LOS ANGELES — The inmates huddled near the front or lingered on the bunk beds lining both sides of their narrow, crowded dorm at the Men's Central Jail, listening as Lt. Sheriff Dwight Miley and nurse practitioner Marissa Negrete offered them COVID vaccinations and answered their questions.
Those who wanted the vaccine should line up at the door, Miley and Negrete said. They'd be taken into a short, cramped hallway where medical workers waited with loaded syringes.
The shot wasn't mandatory, Miley said, but he encouraged them to get it by dangling a carrot that might seem odd to someone on the outside: Being vaccinated would help them get transferred more quickly to state prison.
"Who do you think they'll take first from here — those who've been vaccinated or those who haven't?" Miley asked the detainees. "Common sense says they'll choose those who've been vaccinated."
Many people who have been convicted and sentenced to long terms in state prison are eager to get there. But because of COVID, transfers from county jails to the state prison system have slowed significantly in the past year.
Jails and prisons have been virtual COVID petri dishes: The infection rate among the nation's prisoners is more than five times higher, and the mortality rate three times higher, than among the general population.
Among the Los Angeles County inmates who agreed to be vaccinated, a common incentive was that they believed — in line with Miley's urgings — it would get them to state prison sooner.
"I took the vaccine to go upstate quicker," said Anthony Contreras, 29, who has been in the jail for three years and was sentenced in February to a term of 15 years to life for attempted murder. Arturo Mendoza, 42, sentenced to six years in prison for illegal firearms possession, said he got the injection to avoid getting sick, but added: "I prefer to be upstate because the living is better."
However, being vaccinated will not necessarily get inmates to state prison faster, said Vanessa Nelson-Sloane, director and founder of Life Support Alliance, an advocacy group for life-term prison inmates. Decisions on sending county jail inmates to state prison are based more on legal factors than vaccination status, she said.
One reason L.A. County inmates want to expedite their transfer is that state prisons are once again open for family visits after a 13-month halt, while the jail is still closed to visitors.
Moreover, prisons offer numerous courses and vocational programs, and prisoners who enroll in them can get time shaved off their sentences, Nelson-Sloane said.
In the Los Angeles County Jail system — the biggest in the nation, with an average of over 15,000 inmates on a given day — 4,313 inmates have tested positive for COVID since the pandemic started. That's more than any jail system or individual prison in the United States, though not the highest per capita rate, according to UCLA's COVID-19 Behind Bars Data Project.
Men's Central Jail, the largest and oldest of the seven county-run detention facilities, has seen the highest number of those cases.
For the first couple of months this year, the jail administered the Moderna vaccine, which requires two shots about a month apart. That created added anxiety for certain inmates and logistical complexity for the medical team, since the jail has high turnover and many incarcerated people leave before receiving a second dose.
When the jail started getting bigger shipments of the Johnson & Johnson vaccine, which requires only one shot, the medical staff and many of the inmates were happy about it.
"Johnson & Johnson is our preferred vaccine," said Dr. Sean Henderson, chief medical officer of L.A. County's Correctional Health Services. "Given that they are often in my care for such a short period of time, and given the fact that it appears Johnson & Johnson has the same long-term efficacy in terms of keeping you from becoming ill or dying, Johnson & Johnson does make more sense for our patient population."
Several of the inmates said they had initially declined when they were offered the two-shot Moderna vaccine but changed their minds with the option of a single shot.
Of the 8,722 total vaccine doses given to inmates as of Friday, 17% were Johnson & Johnson, Henderson said. Fewer than 4% of the shots given nationwide have been Johnson & Johnson.
On April 13, federal health officials recommended suspending use of the single-shot vaccine over concerns about a possible link to a rare type of blood clot. For the next 10 days, the county's jails were giving only Moderna, but the Johnson & Johnson suspension was lifted Friday.
So far, just over 4,000 L.A. County Jail inmates have been fully vaccinated, Henderson said — about 26% of the jail system's average daily population. That compares with 60% in the California state prison system.
But county jails have much higher turnover rates than state prisons, and Henderson's team has not vaccinated as many of the short-term inmates as it would like.
Instead, the medical team has been targeting longer-term inmates, including those awaiting transfer to state prison and nonviolent prisoners who have been returned by state prisons to serve the rest of their sentences in county jail.
Despite the high risk of infection among incarcerated people, California granted vaccine access to them more slowly than to some other high-risk groups, including nursing home residents and seniors. Officials in the Golden State did not start vaccinating all jail and prison inmates, regardless of age or health status, until March 15.
Florida delayed even longer, blocking vaccine access to prisoners until the first week of April.
The crowded, unsanitary conditions in which inmates typically live make them highly susceptible to infection, and their high rate of chronic diseases puts them at greater risk of severe COVID illness. Jails and prisons are disproportionately populated by Latino and Black men, who have been hardest hit by the pandemic. In the L.A. County correctional system, 31% of prisoners are Black and 53% are Latino.
Now that jail officials have the green light to vaccinate all inmates who want to be vaccinated, they face another challenge: vaccine hesitancy.
Henderson said about half of L.A. County Jail inmates decline when asked if they want the vaccine, though some change their minds after repeated offers.
A survey published in December by the Centers for Disease Control and Prevention found that 55% of jail and prison inmates would hesitate or refuse to take the vaccine. Willingness to be vaccinated was lowest among Black prisoners and people ages 18 to 29. The most common reason for refusal was distrust of government and other institutions.
Andre Moore, a 33-year-old inmate in the Men's Central Jail who said he was wrongly convicted of sexual assault and sentenced in October 2019 to a long term in state prison, refused the vaccine because "I don't think anything the government does is good."
Living in a crowded dorm with inmates who are less meticulous about hygiene than he is, and where many don't wear masks, makes him worry about getting COVID. "But I'm way more nervous about the vaccine," Moore said.
Sharon Dolovich, a UCLA law professor who created the COVID-19 Behind Bars project, said corrections officials need to try to instill trust in the inmates. "With this population, you can't just go in and say, 'Here's the vaccination, take it,'" she said. "There's a lot of distrust and resentment and fatalism."
After a year of much public lionizing of doctors and other health professionals on the front lines of the COVID fight, it's a lot harder to make the case hospitals are fleecing patients.
This article was published on Thursday, April 29, 2021 in Kaiser Health News.
DENVER — Before the pandemic, Colorado looked set to become the second state to pass what's known as a "public option" health insurance plan, which would have forced hospitals that lawmakers said were raking in obscene profits to accept lower payments. But when COVID-19 struck, legislators hit pause.
Now, after a year of much public lionizing of doctors and other health professionals on the front lines of the COVID fight, it's a lot harder to make the case hospitals are fleecing patients.
"It is much more difficult now that we have this narrative of the healthcare heroes," said Sarah McAfee, director of communications for the Center for Health Progress, a Denver-based health advocacy organization that pushed for the public option. "Part of this is separating the two: The people who are providing the healthcare are not the same as the corporations who are focused on the bottom line."
Colorado legislators had tried to walk a tightrope, targeting their criticism toward the business side of the industry while continuing to praise front-line health workers and trying to get buy-in from all sides. But on Monday, Democratic legislators said they'd made a deal with the health industry to scrap the public option and instead mandate lower premiums for those buying coverage on the individual or small-group markets. The bill still must be approved.
Colorado's compromise highlights the political tap dance likely to play out across the country as the pandemic changes the political discussion on healthcare costs. With states including Connecticut, Nevada and Oregon also considering public option plans this year, Colorado's example may be a sign that major healthcare upheavals will be delayed for at least another year as hospitals, providers and insurers unite and push back together.
"Nationally, there's little appetite to pursue policies that would potentially cut revenues for hospitals and other providers," said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University. "It's very hard to do when the public sees these providers as true heroes."
At the start of this year's legislative session, Colorado Democrats had proposed giving the health industry four years to reduce health insurance premiums by 20%. Failure to meet that target would have triggered a state-designed public option plan in 2025 that would likely undercut the cost of private insurance plans. Proponents argued that as a nonprofit-run plan without the need for hefty spending for administration, marketing and profit, it could pass on significant savings to consumers. To lower premiums, insurers would have to pressure providers into taking lower payments for their services.
