are on the San Carlos Apache Reservation. That is near Globe, Arizona.
His mother does not live at Hacienda anymore. She lives at a smaller facility in Phoenix. Her family would like her to live closer to them. But there are no places nearby that could help her the way she needs.
Her lawyer is John Micheaels. He sued:
Hacienda HealthCare
The woman’s doctors
The state of Arizona
Three cases are settled. Arizona paid her $7.5 million. Hacienda and one doctor did not announce how much they paid. None of the three admitted to doing anything wrong.
Nathan Sutherland used to work at Hacienda. He was arrested in January 2019. He is charged with sexual assault and abuse. He pleaded not guilty. His lawyer did not return our call asking for a comment.
John Michaeals says the woman’s parents are raising her son. They have help from his mother’s 6 siblings. He says the boy is healthy. People were worried because his mother was taking medicine for seizures when he was born.
The family did not want to talk to us for the story. They have not spoken to the news. The boy’s grandmother told us no.
John said, “She told me that thinking about it gives her a pit in her stomach.”
States are struggling to plan their vaccination programs with just one week's notice for how many doses they'll receive from the federal government. The incoming Biden administration is deciding what to do with this dysfunctional system.
This article was published on Tuesday, January 19, 2021 in ProPublica.
Hospitals and clinics across the country are canceling vaccine appointments because the Trump administration tells states how many doses they'll receive only one week at a time, making it all but impossible to plan a comprehensive vaccination campaign.
The decision to go week by week was made by Operation Warp Speed's chief operating officer, Gen. Gustave Perna, because he didn't want to count on supplies before they were ready. Overly optimistic production forecasts turned out to be a major disappointment in the rollout of the H1N1 vaccine more than a decade ago, also leading to canceled appointments and widespread frustrations with the government's messaging.
This time, however, the most pressing problem isn't the overpromising of supply. For each of the past three weeks, the federal government got about 4.3 million shots. But the amount that each state is sent has fluctuated as Operation Warp Speed changes the quantities available week by week.
State health officials say the unpredictable shipments have led to chaos on the ground, including the inability to quickly use up all of the doses sent to them. The week-by-week system also makes it hard to plan for the second doses that everyone needs because they come three or four weeks after the initial dose.
"It's a huge problem. When you're setting up clinics and registration systems, you have to have some idea of the supply," said Lori Freeman, chief executive officer of the National Association of County and City Health Officials. "If you're starting and stopping all the time, it can lead to confusion in the community — they'll think you don't know what you're doing."
As President-elect Joe Biden's team prepares to take over on Wednesday, officials are aware of the problem and will have to decide how to address it, according to a member of the transition team. Sorting it out will be critical to meeting Biden's goal of 100 million vaccinations in his first 100 days.
In the meantime, many Americans are experiencing this problem firsthand in the form of canceled appointments. On Jan. 14, Mount Sinai Health System sent a flurry of emails out to elderly patients across New York City, just two days after expanding eligibility to New Yorkers ages 65 and up. "You are receiving this email because you are scheduled for a vaccine appointment. ... Unfortunately, your appointment has been cancelled due to a sudden decrease in the amount of COVID-19 vaccine being supplied to us," the email said. "We are truly sorry, but unfortunately, the vaccine supply is not under our control."
In Virginia, allocations to the state Department of Health vary not only week to week, but day to day. Dr. Danny Avula, Virginia's COVID-19 vaccine coordinator, said the department learned in the middle of last week that it could get up to 80,000 doses, but — for reasons unclear to the Virginia team — the allocation increased to 106,000 by Thursday when it went to place orders. The state agency has tried to give local health providers consistent information about how many doses they'll receive at their clinics and hospitals, but Avula said state officials will have to instead explain the erratic allocations.
"States don't know what they will get week to week," said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. "The locals get frustrated with states, thinking the states have all this information, but the states are in the same position as the locals."
The way that Operation Warp Speed leaves it up to states to hand out vaccines within their borders harks back to the Trump administration's strategy of passing down responsibility during earlier phases of pandemic response. In April, White House adviser Jared Kushner chided governors for seeking help from the federal government's stockpile of emergency medical supplies. And President Donald Trump left states to decide how to reopen their economies, telling governors, "You're going to call your own shots."
The root of the problem now is the system designed around weekly allotments. Perna has said he set up the system this way because he wanted to act on only supplies in hand, not predictions.
"Every week I get an update, I know exactly what has been approved by the FDA for final distribution," he explained in a Dec. 12 briefing. "I will not allow those estimates to go forward for speculation because I want people to focus on what is actually available."
The makers of the two authorized vaccines, Pfizer and Moderna, are each contracted to supply 100 million doses by the end of March. But with just 31.2 million delivered as of Jan. 15, according to data from the Centers for Disease Control and Prevention, the companies will need to ramp up their pace to hit their targets.
The companies give the federal government weekly or daily updates on their production numbers, according to their contracts. Then Operation Warp Speed takes the total number of available Pfizer and Moderna doses for the week and divides them up between the states. The allocations are currently based on the state's population over age 18, but the Trump administration said last week it would soon change the formula to be based on each state's elderly population and ongoing pace of vaccinations. That change hasn't taken effect yet, and the new administration may not decide to stick with it.
Every Tuesday, these state-by-state allocations are keyed into a software system called Tiberius, which was built for the government by the data analysis company Palantir. (Tiberius is the middle name of Star Trek's Capt. James T. Kirk; "Warp Speed" is also a Star Trek reference.) The numbers show up on states' screens around noon Eastern time, according to Oregon health authority spokesperson Jonathan Modie.
But these allocations aren't final: Adjustments are made that can result in further daily changes. The system subtracts out doses that are set aside for long-term care facilities, which are administered by Walgreens and CVS, as well as "any corrections from the prior week, including doses that weren't ordered by states in previous weeks, or doses shipped to states accidentally that CDC needs paid back," explained Modie. Only then is a maximum order "cap" calculated for the week, which is placed into a separate system, called VTrckS.
Perna publicly apologized in December when states received fewer doses than he'd told them to expect. The general said at the time that the discrepancy was a one-time mistake that resulted from moving the releases from Fridays to Tuesdays. "This is a herculean effort and we are not perfect," he said. "It looked very good on paper. Paper plans are very good. Execution is where we learn and we adapt it."
But the problem of unpredictable numbers has persisted as states continue to grapple with last-minute adjustments to their allocations.
For this coming week, Michigan was initially told on Tuesday it was receiving 62,400 doses of the Pfizer vaccine to distribute among vaccination sites, according to Lynn Sutfin, spokesperson for the state's Department of Health and Human Services. Then on Wednesday, Michigan was told that an additional 60,000 doses of the Moderna vaccine that were initially earmarked for long-term care facilities were available for general vaccination sites instead. On one hand, that was good news, because the state got twice as many doses to give out, since the long-term care program wasn't ready to use them. On the other, this meant the Michigan department had only a day to figure out where to send the extra doses.
The states are responsible for deciding how to distribute their doses to local vaccination sites, and they usually have only two days to figure that out. After receiving their allocations on Tuesday, each jurisdiction must then submit its orders in VTrckS by Thursday. Shipments arrive the following week.
Second doses are ordered separately, on Sundays, according to a spokesperson from the Department of Health and Human Services, the government agency that houses Operation Warp Speed.
"For the past three weeks, jurisdiction allocations have remained relatively steady around 4.3 million total doses (or just over 2 million first doses) of both Pfizer and Moderna, which has provided additional predictability," the HHS spokesperson said. "Operation Warp Speed is committed to providing as much planning time as possible, while balancing manufacturing schedules and maximizing doses available."
Pfizer and Moderna declined to comment on what production numbers they shared with the government program during their regular updates. (Paul Sagan, board chairman of ProPublica, is a member of Moderna's board.)
Despite stable total doses at the national level in recent weeks, individual states still don't know what to expect from Operation Warp Speed more than a week ahead, creating continued chaos on the ground.
In Columbus, Ohio, health commissioner Dr. Mysheika Roberts was feeling both encouraged and concerned about the vaccine rollout in her city. It had gotten off to a slow start with the holidays, but after some outreach efforts, the vaccine clinic was steadily booking all 700 slots it had each day. Then, she had a new problem. She was starting to run out of vaccines. "What we have on hand will run out by the end of day Wednesday," she said in a Monday interview. "We're just calling the state and telling them we need more. We're potentially going to have to cancel clinics on the 14th, 15th, 16th." Roberts was saved from having to cancel appointments because the state managed to send her more shots at the last minute, according to a spokesperson, but the site's supply is once again limited, so the cycle is beginning again.
Starting Wednesday, it will be up to the Biden administration to provide clear visibility for states, according to a member of the president-elect's COVID-19 team, who asked not to be identified because he wasn't authorized to speak on behalf of the new administration.
"The government can point at the manufacturer, but it's like asking the [Defense Department], 'How many planes do you have?' and them saying, 'I don't know, ask Boeing,'" the person said.
It's critical for the government to know how many doses are available at any given time and how many are coming through the pipeline, the person added. "How can this not be known?" he said. "It's the most basic question."
The county's decision to prioritize vaccinations for internet users — and its failure to set aside any appointments for callers — raises issues of equity and access, say experts.
This article was published on Friday, January 15, 2021 in ProPublica.
MEMPHIS, Tenn. — Last Friday afternoon’s email had good news: The state of Tennessee confirmed it would send the Shelby County Health Department an allotment of the vaccine each week in January. Eligible residents, including a range of health care workers and people 75 and older, could schedule an appointment online starting immediately, the SCHD said.
But those who needed to register by phone would have to wait two and a half days, until Monday morning, to call a designated number.
Three hours after the SCHD’s email was sent to media and community partners, residents had already snapped up more than 40% of the 10,800 appointments available, according to a review of the online registration site by MLK50: Justice Through Journalism and ProPublica. By 1 p.m. Saturday, fewer than 70 appointments remained. And late Saturday afternoon, the SCHD sent another email: There were no appointments left.
SCHD Director Dr. Alisa Haushalter said the department was surprised by how quickly appointments were claimed, but health equity experts say the SCHD should have anticipated the response. She said the department was planning changes to the system going forward.
SCHD’s decision to give early access to internet users — and its failure to set aside any appointments for callers — raises issues of equity and access, those experts said. By creating a two-tiered system, the SCHD risks disadvantaging Black residents, who research shows are less likely to have broadband access and who have been disproportionately affected by the virus; it also would impact access by the elderly, who are less likely than other Americans to use the internet at all.
As glitchy vaccine rollouts occur across the country, issues of who gets access matter a lot. Last weekend’s flubbed effort in Shelby County provides a look at what can go wrong when an overtaxed public health department, hamstrung by the state’s last-minute announcements about vaccine availability, is caught without an outreach strategy that centers on the most vulnerable residents.
“Anybody who has done anything in disparities in Memphis knows that computer access is a major issue,” said Carla Baker, a longtime nurse and chief operating officer for Common Table Health Alliance, a nonprofit health care collaborative serving Memphis and the region. “If you had 200 appointments, you should have set 50 aside for phone calls.”
In Shelby County, where the population is 54% Black, internet use and computer access vary broadly by ZIP code. Shelby County’s poorest ZIP code, 38126 in South Memphis, has a poverty rate over 65%, and 96% of residents are Black. Just over 70% of residents there have no internet access, according to census data.
Among the ZIP codes where the COVID-19 case rate per 100,000 residents is the highest, internet access varies wildly, with between 6% and 36% of households having no internet access, according to census data. Yet the SCHD’s communication strategy has been primarily digital, such as emails, press releases and social media posts.
In an interview Tuesday, Haushalter said that because the state didn’t notify her agency until Friday that additional doses were on their way, the department didn’t have time to develop a grassroots communication strategy that would have, for example, partnered with radio stations with a high share of Black listeners in order to reach people without internet access.
That explanation didn’t fly with Dr. Gary Puckrein, president and CEO of the National Minority Quality Forum, a nonprofit research and education organization focused on eliminating health disparities.
“Clearly there was time not only to notify people, but to construct a well-thought-out plan,” he said.
Haushalter noted that while some other communities only have online sign-up available, Shelby County has a phone line too. The existence of a phone line proved irrelevant, however, as all appointments had been claimed online by the time the registration phone line opened.
“That’s not how the game is supposed to be played,” Puckrein said. These kind of missteps can erode the public’s trust — particularly the trust of Black residents who have good reason to be leery of medical institutions and public health campaigns given the country’s racist medical past, including the Tuskegee syphilis study. Surveys show that Black people are more hesitant to get the vaccine than white and Latino people.
As it happens, there were some who were able to make appointments by phone Saturday by calling other SCHD phone numbers and reaching employees working on the weekend. Those workers made online appointments for callers, although Haushalter said she didn’t know how many appointments were made this way.
Issues with distribution and access aren’t unique to Shelby County. After Tennessee’s Hamilton County officials turned away waiting seniors in a long car line, officials realized they had more doses than expected, causing them to scramble to find people before the vaccine expired. In Daytona Beach, Florida, some seniors waited in line overnight to get a vaccine. In New York City, one online vaccination sign-up asked users to complete as many as 51 questions or fields and upload an insurance card, according to the city’s comptroller.
Changes Underway
As of Friday, COVID-19 has claimed just over 1,100 lives in Shelby County, according to the SCHD. Black residents are slightly overrepresented in the share of COVID-19 deaths, according to the most recent SCHD data, comprising about 58%, though they make up 54% of the county’s population. People 75 and older make up the largest share of deaths in Shelby County.
In a press conference Thursday, Haushalter said it’s too soon to determine whether there’s a racial disparity in vaccinations because the pool of people is still limited mostly to health care workers and first responders, groups for which the county doesn’t have racial data.
The state’s vaccination plan does acknowledge that “equity remains a crosscutting consideration” in vaccine distribution, and it notes that some “higher risk” counties, including Shelby, are “disadvantaged and slower to recover from adversity.” Some states’ vaccinations plans, such as North Carolina’s, include specific outreach strategies to the Black community. Tennessee’s plan does not include the words “Black” or “African American.”
