At risk are not just the inmates behind bars, but also the people in the community, many of whom work at the prisons.

This article was first published on Thursday, May 14, 2020 in Kaiser Health News.

By LJ Dawson

As the COVID-19 pandemic swept into Montana, it spread into the Marias Heritage Center assisted living facility, then flowed into the nearby 21-bed hospital.

Toole County quickly became the state's hot spot for COVID-19 deaths, with more than four times the infection rate of all other counties and the most recorded deaths in the state. Six of the state's 16 COVID deaths through Tuesday have occurred here.

But another danger loomed: What if it got into the prison, less than 4 miles away from the hospital and assisted living facility? The county was nearly overwhelmed as it was. Across rural America, prisons and jails sit in places like Toole County that have minimal intensive care unit beds and ventilators and few additional medical resources. Many hospitals there were strained before the pandemic.

 This rural, 5,000-person county tucked under the Canadian border might not have seemed like a breeding ground for the contagion. It is a primarily agricultural community almost twice as large as Rhode Island situated in the Great Plains under a big Montana sky. Some areas of the county don't have cellphone coverage, much less internet, and winters are cold enough that people plug in their cars not because they are electric but because they must heat the engines to keep them from freezing.

"When you look at the per capita infection rate in the county and deaths, unfortunately, in our community, it's very, very staggering," said William Kiefer, CEO of the Marias Medical Center, which is affiliated with the assisted living facility. "And the impact is clearly similar to what's happening in some of the urban areas that have been hit really hard."

The two original cases of COVID-19 at the assisted living facility exposed 63 staffers at the center and the affiliated hospital. Thirteen tested positive, and one was hospitalized. All of them recovered. It took a monumental effort by the entire county to keep the hospital from shuttering.

At the worst point, Kiefer and his CFO were the only original staff members not quarantined and able to work. The Montana National Guard helped wash laundry, former employees came out of retirement to fill in, nurses worked as many as five different roles for weeks on end, and quarantined staff coordinated administrative work from sunup to sundown while isolating from their families.

But, through it all, the dreaded coronavirus hasn't yet crept into the site of one of the community's largest employers, the Crossroads Correctional Center prison. It holds almost 15% of the county's total population with a 712-bed facility for both federal and state inmates.

Almost 70% of the nation's more than 1,100 prisons are located outside of metropolitan areas, according to 2017 research by John M. Eason, an associate professor in sociology at the University of Wisconsin-Madison. A building boom occurred from 1980 through 1999 as struggling towns eyed prisons as economic salvations.

But in many of those same communities, rural hospitals that would be tasked to care for inmates during a pandemic have since struggled, with more than 120 rural hospitals closing nationwide in the past decade.

"It's going to be a nightmare because rural communities are so disadvantaged," Eason said. "We're going to see a lot of people in prison contract and die of COVID."

It is not just the inmates behind bars, but also the people in the surrounding community, many of whom work at the facilities, who would be at risk. The employees leaving prisons and jails daily could spread the virus to inmates on the inside and community members on the outside. Already such rural communities on average have sicker and older populations than the rest of the country, even before considering the added risk of close-quartered prisons and jails.

"What is at stake is, in some way, always what's been at stake," said Jessica Pishko, the senior legal adviser at the Justice Collaborative, a nonprofit focused on the justice system. "The most vulnerable are already the ones who are the most impacted."

The Justice Collaborative released a report last month finding that 12% of people held in jails are in counties without intensive care unit beds. In Montana, the report said, over a third of jail detainees are in counties without them. And Toole County has none. Jails, which hold people pretrial, often have a higher rate of turnover of inmates moving in and out of the facility than prisons, increasing the chance of spreading the disease. Still, prisons have similar difficulties with COVID-19 prevention inside facilities.

Of course, not all people infected with the coronavirus end up in need of intensive care, but even a small number of serious cases in a small jail or prison could overwhelm limited resources.

"You can't just airlift 10 people to another hospital," Pishko said.

The Marias Medical Center has two ventilators and added a six-bed COVID-19 isolation tent behind the hospital. It has two regular staff nurses. But, like many rural hospitals, it is designed to stabilize patients and then transfer them to other, bigger hospitals, if needed. Those are some 80 and 160 miles away.

COVID-19 has only magnified the existing resource problems of the medical center.

"We almost got pushed to the limit where we didn't have sufficient staff to maintain our emergency room open, and that would be catastrophic to a community," Kiefer said.