Instead, under the deal reached with the health industry this week, insurance plans would commit to reducing premiums by 18% over three years. If they fail to do so, insurers would have to justify their premiums and state officials would get some say over provider payment rates. Those rates would not dip below 165% of Medicare rates for hospitals, or 135% for other health providers. Hospitals had been pushing for a floor of 200% of Medicare, and physician groups are still negotiating with the bill sponsors to increase their minimum rates.
The state would design a standardized benefit plan that would limit the insurance companies' ability to skimp on benefits or increase cost sharing to make up for the drop in premiums.
Democratic Rep. Dylan Roberts, the legislation's lead sponsor, said the compromise would offer significant cost reductions for Coloradans, a benefit that was ultimately more important to him than how those savings were achieved.
"Healthcare access is the No. 1 thing I hear from my constituents," Roberts said. "Do they care whether their health insurance product is coming from a public entity or a private insurance company? I don't think they care as much about that as whether it's affordable."
But some disconnect may be occurring between what people say they want and the political will at the Statehouse to take on the unified healthcare industry. According to a November poll by Healthier Colorado, 66% of Coloradans supported the public option plan, including 78% of Blacks and 76% of Hispanics. That's virtually unchanged from polling done before the pandemic and after a hefty advertising campaign against the legislation.
Kyle Piccola, spokesperson for the advocacy group, said polling in some of the more rural, conservative districts showed 57% to 66% support. About 40% of those identifying themselves as Republicans supported the bill as it was.
"This data point," he said, "is really showing that everybody, regardless of who you are, is really feeling the high cost of care."
Democrats have the votes to push just about any bill through the House and Senate on their own, and Democratic Gov. Jared Polis had supported a public option after campaigning on the issue. But Joe Hanel, spokesperson for the nonpartisan Colorado Health Institute that analyzes health policy, said the sponsors likely courted industry and Republican support to avoid having opponents undermine the effort for years to come, as happened on the federal level with the Affordable Care Act.
"It just really seems like they just want buy-in to make this be more durable, and not be a lightning rod, not have millions of dollars of ads out there against them for years, like they are right now," Hanel said.
Industry groups had opposed last year's bill and the initial proposal this session. National groups ran a campaign with TV ads and mailers warning consumers a public option would put hospitals out of business. With the compromise, Colorado hospital, insurance and other provider associations have withdrawn their opposition.
Still, the new proposal passed its first test along a strict party-line vote in a House committee on Tuesday, as the pandemic loomed heavily over the debate. Republicans argued healthcare is dramatically different now than when a 2019 actuarial analysis suggested hospitals could easily absorb lower payment rates.
"And nothing has changed in the medical world since 2019?" Republican Rep. Hugh McKean asked the sponsors, tongue in cheek. "There hasn't been any big stuff that we're still in the middle of?"
Hospitals have also taken every opportunity to remind legislators of their role in battling the challenges of the past year.
"These are the very same hospitals who supported Colorado at every turn during the COVID-19 pandemic. They were and continue to be there for their communities," said Chris Tholen, president and CEO of the Colorado Hospital Association. "It is critical that we carefully implement this legislation and monitor it to be sure that hospitals can continue to be vital resources for their communities."
An analysis done on behalf of the Colorado Business Group on Health found that Colorado hospitals averaged a 15.6% profit margin in 2018, beating out Utah and California for the highest margins in the country. While financial data for 2020 has not yet been released, Roberts said, many of the larger hospital systems did well amid the pandemic. They also benefited from millions in federal relief money. The bill would provide additional support for many of the smaller or rural hospitals that have struggled.
Those provisions were not enough to assuage Republicans.
"If we want to have good healthcare providers in Colorado, we can't cut their funds while they are recovering from COVID," said Colorado GOP chairperson Kristi Burton Brown. "This bill completely disregards our healthcare workers and our healthcare facilities. At a time when we should be ensuring they can operate in Colorado, the Democrats are working to shut them down."
Colorado has been aggressive on healthcare policy in recent years, pushing through measures aimed at reducing healthcare costs for its residents. Proponents of the public option bill have played up the example of the Peak Health Alliance, in which communities in seven counties in western Colorado negotiated price concessions from hospitals, lowering premiums by 20% to 40%.
Tamara Pogue, a Summit County commissioner and former CEO of the alliance, said she saw similarities between the bill's approach and the Peak Health model. "It's creating incentives for the industry and the communities to work together," she said.
The Peak Health example helps to fend off criticisms that cutting costs would close hospitals and reduce access.
"We don't even have to entertain hypotheticals," Roberts said. "We have a real-world example there."
In his first speech before Congress, President Joe Biden argued it was time to turn the coronavirus pandemic into a historic opportunity to expand government for the benefit of a wider range of Americans, urging investments in jobs, climate change, child care, infrastructure and more.
Biden said that taxes should be increased on corporations and the wealthy to pay for new spending, as well as to address escalating inequality.
"My fellow Americans, trickle-down economics has never worked. It's time to grow the economy from the bottom up and middle out," Biden said.
He repeatedly urged Congress to act on a variety of measures, including issues like gun control and immigration that have frozen Congress for decades. He said police reforms proposed in the wake of the death of George Floyd should be enacted and specifically urged bipartisan consensus.
"I know the Republicans have their own ideas and are engaged in productive discussions with Democrats. We need to work together to find a consensus," Biden said.
The coronavirus pandemic limited the audience to 200 masked and distanced members of Congress and other officials, down from a typical audience of about 1,600.
Only two members from the president's Cabinet were invited: Secretary of State Antony Blinken and Defense Secretary Lloyd Austin. Chief Justice John Roberts represented the Supreme Court. First lady Jill Biden's guests were invited to watch the event virtually.
And for the first time in U.S. history, two women sat directly behind the president as he delivered his speech: House Speaker Nancy Pelosi (D-Calif.) and Vice President Kamala Harris, the first woman to serve in that position.
"Madam vice president," Biden said. "No president has ever said those words, and it is about time."
For the most part, Biden's statements about his progress and future plans aligned with estimates from think tanks or government data. In some cases, he left out information that would give Americans a full picture. Our PolitiFact partners checked his statements regarding a range of subjects. You can read their complete story here. Biden also discussed the ongoing COVID pandemic and other healthcare issues. Here are highlights from his speech:
"During these 100 days, an additional 800,000 Americans enrolled in the Affordable Care Act when I established a special sign-up period to do that. 800,000 in that period."
This appears accurate but needs context.
Biden did create a special enrollment period for Americans to sign up for health insurance through the Affordable Care Act marketplace plans, due to the COVID-19 pandemic. That special enrollment period began Feb. 15 and will run through Aug. 15. According to numbers released by the Department of Health and Human Services, more than 528,000 Americans enrolled in health insurance coverage since that special enrollment period began through March 31. A senior administration official said that Biden's reference to the 800,000 new sign-ups reflected the most up-to-date tally, though it hasn't been previously announced.
"When I was sworn in on Jan. 20, less than 1% of seniors in America were fully vaccinated against COVID-19. One hundred days later, 70% of seniors over 65 are protected. Senior deaths from COVID-19 are down 80% since January."
This is largely accurate, but uncertainties exist in the data.
However, when Biden took office, the U.S. vaccination program had been in place only for about a month — the Pfizer-BioNTech and Moderna vaccines weren't authorized for emergency use until mid-December. And initial recommendations from the independent Advisory Committee on Immunization Practices prioritized vaccination of healthcare workers, and then long-term care facility residents. The next two phases included people 75 and older and then 65 and older, meaning that some states may not have started vaccinating these age groups until mid-January.
As of Wednesday, the CDC reported the share of those 65 and up who had received complete doses of a COVID-19 vaccine and are fully protected at nearly 70% — it was 68.3%. The percentage who have received at least one dose is higher: 82%.
A senior administration official provided CDC mortality data for all Americans, but not statistics specifically about seniors. That data shows the COVID daily death rate dropped by nearly 80% from Jan. 20 to April 27.
The Associated Press reported on April 22 that the best available data appeared to show COVID deaths for those 65 and older had declined by more than 50% since a peak in January, but said the "picture is not entirely clear because the most recent data on deaths by age from the Centers for Disease Control and Prevention is incomplete and subject to revision."
The recession caused by the coronavirus pandemic was "the worst economic crisis since the Great Depression."
Two key metrics back this up.