But while the state doles out doses to counties and dictates the priority groups and the order in which those groups are eligible for vaccination, it doesn’t implement the rollout on the ground. It is the SCHD that decides the location of the vaccination sites and how it spreads the word. And while the state’s plan is publicly available, the county’s vaccination plan is not online, a SCHD spokesperson confirmed.
The SCHD is reviewing what worked well and how it can improve, Haushalter said, and changes are on the way as the incoming Biden administration has committed to releasing almost all available doses immediately.
The phone line and online registration system will open simultaneously, she said, and they’re developing a preregistration system. Contingent on a predictable supply and more staffing, the SCHD plans to add vaccination sites this month. And at some point, the department may have walk-up vaccination sites, no appointment required.
According to the Centers for Disease Control and Prevention, Tennessee has administered about 40% of its vaccine supply. Based on the 55% of people who indicated their race, less than 4% of the vaccine supply has gone to Black Tennesseans, although Black residents make up about 17% of the state’s population. The incomplete data makes it difficult to determine if distribution has been equitable.
State Health Department data shows that as of Monday, Shelby County had given at least one dose to just under 2% of the population, the second-lowest percentage among Tennessee counties.
The impact of unequal access is evident in Shelby County in other ways too. Regional One Health, a large Memphis-area health care system, emailed hospital volunteers — including the wife of the hospital’s CEO — inviting them to be vaccinated to avoid wasting doses.
At a county-run vaccination site in late December, which was only vaccinating health care workers and first responders at the time, elderly people — who said they were told they could get vaccinated — waited in line for hours only to be told they were ineligible, although some got the vaccine anyway.
A SCHD spokesperson acknowledged that county staffers “did vaccinate some people out of phase who were in line at the vaccination site,” but shifted responsibility to residents.
“We ask that people honor the priorities also detailed in the state plan. We ask the public to help us achieve our goal of protecting the most vulnerable persons first by waiting their turn.”
But the problem of people accessing vaccines too soon matters less than those who access them too late — or not at all. And experts such as Bhaskar Chakravorti, dean of global business at The Fletcher School at Tufts University, worry that’s what will happen without a clear communication plan that addresses the county’s digital divide.
“Unfortunately, all of this is highly dependent on the creativity and commitment of local officials,” said Chakravorti, who is also the chair of Digital Planet, a research initiative that explores emerging technology and its impact on the world.
Dr. Bon Ku, a Philadelphia ER doctor and director of the Health Design Lab, which promotes inclusive design in health care, suggested that ensuring equitable access to the vaccine requires efforts that rival Georgia organizers’ get-out-the-vote campaign. Door knocking, flyering, mailers, an onslaught of text messages and even robocalls should be deployed — and public health officials could borrow from census takers’ tactics too, health equity advocates said.
It will be important, Ku said, for health departments to build deep relationships with groups that already have the trust of vulnerable communities.
Asked if the SCHD was partnering with Meals on Wheels, whose volunteers have regular contact with elderly residents, Haushalter said the department hadn’t, but that it was a “great idea.”
“If you have suggestions or others have suggestions on how to more effectively get the message out, particularly when things are changing so quickly, we are always open to that.”
The "King of Debt" promised to reduce the national debt — then his tax cuts made it surge. Add in the pandemic, and he oversaw the third-biggest deficit increase of any president.
This article was published on Thursday, January 14, 2021 in ProPublica.
One of President Donald Trump’s lesser known but profoundly damaging legacies will be the explosive rise in the national debt that occurred on his watch. The financial burden that he’s inflicted on our government will wreak havoc for decades, saddling our kids and grandkids with debt.
The national debt has risen by almost $7.8 trillion during Trump’s time in office. That’s nearly twice as much as what Americans owe on student loans, car loans, credit cards and every other type of debt other than mortgages, combined, according to data from the Federal Reserve Bank of New York. It amounts to about $23,500 in new federal debt for every person in the country.
The growth in the annual deficit under Trump ranks as the third-biggest increase, relative to the size of the economy, of any U.S. presidential administration, according to a calculation by a leading Washington budget maven, Eugene Steuerle, co-founder of the Urban-Brookings Tax Policy Center. And unlike George W. Bush and Abraham Lincoln, who oversaw the larger relative increases in deficits, Trump did not launch two foreign conflicts or have to pay for a civil war.
Economists agree that we needed massive deficit spending during the COVID-19 crisis to ward off an economic cataclysm, but federal finances under Trump had become dire even before the pandemic. That happened even though the economy was booming and unemployment was at historically low levels. By the Trump administration’s own description, the pre-pandemic national debt level was already a “crisis” and a “grave threat.”
The combination of Trump’s 2017 tax cut and the lack of any serious spending restraint helped both the deficit and the debt soar. So when the once-in-a-lifetime viral disaster slammed our country and we threw more than $3 trillion into COVID-19-related stimulus, there was no longer any margin for error.
Our national debt has reached immense levels relative to our economy, nearly as high as it was at the end of World War II. But unlike 75 years ago, the massive financial overhang from Medicare and Social Security will make it dramatically more difficult to dig ourselves out of the debt ditch.
Falling deeper into the red is the opposite of what Trump, the self-styled “King of Debt,” said would happen if he became president. In a March 31, 2016, interview with Bob Woodward and Robert Costa of The Washington Post, Trump said he could pay down the national debt, then about $19 trillion, “over a period of eight years” by renegotiating trade deals and spurring economic growth.
After he took office, Trump predicted that economic growth created by the 2017 tax cut, combined with the proceeds from the tariffs he imposed on a wide range of goods from numerous countries, would help eliminate the budget deficit and let the U.S. begin to pay down its debt. On July 27, 2018, he told Sean Hannityof Fox News: “We have $21 trillion in debt. When this [the 2017 tax cut] really kicks in, we’ll start paying off that debt like it’s water.”
Nine days later, he tweeted, “Because of Tariffs we will be able to start paying down large amounts of the $21 trillion in debt that has been accumulated, much by the Obama Administration.”
That’s not how it played out. When Trump took office in January 2017, the nonpartisan Congressional Budget Office was projecting that federal budget deficits would be 2% to 3% of our gross domestic product during Trump’s term. Instead, the deficit reached nearly 4% of gross domestic product in 2018 and 4.6% in 2019.
There were multiple culprits. Trump’s tax cuts, especially the sharp reduction in the corporate tax rate to 21% from 35%, took a big bite out of federal revenue. The CBO estimated in 2018 that the tax cut would increase deficits by about $1.9 trillion over 11 years.
Meanwhile, Trump’s claim that increased revenue from the tariffs would help eliminate (or at least reduce) our national debt hasn’t panned out. In 2018, Trump’s administration began hiking tariffs on aluminum, steel and many other products, launching what became a global trade war with China, the European Union and other countries.
The tariffs did bring in additional revenue. In fiscal 2019, they netted about $71 billion, up about $36 billion from President Barack Obama’s last year in office. But although $36 billion is a lot of money, it’s less than 1/750th of the national debt. That $36 billion could have covered a bit more than three weeks of interest on the national debt — that is, had Trump not unilaterally decided to send a chunk of the tariff revenue to farmers affected by his trade wars. Businesses that struggled as a result of the tariffs also paid fewer taxes, offsetting some of the increased tariff revenue.
By early 2019, the national debt had climbed to $22 trillion. Trump’s budget proposal for 2020 called it a “grave threat to our economic and societal prosperity” and asserted that the U.S. was experiencing a “national debt crisis.” However, that same budget proposal included substantial growth in the national debt.
By the end of 2019, the debt had risen to $23.2 trillion and more federal officials were sounding the alarm. “Not since World War II has the country seen deficits during times of low unemployment that are as large as those that we project — nor, in the past century, has it experienced large deficits for as long as we project,” Phillip Swagel, director of the CBO, said in January 2020.
Weeks later, COVID-19 erupted and made the financial situation far worse. As of Dec. 31, 2020, the national debt had jumped to $27.75 trillion, up 39% from $19.95 trillion when Trump was sworn in. The government ended its 2020 fiscal year with the portion of the national debt owed to investors, the metric favored by the CBO, at around 100% of GDP. The CBO had predictedless than a year earlier that it would take until 2030 to reach that approximate level of debt. Including the trillions owed to various governmental trust funds, the total debt is now about 130% of GDP.
Normally, this is where we’d give you Trump’s version of events. But we couldn’t get anyone to give us Trump’s side. Judd Deere, a White House spokesman, referred us to the Office of Management and Budget, which is a branch of the White House.
OMB didn’t respond to our requests. The Treasury directed us to comments made by OMB director Russell Vought in October, in which he predicted that as the pandemic eases and economic growth rebounds, the “fiscal picture” will improve. The OMB blamed legislators for deficits when Trump submitted his proposed 2021 budget: “Unfortunately, the Congress continues to reject any efforts to restrain spending. Instead, they have greatly contributed to the continued ballooning of Federal debt and deficits, putting the Nation’s fiscal future at risk.”
Still, the deficit growth under Trump has been historic. Steuerle, of the Tax Policy Center, has done a comparison of every American president using a metric called the “primary deficit.” It’s defined as the deficit minus interest costs, because interest is the only budget expense that presidents and Congress can’t control unless they want to do the unthinkable and default on the debt. Steuerle examined the records of 45 presidents to see how the primary deficit had shrunk or grown relative to the size of the economy between the first and final years of each president’s administration.
Trump had the third-biggest primary deficit growth, 5.2% of GDP, behind only George W. Bush (11.7%) and Abraham Lincoln (9.4%). Bush, of course, not only passed a big tax cut, as Trump has, but also launched two wars, which greatly inflated the defense budget. Lincoln had to pay for the Civil War. By contrast, Trump’s wars have been almost entirely of the political variety.
Our national debt is now at its highest level relative to our economy since the end of World War II. After the war ended, the extraordinary military expenses disappeared, a postwar recovery began and the debt began to fall rapidly relative to the size of the economy.
But that’s not going to happen this time. When World War II ended 75 years ago, Social Security was in its infancy and Medicare didn’t exist. Today, many of our biggest and most rapidly growing expenses, especially Social Security and Medicare, are baked into the budget because of our nation’s aging population. These outlays are slated to rise sharply. Steuerle recently calculated that Social Security, health care and interest costs are projected to absorb 122% of the total growth in federal revenues from 2019 to 2030.
What’s more, our investment in the future — things like research and development, education, infrastructure, workforce training and such — is declining as a proportion of the budget. OMB data shows that in 1970, mandatory spending (such as Social Security and Medicare, but not including interest on the debt) and investment each made up around 30% of total federal spending. But as of 2019, the most recent available year, mandatory spending had doubled to around 61% of total federal spending while investment fell by more than half, to around 12.5%.
Spending more and more on past promises and shrinking the proportion of spending for the future doesn’t bode well for our kids and grandkids. Had Trump done what he said he’d do and paid off part of the national debt before COVID-19 struck rather than adding significantly to the debt, the situation would be considerably less dire. And had Trump done a better job of coping with COVID-19, the economic and human costs would’ve been greatly reduced.
In addition to forcing us to reduce the proportion of the budget spent on the future to help pay for the past, there’s a second reason that huge and growing budget deficits matter: interest costs.
Bigger debt ultimately means bigger interest costs, even in an era when the Federal Reserve has forced down Treasury rates to ultralow levels. The government’s net interest cost (including interest paid to government trust funds) was around $523 billion in the 2020 fiscal year. That outstrips all spending on education, employment training, research and social services, Treasury data shows.
Interest costs are way below where they’d be if the Fed hadn’t forced rates down to try to stimulate the economy and mitigate the impact of the pandemic. One-year Treasury securities cost taxpayers a minuscule 0.10% in interest at year-end, down from 1.59% at the end of 2019. The 10-year Treasury rate was 0.93%, down from 1.92%.
In late December, the Fed reported boosting its Treasury holdings by more than $2 trillion from a year earlier. The increase is primarily in longer-term securities. That has kept the federal government from having to raise trillions of dollars in the capital markets, and therefore has kept longer-term interest rates way below where they would otherwise be.
But unless something changes, even the Fed’s promise to keep interest rates near current levels for several years won’t fend off future problems. Most of the government’s borrowing to fund pandemic relief has been shorter-term borrowing that will have to be refinanced in the coming years. If rates rise, so will the government’s interest expense.
Even with rates where they are, interest on the debt is already going to be the fastest-growing budget category this decade, according to the Peter G. Peterson Foundation, which tracks the issue. Annual net interest costs are projected to double in 10 years and grow so large beyond 2030 that interest will become a driving factor in annual deficit growth, according to Peterson estimates.
Listen to what CBO Director Swagel had to say on the subject in a report to congressional Republicans in December: “Although the current low interest rates indicate that the debt is manageable for now and that the United States is not facing an immediate fiscal crisis, in which interest rates abruptly escalated or other disruptions occurred, the risk and potential budgetary consequences of such a crisis become greater over time.”
Trump was asked about this risk during a virtual discussion with the Economic Club of New York last October. “If we have another stimulus bill out of Congress, are you worried that the entire amount of federal debt will be too large for us to pay off in a sensible way?” asked David Rubenstein, a private equity executive.
Trump answered by falsely claiming that the U.S. was starting to pay off the national debt before the pandemic, and he claimed that future economic growth would let it do so. “I think you’re going to see tremendous growth, David, and the growth is going to get it done,” Trump said.
Two months later, when Congress finally approved $900 billion of economic stimulus that is being financed with debt, Trump challenged Congress to spend — and borrow — even more. Then he went golfing.
A CDC lab involved in making faulty coronavirus tests sent to state and local officials early in the pandemic was closed down hours after an October investigation by ProPublica exposed key mistakes the CDC made in manufacturing those tests.
This article was published on Friday, January 8, 2021 in ProPublica.
With no public notice, the Centers for Disease Control and Prevention in October shut down a key lab involved in making faulty COVID-19 tests for state and local health authorities early in the pandemic. The move came less than six hours after ProPublica published an investigation that detailed for the first time the chain of mistakes and disputes that unfolded inside CDC labs, which culminated in one of the biggest fumbles in the agency’s 74-year history.