In normal times, the facility saw about five of the prison's inmates a month in the emergency room. Now, amid the pandemic, officials from the medical center and county have been coordinating with the company that runs Crossroads to form plans in case a new wave of COVID-19 compromises the facility. Ryan Gustin, a spokesperson for CoreCivic, which runs Crossroads, said they are all sharing information to "strengthen our collective response."

The Montana Department of Corrections also helped the private prison distribute educational materials, such as newsletters detailing information about the virus and prevention. As of Monday, no inmates had tested positive in Montana state-run facilities and three staff had tested positive.

Even so, Toole County Health Department interim director Blair Tomsheck wrote in an email that "any outbreak has the potential to overwhelm our medical resources."

LJ Dawson: @LJDawson0

Officials are finding it's still difficult to talk about race and COVID-19. Fear of stigmatization remains high.

This article was first published on Wednesday, May 13, 2020 in Kaiser Health News.

By Anna Almendrala

In early March, Madalynn Rucker, then 69, agonized over whether to close her Sacramento consultancy office. On the 16th, she finally succumbed to a barrage of texts and calls from her daughter about the heightened risk of the coronavirus, and told her employees to begin working from home. That was three days before California Gov. Gavin Newsom's statewide stay-at-home order.

Her daughter was right in more ways than one. While Rucker's age alone raised her potential danger of being hospitalized or dying of COVID-19, she and many of her employees share another risk factor: They are black. Rucker wonders if more public health messages targeting African Americans could have helped millions like her better prepare for the disease's onslaught.

Officials and commentators said little about race early in the pandemic, recalled Rucker, now 70 and the executive director of OnTrack, a diversity consulting firm. "Could this have made a difference in some way? Not just in educating ourselves, but in how the pandemic was controlled and managed?"

By late February, doctors in China had published that, in addition to older patients, those with chronic health conditions, particularly hypertension and diabetes, were more likely to have severe cases of COVID-19 that ended in ICU admission, mechanical ventilation or death.

It wouldn't have been difficult, some community leaders say, for officials to make an explicit connection between the coronavirus risk factors and African Americans and Latinos, who are more likely to have chronic diseases, and at younger ages ― and then craft tailored, respectful messages for them.

"The messaging I got from the news was, is that if you're young, you're good, and if you're old, you've got to stay home," said Eddie Anderson, the 30-year-old pastor of McCarty Memorial Christian Church, an African American congregation in South Los Angeles.

When Anderson became ill with what turned out to be another viral infection in early March, he was alarmed by the lack of information about how to get tested for COVID-19. The experience motivated him to bring a physician friend to church the next week to explain the disease to his flock.

"I think targeted messaging to the African American community would have been helpful," he said.

But public health and infectious disease experts say the novelty of the virus, whose targets and mode of attack continue to confound scientists, meant that specific racial disparities weren't a foregone conclusion.

"I don't know that it's fair to say that it would have been something that could be 100% predicted," said California Surgeon General Nadine Burke Harris. She called the novel coronavirus "a little bit of a head-scratcher." For example, it doesn't appear to affect children under age 2 or pregnant women the same way similar viruses would, she noted.

"Sometimes when you predict too strongly, it can have the effect of assuming that's going to be the outcome, and it can come across pejoratively," Burke Harris said.

But the disease has disproportionately hurt blacks. In California, 10% of COVID-19 deaths occurred among African Americans, who make up 6% of the state population. A national Centers for Disease Control and Prevention survey showed that 33% of hospitalized COVID patients were non-Hispanic blacks, though that group represented only 18% of residents in the surveyed communities.

Officials are finding it's still difficult to talk about race and COVID-19. Fear of stigmatization remains high, said Burke Harris, who said she walks a fine line by letting certain groups know about the heightened risks without casting blame on them.

"One of the things I've been dealing with a lot in having conversations with black media and black health researchers, right, is this notion of, well, wait a minute, as this data is coming out, how are we not blaming black and brown communities?" said Burke Harris, who is black. "It's like, 'Oh, are you saying we're sicker?'"

Preexisting conditions aren't the only reason black people are dying at disproportionate rates of COVID-19, said Dr. Sonia Angell, director of the California Department of Public Health.

Despite states' orders to stay at home, entire sectors of "essential" jobs have disproportionately high rates of minority employees, which increases their exposure risk. These workers don't benefit as much from social distancing, Angell said.

"They're the ones that are keeping our care delivery system functioning so that when any of us get sick, we have a place to go," she said. "They're the ones that are keeping our grocery stores running and stocked."