The biggest economic hit since the Great Depression in the 1930s was generally considered to be the Great Recession from 2007 to 2009, but the recession caused by the pandemic packed a bigger punch.
The peak unemployment rate in the Great Recession was 10% in October 2009, but that pales compared with the peak unemployment rate during the pandemic, 14.8% in April 2020.
Sen. Tim Scott and the Republican Response
Sen. Tim Scott (R-S.C.), the Senate's lone Black Republican, was chosen to deliver the GOP rebuttal to Biden's speech. He said the president is dividing Americans and has failed to deliver on his promise of unity.
"I want to have an honest conversation," Scott said. "About common sense and common ground. About this feeling that our nation is sliding off its shared foundation and how we move forward together."
PolitiFact checked five of Scott's claims, including this statement in which he asserted that it has been safe for some time for schools to conduct in-person learning.
"Our public schools should have reopened months ago. … Private and religious schools did. Science has shown for months that schools are safe."
Scott's statement about what the science has shown is generally accurate, but omits public health experts' warnings that schools should implement infection control precautions.
"Most private and religious schools have been open for the majority of the school year, and the vast majority have been extremely successful with minimal in-school transmission," said Dr. David Rosen, an assistant professor of pediatrics at Washington University in St. Louis. "But this is based on the premise that schools are performing the proper mitigations, especially universal masking and preventing symptomatic children from being in the classroom."
There have also been many examples of large public school districts that have had very few cases of SARS-CoV-2 transmitted in the classroom, Rosen said.
The American Academy of Pediatrics released guidance in June 2020 that said, "All policy considerations for the coming school year should start with a goal of having students physically present in school" for the fall 2020 semester. The recommendations included requiring students to wear masks, maintaining a physical distance of 3 to 6 feet and potentially including testing and temperature checks in the safety protocol.
Schools have increasingly opened for in-person instruction throughout the year, but some remain virtual. As of April 19, 4% of districts were fully remote while 47% of districts were fully in-person and about 48% of districts are offering some type of hybrid instruction, according to a tracker by the American Enterprise Institute.
Rosen said it was the right thing to do to shut down schools in March 2020 when we didn't know much about the virus.
"We continued to learn over the summer of 2020, and by the fall it was pretty clear that the virus was not as morbid in children and that masking was key in preventing person-to-person spread," Rosen said.
The Amish communities of northeastern Ohio engage in textbook communal living. Families eat, work and go to church together, and through the pandemic, mask-wearing and physical distancing have been spotty. That has meant that these communities bore a high rate of infection and death.
Despite this, health officials are struggling to encourage residents to get vaccinated against COVID-19. Holmes County, where half the population is Amish, has the lowest vaccination rate in Ohio, with just 10% of the population fully vaccinated.
"About less than a percent [of Amish] are coming in," said Holmes County health commissioner Michael Derr.
Marcus Yoder, who was born Amish and is now Mennonite, said the few Amish who are getting the shots are doing so privately through doctors' offices and small rural clinics — and, they generally are keeping it to themselves.
"There were Amish people getting the vaccination the same day I was … and we all kind of looked at each other and smiled underneath our masks and assumed that we wouldn't say that we saw them," Yoder said.
Many Amish do not want to get vaccinated because they've already had COVID and believe the area has reached herd immunity, he said.
"I think one of the main driving forces is the misinformation about COVID itself — that it's not more serious than the flu," said Yoder, who lives in Holmes County and still has close ties to the religion and community. "They're saying, 'Well, it didn't affect me that much. Look at all these old people who survived.'"
Anti-vaccination conspiracy theories also have spread throughout the community, and there is a lack of awareness about the more contagious variants spreading across the country, Yoder said.
"I think we're going to see some more cases in our community, unfortunately, because of this," he said. "There simply is a lot of COVID news fatigue. They simply do not want to hear about it, and that's really unfortunate."
While some sort of herd immunity could explain why Holmes currently has a low incidence of new cases, Derr at the health department is concerned that those who previously had the virus may not be protected.
"As a region, we definitely surged over the winter, and we know that that happened about 90 days ago," Derr said. "We're primed and ready for another surge because we're not vaccinating enough."
Health officials in Indiana and Pennsylvania are also ramping up outreach in heavily Amish areas. Local health departments in Lancaster County, Pennsylvania, home to the largest Amish population in the country, are connecting with Amish bishops to try to spread the word about the vaccines.
The widespread reluctance to be vaccinated in Amish communities is not surprising to West Virginia University sociologist Rachel Stein, who studies Amish populations across the country.
"We as non-Amish are more on board with preventative medicine," Stein said. "They certainly don't have that mindset that we need to do things to stop this from happening."
Instead, she said, there's an acceptance that people will get sick and get better — or not. While childhood vaccinations have increased in Ohio's Amish communities in recent years, adults are still more hesitant, she added.
"There's oftentimes frequent breakouts of whooping cough in a settlement, and it's just like … 'This is happening now. We're in whooping cough season, and so it's time to deal with this sort of thing,'" she said.
A recent poll from KFF found 3 in 10 rural residents will "definitely not" get a COVID vaccine or will get vaccinated only if it is mandated.
Yoder thinks the best path forward is to encourage Amish residents who did get the vaccine to talk openly about their positive experience getting the shots.
"I think that hammering people for not doing it will not get us anywhere," Yoder said. "Some of the local business leaders have done very, very well at saying, 'Look, let's get the vaccination so we don't have to wear masks in the future, so we don't have to worry about social distancing as much in the future.' And they've used that tack and that has been a healthy way to approach it."
Derr is trying to get business owners who employ Amish workers to encourage their staffers to get a shot. Health officials hope to eventually hold vaccine clinics at these businesses and take the shots to them, but not every business owner is on board with that yet, he said.
"People are going to listen to their friends and their family, people who they interact with more, and it's going to be that telephone effect," he said. "The more and more people we tell about it and the better experiences they have, word will get around."
Derr expects more Amish will get vaccinated in the fall after the shots have been around for some time but worries that the community could see a spike in cases long before then.
This story is part of a partnership that includes WCPN-Ideastream, NPR and KHN.
If you think vaccination is an ordeal now, consider the 18th-century version. After having pus from a smallpox boil scratched into your arm, you would be subject to three weeks of fever, sweats, chills, bleeding and purging with dangerous medicines, accompanied by hymns, prayers and hell-fire sermons by dour preachers.
That was smallpox vaccination, back then. The process generally worked and was preferred to enduring "natural" smallpox, which killed around a third of those who got it. Patients were often grateful for trial-by-immunization — once it was over, anyway.
"Thus through the Mercy of God, I have been preserved through the Distemper of the Small Pox," wrote one Peter Thatcher in 1764, after undergoing the process in a Boston inoculation hospital. "Many and heinous have been my sins, but I hope they will be washed away."
Today, Americans are once again surprisingly willing, even eager, to suffer a little for the reward of immunity from a virus that has turned the world upside down.
Roughly half of those vaccinated with the Moderna or Pfizer-BioNTech vaccines, and in particular women, experience unpleasantness, from hot, sore arms to chills, headache, fever and exhaustion. Sometimes they boast about the symptoms. They often welcome them.
Suspicion about what was in the shots grew in the mind of Patricia Mandatori, an Argentine immigrant in Los Angeles, when she hardly felt the needle going in after her first dose of the Moderna vaccine at a March appointment.
A day later, though, with satisfaction, she "felt like a truck hit me," Mandatori said. "When I started to feel rotten I said, 'Yay, I got the vaccination.' I was happy. I felt relieved."
While the symptoms show your immune system is responding to the vaccine in a way that will protect against disease, evidence from clinical trials showed that people with few or no symptoms were also protected. Don't feel bad if you don't feel bad, the experts say.
"This is the first vaccine in history where anyone has ever complained about not having symptoms," said immunologist Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia.
To be sure, there is some evidence of stronger immune response in younger people — and in those who get sick when vaccinated. A small study at the University of Pennsylvania showed that people who reported systemic side effects such as fever, chills and headache may have had somewhat higher levels of antibodies. The large trial for Pfizer's vaccine showed the same trend in younger patients.