A CDC acting branch chief told the staff of the Respiratory Viruses Diagnostics Team lab on Oct. 15 that the closure would be for two to four weeks while the CDC investigated and the staff worked on corrective action plans, according to internal sources. But more than two months later, the lab still is not performing tests.
ProPublica’s investigation revealed that Stephen Lindstrom, a respected CDC veteran who led the lab and was in charge of the production of tests in the early days of the pandemic, made a fateful decision in January 2020 to use an internal CDC manufacturing process that was fast but risked contamination. Lindstrom then released tests to state and local public health labs the following month even though one of his staff’s quality checks showed that plain water tested positive for the virus, according to CDC lab records.
Complaints poured in from the state and local facilities shortly after the tests arrived. At that time, Lindstrom’s CDC lab was the only one in the country that could confirm whether a patient had COVID-19, and the scarcity of working tests at state and local public health labs had serious consequences in the early days of the pandemic.
The roots of that early public failure had remained largely a mystery, even to those within the CDC. ProPublica’s account of what transpired inside the lab was news even to some senior CDC officials. The story, based on interviews and exclusively obtained lab records, detailed the mounting pressures on the lab staff, the mystifying appearance of contamination at every turn and the three-week scramble to fix the tests.
Since then, work in the lab has been intermittent, with tests diverted for a time in March and a temporary closure in May. In October, the lab, which by then was no longer managed by Lindstrom, was faulted for making what higher-ups considered an error while handling materials for a new test designed to detect both the flu and the coronavirus, according to people familiar with the matter. It’s not clear whether that issue, the revelations in the ProPublica investigation or a combination of both led to the Oct.15 shutdown.
The CDC media team declined to answer questions about the reasons for the closure or the ongoing efforts to bring the lab back into compliance. Lindstrom referred a reporter to the media team, which did not make him available for an interview.
Debate has simmered within the CDC about whether the flawed tests were due to contamination, which can happen in the best of labs, or a faulty design. Two CDC labs were involved in making ingredients for the flawed tests in January and February last year, and a report by lawyers at the Department of Health and Human Services last June said Lindstrom’s lab was the likely source of contamination.
Lindstrom had created well-regarded tests for the flu, including the first test for H1N1 during that pandemic in 2009. Records show he was adamant that the COVID-19 test design was not flawed and that evidence showed the contamination happened at the other CDC facility that made testing components, not his own lab. In July he was reassigned to a new job with no official title and few responsibilities.
A different CDC scientist familiar with the Oct.15 lab closure said Lindstrom’s lab made mistakes. But the scientist, who asked not to be identified, said there was a sense among some CDC staff that Lindstrom and his team were being scapegoated and unfairly blamed for contamination that may have involved another CDC lab. The scientist believes that shutting down the lab on the day of the ProPublica story was to protect top CDC officials, including the task force in charge of labs during the COVID-19 response. “When something bad happens and it goes public, heads have to roll, and they pick people to take the fall,” the scientist said.
In early April, before COVID-19 hit her state hard, Palestine Howze was in a Durham, North Carolina, nursing home, living in pain.
She had lost her legs to diabetes, and for months she had been suffering through a bedsore. In her medical records, staff noted that Howze, 71, would moan through the night.
Her daughters had been told about the bedsore back in August 2019, and it was a small spot, no bigger than a quarter when Howze’s daughter Lisa saw it. But as it persisted, they wondered why it wasn’t going away. They say the facility reassured them that the wound was under control.
Then on April 2, 2020, Lisa Howze received a call from the nursing home. The sore had become infected.
In fact the bedsore had been worsening for months. By December 2019 it was, in clinical terms, a “stage 4 pressure ulcer.” The wound specialist treating the sore had to resort to cutting away rotting flesh and bone. In early April, the doctor said Howze should be switched to intravenous antibiotics.
Lisa Howze wasn’t told any of those particulars, she said.
What she did sense was that her mother needed more care than the home, the Treyburn Rehabilitation Center, could provide.
So in the days that followed, she and her sisters repeatedly sought to have their mother hospitalized, they said. As the wound worsened, a nurse wrote, “If condition declines,” daughter “would like patient sent to hospital.”
Lisa Howze had her mother’s health care power of attorney, but it seemed to carry little weight with the nursing home.
“We were fighting for her to go into the hospital because we knew they couldn’t treat her,” Lisa Howze said.
Desperate, she contacted the state health department to complain about her mother’s care.
On April 14, Palestine Howze died, still at Treyburn.
And it wasn’t COVID-19. Howze had tested negative.
Her daughters were devastated. “I couldn’t mourn through my anger, because I felt guilty that I had failed her,” Lisa Howze said, “like there was something more I could have done to make them send her to the hospital.”
She wanted answers, and she wanted Treyburn held to account for her mother’s death. So she hired a lawyer to file suit against the facility, which, the family would learn, has a history of low government ratings for quality of care and sizable fines from federal regulators.
But while COVID-19 hadn’t killed her mother, the pandemic was going to make her lawsuit against Treyburn all but impossible to pursue.
As COVID-19 deaths were rising and scenes from the epicenter in New York offered a grim warning of what lay ahead, North Carolina gave nursing homes, hospitals and other health providers remarkably broad immunity from lawsuits.
Signed into law in early May, just days after being proposed, North Carolina’s protections went further than many states, precluding even claims that don’t involve COVID-19 treatment or that stem from staffing shortages that could otherwise be evidence of gross negligence.
Gov. Roy Cooper, a Democrat, had already issued an executive order shielding health workers from being sued in connection with work during the emergency. But the industry wanted broader protections, for hospitals, nursing homes, clinics and medical practices.
A few lawmakers tried to slow down the legislation, warning that the protections were too expansive. But the immunity provisions had been rolled into a COVID-19 relief bill that seemed too important to be delayed. Lawmakers championing the measure told their colleagues to “trust the process.”
Five days after the immunity language was introduced — by a legislator who is himself a physician — the bill was on the floor of the General Assembly. Six days after that, it was signed into law by Cooper. And it was retroactive to the governor’s state of emergency declaration on March 10 — more than a month before Palestine Howze died.
In a state that has cast itself as a friend to industry, the breadth of North Carolina’s protections spoke to the power of Republicans over the economic agenda and the influence of the health care lobby. The industry contributed more money to state legislative races than any other business sector over the past decade, according to the data collected by the nonprofit National Institute on Money in Politics.
For the Howze sisters, the law has upended their quest for accountability. Their lawyer wasn’t even sure she could continue with the case after the immunity provisions were enacted. And after investigating the family’s complaint, the state health department told Lisa Howze that its inspection of Treyburn, conducted several weeks after Palestine Howze died, had not found evidence of “noncompliance.”
ProPublica sent Treyburn and its parent company, Sovereign Healthcare Holdings LLC, a list of questions about the Howze case. ProPublica also said the family had agreed to waive its privacy rights so that the facility could comment.
In response to ProPublica’s inquiry, a lawyer representing Treyburn and its parent company declined to respond to specific questions about the lawsuit, which is being heard in Durham County Superior Court. In court papers, the nursing home has denied that Lisa Howze ever asked for her mother to be sent to the hospital.
In a filing in the case, Treyburn and its parent company said the new law makes them immune from liability, and in another filing, they denied all allegations of negligence and argued that the contract Palestine Howze signed requires her family’s claims to be heard by a panel of arbitrators, not a judge or jury.
“While we regret and sympathize with the Howze family’s loss of a loved one during this difficult time, we feel that the case is defensible, factually and legally, and we would prefer to let the legal process run its course on both fronts,” the lawyer, H. Lee Evans Jr., told ProPublica.
Richard S. Saver, an expert in health law at the University of North Carolina at Chapel Hill, said that many nursing homes were short-staffed well before the pandemic and that by eliminating the ability to claim that staff shortages affected care, the state has made it extremely difficult to hold nursing homes accountable during the pandemic.
“This has been an industry with a long and sad and complicated history of insufficient quality regulation,” he said. “Given that may be the norm and the custom, proving that this is so beyond the pale for bad faith is going to be an uphill battle for plaintiffs.”
“Flying Blind”
Hospitals and nursing homes weren’t the only industries worried about being sued as the pandemic unfolded. Everyone from grocery stores to universities had concerns, and many asked legislators to shield them from liability.
But the health care industry was at the center of the crisis and had extra cause for concern. So across the country, lobbyists for hospitals, nursing homes, clinics and medical practices were working the virtual corridors of power in the first weeks of the pandemic.
The North Carolina Medical Society, which represents physicians’ interests and has over 10,000 members, asked for “blanket immunity for all health care workers” responding to the emergency.
Speaking to state legislators on March 26, the head of the medical society, Chip Baggett, said his members didn’t yet have the resources they needed and were anxious about the potential for malpractice lawsuits.
“We were flying blind in that situation,” he told ProPublica.
In North Carolina and around the country, all eyes were on New York, which was losing hundreds of people a day. There, the powerful Greater New York Hospital Association had drafted legislation asking for broad immunity, and on April 3, Gov. Andrew Cuomo signed a bill with expansive protections.
The New York bill would serve as a template for the lobbying effort in North Carolina, and the industry succeeded in having the language included when the House’s health care working group was drafting the state’s first public health legislation of the pandemic.
In the group’s final meeting before the start of the 2020 legislative session, Republican Rep. Perrin Jones, a practicing anesthesiologist, introduced his amendment to the public health bill that gave broad immunity to health care providers from lawsuits.
“If you are acting in good faith for that patient, then you should be doing the best that you can and not having to worry about civil or criminal liability concerns after the fact,” said Jones (whose last day in office was Dec. 31, after he lost his bid for reelection in November).
The amendment mirrored the measure that had been signed into law in New York weeks earlier. The two pieces of legislation even have the same name: the Emergency or Disaster Treatment Protection Act.
Addressing fellow legislators, Rep. Gale Adcock, a Democrat, said that as a nurse practitioner, she knew how hard working during the pandemic must be for health workers and lauded the amendment. “It really adds a lot to this bill.”
Right before the vote by the working group, Rep. Lee Zachary, a Republican like Jones and the lone lawyer in the group, interrupted.
“I don’t know if it was filed last night, or what, but I haven’t seen it,” Zachary said, and plaintiffs’ groups hadn’t seen it. (Nor had North Carolina’s health department, which regulates the state’s nursing homes, according to the agency.)
Rep. Donny Lambeth, a Republican, who is a health care consultant and former hospital executive, defended the amendment and said there would be opportunities to change the bill in future meetings.
The amendment passed, with Zachary the lone holdout.
Lambeth and Adcock did not respond to requests to their legislative offices for comment about the amendment; Jones, who is no longer in office, did not respond to repeated attempts.
Zachary thought the measure was too broad, and later floated a proposal to narrow it, but said he was told, “It’s going to be the way it is, and that’s the way it is going to be.”
Similar concerns surfaced when the protections reached the House, and Rep. Yvonne Holley drafted an amendment to restrict the measure.
“We’re opening up a can of worms across the state,” Holley told fellow lawmakers in a Rules Committee meeting.
But like Zachary, Holley found little support among her colleagues. Adcock pushed Holley, a fellow Democrat, to withdraw the amendment, and Holley did. (Holley, who lost her run for lieutenant governor last year, left the legislature at the end of her term on Dec. 31.)
When the state’s COVID-19 relief bill was up for a final vote on the House floor three days later, the immunity provision again faced questions, and again it was defended.
“It basically says that if you’re operating in good faith and doing all that you can in this trying time, it provides a limited amount of immunity in case there is a small mistake that is made,” then-Rep. David Lewis told a fellow legislator who questioned the immunity.
The bill passed both chambers unanimously and two days later was signed into law by Cooper. The governor’s spokesman, Ford Porter, declined to answer questions from ProPublica about the immunity provisions.
In New York, legislators faced an outcry over the expansive scope of the liability protections and four months later scaled them back.
But North Carolina’s immunity coverage has expanded. On July 2, the state became one of at least 16 that extends the liability shield to any business for claims that stem from COVID-19 exposure. In Washington, D.C., Republicans have been trying to make similar protections part of national COVID-19 relief, but the Senate majority leader, Mitch McConnell, hasn’t found a way to pass broad immunity for businesses.
Both North Carolina laws were cited by Treyburn in its motion to dismiss Lisa Howze’s lawsuit.
“This is the thing I was trying to fight against,” Holley said after learning of the Howze lawsuit and the nursing home’s efforts to have the case dismissed.
“Mama, Are You in Any Pain?” The Road to Treyburn.
Palestine Howze and her four daughters had always lived near one another in Durham, and they gathered often for family cookouts. The matriarch was active until complications from diabetes started causing intense pain in her legs. Eventually she had to have both limbs amputated above the knee.
She was placed in a series of nursing facilities for rehabilitation after her surgeries. In one, she had a stroke, and soon after she was hospitalized for a bedsore on her tailbone. She was then discharged to another nursing home before the sisters decided to move their mother in with her daughter Lisa.
Lisa Howze was out of work and on disability because of arthritis, but she became her mother’s primary caregiver, changing her mother’s dressings and keeping her wound clean and dry.
Her mother’s health improved and the bedsore healed. Howze family gatherings became a staple once again. “Everything just flowed,” Lisa Howze said.
But Lisa Howze’s energy couldn’t hold out. As the months passed, she found herself increasingly drained.
Her mother had vascular dementia. Sometimes Lisa Howze would have a conversation with her mother, and later she would scream for her daughter to come back, late into the night. Lisa Howze was already caring for a 4-year-old daughter.
One day, when she went to lift her mother from her bed into her wheelchair, she dropped her. It was a warning. “I couldn’t care for her and myself,” Lisa Howze said.
Treyburn, a 132-bed, for-profit facility on the northeastern edge of Durham, was a short drive from the sisters’ homes. The administrator they met was friendly. Like Howze, many of the residents were Black. From what the sisters saw on their first visit, it seemed like a good facility. They said the administrator emphasized the good care Palestine Howze would receive.
But Treyburn does not have a good record. It has a one-star quality rating from the federal Centers for Medicare and Medicaid Services, which means it is in the bottom 14% of nursing homes nationwide. Most of the residents’ care is paid through Medicaid, the state and federal health care program that serves people with low incomes.