The absence of coordinated, official public messaging in February and early March about the potential racial disparity of COVID-19's impact created a vacuum into which conspiracy theories rushed.

Initially came rumors that black people were somehow resistant to the coronavirus. At the same time, black media outlets like The Philadelphia Tribune (Feb. 4), Essence (March 2), the St. Louis American (March 11) and The Undefeated (March 13) made the connection between the virus and America's preexisting health inequalities, publishing forward-thinking pieces about the virus' potential threat to black Americans because of chronic medical conditions, working and commuting conditions, and a historical lack of access to health care and insurance due to institutionalized racism.

Their predictions soon proved true. Local officials began noting higher death rates for black COVID-19 patients in Milwaukee on March 23. In the first week of April, city officials in Chicago, Los Angeles and New Orleans made similar announcements. The CDC published its first national data on racial disparities on April 8. A recent CDC study, published April 29, found that black people made up 83% of COVID-19 hospitalizations in Georgia, a disproportionate level compared with overall hospitalizations.

Public health messages targeting specific populations should be voiced by trusted community leaders, or at least someone of the same race, on media platforms where they're most likely to be seen or heard, said Dr. Oliver Brooks, president of the National Medical Association, which represents black physicians.

A week after announcing the statewide shelter order, Newsom tweeted a public service announcement from Snoop Dogg, who said, "The longer you stay outside, the longer we're going to be inside."

Other targeted messages include Spanish-language public service announcements featuring Burke Harris and LA Galaxy soccer player Javier "Chicharito" Hernández. Those have run on Univision; Radio Bilingüe, a Spanish-language public radio network; and other Spanish-language stations, as well as Instagram and Facebook. In Hernández's clip, he encourages listeners in Spanish to seek medical attention if they have COVID-19 symptoms, no matter what their immigration status is.

Targeted messaging can sometimes offend or insult, even with the best of intentions, said Daniel Schober, assistant professor of public health and behavioral psychology at DePaul University in Chicago.

The city of Chicago offended some with a 2015 flu shot campaign that featured a black baby on a billboard next to the words, "I am an outbreak." It inspired graffiti artists to weigh in with their own message: "I am beautiful."

But the city's COVID-19 campaign, featuring Mayor Lori Lightfoot, who is black, has charmed residents, said Schober. The campaign played off social media memes depicting a no-nonsense Lightfoot shutting down iconic Chicago landmarks under shelter-in-place directives. The city's official video showed the mayor baking, learning the guitar and sipping tea while exhorting people to "stay home, save lives."

"That's a great example of a message that isn't necessarily tailored toward specific racial or ethnic groups, but is really meant to be universal in its reach," Schober said.

Anna Almendrala: aalmendrala@kff.org, @annaalmendrala

For older adults contemplating what might happen to them during this pandemic, ventilators are a fraught symbol, representing a terrifying lack of personal control as well as the fearsome power of technology.

This article was first published on Tuesday, May 12, 2020 in Kaiser Health News.

By Judith Graham

DENVER ― Last month, Minna Buck revised a document specifying her wishes should she become critically ill.

"No intubation," she wrote in large letters on the form, making sure to include the date and her initials.

Buck, 91, had been following the news about COVID-19. She knew her chances of surviving a serious bout of the illness were slim. And she wanted to make sure she wouldn't be put on a ventilator under any circumstances.

"I don't want to put everybody through the anguish," said Buck, who lives in a continuing care retirement community in Denver.

For older adults contemplating what might happen to them during this pandemic, ventilators are a fraught symbol, representing a terrifying lack of personal control as well as the fearsome power of technology.

Used for people with respiratory failure, a signature consequence of severe COVID-19, these machines pump oxygen into a patient's body while he or she lies in bed, typically sedated, with a breathing tube snaked down the windpipe (known as "intubation").

For some seniors, this is their greatest fear: being hooked to a machine, helpless, with the end of life looming. For others, there is hope that the machine might pull them back from the brink, giving them another shot at life.

"I'm a very vital person: I'm very active and busy," said Cecile Cohan, 85, who has no diagnosed medical conditions and lives independently in a house in Denver. If she became critically ill with COVID-19 but had the chance of recovering and being active again, she said, "yes, I would try a ventilator."

What's known about people's chances?

Although several reports have come out of China, Italy and, most recently, the area around New York City, "the data is really scanty," said Dr. Carolyn Calfee, a professor of anesthesia at the University of California-San Francisco.