But that doesn't mean people who don't react to the vaccine severely are less protected, said Dr. Joanna Schaenman, an expert on infectious diseases and the immunology of aging at the David Geffen School of Medicine at UCLA. While the symptoms of illness are undoubtedly part of the immune response, the immune response that counts is protection, she said. "That is preserved across age groups and likely to be independent of whether you had local or systemic side effects or not."
The immune system responses that produce post-vaccination symptoms are thought to be triggered by proteins called toll-like receptors, which reside on certain immune cells. These receptors are less functional in older people, who are also likely to have chronic, low-grade activation of their immune systems that paradoxically mutes the more rapid response to a vaccine.
But other parts of their immune systems are responding more gradually to the vaccine by creating the specific types of cells needed to protect against the coronavirus. These are the so-called memory B cells, which make antibodies to attack the virus, and "killer T cells" that track and destroy virus-infected cells.
Many other vaccines, including those that prevent hepatitis B and bacterial pneumonia, are highly effective while having relatively mild side effect profiles, Schaenman noted.
Whether you have a strong reaction to the vaccine "is an interesting but, in a sense, not vital question," said Dr. William Schaffner, a professor of infectious disease at Vanderbilt University Medical Center. The bottom line, he said: "Don't worry about it."
There was a time when doctors prescribed cod-liver oil and people thought medicine had to taste bad to be effective. People who get sick after COVID vaccination "feel like we've had a tiny bit of suffering, we've girded our loins against the real thing," said Schaenman (who had a slight fever). "When people don't have the side effects, they feel they've been robbed" of the experience.
Still, side effects can be a hopeful sign, especially when they end, says McCarty Memorial Christian Church leader Eddie Anderson, who has led efforts to vaccinate Black churchgoers in Los Angeles. He helps them through the rocky period by reminding them of the joyful reunions with children and grandchildren that will be possible post-vaccination.
"I'm a Christian pastor,'' he said. "I tell them, 'If you make it through the pain and discomfort, healing is on the other side. You can be fully human again.'"
Experts fear that even a small increase in the inappropriate use of addictive pain pills will lead to a resurgence of the prescription opioid crisis, given the large number of COVID survivors.
This article was published on Wednesday, April 28, 2021 in Kaiser Health News.
COVID survivors are at risk from a possible second pandemic, this time of opioid addiction, given the high rate of painkillers being prescribed to these patients, health experts say.
A new study in Nature found alarmingly high rates of opioid use among COVID survivors with lingering symptoms at Veterans Health Administration facilities. About 10% of COVID survivors develop "long COVID," struggling with often disabling health problems even six months or longer after a diagnosis.
For every 1,000 long-COVID patients, known as "long haulers," who were treated at a Veterans Affairs facility, doctors wrote nine more prescriptions for opioids than they otherwise would have, along with 22 additional prescriptions for benzodiazepines, which include Xanax and other addictive pills used to treat anxiety.
Although previous studies have found many COVID survivors experience persistent health problems, the new article is the first to show they're using more addictive medications, said Dr. Ziyad Al-Aly, the paper's lead author.
He's concerned that even an apparently small increase in the inappropriate use of addictive pain pills will lead to a resurgence of the prescription opioid crisis, given the large number of COVID survivors. More than 3 million of the 31 million Americans infected with COVID develop long-term symptoms, which can include fatigue, shortness of breath, depression, anxiety and memory problems known as "brain fog."
The new study also found many patients have significant muscle and bone pain.
The frequent use of opioids was surprising, given concerns about their potential for addiction, said Al-Aly, chief of research and education service at the VA St. Louis Healthcare System.
"Physicians now are supposed to shy away from prescribing opioids," said Al-Aly, who studied more than 73,000 patients in the VA system. When Al-Aly saw the number of opioids prescriptions, he said, he thought to himself, "Is this really happening all over again?"
Doctors need to act now, before "it's too late to do something," Al-Aly said. "We must act now and ensure that people are getting the care they need. We do not want this to balloon into a suicide crisis or another opioid epidemic."
As more doctors became aware of their addictive potential, new opioid prescriptions fell, by more than half since 2012. But U.S. doctors still prescribe far more of the drugs — which include OxyContin, Vicodin and codeine — than physicians in other countries, said Dr. Andrew Kolodny, medical director of opioid policy research at Brandeis University.
Some patients who became addicted to prescription painkillers switched to heroin, either because it was cheaper or because they could no longer obtain opioids from their doctors. Overdose deaths surged in recent years as drug dealers began spiking heroin with a powerful synthetic opioid called fentanyl.
More than 88,000 Americans died from overdoses during the 12 months ending in August 2020, according to the Centers for Disease Control and Prevention. Health experts now advise doctors to avoid prescribing opioids for long periods.
The new study "suggests to me that many clinicians still don't get it," Kolodny said. "Many clinicians are under the false impression that opioids are appropriate for chronic pain patients."
Hospitalized COVID patients often receive a lot of medication to control pain and anxiety, especially in intensive care units, said Dr. Greg Martin, president of the Society of Critical Care Medicine. Patients placed on ventilators, for example, are often sedated to make them more comfortable.
Martin said he's concerned by the study's findings, which suggest patients are unnecessarily continuing medications after leaving the hospital.
"I worry that COVID-19 patients, especially those who are severely and critically ill, receive a lot of medications during the hospitalization, and because they have persistent symptoms, the medications are continued after hospital discharge," Martin said.
While some COVID patients are experiencing muscle and bone pain for the first time, others say the illness has intensified their preexisting pain.
Rachael Sunshine Burnett has suffered from chronic pain in her back and feet for 20 years, ever since an accident at a warehouse where she once worked. But Burnett, who first was diagnosed with COVID in April 2020, said the pain soon became 10 times worse and spread to the area between her shoulders and spine. Although she was already taking long-acting OxyContin twice a day, her doctor prescribed an additional opioid called oxycodone, which relieves pain immediately. She was reinfected with COVID in December.
"It's been a horrible, horrible year," said Burnett, 43, of Coxsackie, New York.
Doctors should recognize that pain can be a part of long COVID, Martin said. "We need to find the proper non-narcotic treatment for it, just like we do with other forms of chronic pain," he said.
The CDC recommends a number of alternatives to opioids — from physical therapy to biofeedback, over-the-counter anti-inflammatories, antidepressants and anti-seizure drugs that also relieve nerve pain.
The country also needs an overall strategy to cope with the wave of post-COVID complications, Al-Aly said
"It's better to be prepared than to be caught off guard years from now, when doctors realize … 'Oh, we have a resurgence in opioids,'" Al-Aly said.
Al-Aly noted that his study may not capture the full complexity of post-COVID patient needs. Although women make up the majority of long-COVID patients in most studies, most patients in the VA system are men.
The study of VA patients makes it "abundantly clear that we are not prepared to meet the needs of 3 million Americans with long COVID," said Dr. Eric Topol, founder and director of the Scripps Research Translational Institute. "We desperately need an intervention that will effectively treat these individuals."
Al-Aly said COVID survivors may need care for years.
"That's going to be a huge, significant burden on the healthcare system," Al-Aly said. "Long COVID will reverberate in the health system for years or even decades to come."
Nursing homes and long-term care facilities, where 182,000 Americans perished during the COVID pandemic, have taken heat from government regulators, residents and their families. Now the industry is hearing it from an unexpected source: their investors.
Investors who own large shares of nursing home companies now are demanding that the operators improve staff working conditions and the quality of care.
Nearly 100 investor groups that manage $3.3 trillion in assets in the U.S. and abroad told nursing home companies in a recent letter that they should increase staffing levels, boost staff pay, offer paid sick leave, improve resident safety programs and allow staff members to unionize.
It's the latest pressure for reform of the nursing home industry, which has come under fire for an epic failure in infection control that spread COVID-19 killing residents and staffers across the U.S.
The move by investors was unexpected, since it could reduce their financial returns. But they are worried about the future of the nursing home industry, which experienced a death wave inside its facilities that accounted for 34% of the nation's COVID toll. That's not good for business.
"These are great principles that aren't necessarily in the best financial interest of investors," said David Grabowski, a healthcare policy professor at Harvard University who studies long-term care. "But it's hard to know if this has any teeth."
Nursing home industry groups themselves have called for reform, but they stress the need for higher Medicaid payment rates.