In 2018, Treyburn was fined $188,762 for injuring a resident and having a resident sit in a soiled diaper for hours, among other violations. Over a three-year period through mid-October, it was cited more than 30 times by federal regulators, including 12 citations in February related to resident care and treatment. The facility was cited for deficiencies again in July and October, including an incident in which a resident was hospitalized for an infected pressure ulcer.
The facility submitted mandated plans to address the deficiencies cited by inspectors, though it noted that it was not admitting or agreeing to the inspectors’ conclusions.
The facility had one of the highest counts of COVID-19 infections and deaths in the state with at least 73 resident cases and 23 deaths, to go along with 26 staff infections, before its first outbreak cleared in July. The facility had to deal with another outbreak between September and November when an additional three staff members and a resident caught the virus.
The family had checked in on their mother regularly, but months before COVID-19, they say the care she received began to wane. In August 2019, she had developed the new bedsore. Lisa Howze said she was shown the pressure ulcer, and it was just a small circle on her mother’s bottom. Such sores can develop when an infirm person remains in the same position for too long in a bed or wheelchair.
As the wound grew worse, the specialist treating it had to cut away dead flesh, Howze’s lawsuit states. The doctor’s notes indicate that in December 2019 Lisa Howze consented to “additional procedures” for wound care, though she said she was not told how invasive those procedures would be.
When Palestine Howze was evaluated by a nurse in February, she said her wound was causing her “terrible” pain and asked, “When can I go home?” But when her family visited, they say she seemed to hide her suffering.
After Cooper issued a state of emergency on March 10, family visits were halted. Worried that their mother’s condition would worsen without their attention, the family asked about having her taken to a hospital for treatment. Her daughters said Treyburn staff reassured them that the facility could care for their mother.
The nurse who told Lisa Howze about the infection wrote in her notes that she was “very angry her mother’s wound is not healing,” and Lisa Howze said that during that call, she reiterated the family’s request that her mother be moved to the hospital.
Lisa Howze’s lawsuit asserts that in refusing that request the nursing home was failing to meet a good-faith standard of care, a claim Treyburn denies.
Palestine Howze’s medical documents show that the facility was struggling to get an infectious disease specialist to assess the infection. A doctor who was treating Palestine Howze recommended that the nursing home begin providing antibiotics intravenously. On April 3, a facility nurse wrote that there is a “dire need for appointment” with a specialist, but that “due to current situation” obtaining such an appointment “is difficult.”
The next day, Lisa Howze mentioned the infection to her sister Angela, who started to cry. “I thought she was going to die,” Angela Howze said.
Three of the sisters, Earlene, Angela and Lisa, went to Treyburn on April 6 to reiterate the demand that their mother be transferred to a hospital for treatment, Howze states through her complaint.
In a video from their visit. Lisa Howze has her face pressed against the window into her mother’s room. “Mama, we love you. Mama, are you in any pain?”
“Deterrence Matters”
When Republicans took control of both houses of the North Carolina legislature in 2010, it was good news for many in the state’s business community.
The health care industry was among those that welcomed the changes, and in 2011, the legislature strengthened the state’s medical malpractice laws, making claims harder to file and capping what plaintiffs could collect.
In states where similar changes were made in recent decades, researchers at Northwestern University found declines in hospital patient safety. Once the risk of lawsuits fell, so too did hospitals’ incentives to maintain safety, the authors wrote in a recent paper examining the effects of caps in six states. In the years following the reforms, patient care worsened in areas like infection control and surgical injuries, compared with the 26 states that did not change their laws. The paper is being submitted to academic journals for publication.
Northwestern law professor Bernard Black, one of the authors of the study, said nursing homes face a similar risk dynamic. “Deterrence matters, and if you make people more liable, then they are more careful,” he said.
In North Carolina, Hillary Kaylor, the state-funded advocate for residents of nursing homes in the Charlotte area, says that since the greater legal protections were introduced, nursing home operators have become less responsive to concerns she raises on behalf of residents and their families. Now, she says the response is generally: “Yeah, go ahead and call the state. We’ll see if it works or not.”
The new protections came at a time when the pandemic was already making it much harder for nursing home regulators to do their job.
On-site inspections of the state’s nursing homes, which include checks for infection control, declined dramatically during the early months of the pandemic, according to a December report from the U.S. Department of Health and Human Services.
At least 45% of the nearly 7,100 people who have been killed by COVID-19 in North Carolina were residents or staff of long-term care facilities, and many more have been stricken by the disease but survived.
One study done by public health researchers in North Carolina found that nursing homes with a low rating from the Centers for Medicare and Medicaid Services had higher infection and transmission rates of COVID-19, compared with higher-rated homes.
The new law, the Emergency or Disaster Treatment Protection Act, shields a health care facility from cases of negligence if the facility was impacted by COVID-19 in any way and is “providing health care services in good faith.”
By that standard, a claim would have to prove “gross negligence” — that harm was almost assured, and that the facility ignored the obvious risk. But the new law precludes claims of gross negligence that are based on shortages of staff or other resources, problems that are often the most common in long-term care facilities.
State court data through the first few months of the pandemic showed a modest decline in civil suits, including medical malpractice claims, after the immunity was put in place. But those declines could be driven by any number of factors, and data from the second half of the year hasn’t been released. With three years to file malpractice claims and two years to file wrongful death suits, prospective plaintiffs and their lawyers may be waiting to see how the new immunity laws play out.
Black, the Northwestern professor, said given the extraordinary demands of the pandemic, nursing homes may well need a measure of additional legal protection. But he said extending those protections beyond COVID-19 and into otherwise routine care is very hard to justify. “It’s one thing to say you didn’t know about COVID, it’s another thing to say that excuses you for bedsores. Come on, that’s nuts.”
Loss and Accountability
While Palestine Howze was still in Treyburn, Lisa Howze said she called the North Carolina Department of Health and Human Services to report the concerns she and her sisters had about their mother’s care. She hoped the state would check on her mother, but by the time she received an initial response, on April 21, her mother was dead. In late May, the facility was inspected by state nursing home investigators, and in June, the state wrote to Lisa Howze to say her complaint had not been substantiated.
On Palestine Howze’s death certificate, dementia is listed as the cause of death. The document does not reference her infected bedsore, which went to the bone, or the signs of sepsis that were noted in her medical records the day before she died.
Lisa Howze said the omissions only added to her anger and pain as she mourned her mother.
The funeral, carried out under pandemic precautions, was a world away from the family’s cherished cookouts. The coffin was placed in an open field in Glenview Cemetery. Attendance was limited to 15 people.
Palestine Howze and her four daughters were dressed in red, the mother’s favorite color. The sisters were seated by the coffin. The other attendees had to watch the service from their cars.
When the funeral was over, the daughters were told to drive away. They didn’t get to see their mother lowered into the ground.
Lisa Howze said Treyburn had made her feel powerless, and she was determined to make the home answer for her mother’s death.
Two weeks later, the liability provisions were signed into law, and the prospects for the case looked very different.
“I told them I had to drop it,” Todd said.
Still, the death of Palestine Howze stuck with her. In July, she decided to take a chance. If she could prove Treyburn wasn’t acting in good faith, then the new law’s protections wouldn’t apply. Todd concluded that the treatment of Palestine Howze was egregious enough to back up the argument. As required under statutes enacted long before the pandemic, Todd had the case certified by a medical expert before filing.
But with the new law, Howze’s lawsuit faces other hurdles. Not only is the nursing home claiming immunity, but it is also asserting that the family’s claims must be made in arbitration. There, the claim would be decided by a panel of private lawyers paid for by the parties to the case, not a judge or jury. If the case were moved to arbitration, the company could invoke immunity there as well, experts say.
With the courts in North Carolina backed up because of the pandemic, it may be months before the motion to dismiss or the motion for arbitration is decided.
Lisa Howze understands it won’t be an easy case to win. But what she’s learned already about her mother’s care has only made the family’s fight more urgent.
Employers trust brokers to guide them to the best value, but conflicts of interest abound. Tucked into the coronavirus relief bill, a new federal requirement will mandate more transparency.
This article was published on Wednesday, January 6, 2021 in ProPublica.
Like a lot of big federal spending bills, the new coronavirus relief package is a grab bag of unrelated legislation.
And one provision in the 5,593-page measure passed last month could lead to revealing conversations between employers and the brokers they rely on to find them the best deals on health insurance and other benefits.
The Consolidated Appropriations Act, 2021, the much-debated legislation that authorized a new round of stimulus checks for many U.S. households, mandates that brokers disclose to employers how much they make from insurance carriers and vendors.
Health benefits brokers are trusted advisers to employers, who sponsor health plans for about 150 million Americans. But ProPublica showed in 2019 how the insurance industry influences the consultants behind the scenes with cash and gifts — from six-figure bonuses to swanky island getaways. Critics called it "a classic conflict-of-interest" that may cause brokers to put the industry's interests above those of their employer clients, which drives up costs. In response to the ProPublica story, senators proposed legislation to require disclosure of the perks and payments.
Companies provide an array of services to employer sponsored health plans, including traditional health insurance, vision and dental products, pharmacy benefits, third-party administration, claims review and more. Each service provider may provide payments to brokers that might be unknown to the employer. For example, a pharmacy benefit manager might pay a broker a fee for every prescription filled under a health plan. Or a third-party administrator might give the broker a payment for each employee on a health plan.
Under the newly passed requirement, brokers and consultants must tell employers the various forms of direct or indirect compensation they receive from vendors associated with a health plan. The disclosures must take place at the time the employer enters into the agreement with the broker or when it's renewed. The act also requires brokers to disclose their compensation to individuals who purchase insurance plans.
"It is a game changer," said Doug Aldeen, a Texas attorney who specializes in law and regulations related to health plans. The requirement goes into effect in December, a year after the bill was signed into law, but Aldeen said employers should demand the "big reveal" now. "Frankly, it's big money."
A broker's base commission can be 3% to 6% of the total health insurance premium, ProPublica found. That means the broker makes more as premiums go up. Commissions for some supplemental products can be as high as 40%, and bonuses could be as high as $150,000 for a single employer group. Bonuses may be based on the size of employers with a carrier or on keeping employers with an insurer when it comes time to renew. In addition to money, the industry treats brokers to bucket-list experiences, like batting against retired Yankee Mariano Rivera or taking a trip to the Super Bowl or a luxury resort.
Aldeen's clients include the small but growing movement of brokers who have stopped taking industry cash. Instead, they get paid directly by employers, which eliminates the conflict of interest and gives them an incentive to deliver better value.
Adam Berkowitz, a St. Louis broker who has transitioned to having employers pay him directly, wrote about the Appropriations Act disclosure requirement on his company blog. He pointed out that industry payments to brokers are not illegal and have been considered the cost of doing business. But requiring their disclosure will at least alert employers of the potential conflicts of interest, he wrote.
Berkowitz told ProPublica he started his career working for an agency that was funded by industry money. He said emails would come from his bosses, urging brokers to push a particular policy or plan to employers because the agency was close to hitting bonus thresholds. "It's absolutely front and center," he said of the influence of industry commissions and bonuses, "and it doesn't get disclosed to the employers."
Almost a year into the pandemic, supply shortages remain so severe that nurse Kristen Cline reuses her N95 for several shifts while her hospital buckles and patients suffer.
In contrast, getting paid directly by employers "allows us the freedom to be truly independent and work on behalf of the employers," Berkowitz said.
Some of the big broker agencies are worth more than $1 billion, including Marsh & McLennan and Willis Towers Watson. Those two companies declined to comment for this story. The National Association of Health Underwriters, the broker trade group, said in a statement posted on Twitter that it supports transparency, but feels the legislation is redundant, and that the requirements "could be a financial burden on carriers, employers, agents and brokers."
Michael Thompson, president of the National Alliance of Healthcare Purchaser Coalitions, which represents employers, called the new disclosure requirements an encouraging "step in the right direction." Knowing about the payments "is critical for plan sponsors if they are to interpret the advice they are getting day to day from their advisers," he told ProPublica.
In 2019, ProPublica sent the country's largest broker agencies a list of questions, asking if they took various types of bonuses and commissions from the insurance industry players. None of them would answer, but employers may soon be asking their brokers some of the same questions. Health Rosetta, an organization that certifies brokers and already requires them to disclose to employers all their sources of income, uses this disclosure form. It includes 17 types of vendors that may be paying a broker, including medical, disability, wellness, disease management and more.
Dave Chase, a Washington businessman, created Rosetta to transform how employers buy benefits. For employers, learning how much their brokers have been making from the health benefits industry may be "the business equivalent of finding out your spouse was cheating on you," Chase said.
Chase said the next step is to reform the contracts that employers sign with the insurance companies and vendors that provide their benefits. They often limit an employer's ability to access the data they need to analyze their spending, or restrict an employer's ability to audit the claims, to make sure they are paid properly, a problem ProPublica has also covered.
Almost a year into the pandemic, supply shortages remain so severe that nurse Kristen Cline reuses her N95 for several shifts while her hospital buckles, patients suffer and folks nearby socialize maskless as if the pandemic were already over.
This article was published on Thursday, December 31, 2020 in ProPublica.
Nurse Kristen Cline was working a 12-hour shift in October at the Royal C. Johnson Veterans Memorial Hospital in Sioux Falls, South Dakota, when a code blue rang through the halls. A patient in an isolation room was dying of a coronavirus that had raged for eight months across the country before it made the state the brightest red dot in a nation of hot spots.
Cline knew she needed to protect herself before entering the room, where a second COVID-19 patient was trembling under the covers, sobbing. She reached for the crinkled and dirty N95 mask she had reused for days.
In her post-death report, Cline described how the patient fell victim to a hospital in chaos. The crash cart and breathing bag that should have been in the room were missing. The patient wasn’t tethered to monitors that could have alerted nurses sooner. He had cried out for help, but the duty nurse was busy with other patients, packed two to a room meant for one.
“He died scared and alone. It didn’t have to be that way. We failed him — not the staff, we did everything we could,” she said. “The system failed him.”