Initial reports suggested that the survival rate for patients on respirators ranged from 14% (Wuhan, China) to 34% (early data from the United Kingdom). A report from the New York City area appeared more discouraging, with survival listed at only 11.9%.

But the New York data incorporated only patients who died or were discharged from hospitals — a minority of a larger sample. Most ventilator patients were still in the hospital, receiving treatment, making it impossible for researchers to draw reliable conclusions.

Calfee worries that data from these early studies may not apply to U.S. patients treated in hospitals with considerable resources.

"The information we have is largely from settings with tremendous resource gaps and from hospitals that are overwhelmed, where patients may not be treated with optimal ventilator support," she said. "I would be very worried if people used that data to make decisions about whether they wanted mechanical ventilation."

Still, a sobering reality emerges from studies published to date: Older adults, especially those with underlying medical conditions such as heart, kidney or lung disease, are least likely to survive critical illness caused by the coronavirus or treatment with a ventilator.

"Their prognosis is not great," said Dr. Douglas White, a professor of critical care medicine at the University of Pittsburgh. He cautioned, however, that frail older adults shouldn't be lumped together with healthy, robust older adults, whose prospects may be somewhat better.

Like other clinicians, White has observed that older COVID patients are spending considerably longer on ventilators ― two weeks or more — than is the case with other critical illnesses. If they survive, they're likely to be extremely weak, deconditioned, suffering from delirium and in need of months of ongoing care and physical rehabilitation.

"It's a very long, uphill battle to recovery," and many older patients may never regain full functioning, said Dr. Negin Hajizadeh, an associate professor of critical care medicine at the School of Medicine at Hofstra/Northwell on New York's Long Island. "My concern is, who's going to take care of these patients after a prolonged ventilator course ― and where?"

In St. Paul, Minnesota, Joyce Edwards, 61, who is unmarried and lives on her own, has been wondering the same thing.

In late April, Edwards revised her advance directive to specify that "for COVID-19, I do not want to be placed on a ventilator." Previously, she had indicated that she was willing to try a ventilator for a few days but wanted it withdrawn if the treatment was needed for a longer period.

"I have to think about what the quality of my life is going to be," Edwards said. "Could I live independently and take care of myself — the things I value the most? There's no spouse to take care of me or adult children. Who would step into the breach and look after me while I'm in recovery?"

People who've said "give a ventilator a try, but discontinue it if improvement isn't occurring" need to realize that they almost surely won't have time to interact with loved ones if treatment is withdrawn, said Dr. Christopher Cox, an associate professor of medicine at Duke University.

"You may not be able to live for more than a few minutes," he noted.

But the choice isn't as black-and-white as go on a ventilator or die.

"We can give you high-flow oxygen and antibiotics," Cox said. "You can use BiPAP or CPAP machines [which also deliver oxygen] and see how those work. And if things go poorly, we're excellent at keeping you comfortable and trying to make it possible for you to interact with family and friends instead of being knocked out in a coma."

Heather McCrone of Bellevue, Washington, realized she'd had an "all-or-nothing" view of ventilation when her 70-year-old husband developed sepsis — a systemic infection ― last year after problems related to foot surgery.

Over nine hours, McCrone sat in the intensive care unit as her husband was stabilized on a ventilator by nurses and respiratory therapists. "They were absolutely fantastic," McCrone said. After a four-day stay in the hospital, her husband returned home.

"Before that experience, my feeling about ventilators was 'You're a goner and there's no coming back,'" McCrone said. "Now, I know that's not necessarily the case."

She and her husband both have advance directives stating that they want "lifesaving measures taken unless we're in a vegetative state with no possibility of recovery." McCrone said they still need to discuss their wishes with their daughters, including their preference for getting treatment with a ventilator.

These discussions are more important than ever ― and perhaps easier than in the past, experts said.

"People are thinking about what could happen to them and they want to talk about it," said Dr. Rebecca Sudore, a professor of medicine at the UCSF. "It's opened up a lot of conversations."

Rather than focusing on whether to be treated with a ventilator, she advises older adults to discuss what's most important to them — independence? time with family? walking? living as long as possible? ― and what they consider a good quality of life. This will provide essential context for decisions about ventilation.

"Some people may say my life is always worth living no matter what type of serious illness or disability I have," she said. "On the other end of the spectrum, some people may feel there are health situations or experiences that would be so hard that life would not be worth living."

Sudore helped create Prepare for Your Care, a website and a set of tools to guide people through these kinds of conversations. Recently it was updated to include a section on COVID-19, as have sites sponsored by Compassion & Choices and The Conversation Project. And the Colorado Program for Patient Centered Decisions has published a decision aid for COVID patients considering life support, also available in Spanish.