The investors' statement of expectations was sent to major for-profit companies and real estate investment trusts that own nursing homes, including Genesis HealthCare, Ventas, Brookdale Senior Living and CareTrust REIT. It was signed by large investor groups including BMO Global Asset Management, Aviva Investors and the Interfaith Center on Corporate Responsibility.
"This is a moment to say, 'Look at what happened during COVID. You don't want it to happen again,'" said Christy Hoffman, general secretary of UNI Global Union, a labor-affiliated group that organized the investors' letter. "These workers are treated so badly, and that led to so many unnecessary deaths."
Nursing home care aides, who provide most of the hands-on care, earn about $12 an hour. Mostly women of color, they often work at more than one facility to cobble together a full-time schedule. That increased COVID transmission among facilities. These workers generally don't get health benefits or paid sick leave, forcing them to come to work even when ill. Few are in unions, which have pushed for stronger safety protections. Annual turnover in the industry occasionally hits 80%.
There were reports across the U.S. that nursing homes did not provide adequate personal protective equipment like face masks and gowns to their workers, had too few workers on duty to properly care for residents, and engaged in shoddy infection control practices such as putting residents with and without COVID in the same rooms.
BMO Global Asset Management already has contacted 13 nursing home companies and REITs urging appropriate staffing levels, improved health and safety standards, proper use of PPE, fair wages, pandemic hazard pay and freedom to unionize, said Nina Roth, director of responsible investment at BMO.
If they fail to meet the expectations with reasonable speed, her investment group, which manages or advises on $755 billion in assets, may take shareholder actions against management and ultimately divest from the companies, Roth said.
The American Healthcare Association, which represents for-profit nursing home companies, said in a written statement, "We appreciate seeing investors taking a considerable interest in the quality of care and workforce challenges." But it added that for nursing homes to offer more competitive wages and benefits, they need "more reliable resources" from federal and state governments.
While higher payments would help, said UNI Global's Hoffman, nursing home companies "have a responsibility to do right by their workers regardless of public policy. We just don't want companies to say they'll do it when the government tells them to do it."
Advocates for nursing home residents say that, if government payment rates are increased, new transparency rules should require nursing homes to show that the additional funds are used for increased staffing and improved services, not for profits or higher salaries for executives.
In line with that, the investors' statement of expectations called on nursing home companies and REITs to publicly disclose whether they are complying with the staffing and quality-of-care targets.
Grabowski said the investors' letter shows they recognize the inevitability of nursing home reform in the wake of the COVID catastrophe and want to get ahead of the wave. "They're thinking, 'Why don't we be more transparent and improve quality, or else what comes from the government could be ugly.'"
In March 2020, just weeks into the COVID-19 pandemic, the incident command center at Brigham and Women's Hospital in Boston was scrambling to understand this deadly new disease. It appeared to be killing more Black and brown patients than whites. For Latinos, there was an additional warning sign: language.
Patients who didn't speak much, or any, English had a 35% greater chance of death.
Clinicians who couldn't communicate clearly with patients in the hospital's COVID units noticed it was affecting outcomes.
"We had an inkling that language was going to be an issue early on," said Dr. Karthik Sivashanker, then Brigham's medical director for quality, safety and equity. "We were getting safety reports saying language is a problem."
Sivashanker dived into the records, isolating and layering the unique characteristics of each of the patients who died: their race, age and sex and whether they spoke English.
"That's where we started to really discover some deeper, previously invisible inequities," he said.
Inequities that weren't about race alone.
Hospitals across the country have reported more hospitalizations and deaths of Black and Latino patients than of whites. Black and brown patients may be more susceptible because they are more likely to have a chronic illness that increases the risk of serious COVID. But when the Brigham team compared Black and brown patients with white patients who had similar chronic illnesses, they found no difference in the risk of death from COVID.
But a difference did emerge for Latino patients who don't speak English. That sobering realization helped them home in on a specific health disparity, think about some possible solutions and begin a commitment to change.
"That's the future," said Sivashanker.
Identifying the Risk
But first, Brigham had to unravel this latest example of a life-threatening health disparity. It started outside the hospital, in lower-income communities in and just outside Boston, where the coronavirus spread quickly among many native Spanish speakers who live in close quarters with jobs they can't do from home.
Some avoided coming to the hospital until they were very sick, because they didn't trust the care in big hospitals or feared detection by immigration authorities. Nevertheless, just weeks into the pandemic, COVID patients who spoke little English began surging into Boston hospitals, including Brigham and Women's.
"We were, frankly, not fully prepared for that surge," said Sivashanker. "We have really amazing interpreter services, but they were starting to get overwhelmed."
"In the beginning, we didn't know how to act. We were panicking," said Ana Maria Rios-Velez, a Spanish-language interpreter at Brigham.
Rios-Velez remembered searching for words to translate this new disease and experience for patients. When called to a COVID patient's room, interpreters were confused about whether they could go in and how close they should get to a patient. Some interpreters said they felt disposable in the early days of the pandemic, when they weren't given adequate personal protective equipment.
When she had PPE, Rios-Velez said, she still struggled to gain a patient's trust from behind a mask, face shield and gown. For safety, many interpreters were urged to work from home. But speaking to patients over the phone created new problems.
"It was extremely difficult, extremely difficult," she said. "The patients were having breathing issues. They were coughing. Their voices were muffled."
And Rios-Velez couldn't look her patients in the eye to put them at ease and build a connection.
"It's not only the voice. Sometimes I need to see the lips, if smiling," she said. "I want them to see the compassion in me."
Adding Interpreters and Tech
Brigham responded by adding more interpreters and buying more iPads so remote workers could see patients. The hospital purchased amplifiers to raise the volume of patients' voices above the beeps and machines humming in an ICU. The Mass General Brigham network is piloting the use of interpreters available via video in primary care offices. A study found Spanish-speaking patients used telemedicine less than white patients during the pandemic.
Brigham's goal is that every patient who needs an interpreter will get one. Sivashanker said that happens now for most patients who make the request. The bigger challenge, he said, is including an interpreter in the care of patients who may need the help but don't ask for it.
In the first surge, interpreters also became translators for the hospital's website, information kiosks, COVID safety signs and brochures.
"It was really tough. I got sick and had to take a week off," said Yilu Ma, Brigham's director of interpreter services. Mass General Brigham is now expanding a centralized translation service for the entire hospital network.
Inequities Within the Hospital Workforce
Brigham and Women's analytics team uncovered other disparities. Lower-paid employees were getting COVID more often than nurses and doctors. Sivashanker said there were dozens of small group meetings with medical assistants, transport workers, security staffers and those in environmental services in which he shared the higher positive test rates and encouraged everyone to get tested.
"We let them know they wouldn't lose their jobs" if they had to miss work, Sivashanker said. And he, along with managers, told these employees "that we realize you're risking your life just like any other doctor of nurse is, every single day you come to work."
Some employees complained of favoritism in the distribution of PPE, which the hospital investigated. To make sure all employees were receiving timely updates as pandemic guidance changed, Brigham started translating all coronavirus messages into Spanish and other languages and sending them via text, which people who are on the move all day are more likely to read. The Mass General Brigham system offered hardship grants of up to $1,000 for employees with added financial pressures, such as additional child care costs.
Angelina German, a hospital housekeeper with limited English, said she appreciates getting updates via text in Spanish, as well as in-person COVID briefings from her bosses.
"Now they're more aware of us all," German said through an interpreter, "making sure people are taking care of themselves. "
Beyond the Hospital Walls
The hospital also set up testing sites in some Boston neighborhoods with high coronavirus infection rates, including neighborhoods where many employees live and were getting infected. At least one of those sites now offers COVID vaccinations.
"No one has to be scheduled. You don't need insurance. You just walk up and we can test you," Dr. Christin Price explained during a visit last fall to a testing site in the Jamaica Plain neighborhood.
Nancy Santiago left the testing site carrying a free 10-pound bag of fruits and vegetables, which she'll share with her mother. Santiago said she's grateful for the help.
"I had to leave my job because of [lack of] day care, and it's been pretty tough," she said. "But, you know, we gotta keep staying strong, and hopefully this is over sooner rather than later."
Brigham recently opened a similar indoor operation at the Strand Theatre in the Dorchester neighborhood. Everyone who comes for a coronavirus test is asked if they have enough to eat, if they can afford their medications, if they need housing assistance and if they're registered to vote.
Mass General Brigham leaders said they'll take what they've learned dissecting disparities during the pandemic and expand the remedies across the hospital network.
"Many of the issues that were identified during the COVID equity response are unfortunately pretty universal issues that we need to address, if we're going to be an anti-racist organization," said Tom Sequist, chief of patient experience and equity for Mass General Brigham.
Brigham's work on health disparities comes, in part, out of a collaboration with the Institute for Healthcare Improvement.
"There's a lot of defensive routines into which we slip as clinicians that the data can help cut through and reveal that there are some biases in your own practice," explained IHI President and CEO Dr. Kedar Mate.
"If we don't name and start to talk about racism and how we intend to dismantle it or undo it," Mate added, "we'll continue to place Band-Aids on the problem and not actually tackle the underlying causes."
"Poverty and social determinants of health needs are not going away any time soon, and so if there's a way to continue to serve the communities, I think that would be tremendous," said Price, who helped organize Brigham's testing program.
But has Brigham's work lowered the risk of death from COVID for Spanish-speaking patients? The hospital hasn't updated the analysis yet, and even when it does, determining whether (or how) the interventions worked will be hard, Sivashanker said.
"It's never going to be as simple as 'We just didn't give them enough iPads or translators and that was the only problem,'" said Sivashanker.
But Sivashanker said more interpreters and iPads, and better messaging to non-English speaking employees — plus all the other steps Brigham has taken during the pandemic — have improved both the patient and the employee experience. That, he said, counts as a success, while work on the next layer of discrimination continues.
This story is part of a partnership that includes WBUR, NPR and KHN.
In the first 100 days, new presidents try to turn campaign promises into quick legislative victories, defuse lingering crises, set themselves apart from their predecessor and set a leadership tone for the next four years — all while avoiding blunders that could destroy their momentum.
So how is President Joe Biden doing as he approaches this mark?
Not bad, experts say, given the scale of the crisis he's tackling and the political opposition he faces in Congress.
"I think there are three accomplishments that stand out so far: the ramped-up coronavirus vaccine distribution, the passage of the American Rescue Plan and the return to the Paris Climate Agreement," said John Frendreis, a political scientist at Loyola University in Chicago.
When Biden took office, the seven-day rolling average for vaccinations was 777,000 a day, but that number rose under Biden to about 3 million a day. As his 100th day approached, about half of the 16-and-older U.S. population had received at least one dose of vaccine. In addition, more than 80% of seniors had received at least one shot, and 25% of American adults were fully vaccinated.
The American Rescue Plan was a $1.9 trillion bill aimed at both providing additional funding for fighting the pandemic and helping the economy through the resulting recession. The measure included aid to state and local governments, increased unemployment insurance, support for vaccination efforts, education aid, refundable child tax credits and housing assistance.
"Few presidents have passed anything as consequential as the relief package" in their first 100 days, said John J. Pitney Jr., a political scientist at Claremont McKenna College.
Beyond these items, our partners at PolitiFact provide a detailed accounting of other actions taken by Biden during his early tenure.
Other moves have been more intangible, but no less significant, experts said. "One word sums it up: normality," Pitney said. "We can now skip the news for a day or two without worrying that we've missed a scandal or a crazy presidential tweet. Biden has made mistakes, such as having to backtrack on refugee policy, but they are the kind of mistakes that presidents normally make early in their term."
Here is a closer look at what the Biden administration has done, and how his overall performance compares with his predecessors. (Biden's 100th day in office is Thursday, if you count his half-day in office on Jan. 20.)
The Coronavirus Pandemic and Healthcare
Experts said it's possible that the vaccine rollout would have ramped up no matter who was president, but they added that Biden deserves credit for taking certain steps. He pushed manufacturers to increase vaccine production, provided federal support for mass vaccination sites and ensured that a vaccine is accessible within 5 miles of almost every American.
"He's done a really good job," said Claire Hannan, executive director of the Association for Immunization Managers. "The first thing he did when he came into office was set a tone and goals, and that was important to have a benchmark."
Biden has also met two goals he'd set for his first 100 days in office — first, 100 million COVID vaccine doses, then, after achieving that goal on the 58th day of his presidency, 200 million doses. On April 22, eight days before his 100th day, that goal was achieved, too.
"At the end of the day, the proof is in the results," said Dr. Georges Benjamin, executive director of the American Public Health Association. "More than half of the population having had at least one shot means they've been extraordinarily successful."
Biden also notched a victory on health insurance. Part of the $1.9 trillion relief package was a provision that no one must spend more than 8.5% of what they earn on insurance premiums, which experts say is among the most significant changes to the affordability of private insurance since the ACA.
In addition, "restoring the [Centers for Disease Control and Prevention] to a place of prominence, having scientists speaking to the general public on a regular basis, this is all evidence that science is clearly a priority for the federal government and for the White House," said Dr. Amesh Adalja, senior scholar at the Johns Hopkins University Center for Health Security.
Other promises on health have been more difficult to keep, such as mandating masks nationwide. While Biden did implement a mask mandate in areas where the federal government has authority, such as federal buildings, airplanes and other types of transportation, Republican governors in states such as Texas and Alabama have rolled back their mask mandates in recent months. We rated this promise as a Compromise.
The administration faces challenges in getting the remainder of the U.S. vaccinated. There are indications that the number of daily vaccinations is slowing, and some people tell pollsters that they are unwilling to get vaccinated at all.
"The challenges ahead include continuing to adjust the vaccination effort in order to get the next 20% of people vaccinated," said Hannan. "And we'll eventually need to get vaccinations to kids, too. We will just have to keep adjusting our efforts for different populations."
Biden's progress in containing the pandemic has also paid dividends for the economy, boosting consumer activity that had been restrained during the pandemic.
Key elements of the American Rescue Plan included unemployment assistance, a temporary expansion of the child tax credit, an increase in food stamp aid and aid to state and local governments for public health, housing and education. Those items "deal squarely and forthrightly with the economic calamities that have stuck working-class and poorer Americans as a result of the public health crisis," said Gary Burtless, an economist at the Brookings Institution.
Critics have expressed concerns about the plan's size and timing, saying it was passed late in the pandemic, when an upturn was in sight. "There's a danger of overheating the economy" from injecting so much spending, said Douglas Holtz-Eakin, president of the center-right American Action Forum.
Comparing Biden With His Predecessors
President Franklin D. Roosevelt's 100-day accomplishments remain head-and-shoulders above any of his successors, experts agree. Roosevelt signed 15 major bills to overhaul the economy and fight the Great Depression. Harry Truman navigated the post-World War II rebuilding of alliances, economies and stability. Bill Clinton signed the Family and Medical Leave Act. Barack Obama authorized a nearly $800 billion stimulus package to combat a devastating recession.
"Biden compares quite favorably with every other president after Franklin Roosevelt," said Max Skidmore, a University of Missouri-Kansas City political scientist.
Biden has faced arguably fiercer partisan polarization than any of those predecessors — no congressional Republican voted for the American Rescue Plan, and most GOP lawmakers have expressed reservations about other aspects of his policy agenda. In addition, Biden's party has narrow majorities in the House and Senate.
Experts believe that the narrow margins in Congress will push Biden to continue using executive orders and other administrative actions to advance his agenda. Biden has so far used executive orders on the coronavirus, immigration and gun policy. In some cases, Biden was able to overturn executive orders signed by Trump, who, like Biden, turned to executive orders when he was unable to get some of his priorities through both chambers of Congress.
"All recent presidents seek legislative change if they can get it, but most have spent the bulk of their terms with divided government," Frendreis said. "Even when they have unified government, they rarely enjoy a filibuster-proof Senate majority. President Biden is no different on this score."
KHN's Emmarie Huetteman and Victoria Knight as well as PolitiFact's Amy Sherman and Miriam Valverde contributed to this report.
Health officials have been subjected to extreme scrutiny from politicians and the public over mask requirements, business closures and the extended interruption of travel and social gatherings.
This article was published on Sunday, April 25, 2021 in Kaiser Health News.
SANTA CRUZ COUNTY, Calif. — Dr. Gail Newel looks back on the past year and struggles to articulate exactly when the public bellows of frustration around her COVID-related health orders morphed into something darker and more menacing.