The system also failed her. Since the pandemic’s early weeks, Cline had complained that the Department of Veterans Affairs, which runs the nation’s largest hospital system, wasn’t doing enough to protect its front-line health care workers. She had filed complaints about inadequate personal protective equipment with the agency’s inspector general and the Occupational Safety and Health Administration, but they had done nothing. Many months into a pandemic, they were still having to ration masks and being asked to reuse them for as many as five shifts.
From Cline’s perspective and that of other health care workers I spoke with from the VA hospital in Sioux Falls, the lack of masks was a symptom of larger failures at the agency overseeing the medical care of 9 million veterans. The hospitals lacked staff and scrounged to find gowns, medical supplies, ventilators — everything needed to battle COVID-19.
While every American hospital was stretched by the pandemic, the VA’s lack of an effective system for tracking and delivering supplies made it particularly vulnerable, according to a recent examination by the federal Government Accountability Office. When the pandemic hit, the agency relied on a few big contractors to supply everything from N95 masks to needles to isolation gowns. Those few big contractors fell victim to a global shortage of masks. And the VA had no reliable tracking system to tell officials what hospitals have, what they need or what was expired. At the Sioux Falls facility, things got so desperate, the supply chain for masks relied on a guy named Steve who gave them out one at time from a nearby warehouse, employees said.
As COVID-19 overwhelmed the antiquated system, VA leadership asked employees at more than 170 hospitals to enter inventory by hand into spreadsheets every day and did “not have insight” into how resources were being deployed, the report said. In other words, the local Best Buy or Walgreen’s had more efficient ways of managing inventory to get supplies to the right place.
The resulting scramble, which ProPublica has investigated over the past eight months, was a disorganized, poorly overseen effort to buy masks and other supplies from just about anyone who said they could deliver. Hoping to compensate for a disastrous lack of preparation, the VA awarded more than 100 contracts worth over $120 million to vendors with whom it had never done business.
The COVID-19 pandemic came at a tough moment for the agency, which was more than a year into a massive reorganization by the administration of President Donald Trump that left hundreds of jobs empty and sent the VA scrambling to hire contract positions to help with, among other things, procurement of supplies.
Kevin Lyons, an associate professor and supply chain expert at Rutgers Business School, said nothing the VA did before or during the pandemic showed it had a handle on its own purchase and delivery of supplies, let alone prepare for a global shortage. His research is exploring how the Trumpadministration’s purge of hundreds of VA staff members created a path to disaster.
VA Secretary Robert Wilkie had boasted about across-the-board staff cutbacks in November 2019, just weeks before the first confirmed U.S. COVID-19 case, noting that he had “relieved people as high as network directors to people at the other end of our employee chain.”
Lyons, an Air Force veteran, told me top VA officials have been able to claim all’s well — even as nurses and doctors describe continued shortages and rationing — because bureaucrats who awarded contracts did little or nothing to track how they worked out. He said the rapid-fire approval of contracts gave “the appearance that we’re doing something. But there was no connection between the nurses and the doctors who actually need it.”
“All they really care about is, you know, signing a contract, and then crossing your fingers and hoping that stuff comes,” Lyons said. “And that’s just not the way that supply chain is supposed to happen.”
Wilkie had acknowledged at one point early in the pandemic that COVID-19 had dried up the agency’s supply chain and forced hospitals to ration critical supplies. The agency has acknowledged the need for improvements to its procurement system. But the VA, which has lost more than 90 staff members to COVID-19, denies that it ever left nurses like Cline with inadequate personal protection. “All VA medical centers have adequate capacity, PPE and supplies to meet current demand, and at no point has a VA facility run out of PPE,” said Jamie Maxymuik, a spokeswoman for the VA Sioux Falls health system, in an email.
Yet Cline and other hospital workers had felt increasingly vulnerable as the raging virus revealed the government’s failure to adequately prepare or to fight back. In late April and May, emails that Cline shared show the VA instructing nurses to stitch together their own fabric masks at home to get through the crisis. The message coming from managers, Cline said, was to be patriotic and do more with less.
“My first reaction was, ‘Which desk jockey sitting at home came up with this nonsense?’” Cline remembered. “And then I thought, ‘Well, at least they are openly acknowledging that they aren’t providing enough protection.’”
In May, Cline had reached out to me, describing the plight of hospital staff dealing with unresponsive VA management. “They have been rationing masks for weeks now, but sending emails daily saying we have plenty of PPE and that rumors of a shortage are completely false. We have suspected for a few days now that they are lying about this,” Cline, 38, wrote.
Her outrage intensified when she read a story I wrote about how the VA awarded a $34.5 million contract to a random mask broker, who then rented a private jet to locate N95s that never existed from suppliers he didn’t know with money from investors he’d never met.
It was just a glimpse at the chaos disrupting the crucial supply chain on which Cline’s existence depended.
States, cities, hospitals and various federal agencies competed against one another for increasingly scarce masks, many held up in Chinese factories or customs. Health care workers like Cline were captive to the machinations transpiring overhead, unsure why they didn’t have the protection they needed.
In this frenzy, masks typically went to the highest bidder. And out of the woodwork came opportunists, counterfeiters, fakes and well-intentioned but clueless mask brokers trying to make a quick buck.
“The incompetence was just stunning to me,” Cline remembers thinking. “If they had just told us what was going on I would have felt better. But instead they just kept saying we have enough masks.”
Through the summer and fall, as I followed a bizarre trail of mask profiteers, Cline kept me aware of the consequences of an unregulated mask market, a situation that might have been comical if it weren’t so crucial to fighting the spread of COVID-19. Cline did not end up contracting COVID-19 but said the months of chaos and collective failure had left its mark.
“When this is over,” Cline told me. “Those of us who don’t die are going to quit.”
Anatomy of a Disaster
How does one account for the incompetence and greed, the poor planning, and the judgment failures at the government’s highest levels that led us into the worst public health crisis in at least a century?
Even if the Trump administration had empowered civil servants to wrangle supply chain logistics immediately — it didn’t. Even if his administration had dusted off and heeded a pandemic response playbook left behind by the Obama administration — it didn’t. Even if Trump had invoked the Defense Production Act to boost domestic mask manufacturing at the first sign of the crisis — it didn’t. Even if everything had gone right, we were in deep trouble before the first American travelers brought back a mysterious respiratory virus from Wuhan, China, and Europe.
The nation had spent years building up emergency medical supplies in a Strategic National Stockpile that was supposed to help us weather a national crisis. But after long stretches of inactivity and inadequate funding, it turns out it wasn’t all that strategic. Jared Kushner, the president’s senior adviser and son-in-law, made it clear that the federal stockpile was not intended to serve the states, leaving them to fend for themselves in the quest for lifesaving supplies.
Retired Navy Rear Adm. John Polowczyk got plucked from the Defense Department in mid-March to lead the White House’s fledgling Coronavirus Task Force. “I walked in,” he told me, “and the National Stockpile had been given out. I did not have a single — really — I didn’t have a single N95 mask, surgical mask, isolation gown, nitrile glove. It had been issued.”
Polowczyk had spent 30 years mastering the complex logistics of getting supplies from manufacturer to user. But the Trump White House, he said, had “no bench depth” of experts to manage purchasing and distributing vital supplies.
It’s exactly as bad as it sounds, said Robert Handfield, a professor at North Carolina State University who interviewed officials who were working inside the federal effort to supply PPE. He detailed his findings in the Harvard Business Review, but early this month, he boiled it all down for me in a quick summary:
“It was a shit show. They had no idea what was going on.”
The VA embarked on a haphazard buying spree through its procurement system, but by the spring, it had to turn for help from FEMA and draw supplies from the stockpile, a “short-term stop-gap buffer” when critical items are not available, according to the GAO. Along with gloves, gowns, swabs and test kits, the VA received more than 8.2 million respirators, and 2.4 million masks.
Despite dire warnings and lessons learned from the SARS outbreak in 2003 and the H1N1 swine flu in 2009, elected officials and administrations led by both parties simply didn’t prepare for what scientists warned was not just a probability but an eventuality.
A 2010 study commissioned by the Centers for Disease Control and Prevention following the swine flu outbreak warned that we needed to stock up on masks or face devastating consequences. The study made sweeping observations about existing and potential breakdowns between the local, state and federal governments.
Today, that report reads like prophecy:
“Delays and conflicts in federal guidance on respiratory protection (N95) led to confusion ...” scientists wrote more than a decade ago.
“States experienced significant challenges with the N95 supply chain …”
“There should be a central repository of N95s which is replenished for future events. Federal contracts with N95 and PPE manufacturers generally should be strengthened …”
By February 2020, as the first U.S. outbreaks began, the stockpile housed just 12 million N95 masks, a fraction of what was needed. That same month, Dr. Robert Kadlec, the emergency preparedness czar in the U.S. Department of Health and Human Services, told Congress that the country needed 3.5 billion N95 masks, itself probably an underestimate. In other words, the country’s stockpile had less than one half of one percent of the masks we needed.
The stockpile was so depleted, that the moment the spread began, the country needed new production inputs, most of which were in China and would take 60 to 90 days to reach U.S. hospitals by traditional export. If we measure the stockpile in time, the U.S. was several months behind before this even started.
By the time the Trump administration pressured domestic manufacturers to ramp up supply and unleashed $17 billion to source supplies in April, it was far too late.
What that eerily prophetic CDC-commissioned study didn’t predict was the beneficiaries of such chaos, of shortages and desperation, and of exceptionally weak government contracting oversight: mask brokers.
We’re so far into this pandemic now that it’s easy to forget just how absurd the notion of a mask broker truly is. In normal times, masks aren’t all that profitable; an N95 should run about a dollar for anyone working on a dusty home improvement project. They’re a cheap widget in a broad catalog of bigger widgets offered by medical supply giants like 3M, Honeywell and Cardinal Health.
Yet the federal government found itself desperate enough to shell out a fortune to unknown people and companies that hadn’t existed just days before.
The gang brought in to help with PPE and other medical equipment included the inexperienced federal contractor whose private jet ride and failed mask adventure inspired Cline to reach out to me; a former NASCAR driver who allegedly tried to sell a trillion N95 masks that didn’t exist; a wealthy tech investor who used the Task Rabbit contractor-for-hire app to pay people to repackage ineffective Chinese masks so they could pass muster with hospitals.
Just to name a few.
As of December, the federal government spent about $8.5 billion to outfit front-line workers with PPE, medical instruments and various other supplies, according to a ProPublica analysis of spending data. It was not all bad. Some brokers delivered a sorely needed product while making a nice profit. And to be fair to the federal government, many states made the same mistakes.
As brokers made their bets, some making a fortune, some making fools of themselves, others making their criminal defense cases, Cline and millions of other health care workers just prayed there would be enough supplies tomorrow.
“Eye of the Hurricane”
I flew out to meet Cline a few days before Thanksgiving, when South Dakota was reporting the nation’s worst COVID-19 infection numbers and nearing 1 in 700 residents dead. While I had only traveled to the Upper Midwest, it felt as though I’d beamed straight into one of Dr. Anthony Fauci’s nightmares.
“If you want to tell the story of why COVID is so bad in America, I think South Dakota is the perfect microcosm of it all,” Cline told me as we met outdoors for coffee.
Just around the corner from the VA hospital where Cline worked, families huddled maskless and gabbed over heaps of pasta at the local Olive Garden. Gov. Kristi Noem had defied calls from public health experts to issue a state mask mandate, and a local one, recently passed by the Sioux Falls City Council, was, in my observation, scarcely observed.
At my hotel, which was connected by a footbridge to the state’s largest hospital, the nonprofit Sanford Medical Center, young people mingled mask-free in the lobby, shouting gleefully over a case of Bud Lights. Around the corner, the hot tub was bubbling, the first I’d seen since March, and was packed with members of two families. It looked ... fun. Like the sort of thing seen in photos coming in lately from Australia, which is averaging zero COVID-19 deaths a day compared with more than 2,000 a day in the U.S.
Cline described a huge disconnect between the devil-may-care attitude of local residents and the reality she was seeing every day. In this alternate universe, she said, there was a “false sense of calm” even as the city moved into the “eye of the hurricane.”
“I had a colleague who went to Sturgis,” Cline said of the August biker rally in South Dakota that may have led to 266,000 new COVID-19 cases. “She said, ‘Well, I drank so much alcohol it probably killed any virus.’ This was a nurse!”
Cline had joined the VA in 2019 after 11 years at Sanford, where her friends kept her posted on their COVID-19 battle. More than 150 COVID-19 patients were filling beds at Sanford, with 27 in the ICU and eight on ventilators, according to state statistics.
Yet the CEO of Sanford, the largest hospital system in the Dakotas, had just days before told thousands of health care workers he’d survived COVID-19 and would not wear a mask because he had “no interest in using masks as a symbolic gesture.” The hospital’s leadership team forced that CEO to retire and sent an email to employees rebutting his comments about masks.
As we sat in the still cold, the city was under silent siege.
Cline and three other VA health care workers I spoke to saw another disconnect between what the VA was saying publicly and conditions on the ground.
“We just had like one surgical face mask for the whole shift,” one VA nurse said, describing a stretch of weeks early in the pandemic when even three-ply blue paper masks were hard to find. “And we were even told to use it for the whole week, which these surgical masks are supposed to just be thrown after single use.”
She said the PPE situation has improved in recent months, but only after the hospital logged 60 COVID-19 deaths. A VA summary of employee deaths shows no medical personnel at the Sioux Falls hospital have died of COVID.
N95 masks, the critical supplies that the CDC recommended for health care workers, were sitting unused in a Sioux Falls warehouse until Cline complained to the VA director. After that, “we magically got fitted for N95s,” this nurse said. “We get it and we stick it in a paper bag, and we use it for five different” shifts.
Such personal accounts were denied by the VA, which signaled to its employees that public comments about hospital conditions would not be tolerated. “In the Spring, Sioux Falls VA Health Care System maintained sufficient PPE for its employees,” the Sioux Falls VA spokeswoman said, noting the agency followed loosened CDC guidelines that allowed for nurses to reuse their masks for several shifts.
The agency was sending mixed messages publicly. Trump had claimed in January that everything was “under control,” but federal contract data showed erratic and desperate purchases with delivery dates for essential hospital purchases that spanned months. Costly supplies sometimes never made it to hospitals, like an order for 5 million masks that in April was diverted by the Federal Emergency Management Agency.
Cline is an outspoken member of the Emergency Nurses Association, an Illinois-based advocacy group, which asked that I point out she’s not speaking on the group’s behalf and offered its own statement:
“When nurses fall ill because of inadequate PPE or other factors in their emergency department, patient care suffers — and that cannot be tolerated. Neither can the ongoing mental stress and burnout ... nurses are suffering because of their daily concern for their personal safety,” ENA President Mike Hastings said.
I expressed amazement to Cline that after spending most of a year tracking mask brokers, watching billions in federal dollars spent to get supplies for hospitals like hers, that PPE was still scarce, rationed or nonexistent in many hospital settings. I had traveled into various outbreaks in Chicago, Los Angeles, three cities in Texas, Pittsburgh, Cleveland, New York and New Haven, Connecticut. Yet nearing the end of this most terrible year, the nation was facing its biggest spike in cases and deaths.
Back in Washington the next day, I opened a sobering email from Cline. Her VA shift had stretched to 15 hours so she could watch over a COVID-19 patient in crisis. No one was available to relieve her. He was delirious, so she and another nurse sedated him and tied him down, which kept him alive.
“It’s like this everywhere,” she wrote. “It just got here later. And the shameful thing is we had 8 months to prepare, and we have made a disaster of it.”
“The Bottom Line”
When Cline first said to me, “The bottom line is it was too expensive to protect us,” I thought she was referring specifically to the VA. This didn’t seem right. The VA alone shelled out at least $77.6 million to get PPE, according to our data analysis, so I asked what she meant.
She said she was making a larger point about politics and economics. The depleted stockpile, the brokers and scams, the open bars and sports stadiums, the insistence on ignoring science, the resistance to wearing masks showed the limits of what Americans would sacrifice to protect themselves and each other.
Those of us lucky enough to be spared the sharp hurt of losing a loved one to this virus, or the palpable loss of a job and income, may still be feeling pressed ourselves under the dull weight of this year and what the virus has done to our way of life.
But for Cline, and many health care workers, that nebulous anxiety comes into high definition every time she puts on a used mask to treat someone who got sick because they or someone they cherish didn’t wear theirs.
It was too expensive to beef up the national stockpile. Too expensive to keep mask manufacturing in the U.S. Too expensive to keep bars closed. The personal cost was too high to stay home or sacrifice rugged individualism for an anonymizing face covering.
And yet as Christmas approached, the early results of Sioux Falls’ mask mandate showed that even the simplest effort could pay off. Cases were trending down.
But Cline had been worn out for weeks, and she wanted to spend time with her boyfriend and her daughter. When I relayed that the VA had categorically denied that nurses were being asked to ration PPE, or that there were shortages early on, she said she was done torturing herself.
The day before Christmas Eve, she told her bosses she was quitting and left her keycard with security.
“Being faceless under PPE for nine months,” she said, “has a way of making you feel inconsequential.”
After a woman with developmental disabilities was raped and gave birth to a child in a state home, a task force recommended changes to improve care for some of Arizona’s most vulnerable residents. Only a third of them have been fully implemented.
This article was published on Monday, December 28, 2020 in ProPublica.
On New Year’s Eve 2018, an Arizona long-term care facility became a crime scene.
A 29-year-old resident with disabilities so profound she could not talk, walk or care for herself shocked staff when she gave birth to a boy. No one had even noticed she was pregnant. Immediately it was clear she had been raped.
In the national outrage that followed the incident at Hacienda HealthCare in Phoenix, Arizona promised to do better. The state, which prized itself on its reputation for providing top-notch services to people with intellectual and developmental disabilities, took action immediately.
Republican Gov. Doug Ducey created a task force charged with finding ways to improve services and protections for some of Arizona’s most vulnerable residents. The task force, made up of more than 40 agency heads, legislators, health care providers, group home operators and advocates, delivered its recommendations more than a year ago. Most of them were supposed to be implemented by the end of 2020.
But a review by ProPublica and the Arizona Daily Star shows that only a third of the 30 recommendations have been fully enacted, with others months or years from completion.
The task force recommended the creation of a central registry to track abusers of children, vulnerable adults and people with developmental disabilities in a single database. That hasn’t happened.
Another goal: training providers, family members and others on how to recognize signs of abuse among people with developmental and intellectual disabilities. That, too, remains incomplete.
Jon Meyers, a task force member and the executive director of The Arc of Arizona, an advocacy group for people with intellectual and developmental disabilities, said many advocates are frustrated by the slow pace of reform.
The most important changes recommended by the task force require money. For instance, it suggested the state may need to increase pay to hire well-qualified care providers and abuse investigators to reduce turnover and foster a safe environment for those with developmental disabilities.
But state agencies — hampered by the demands of the pandemic — have not requested any budget increase for more staff or higher pay levels, and there is no sign the state Legislature is willing to boost funds.
“That’s so obviously not going to happen it’s a wonder we could include it with a straight face,” Meyers said.
Advocates who served on the task force said the Division of Developmental Disabilities, or DDD, the agency charged with caring for people with intellectual and developmental disabilities, ignored recommendations for increased transparency and accountability.
The agency created a website “dashboard” to provide more insight for families and clients. However, it lists only the most basic information about the safety of government-funded residential settings.
Adult Protective Services, which investigates allegations of abuse against people with developmental disabilities, redesigned its website, too. But it’s still not possible to get detailed information, such as the complaint history of a facility.
A spokesman for DDD and Adult Protective Services said the agencies are providing as much information as is legally allowed. But advocates dispute the agencies’ interpretation. They point to other government agencies that require nursing homes and hospitals to disclose far more data.
“At a real practical level, a family member who is considering a group home environment should be able to look at all the complaints that have been filed and the resolutions to get the compliance history for that individual home and that individual provider,” said Will Humble, the executive director of the Arizona Public Health Association and father of a grown son with Down syndrome.
One achievement: The state’s Medicaid agency has accomplished its task of rewriting contracts, including a provision requiring that group homes and other facilities post signs informing people with developmental disabilities, their loved ones and staff about how to report physical and sexual abuse.
But two years later, there are no signs to hang. DDD officials are redesigning them after self-advocates reported that the signs were too hard to understand.
State officials responsible for implementing task force guidelines said that more than half of the task force recommendations were either complete or in the process.
“I actually am really proud of the work that the task force has done,” said Jami Snyder, director of the Arizona Health Care Cost Containment System, the agency that took the lead on the task force. “I think the agencies have done a lot of really phenomenal work since that time. I think we have more work to do.”
Christina Corieri, senior policy adviser to Ducey, said she was impressed with the work of the task force, formally known as the Governor’s Abuse and Neglect Prevention Task Force.
“We have implemented many of [the recommendations]. We are committed to implementing all of them,” Corieri said.
The Department of Economic Security, which oversees the DDD, said in a statement that it remained “committed to ensuring the health and safety of vulnerable individuals.”
“We support the work and recommendations of the Task Force and have strong collaboration across state agencies and with stakeholders in the joint commitment to improve the quality of life for vulnerable Arizonans,” the statement said.
The Wheels of Government
This fall, DDD released instructions to show staff how to recognize abuse, to avoid retraumatizing a victim and to seek out whistleblower status. But with no funding to accompany the mandate, it will be difficult to actually conduct the four-hour training sessions, said Gina Griffiths, director of programs for The Opportunity Tree, a Phoenix-based company that runs group homes and a day treatment program. Griffiths sat on some of the task force work groups.
“I don’t know why any of this has taken as long as it’s taken,” Griffiths said. “The wheels of government really do turn slowly.”
The task force called for all Adult Protective Services investigators to receive training to better recognize signs of sexual abuse in people with developmental disabilities. A spokesman for the agency said that training is underway and should be completed by June 2021.
Task force members did not even address some long-term problems with Arizona’s system. DDD relies upon support coordinators to meet with families and clients to make sure clients are receiving the services and medical care they need. Despite issues of low pay, high turnover and a lack of training, the support coordinators were not even mentioned in the recommendations.
Diedra Freedman worked on the task force and also serves as the chair of an independent oversight committee, which is supposed to safeguard the rights of DDD clients. Her son has autism.
“In two years of work, the bureaucracy has created a flowchart that explains the system, but they have not in any way improved the system,” Freedman said.
Pandemic Problems
The pandemic, of course, helps to explain many of the delays. Task force members, including state officials, have been forced to postpone meetings in order to deal with medical crises.
But advocates like Erica McFadden, executive director of the Arizona Developmental Disabilities Planning Council and a task force member, said that instead of slowing work down, COVID-19 should have sped it up.
The isolation faced by people in group homes and other settings that shut down to visitors in early 2020 makes the possibility of abuse more serious, she said.
If state leaders took seriously the lessons of Hacienda, McFadden said, they “would have ensured how to proactively react to members at this time.”
“This should not be a fight,” she said.
Another challenge for the task force was that several key members left their state jobs, taking valuable institutional knowledge with them. They include the directors of the Department of Economic Security, the DDD and Adult Protective Services.
Other members lost interest, convinced they were not going to make a difference.
G’Kyshia Hughes, who works in social services and is guardian to her brother, who has autism, said she stopped attending meetings when she realized the task force could not accomplish much without funding.
“What’s the point of putting these things together if you don’t know for sure that the Legislature is going to give you funding for it?” she asked. “It’s just a document with no teeth.”
Dana Kennedy, state director for AARP Arizona and a task force member, said that improving safety for those with developmental disabilities is not a high priority for lawmakers in the upcoming 2021 legislative session.
“It’s just maddening to me because we already had a Hacienda. We didn’t get anything done through the Legislature. And now here we are starting another legislative session and ... nobody's talking about it.”
A Healthy Child
A little boy turns 2 on Dec. 31.
He is being raised by his grandparents on the San Carlos Apache Reservation near the town of Globe. His mother has left Hacienda, where she was raped, and now lives in a smaller facility in Phoenix, said John Micheaels, her attorney. Family members would have liked to have her closer to them, but there are no suitable residential facilities nearby.
Micheaels has now settled lawsuits against Hacienda, the state of Arizona and one of the woman’s physicians. The state settled for $7.5 million. Hacienda did not release the amount, nor did the physician. None admitted wrongdoing.
Nathan Sutherland, the Hacienda worker arrested in late January 2019 and charged with sexual assault and abuse of the woman, is awaiting trial. He has pleaded not guilty. His lawyer did not return a call for comment.
Micheaels said that the little boy’s grandparents are raising him as if he were their son, with help from his mother’s six siblings. He said that the boy is healthy, despite concerns over the strong medications his mother was taking to help control seizures.
The family has not spoken with the media, and the latest request from the Daily Star and ProPublica was rejected by the boy’s grandmother.
Said Micheaels: “She told me that thinking about it gives her a pit in her stomach.”
They were pillars of their communities and families, and they are not replaceable. To understand why COVID-19 killed so many young Black men, you need to know the legend of John Henry.
This article was published on Tuesday, December 22, 2020 in ProPublica.
The Rev. Dr. Kejuane Artez Bates was a big man with big responsibilities. The arrival of the novel coronavirus in Vidalia, Louisiana, was another burden on a body already breaking under the load. Bates was in his 10th year with the Vidalia Police Department, assigned as a resource officer to the upper elementary school. But with classrooms indefinitely closed, he was back on patrol duty and, like most people in those early days of the pandemic, unprotected by a mask. On Friday, March 20, he was coughing and his nose was bleeding. The next day, he couldn’t get out of bed.
Bates was only 36, too young to be at risk for COVID-19, or so the conventional wisdom went. He attributed his malaise to allergies and pushed forward with his second full-time job, as head pastor of Forest Aid Baptist Church, working on his Sunday sermon between naps. Online church was a new concept to his parishioners, and during the next morning’s service, he had to keep reminding them to mute their phones. As he preached about Daniel in the lion’s den — we will be tested, but if we continue to have faith, we will come through — he grimaced from the effort. That night he was burning up with fever. Five days later he was on a ventilator; five days after that, he died.
While COVID-19 has killed 1 out of every 800 African Americans, a toll that overwhelms the imagination, even more stunning is the deadly efficiency with which it has targeted young Black men like Bates. One study using data through July found that Black people ages 35 to 44 were dying at nine times the rate of white people the same age, though the gap slightly narrowed later in the year. And in an analysis for ProPublica this summer using the only reliable data at the time accounting for age, race and gender, from Michigan and Georgia, Harvard researcher Tamara Rushovich found that the disparity was greatest in Black men. It was a phenomenon Enrique Neblett Jr. noticed when he kept seeing online memorials for men his age. “I’ll be 45 this year,” said the University of Michigan professor, who studies racism and health. “I wasn’t seeing 60- and 70-year-old men. We absolutely need to be asking what is going on here?”
To help illuminate this gap in knowledge and gain a deeper understanding of why America has lost so many young Black men to COVID-19, ProPublica spent months gathering their stories, starting with hundreds of news articles, obituaries and medical examiners’ reports, then interviewing the relatives and friends of nearly two dozen men, along with researchers who specialize in Black men’s health. Our efforts led us to a little-known body of research that takes its name from one of the most enduring symbols of Black American resilience.
As the legend goes, John Henry was a steel-driving man who defeated a steam-powered drill and died with a hammer in his hand. The folktale celebrates one man’s victory against seemingly insurmountable odds. But it holds another, harsher truth: His determination and strength are also what killed him. The John Henry of contemporary social theory is a man striving to get ahead in an unequal society. The effort of confronting that machine, day in and day out, compounded over a lifetime, leads to stress so corrosive that it physically changes bodies, causing Black men to age quicker, become sicker and die younger than nearly any other U.S. demographic group. COVID-19 is a new gear in an old machine.
In interviews about the young men who died from the virus, a portrait emerged of a modern John Henry: hard-working, ambitious, optimistic and persistent, trying to lift others along with themselves. They were the very people communities would have turned to first to help recover from the pandemic: entrepreneurs who were also employers; confidants like coaches, pastors and barbers; family men forced into a sandwich generation younger than their white counterparts, because their parents got sick earlier and they had to care for them while raising kids of their own.
They were ordinary men. Time and again, it was their fight that was remarkable.
Bates, the only child of a single mother who supported him as a teacher’s aide, made it to Alcorn State University on football and choir scholarships. When his mother got sick with breast cancer, he had to drop out; after she died, he was almost destitute. Over the years, he built himself into multiple men at once, each a pillar to many others: the pastor whose flock depended on his counsel; the mentor known to school kids as Uncle Officer Bates; the assistant football coach and band director; the adoring father to 5-year-old Madison — his “heartbeat,” he called her. Recently he and his wife, Chelsea, a second grade teacher, had launched One Love Travel, organizing excursion packages and cruises as part of their long-term plan to build generational wealth.
He carried the stress of his efforts in his blood vessels, in his kidneys, in the extra pounds that accumulated with each passing year; he had diabetes and hypertension and at 6-foot-6, he was more than 100 pounds overweight. His official cause of death, on April 1, was COVID-19-related pneumonia and acute respiratory distress syndrome.
But Chelsea knows that the virus, no matter how powerful, didn’t kill her husband on its own. It was the years of working nonstop, taking care of other people more than himself, that wore his body down. And when the virus attacked, he couldn’t fight back.
In the summer of 1978, the social epidemiologist Sherman James, then a 34-year-old researcher at the University of North Carolina at Chapel Hill, met the man who would shape his life’s work. At 70, John Martin was a retired farmer who suffered from debilitating osteoarthritis and hypertension. He had peptic ulcers so severe that doctors had to remove 40% of his stomach. Recounting his story in his backyard rocking chair, his cane resting on his lap, the old man had no doubt why his health was so bad: “I worked too hard.”
Born in 1907, Martin grew up in a family of sharecroppers who were only paid half of what their labor in the tobacco fields earned. Throughout the South at the time, most Black farmers lived at the economic mercy of landowners who were employers, landlords and vendors all at once. Martin watched as the system ruthlessly exploited his father; after one particularly harsh winter spent hungry, Martin vowed he would be different. Borrowing $3,725 in 1941, he purchased 75 acres. He had 40 years to settle the mortgage but accomplished the near-impossible: He paid it off in five. “That’s the reason my legs [are] all out of whack today,” he told James.
James listened, spellbound, until Martin’s wife called out, “John Henry, it’s time for lunch.” At that moment, something clicked. Holy cow, James remembers thinking. “It was just like the ancestors were speaking to me.” The power of Martin’s story wasn’t simply that it echoed the legend of John Henry; it also echoed the life experiences of most of the working-class African American men James knew.
Five years out of graduate school, James was among a small group of researchers focusing on one of the most enduring public health problems in the United States: why health outcomes for Black men are so poor. Black men live shorter lives than all other Americans — 71.5 years versus 76.1 years for white men — and have for generations. Black men’s life expectancy didn’t reach 65, the eligibility age for Medicare, until 1995, 30 years after the federal health program for the elderly became law; white men were living into their mid-60s by 1950. The shorter lifespans reflect a broader disparity: Black people have much higher rates of hypertension, obesity, diabetes and strokes than white people do, and they develop those chronic conditions up to 10 years earlier. The gap persisted this year when the Brookings Institution examined COVID-19 deaths by race; in each age category, Black people were dying at roughly the same rate as white people more than a decade older.
For generations, public health experts mostly ignored the disparities. When they did pay attention, they invariably blamed the victims — their “unhealthy” behaviors and diets, their genes, the under-resourced neighborhoods they “chose” to live in and the low-paying jobs they “chose” to work. Their chronic illnesses were seen as failures of personal responsibility. Their shorter life expectancy was written off to addiction and the myth of “black-on-black” violence. Many of those arguments were legacies of the slave and Jim Crow eras, when the white medical and science establishment promoted the idea of innate Black inferiority and criminality to rationalize systems built on servitude and segregation.
Pondering the lessons of John Henry Martin, James began to see what many of his colleagues had been missing. It wasn’t just living in poverty that wore down Black men’s bodies, he hypothesized, but the struggle to break out of poverty. It wasn’t just inequality that made them sick, but the effort to be equal in a system that was fundamentally unjust. “It’s this striving to make something of themselves … to live their lives with dignity and purpose and to be successful against extraordinary circumstances,” James said. “They’re trying to make a way out of no way. It’s the Black American story.”
America has changed profoundly since Martin’s day. Yet the machinery of racial inequality continues to be omnipresent. It’s in the hospitals where Black newborns double their chances of surviving if they’re cared for by Black doctors rather than white ones. In the redlined neighborhoods where poverty and pollution are concentrated — but not affordable housing or grocery stores or reliable internet. It’s in the crumbling, exploitative economies that force parents to risk their lives working long hours for low pay without sick leave. In mass incarceration and voter suppression. In the innumerable hurdles, one piled upon another, that make Black Americans’ climb up the socioeconomic ladder more daunting than ever, their successes more fragile and their setbacks more consequential.
“Everyone thinks about racism as something that is personally mediated, like someone insulting me,” said Linda Sprague Martinez, a professor at Boston University’s School of Social Work who conducts community health research with adolescents and young adults. “But the way in which it’s really pervasive is how it disrupts life chances and opportunity. … These are systems that are designed for you to fail, essentially, and for you to be erased and to be maintained in a certain position in our society.”
Challenging such a relentless machine, through “high-effort coping,” James concluded, requires three categories of personal traits that are major themes of the John Henry legend: tenacity, mental and physical vigor and a commitment to hard work. To measure them, he developed the John Henryism scale, with scores determined by how strongly people identify with 12 statements, including: “Once I make up my mind to do something, I stay with it until the job is completely done,” and, “It’s not always easy, but I usually find a way to do what really needs to be done.”
To score high in John Henryism, you don’t have to be Black or male or economically disadvantaged. But over the years, James and other researchers have found that Black people, especially those who are poor and working-class, do score high and tend to suffer greater cardiovascular risks, perhaps because the innumerable hurdles in their paths require greater effort to overcome. “The stress,” James said, “is going to be far more overwhelming than it has a human right to be.”
Stress is a physiological reaction, hard-wired in the body, that helps protect it against external threats. At the first sign of danger, the brain sounds an alarm, setting off a torrent of neurological and hormonal signals that whoosh into the blood, stimulating the body to fight or give flight. The heart beats faster and breathing quickens; blood vessels dilate, so more oxygen reaches the brain and muscles. The immune system’s inflammatory response is activated to promote quick healing. When the threat passes, hormone levels return to normal, blood glucose ebbs and heart rate and blood pressure go back to baseline. At least, that’s how the human body is designed to work.
But overexposure to cortisol and other stress hormones can cause the gears to malfunction. “Your body’s over-producing, always working hard to bring itself back down to the normal level,” said Roland J. Thorpe Jr., a professor at the Johns Hopkins Bloomberg School of Public Health and founding director of the Program for Research on Men’s Health at the Hopkins Center for Health Disparities Solutions. The constant strain “resets the normal,” he said. As blood pressure remains high and inflammation becomes chronic, the inner linings of blood vessels start to thicken and stiffen, which forces the heart to work harder, which dysregulates other organs until they, too, begin to fail. “Your body starts to wear down,” Thorpe said — a phenomenon known as weathering.
The cumulative effects of stress begin in the womb, when cortisol released into a pregnant woman’s bloodstream crosses the placenta; it is one of the reasons a disproportionate number of Black babies are born too early and too small. Then, exposure to adverse childhood experiences — anything from abuse and neglect to poverty and hunger — continues the toxic stream; too much exposure to cortisol at a critical stage in development can rewire the neurological system’s fight-or-flight response, essentially causing the brain’s stress switch to break. The more stress a youngster endures, the more likely he or she is to have academic, behavioral and health problems from depression to obesity.
Weathering isn’t specific to race, but it is believed to take a particular toll on Black people because of the unique, unrelenting stress caused by racism that wears away the body and the spirit, “just like you have siding on the house, and the rain or the sun beats on it, and eventually it starts to fade,” said Dr. Jerome Adams, the U.S. surgeon general under the Trump administration. Shawnita Sealy-Jefferson, a social epidemiologist at Ohio State University, says the human body isn’t designed to withstand such biological and emotional assaults: “It’s the same thing as if you revved the engine of your car all day, every day. Sooner or later, the car is going to break down.”
The effects of stress can be seen at the cellular level. Researchers have found that in Black people, telomeres — repeated sequences of DNA that protect the ends of chromosomes by forming a cap, much like the plastic tip on a shoelace — become shortened at a faster rate, a sign of premature aging. In a 2018 study examining changes in seven biomarkers in cardiac patients over a 30-year period, researchers found that Black patients weathered at an average of about six years faster than whites. And it was the extraordinarily high rates of hypertension in the Black community that prompted scientists to look at the impact of stress in the first place. By age 55, about 76% of Black men and women develop high blood pressure, versus 54% of white men and 40% of white women, which increases the risk of heart attacks and strokes.
Sustained stress has strong links to obesity, which Black children and adults have at much higher rates than whites. Some of this is physiological: The interplay between cortisol and glucose is complex and insidious, triggering metabolic changes that can lead to diabetes and other chronic diseases. Some of it is psychological and behavioral: Stress is strongly associated with depression and other mental health disorders. “The way that people deal with stress is by strategies that make us feel better,” such as comfort eating, said Thomas LaVeist, dean of Tulane University School of Public Health and Tropical Medicine. Stress and anxiety cause sleeplessness, which itself is correlated with weight gain. The result is often a cascade of health problems — hypertension, cardiovascular disease, metabolic syndrome — that strike early and feed off of each other.
Because Black Americans experience many forms of stress, often at once, researchers have more questions than answers about the specific role John Henryism plays in these outcomes. The study of Black men’s health remains an under-examined frontier, with little in the way of funding or will because “Black men are not viewed as sympathetic,” said LaVeist, and because so few go into the health research professions. He and Thorpe, the Johns Hopkins professor, co-founded the Black Men’s Health Project, the first large-scale national study focused solely on Black men’s needs, with a goal sample size of 5,000. They hope to learn how stressors like segregation and adverse early life experiences impact health outcomes.
If this segregated body of emerging knowledge were to grow and infiltrate the mainstream medical and research communities, James can only imagine how beneficial that would be. Health professionals could build deeper relationships with their patients by better understanding the sources of stress that wreak havoc on their cardiovascular systems. They could test for high blood pressure, diabetes and cholesterol levels more frequently and at younger ages. “Until we can have a society that is more just racially,” James said, “we do need to find these intermediate steps.”
As ProPublica examined the lives lost to COVID-19, themes emerged in the pressure points faced by many young Black men. The wearing down typically begins when they are boys and must become little John Henrys to navigate white spaces or push through the adverse experiences endemic to Black communities. It continues when they grow into men, as most need to navigate the public’s projections of danger with unwavering vigilance. The more they succeed, the more responsibility they feel to lift their families and communities with them, and with that, comes more stress.
As James listened to the stories ProPublica was gathering, he instantly recognized the cycle of striving and succumbing that he has been writing about for 40 years. “They could have done so much more had the struggle not been so intense,” James said. “They were cut down too soon.”
Thomas Fields Jr. was barely a year old when his father first went to prison. The loss altered the trajectory of his life in ways that many children wouldn’t have been able to overcome. His mother, just 17 when he was born, moved with him from the suburbs of Washington, D.C., to Detroit, where her own mother had recently relocated. The city was in freefall: manufacturing jobs were disappearing; crime was surging; middle-class and white flight was stripping away the city’s tax base, eroding vital services and causing schools to fail. Just waiting at the wrong bus stop could get you robbed or shot.
“When you’re a young male living in Detroit, if you live past 18, it’s like you’re 50 years old,” Fields, then 31, said on a Facebook Live chat last year. “I swear that’s how it feels.”
Mitigating childhood adversity requires deep wells of resilience; researchers say one of the best ways to build those reserves is having a nurturing caregiver. In this, young Thomas was exceptionally lucky. His mother worked two jobs and still managed to watch him like a hawk; she told him constantly that she loved him. His grandmothers looked after him after school and during summer breaks. His father, Thomas Sr., did his best to be involved from behind bars, urging him to not make the same mistakes. “I wanted this Thomas Fields to break the mold,” he said.
To do that, Thomas became a little John Henry. He got decent grades, stayed out of trouble and taught himself to cook — healthy food, not the junk so many of his peers ate. After high school, he attended Grambling State University in Louisiana for a couple of years, then joined the U.S. Navy, where he went from being a talented amateur chef to a trained professional. He also became a father. When there were setbacks, he was already planning his next move. It’s a strategy that Black adolescents absorb like the air they breathe and the water they drink, Sprague Martinez said. “The mentality is: ‘Even if this system is not designed to work for me ... I’m going to win this game. I haven’t gotten the prize yet? I must not be working hard enough.’”
High-effort coping can confer mental health benefits even for children raised in the direst of circumstances. Dosha DJay Joi endured the kind of trauma that dooms many children — beatings, neglect, sexual abuse. Born in Chicago, he spent much of his adolescence in group homes in the Wisconsin system. For years he was afraid to talk about the abuse and scared to tell his birth mother he was queer. He learned to channel himself into education and advocacy, helping other LGBTQ and foster kids; he especially wanted to make sure children remained connected with their siblings. He was inspired to study social work because of what he’d been through, said his mother, Kecha Kitchens. “Then a family member got sick, and he didn’t like how the nurses were treating the other patients in the nursing home, so he wanted to become a nurse.”
By the age of 28, Joi had a bachelor’s degree in human services, he had trained as a substance abuse counselor and he was working toward his nursing degree. He served as a court-appointed special advocate for kids aging out of foster care and lobbied lawmakers in the Wisconsin capitol and Washington D.C., forming a special bond with Rep. Gwen Moore, who represents Milwaukee in Congress. But the years of hardship took an enormous physical toll; Joi suffered from hypertension, heart and lung problems and at his heaviest, he weighed more than 500 pounds. When COVID-19 arrived in the Midwest, he was particularly vulnerable. He died on May 14.
For young John Henrys, the psychological benefits of high-effort coping seem to be complicated by what’s happening inside the body. “Typically when you study resilience in any group, and [subjects are] doing well by our typical metrics” — going to college, getting a good job, not taking drugs — “we say, ‘Woo-hoo,’” University of Georgia researcher Gene Brody said. “Logically, we thought this would transfer to have health benefits.” But for Black young adults trying to climb the economic ladder, they found just the opposite. “When you look under the skin, doing blood draws and using other kinds of measures, they look like their health is starting to suffer.”
In more than 25 years spent tracking the health of Black families in rural Georgia, Brody and his colleagues found that adolescents identified by their teachers as being success-oriented already had higher “allostatic loads” — science jargon for wear-and-tear on the body — at age 19 than their peers. By age 25, those from more disadvantaged backgrounds who scored high on the John Henryism scale were more likely to have metabolic syndrome, a cluster of conditions that are precursors to diabetes and heart disease, than people from less disadvantaged backgrounds. Brody and his colleagues have dubbed this phenomenon“skin-deep resilience.” The same effects are not found for young white strivers.
In his late 20s, Fields was diagnosed with such a severe case of diabetes that his military career came to a screeching halt. When he returned to Detroit last year, he was a little brawnier, with more tattoos. “Diabetes was something that he was going to beat, because he wasn’t going to lose to anything,” said the Rev. Torion Bridges, one of his best friends for 20 years. He became a personal chef and motivational speaker, started a podcast and wrote a cookbook. He helped out his mom, who had multiple sclerosis. And he took a job as a “school culture facilitator,” working with kids who had discipline problems, at Paul Robeson Malcolm X Academy, the pioneering Afrocentric public school he had attended. He was especially good with troubled boys who didn’t have a father at home, said principal Jeffrey Robinson, his onetime homeroom teacher, later his boss. “He could identify with the feeling of the loss.”
In March, Fields and his mother caught the coronavirus at the same time.
She recovered. He did not.
To navigate life as a Black man is to be constantly vigilant. The ubiquity of racism means that everyday interactions, while driving or shopping or birdwatching, can have potentially dangerous outcomes. So John Henrys live in a heightened state of awareness, continually adjusting. It might mean placing family photos near the front door to quickly prove your son belongs should police ever respond. It often means being able to “strategically assimilate” — to assume a public identity aimed at neutralizing stereotypes of blackness and defusing irrational white fears. This, W.E.B. DuBois explained more than a century ago, is “double-consciousness, this sense of always looking at one’s self through the eyes of others, of measuring one’s soul by the tape of a world that looks on in amused contempt and pity.”
New York Times columnist Brent Staples would whistle Vivaldi in graduate school to signal that he was too cultured to be threatening. Darrell Hudson, who researches health disparities at Washington University in St. Louis, scans the closet each day before teaching class to select what he calls his “Non- Threatening Black Guy Uniform.”
“What’s not appreciated fully, I think, is how much energy it takes,” said Derek M. Griffith, professor and director of the Center for Research on Men’s Health at Vanderbilt University. “All of these different things that you have to do to modulate your body and so forth, all that additional attention that you have to pay to that, is a burden that most people don’t have to bear. It is a cause of weathering that we don’t fully appreciate.”
A 2014 study found that vigilance was positively associated with the prevalence of hypertension for Blacks but not whites. The more vigilant Black people were, the more the disparity grew. And researchers have found that Black people who are on guard against anticipated discrimination have higher blood pressures while they sleep. “When you experience racism or discrimination and it could cost your life, it’s good to be vigilant; but a prolonged and heightened state of vigilance is not good,” the University of Michigan’s Neblett said. “It can kill you in the end.”
Leslie Lamar Parker grew up in the Minneapolis suburbs, in a state that was 84% white. Like many John Henrys in this story, he was large — tall and wide — in a way that made him stand out to cruel classmates and clueless teachers. Bigness can be perilous for Black boys, who are often seen as older, stronger and less innocent than their white counterparts, stereotypes that underlie higher rates of school discipline and police violence. Parker learned to play the class clown and questioned authority. “School couldn’t hold his attention, not because he wasn’t smart. He wouldn’t go,” his mother, Tyuon Brazell, said. Because he wasn’t on track to graduate, she did what other parents might not and suggested he drop out his junior year. That’s when he started to thrive, earning his GED, graduating from college and becoming an IT specialist in his old school district, where he mentored students of color, ordering them lunch from DoorDash and supervising the tech club. “That was really important to him,” said his wife, Whitney, “making sure they didn’t fail any other brown kids like they failed him.”
One key to his coping was overcorrecting for how he might be perceived. Strangers would approach him to say how lovely it was to see him with his son and daughter, a microaggression masquerading as a compliment. He was so sensitive to stereotypes about absent Black fathers, his wife said, he was “a present parent on steroids.” To walk through the world as a Black man is to be simultaneously hypervisible and invisible, under surveillance yet never really seen. So he turned his wardrobe into a “conversation starter,” an expression of his irreverent personality but also armor against snap judgments about his imposingness. He carried a Spongebob SquarePants backpack to work and often wore a pro-wrestling or superhero T-shirt during off hours.
Parker was constantly scanning the horizon for threats against his family and his kids at school, wondering whether there was something more that he could do for them. He projected a cool demeanor, his argumentative wit camouflaging worries that his mother knew kept his head in overdrive. “I kept telling him: ‘Son, you need to rest. You don’t have to do everything in a day.’” He was diagnosed with high blood pressure at just 27 and worried it, and the extra pounds, would keep him from seeing his two children grow up. He died in May from COVID-19 at the age of 31.
The effort it takes for Black people to navigate mostly white spaces — to get an education, earn a living, take out a loan, raise a child — can be caustic. Their credentials are questioned; expertise doubted. On college campuses, Black students are often asked if they’re on a sports scholarship or if they’re really students. Research shows that a person doesn’t need to be the target of a racist incident for his body to be affected. Watching videos of police killing Black people or even just anticipating a racist experience can trigger the fight-or-flight response. Incidents build up in memories and transform into chronic stressors; ruminating on them can activate the body’s biological stress reaction. This happens over and over again, often many times a day, until the cortisol pump essentially breaks.
Joshua Bush, who died in April of COVID-19, slammed up against racial stereotypes in his work as a nurse in South Carolina. There were funny looks from people who didn’t expect to see a Black man when he arrived at job interviews and white patients who refused to let him touch them. He told them, “That is your choice, but you’re missing out on great help,” his mother, Linda, recalled. He and his wife, LaKita, saw the health care industry as their route to upward mobility. She worked in hospital administration; at 30, he was studying to become a registered nurse, working as an LPN.
Bush also suffered from a rare enzyme abnormality that caused severe muscle cramps from overexertion, and because of it, trips to the emergency room weren’t uncommon. He’d come to accept that the first image doctors and nurses saw — someone Black and overweight — influenced their bedside manner. They treated him like he had no medical knowledge and lectured him about diabetes, though it had nothing to do with why he was seeking care. His experience informed the way he cared for his own patients, part of his “fight against the system,” his wife said. At the same time, she could see her husband’s stress “all over his body.”
Lifting as we climb, onward and upward we go. Words that started as a call-to-action at the rise of the Jim Crow South have become an enduring part of the African American experience — and can serve as a unique form of stress. The proverb was born of Black suffragist Mary Eliza Church Terrell’s belief that it was incumbent upon the growing Black middle and upper class to use their position to fight racial discrimination and help others rise through education, work and community activism. It is why Thomas Fields was told as a boy that he was “duty-bound” to give back to the community once he got an education. Why Dosha Joi advocated for young people in the system “because someone helped bring out the sunshine in me.”
“You’re socialized to say it’s not just about you. It’s really about what you’re going to do for your broader community and for your family,” Washington University’s Hudson explained. “People take it very seriously, trying to light a path for those behind them — even when they’re not necessarily in the most stable situation themselves. … But they’re lifting as they climb. That’s taxing. That’s a visceral stress.”
In the Brookhaven, Mississippi, of Eugene Thompson’s youth, Black business owners understood that Brookway Boulevard — at least the stretch that ran through downtown — was for white businesses. The election of Barack Obama was a turning point; Thompson figured if a Black man could become president of the United States, surely he could rent a modest space on “the Boulevard.” Publicly, his goal was to grow his client base by cutting white people’s hair, too. His family knew his aspirations were grander. “He wanted to do something in Brookhaven to help Black people to get off their knees,” his mother, Odell Edwards, said. “We are on our knees.”
It’s not easy earning a living in Mississippi, where the single most common job is working as a cashier and the $7.25 minimum wage hasn’t budged in a decade. Cutting hair came naturally for Thompson, who started on himself at 12. He attended a local beauty academy before he could afford to go to barber school and over the years took the same methodical approach to growing his business — buying secondhand equipment, doing the construction himself, all without bank loans, mentoring or government support.
But Thompson’s real ambition was to start his own school. “He always tried to encourage the boys in the community, or people who had been in prison and couldn’t find a job — ’I can teach you how to cut hair and you can have your own business,’” his younger sister, Dedra Edwards, said. After three years spent earning his teaching credential, Thompson opened his TaperNation Barber Academy for students last fall. Then he realized graduates needed places to work, so he launched his next project: renovating a second shop nearby where other barbers and hair stylists could rent chairs.
“It was running him ragged,” Odell said.
At 46, Thompson was severely overweight and suffered from lifelong respiratory problems as well as anxiety and sleeplessness. High blood pressure and diabetes ran in his family, but Thompson’s true health status was unclear — like more than 15% of Black people in Mississippi, he wasn’t insured and avoided going to the doctor except in an emergency. When he started feeling symptoms of COVID-19 in late March, he shrugged them off at first; he’d been having heart palpitations and panic attacks, which his family attributed to stress from work.
After he died in early April, leaving behind six children, TaperNation had to shut down. “You have to have a barber’s instructor license to keep it going, and no one else in the family has one,” his sister said. “We had to sell almost everything.”
Recent disasters — Hurricane Katrina, the Great Recession — have shown that Black communities aren’t just more vulnerable than white populations to economic and social dislocations; they recover more slowly. The impacts of the pandemic are likely to be magnified because so many deaths have occurred among Black people under age 60, the peak earning years when people raise families, start businesses, amass social capital and create lasting legacies. In addition to the lives it took, COVID-19 has robbed wealth that John Henrys were only beginning to accrue and toppled what they had begun to build for themselves and those around them.
In many cases, they were the structural beams, holding everything up. “These are people who help pay bills for people who aren’t their biological family members,” said Sealy-Jefferson, the Ohio State social epidemiologist. “They bring food when somebody dies. They watch kids when a single mother has to work.” Some of the biggest losses are intangible, she said: “social support, emotional support, resource sharing, encouragement, storytelling, role modeling— all of these things that are vital for African Americans in particular, given our history in this country.”
Fields couldn’t comfort students reeling from a crisis that has killed more than 1,600 of their loved ones and neighbors. “It’s a tremendous loss,” said Robinson, his principal. Bates’ wife, Chelsea, was too bereaved to go back to work when school resumed, which meant living off of her husband’s death benefits and savings; she focused on trying to help Madison process a grief she’s too young to understand. “Sometimes she lays on the floor and kicks and screams that she wants her daddy, that she misses daddy and why did he have to leave?” she said. “I tell her, I’m sorry, I wish that mama could do something to bring him back. I really do.”
Weekday mornings have been quiet without Kendall Pierre Sr. puttering around the house before sunrise so he could open his barbershop by 5 a.m. That’s when workers from nearby chemical plants would stop in for a cut or shave after their graveyard shifts. Sundays are different without his sermons at Mt. Zion Baptist Church, in the little town of Ama, Louisiana, followed by a family breakfast his son always looked forward to. “My grandmother would come. Some of my aunties and cousins. He would put Aunt Jemima batter in the waffle iron and say: ‘See? This is better than Waffle House!’”
Since his dad died in May of COVID-19, Kendall Pierre Jr., a 20-year-old student at Louisiana State University, has felt an overwhelming absence and, at the same time, his father’s equally consuming presence. “I can still hear him,” he said.
Don’t drive with your hoodie on.
Work twice as hard.
Real men don’t wear slippers in public; put on some shoes.
The only child of a single mother, 45-year-old Pierre Sr. took his role as father figure seriously. To nieces and nephews, he was Uncle Dad. To his sons’ basketball teams, he was Coach Kendall with the pep talks.
If a task has begun, never leave it until it’s done.
Be the labor great or small, do it well or not at all.
When players couldn’t afford uniforms or travel for tournaments, he would pay. “Their parents would send them with all they could, which was sometimes only $5,” Pierre Jr. said. They could count on him for food, deodorant, even a haircut. “He would bring his clippers to make sure all the players looked nice.”
When the killing of George Floyd roiled the country, Pierre Jr. had no doubt about how his father would have reacted. He would have talked to officials at the sheriff’s office, school board administrators, government leaders. He would have organized community meetings at the church.
We’re living in troubled times.
His son thought about that when his friend texted him about organizing a Black Lives Matter protest. “Since my dad passed, I’ve had this newfound courage, and this urge to act on things … to just do things outside of my comfort zone,” he said.
On a Saturday morning in June, 400 people joined in the 2.6-mile march from Westbank Bridge Park to St. Charles Parish Courthouse. A local reporter covered it and interviewed Pierre Jr. for a story. “If we don’t speak about systemic racism and police brutality, no change will ever happen,” he said. “I feel like it’s something that I have to do and be a part of something bigger than just me.”
He knows his father would have been proud. His mother was. But she worries, too. Her husband didn’t make enough time for doctor’s appointments to monitor his Type 2 diabetes, nor did he get much sleep. “I would tell him, ‘Kendall, you need to rest,’” recalled Sabrina, his wife of 24 years and a registered nurse. “He would say he could rest when he’s dead and gone.”
She knows how much goes into taking care of yourself as a Black man and thinks about that every time her sons walk out the door; her daughter, too. “Lord, I pray for them. … I tell them: ‘Put the seat belt on, drive the speed limit. Make sure you don’t get any tickets.’ I don’t want them to get stopped by a cop.” Her husband’s stature in the community conferred a kind of protection. “Because of my husband and who he was, people would be looking out for my sons. We don’t have that anymore.”