Some older adults have another worry: What if there aren't enough ventilators for all the COVID patients who need them?

In that situation, "I would like to say 'no' because other people need that intervention more than I do and would benefit, in all probability, more than I would," said Larry Churchill, 74, an emeritus professor of medical ethics at Vanderbilt.

"In a non-scarcity situation, I'm not sure what I'd do. I'm in pretty good health, but people my age don't survive as well from any major problem," Churchill said. "Most of us don't want a long, lingering death in a custodial facility where the chances of recovery are small and the quality of life may be one we're not willing to tolerate."

 Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

For-profit companies that typically pay $50 per donation of plasma used in other lifesaving therapies are advertising aggressively — and significantly bumping up their rates for COVID donors.

This article was first published on Monday, May 11, 2020 in Kaiser Health News.

By JoNel Aleccia

Diana Berrent learned she had tested positive for COVID-19 on a Wednesday in mid-March. Within a day, she had received 30 emails from people urging her to donate blood.

Friends and acquaintances, aware of her diagnosis, passed along a pressing request from New York's Mount Sinai Health System, one of the first centers to seek plasma, a blood component, to be used in a therapy that might fight the deadly disease. Berrent, 45, said she immediately recognized the need for the precious plasma — and the demand that would follow.

"When I saw that email going around, I saw what was going to happen in the landscape," said Berrent, a photographer and mother of two who lives on Long Island. She went on to found Survivor Corps, a grassroots clearinghouse that connects people who have recovered from COVID-19 with organizations eager to collect their blood.

"What I saw was going to emerge was a free market where survivors were a commodity."

Nearly two months later, Berrent's prediction is coming true. The coronavirus has infected more than 1.2 million people in the U.S., and now government scientists, academic researchers and for-profit pharmaceutical firms all are scrambling for blood plasma from COVID-19 survivors in hopes of developing a range of potential treatments.

In Minnesota, a program coordinated by the Mayo Clinic has collected plasma from more than 12,000 COVID survivors for transfusion into more than 7,000 gravely ill patients, the result of a massive public appeal led by government leaders and nonprofit groups like the Red Cross.

Meanwhile, for-profit companies that typically pay $50 per donation of plasma used in other lifesaving therapies are advertising aggressively — and significantly bumping up their rates for COVID donors.

In Utah, John and Melanie Haering, who contracted COVID-19 aboard the ill-fated Diamond Princess cruise ship, received gift cards worth $800 after making two donations apiece at a Takeda Pharmaceuticals BioLife Plasma Services center. BioLife runs several of the more than 800 paid-plasma collection sites in the U.S., part of an industry that produces plasma protein

"Given the urgency and importance of collecting convalescent plasma from the small population of recovered COVID-19 patients, BioLife is currently offering an added incentive for the first two donations from recovered COVID-19 patients," Takeda spokesperson Julia Ellwanger said in an email.

The money was "a nice surprise" for the Haerings, though they said they were motivated more by the opportunity to prevent others from suffering.

"If we could help anybody, we'd go every day," said John Haering, 63, a retired railroad manager who spent two weeks in a hospital in Japan after testing positive for the virus.

Donors like Berrent and the Haerings are needed to supply the building blocks of potentially lifesaving treatments. Rich with antibodies, convalescent plasma from COVID-19 patients is being tested as a possible therapy to promote recovery in people who are critically ill with the disease.

It's also being collected to create a concentrated antibody serum known as hyperimmune globulin that may prevent or halt infection in the future. Similar products are used to treat rabies and illnesses like infant botulism. If plasma from COVID-19 donors is shown to halt the disease, coming up with an antidote could offer companies the prospect of making millions of dollars.

And there's the possibility of a third treatment, monoclonal antibody therapy, which would use antibody-producing cells from high-antibody donors to create lab-produced molecules to fight the disease.

All three therapies are promising, but all three require human blood plasma, said Dr. Michael Busch, a professor of laboratory medicine at the University of California-San Francisco and director of the Vitalant Research Institute, one of the largest blood center-based transfusion medicine research programs in the U.S.

"At some level, they're all competing with the regular blood banks like mine," Busch said.

Only a fraction of those infected with COVID-19 have recovered sufficiently to donate, though more are eligible every day. But as demand for donors has grown, so has the need to wrangle the supply, ensuring that competition for plasma doesn't undercut the larger mission, said Dr. Michael Joyner, who heads the Mayo Clinic program.