Certainly, there was that Sunday afternoon in May, when protesters broke through the gates to her private hillside neighborhood, took up positions around her home, and sang "Gail to Jail," a ritual they would repeat every Sunday for weeks.
Or the county Board of Supervisors meeting not long after, where a visibly agitated man waiting for his turn at the microphone suddenly lunged at her over a small partition, staring her down even as sheriff's deputies flanked him and authorities cleared the room.
The letters, emails and cellphone calls that now number in the hundreds and inevitably open with "Bitch," and make clear people know where she lives and wish her dead.
And that January meeting with Santa Cruz County Sheriff Jim Hart, after the vicious mob attack on the U.S. Capitol, when he recommended to a roomful of county officials that deputies do a threat assessment at each of their homes. Newel, who'd already been through the process, casually mentioned a New Year's resolution to get more exercise and start walking to work. Absolutely not, Hart told her. She wasn't walking anywhere without an escort.
Newel, 63, is the health officer in Santa Cruz County, a picturesque string of communities hugging California's rugged Central Coast. In normal years, hers would be a largely invisible job that involves tracking measles outbreaks and STD infections, testing children for lead exposure, and alerting the public to tainted lettuce and unhealthy air. COVID has changed all that, in ways both expected and not. Newel, like health officials across the nation, has been thrust into an unwelcome spotlight and subjected to extreme scrutiny from politicians and the public over mask requirements, business closures and the extended interruption of travel and social gatherings.
Some of the dissent was understandable: the shocked response of residents asked to make unprecedented sacrifices during a time of great uncertainty. But in Santa Cruz and many other U.S. communities, legitimate debate has devolved into overt intimidation and threats of violence.
Public servants like Newel have become the face of government authority in the pandemic. And, in turn, they have become targets for the same loose-knit militia and white nationalist groups that stormed the U.S. Capitol in January, smashing windows, bloodying officers and savagely chanting "Hang Mike Pence."
Over the course of a year, Newel and her boss, Santa Cruz County's health services director, Mimi Hall, have seen their lives upended for reasons well beyond the exhausting workload that comes with battling a devastating pandemic. Their daily routines now incorporate security patrols, surveillance cameras and, in some cases, personal firearms.
They are public servants who no longer feel safe in public.
"When I do have days off, I don't want to be out in the community. I'm intimidated to be out in the community," Newel said. "I'm looking to see who might be close to me or to my car, who might be following me — looking to see if there's any kind of situation that I might not be able to get out of or that might be dangerous to me in some way."
Newel was born and raised in the city of Fresno in California's Central Valley, a region known for industrial-scale farming and conservative politics. After completing degrees in medicine and public health, Newel returned home to work as an obstetrician. There, in addition to delivering hundreds of babies, she helped develop a lactation center, a program for pregnant women with substance abuse issues and a teen pregnancy program. After 30 years of "catching babies," she'd planned to retire as a doctor's wife in Santa Cruz, where her wife, also a physician, had taken a job.
The couple call themselves Central Valley refugees; they often felt unwelcome in Fresno County as a same-sex couple. With their adult children already out of the house, they bought a home in Santa Cruz and made plans to spend the rest of their lives there. Newel felt called to serve when the health officer in a neighboring county urged her to consider a second career in public health. She became Santa Cruz County's health officer on July 1, 2019.
Newel developed an easy affinity with director Hall, who has the broader responsibility of managing all countywide medical, behavioral and environmental health programs. Hall, 53, was born in Myanmar, where her parents worked as doctors in a small hospital without running water or electricity. The family relocated to the U.S. when she was a young child. Hall has spent her entire adult life working in public health, the past 22 years in California county government. She worked in the heart of the Sierra Nevada before moving north to Plumas, a county bigger than Delaware but so sparsely populated that its county seat isn't designated a city.
There, she said, she fought with elected officials who didn't believe in her work. She said her children, among the few Asian Americans in Plumas, experienced racism and bullying. When Hall was hired by Santa Cruz County in 2018, she moved her husband and three kids to a seemingly bucolic home in the redwood forests of the Santa Cruz Mountains.
As health officer, Newel is part of a fraternity of greater Bay Area health officers who, since the early AIDS era, have met regularly to work on public health issues. Many of her local counterparts have deep knowledge of infectious diseases and, in the early days of the pandemic, she leaned on them heavily. In California, like many other states, every county is required to have a health officer. That person must have training in medicine, and, in emergencies, is granted broad authority to keep the public safe.
When Newel's Bay Area counterparts issued the first sweeping stay-at-home orders in the nation on March 16, 2020, she was just hours behind in issuing one for Santa Cruz. It ordered most businesses to close and banned most travel and social gatherings. A few weeks later, in an effort to keep tourists away, she ordered the beaches closed as well.
It was a grueling time — both Newel and Hall went months without a real day off — but adrenaline-filled. They set up testing sites, organized data-tracking operations, coordinated with dozens of state and local groups on COVID response and oversaw contact tracing for hundreds of cases.
And, as life-threatening pandemics go, they were off to a good start. Research suggests that lockdowns are most effective when initiated early, and that research is reflected in the Santa Cruz experience. Through June 2020, only a handful of people were diagnosed in Santa Cruz each week, and just two people had died from the virus in a county of 280,000, a fraction of the national death rate.
Santa Cruz County might seem an unlikely venue for menace. It's known for its laid-back vibe and hippie communes. But it's also a study in divergence: Multimillion-dollar estates are tucked into the Santa Cruz Mountains alongside the barricaded compounds of well-armed survivalists. Farmworkers tend to world-class strawberry fields in the southern part of the county alongside exclusive vacation rentals.
In the early months of the pandemic, the COVID diagnoses mostly came from south county, among agricultural workers still tending crops and living in crowded housing. The complaints, however, were mostly from people in the wealthy beach communities, and out-of-towners deeply resentful of the highly publicized restrictions.
The pushback started with angry emails and voicemails, people who contested the beach closures, the intrusion on personal freedoms. But over time, it ventured further, into language that was personal and terrorizing. Newel remembers threatening letters that stated her address and the names of her children. Others included photographs of the front and back of her home from close range, and messages like "Look out; we're coming for you." The county clerk helped scrub her address from the internet.
Hall remembers obscene late-night phone calls, and a man who seemed to be casing her home. She took her cell number off her email signature.
Then came the Sunday protesters, who would surround Newel's home with bullhorns and sirens blaring, their hostile rants making her — and, worse, her family — feel like hostages. "I'm willing to be a public servant, but I don't think that includes having people trespass onto my private property," she said. "I was quite worried for my family and for myself and our safety."
Most local health officials in the U.S. are women and, as the pandemic wore on, the threats took on a clearly misogynistic tone. People used words like "bitch" and "cunt," and made disturbing veers into sexually explicit references.
At a county Board of Supervisors meeting in late May, a young man, his voice thick with rage, accused Newel of ruining his life by closing the beaches. "You want me to stay inside, get fat, watch Netflix and masturbate?" The hearing was packed with people lobbying for a variance from state closure rules. As in previous meetings, people filmed Newel at close range. During the public comment period, they streamed to the microphone. Many removed their masks. People were visibly agitated, tapping feet, muttering swear words.
Then, a man started toward the mic, but made a beeline for Newel instead. Sheriff's deputies surrounded him and whisked Newel and Hall out of the room, while a county executive evacuated the meeting. Feeling he could no longer ensure her safety, Sheriff Hart asked Newel to stop attending meetings in person.
In the days and weeks that followed, Hall, too, adopted new routines. She would leave work at 7 p.m., when the security guards ended their shift. On her way out of her office, she called her husband, staying on the phone with him until she was locked in her car. Once home, she checked the charge on the security cameras that provide a full-perimeter view of her home and greeted her dog, who works double time as family member and security detail.
Still, she didn't know what to make of it all. "You're not sure — is it really dangerous? You feel this feeling of, well, maybe we're overreacting, you know?" Hall said.
Many of the people expressing the most vicious anger over the past year have histories of anti-government sentiment. There are the white supremacists, and groups with adopted militia names. The "sovereign citizens," who view themselves as governed only by their own interpretations of common law. The people who oppose any government mandates to be vaccinated.
Still, things accelerated during the collision of Donald Trump's presidency with the pandemic.
Membership in right-wing, white supremacist, anti-government and anti-vaccine groups was on the rise before 2020, under a Trump presidency seen as sympathetic to such ideologies and facilitated by the use of social media to draw in new adherents.
Then came the pandemic, which stranded people in their homes and transformed screens into their primary social gateways. Across chatrooms and websites, folks converged online to share grievances about perceived threats to personal freedoms. They found common cause in rebelling against closures and mask mandates and rallying around Trump. Groups that had previously protested vaccine requirements adopted militia language and imagery. Militias began organizing against health orders, and their tactics were adopted by yet more newly organized groups that formed online.
On April 17, Trump used his favored platform, Twitter, to send a series of calls to "LIBERATE MINNESOTA!" Then to "LIBERATE MICHIGAN!" and "LIBERATE VIRGINIA, and save your great 2nd Amendment. It is under siege!"
It set off a cascade of repercussions for health officials. Thousands of Facebook pages sprung up to organize against stay-at-home orders.
"They just erupted in rage at the lockdowns. [Trump] immediately undercut the credibility of public health officials," said Heidi Beirich, co-founder of the Global Project Against Hate and Extremism and an expert on militia and white nationalist organizations. "He turned the public health sector into liars and enemies of his supporters."
Public health is inherently not an individualistic endeavor. It's the science of improving the health of populations, and more often than not, those improvements are of a collective nature. To bring down rates of smoking, we've taxed cigarettes and restricted where people can smoke. Workplaces were made safer through regulations limiting exposure to toxic materials and risky machinery. Infectious diseases are slowed to a crawl through vaccination requirements.
It's not surprising that health officials would become the recipients of the backlash associated with anti-government ideologies, said Jason Blazakis, director of the Center on Terrorism, Extremism and Counterterrorism at the Middlebury Institute of International Studies in Monterey. But the country hasn't reckoned with how COVID disinformation is animating those threats.
By the end of May, health leaders across the nation were quitting in droves. In California alone, eight public health officials had left top posts, including Orange County's public health officer, Dr. Nichole Quick, who'd been given a security detail before she resigned. These were people with extensive training in public health, but also people with deep relationships in the community, the kind of expertise you can't gain in school.
Just up the coast from Santa Cruz, the health officer for Santa Clara County, Dr. Sara Cody, was receiving so many credible threats by spring 2020 that she and her family were given 24-hour security details. A series of threatening letters were particularly disturbing. They were suspected of coming from the same anonymous author because of sentence structure, but also their "misogynistic content … and clear anti-government position," a sheriff's report said. One said: "You are fucking so many for no reason … you will pay a heavy price for your stupidity bitch." Another read: "You must go no matter how you go … you stupid fucking bitch."
Santa Clara's sheriff's office began investigating.
Sheriff Hart grew up in Santa Cruz and has been with the department for 33 years. It's a rustic place without a lot of serious crime. Hart was aware of some members of white supremacist groups in the mountains, but largely considered them benign carryovers from a previous era. "I would always take threats, especially to myself and to some of our staff, with a grain of salt," Hart said. "We're in law enforcement; some people don't like us. I get that."
June 6, 2020, changed his thinking.
Seven months to the day before the siege on the U.S. Capitol, on a warm Saturday afternoon, a 911 call came into the sheriff's office. A suspicious-looking van was parked on the side of a road in the mountain town of Boulder Creek, the caller said, and it matched the description of a van used in a drive-by shooting a week earlier in Oakland, when a federal security officer was killed during a Black Lives Matter protest.
Using the vehicle identification number to determine the owner of the van, Santa Cruz sheriff's deputies made their way to his home, which was just up the road from Hall's. There, a violent ambush unfolded.
According to law enforcement reports, Steven Carrillo, an active-duty Air Force sergeant, shot at officers with a homemade AR-15-style rifle and threw at least one explosive. He fled, hitting an officer with a car. Driving the backroads, he carjacked at least one person. The brutal episode came to an end when Carrillo was tackled by a young man while attempting to steal another vehicle.
Sgt. Damon Gutzwiller, 38, was fatally shot in the ambush, the first member of Santa Cruz County law enforcement to die on the job since 1983.
Authorities have since tied Carrillo to an active state faction of the Boogaloo Bois, a secretive and decentralized anti-government movement. Unlike many of the groups pushing back against public health measures over the past year, they are expressly anti-cop. One of their stated goals has been to infiltrate Black Lives Matter protests and cause violence that will be blamed on the left, to incite a civil war. Carrillo has since pleaded not guilty to multiple charges of murder in the Santa Cruz and Oakland attacks.
Hall immediately took down the signs from her fence celebrating her daughter's graduation and declaring Black Lives Matter — anything that identified them — and installed more security cameras. "I started wondering, Who around me thinks this way? And how close are they?" Hall said.
Newel had a similar response: "Until that time, the threats seemed like nothing but threats. Like, oh, people might say these horrible things to me, but they're not going to act on them. And then that one action completely changed how I thought about my community."
Hart was devastated. He had known Gutzwiller since the deputy was a teenager. Before that day, Hart said, he realized that right-wing ideology existed but didn't understand the level of cold-blooded commitment. He started rethinking the threats to Hall and Newel. "I never thought in my career that I would see professionals, doctors being threatened for doing their job. It's been mind-boggling to me," said Hart.
A month later, Hall received a chilling letter containing references to the Boogaloo movement. It began with "Hey, CUNT," threatened her family and wished her a slow death. Similar letters had been sent to Sgt. Gutzwiller's widow and the sheriff's department.
Hart's department put out a bulletin to other law enforcement, including details of the letters and information about the man they suspected might have sent them. In neighboring Santa Clara, the sheriff's department noticed similarities to the string of letters their own health officer had been receiving since April.
When the suspect left work midday to mail yet another anonymous letter to Cody, a Santa Clara County sheriff's deputy was tailing him, according to court records. The suspect, Alan Viarengo, was arrested and charged with felony stalking and harassment of a public figure related to the letters to Cody; he has pleaded not guilty. Detectives searched his Gilroy home and found more than 130 firearms, thousands of rounds of ammunition and materials to build explosives, according to law enforcement reports.
As the criminal case moved forward, Hart suggested that, in addition to security systems, the women acquire firearms. Hall's husband came home with a shotgun. For Newel, who holds pacifist beliefs, it wasn't an option. "I wouldn't ever have a gun in my home," she said.
That same month, adherents of a sovereign citizens movement the FBI characterizes as extremist and a form of domestic terrorism went to Newel's home and served her "papers" claiming she'd broken the law. The same group, irate that Santa Cruz Police Chief Andrew Mills had supported Newel's closure orders and mask mandates, left papers inside his home, on his bedroom pillow, according to law enforcement.
Throughout these episodes, Newel and Hall were still responding to the pandemic. Even as fires raged through the mountains, forcing them to evacuate their homes. Even as they were placed on furlough to make up for budget shortfalls.
When you ask Newel and Hall about the effects of living amid so much bile and unease, both say they are not ruled by fear. But they also describe sleepless nights when their spouses are out of town, and both have withdrawn from the community. Hall stopped joining her children's school events on Zoom, afraid other parents would recognize her, and goes to the grocery store incognito, beneath a hat and messy ponytail. Newel just doesn't go out much at all.
Since last April, 22 top health officials have left their posts in California. In December, just as vaccines were arriving, Hall seriously considered resigning. She'd gained 30 pounds and started taking blood pressure medication. She was bringing her laptop into bed every night and not spending enough time with family. Her children wanted her to quit. "There were days I just felt like, I can't do this. I can't do it anymore. I can't get up tomorrow morning. I was mentally, physically, emotionally exhausted."
She has stayed, not because she thinks things will necessarily get better, but because quitting wouldn't make her life easier. It'd just teach people that if they're loud enough and mean enough they can get what they want. If she had learned anything from her refugee parents, it was that she could go on, and so she must. "It's not the idea that everything will turn out fine. It is that no matter what, you can survive this," she said.
As for Newel, she said she'll stick the job out because she's stubborn that way. But she and her wife have rethought their retirement plans. "If we don't feel comfortable being out in the community, or if we're afraid to live here, we're not going to want to stay," she said. "And that's something of a heartbreak.
This story was done as a collaboration between KHN and "This American Life." Listen to the companion audio story here.