"We're going to get it all worked out," he said. "It's in everybody's enlightened self-interest to do this in an intelligent way."

To avoid what Joyner described as a "range war" for COVID-19 plasma, he's spearheading an effort that calls for unprecedented collaboration to distribute separate streams of plasma among producers of therapies in a global market estimated to reach $35.5 billion by 2023.

"It's like the oil market," he said. "You send oil that needs one type of refining to one market and oil that needs another type of refining to another market."

His plan — floated last month to a group that included representatives from philanthropic organizations along with executives from for-profit and nonprofit blood collectors — relies in part on blood plasma from up to 10,000 Hasidic women in New York City, where the Orthodox Jewish community has been hit hard by the disease.

Tens of thousands of people have fallen ill with the virus in the city's Hasidic neighborhoods, and more than 700 have died. In recent weeks, thousands of men in the community who have recovered from COVID-19 have rushed to donate plasma. Chaim Lebovits, 45, who has helped organize the effort, said the donations are an act of faith.

"We have an obligation to protect and save lives," Lebovits said.

So far, however, many women in the Hasidic community have been unable to participate. Hasidic families are often large, and women who have had several children may have high levels of certain antibodies that are sometimes produced during a pregnancy. Rarely, such antibodies can cause a dangerous reaction — transfusion-related acute lung injury — in some recipients of plasma from women who have been pregnant. In COVID-19 patients, battling a virus that targets the lungs, such reactions could be deadly.

Given the risk, many Hasidic mothers who want to join the men in donating have been deferred from providing plasma for immediate transfusion, Joyner said. But those women could be an ideal and ongoing source of plasma for hyperimmune globulin, which is processed in a way that dilutes or removes the antibodies.

Roughly 10,000 women could donate up to four times each, generating some 30,000 liters of COVID-19 plasma that could be directed to the for-profit collectors to make hyperimmune globulin, Joyner estimated. That's enough for the companies to get started.

"This is the basis of a true win-win," Joyner said.

In the future, other groups deemed ineligible to provide convalescent plasma for transfusion, out of concern about disease transmission, could be diverted for hyperimmune globulin creation, he said.

One key part of the plan will be the ability to identify eligible donors through antibody tests, Joyner said. Mayo Clinic scientists have already conducted more than 5,000 serology tests and identified hundreds of potential plasma donors.

So far, however, neither the nonprofit organizations nor the for-profit firms have agreed to the plan.

"Ways to facilitate these donations and recommendations for how to allocate donors to one donation stream or the other are still in progress," said Natalie de Vane, a spokesperson for CSL Behring, a biopharmaceutical company based in King of Prussia, Pennsylvania.

CSL has joined with Takeda, a Japanese pharmaceutical company, to lead the CoVIg-19 Plasma Alliance, a coalition of six companies developing a single, unbranded hyperimmune globulin product that could treat COVID-19.

Meanwhile, officials with the AABB, an international nonprofit focused on transfusion medicine and cellular therapies, have focused efforts primarily on collecting plasma for immediate use. But they acknowledged that convalescent plasma could end up serving as "bridge therapy" to buy time until the hyperimmune globulin products are available.

"AABB recognizes the importance of ensuring that convalescent plasma is available as a transfusion therapy for patients today, as well as to develop future treatments," the agency said in a statement.

Representatives from all sides agree that the most pressing need is to increase the pool of COVID-19 survivors willing to donate plasma. They downplay talk of jockeying for donors in the nonprofit and for-profit worlds.

"We don't view it as competition," said Chris Healey, president of corporate affairs at Grifols, a Spanish pharmaceutical company that has received nearly $13 million in funding from the U.S. Department of Defense to develop its own hyperimmune globulin product. "We're all pointed in the same direction."

One solution may be groups like Berrent's nonprofit Survivor Corps, which started in late March with a Facebook group that's grown to 42,000 members and now includes international partnerships and a pro bono advertising campaign, A Call to Arms.

Berrent has given plasma four times now, including to a biotech firm that sent a phlebotomist to her home and gave her a $100 Amazon card for her trouble.

Survivor Corps aims to function as a "one-stop shop" for donors interested in giving COVID-19 plasma, said Berrent. And, she said, it also could serve as a single source for recruitment, freeing scientists in government, academia and industry to focus on finding answers, not scouting survivors.

"Free markets work beautifully in many, many situations," said Berrent. "During a global pandemic, during a time of crisis, we need collaboration and efficiency."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia