Joe Biden on Wednesday took the oath to become the 46th president of the United States, vowing to bring the nation together in the midst of an ongoing pandemic that has claimed more than 400,000 lives, enormous economic dislocation and civil unrest so serious that the U.S. Capitol steps where he took his oath were surrounded not by cheering crowds, but by tens of thousands of armed police and National Guard troops.
In his inaugural address, given outside despite concerns for his physical security, Biden emphasized unity, the driving theme of his campaign. "My whole soul is in this, bringing America together, uniting our nation," he said. "And I ask every American to join me in this cause."
On health care, Biden made it clear that combating the covid-19 pandemic will be his top priority. "We must set aside politics and finally face this pandemic as one nation," he said. "We will get through this together."
Among Biden's first official actions Wednesday afternoon were several covid-related executive orders. As promised, Biden is requiring masks and physical distancing in federal buildings and on other federal properties, and by federal workers and contractors. He also announced the U.S. will renew its membership with the World Health Organization, which former President Donald Trump was in the process of leaving. And he will re-establish the pandemic preparedness office in the National Security Council, which the Trump administration had dissolved.
Last week, Biden unveiled a covid plan that also includes using the Defense Production Act to speed the manufacture of syringes and other supplies needed to administer vaccines; creating federal vaccination centers and mobilizing the Federal Emergency Management Agency, the National Guard and others to administer the vaccines, and launching a communications campaign to convince reluctant members of the public that the vaccine is safe. Details on his vaccination plan followed his unveiling the day before of a $1.9 trillion covid emergency relief package.
Biden got a separate boost earlier in the day with the swearing in of two new Democratic senators from Georgia, fresh off their victories in a Jan. 5 runoff election. The additions of Sen. Jon Ossoff and Raphael Warnock, plus a tie-breaking vote from new Vice President Kamala Harris, gives Democrats 51 votes in the Senate and effective control of both chambers of Congress for the first time since 2010.
With such narrow majorities in the House and Senate, it seems unlikely Biden will be able to make good on some of his more sweeping health-related campaign promises, including creating a "public option" to help expand insurance coverage and lowering the Medicare eligibility age from 65 to 60.
But even the barest of control will make it substantially easier for Biden to get his appointees confirmed in the Senate, and the possibility is open to use a fast-track process called budget reconciliation to make health-related budget changes, perhaps including modifications of the Affordable Care Act that might make coverage less expensive for some families.
Beyond covid, health is likely to take a back seat in the early going of the administration as officials deal with more pressing problems like the economy, immigration and climate change.
Biden health aides are expected to begin to unwind many of the changes made by Trump that do not require legislation, such as restoring anti-discrimination protections for transgender people and reversing the Trump administration's decision to allow some states to implement work requirements for adults covered by Medicaid. But even that could take weeks or months.
Update: This story was updated at 5:25 p.m. ET to add information about the executive orders President Joe Biden signed in the afternoon.
By the time he tested positive for covid-19 on Jan. 12, Gary Herritz was feeling pretty sick. He suspects he was infected a week earlier, during a medical appointment in which he saw health workers who were wearing masks beneath their noses or who had removed them entirely.
His scratchy throat had turned to a dry cough, headache, joint pain and fever — all warning signs to Herritz, who underwent liver transplant surgery in 2012, followed by a rejection scare in 2018. He knew his compromised immune system left him especially vulnerable to a potentially deadly case of covid.
"The thing with transplant patients is we can crash in a heartbeat," said Herritz, 39. "The outcome for transplant patients [with covid] is not good."
On Twitter, Herritz had read about monoclonal antibody therapy, the treatment famously given to President Donald Trump and other high-profile politicians and authorized by the Food and Drug Administration for emergency use in high-risk covid patients. But as his symptoms worsened, Herritz found himself very much on his own as he scrambled for access.
His primary care doctor wasn't sure he qualified for treatment. His transplant team in Wisconsin, where he'd had the liver surgery, wasn't calling back. No one was sure exactly where he should go to get it. From bed in Pascagoula, Mississippi, he spent two days punching in phone numbers, reaching out to health officials in four states, before he finally landed an appointment to receive a treatment aimed at keeping patients like him out of the hospital — and, perhaps, the morgue.
"I am not rich, I am not special, I am not a political figure," Herritz, a former community service officer, wrote on Twitter. "I just called until someone would listen."
Months after Trump emphatically credited an experimental antibody therapy for his quick recovery from covid and even as drugmakers ramp up supplies, only a trickle of the product has found its way into regular people. While hundreds of thousands of vials sit unused, sick patients who, research indicates, could benefit from early treatment — available for free — have largely been fending for themselves.
Federal officials have allocated more than 785,000 doses of two antibody treatments authorized for emergency use during the pandemic, and more than 550,000 doses have been delivered to sites across the nation. The federal government has contracted for nearly 2.5 million doses of the products from drugmakers Eli Lilly and Co. and Regeneron Pharmaceuticals at a cost of more than $4.4 billion.
So far, however, only about 30% of the available doses have been administered to patients, federal Department of Health and Human Services officials said.
Scores of high-risk covid patients who are eligible remain unaware or have not been offered the option. Research has shown the therapy is most effective if given early in the illness, within 10 days of a positive covid test. But many would-be recipients have missed this crucial window because of a patchwork system in the U.S. that can delay testing and diagnosis.
"The bottleneck here in the funnel is administration, not availability of the product," said Dr. Janet Woodcock, a veteran FDA official in charge of therapeutics for the federal Operation Warp Speed effort.
Among the daunting hurdles: Until this week, there has been no nationwide system to tell people where they could obtain the drugs, which are delivered through IV infusions that require hours to administer and monitor. Finding space to keep covid-infected patients separate from others has been difficult in some health centers slammed by the pandemic.
"The health care system is crashing," Woodcock told reporters. "What we've heard around the country is the No. 1 barrier is staffing."
At the same time, many hospitals have refused to offer the therapy because doctors were unimpressed with the research federal officials used to justify its use.
Monoclonal antibodies are lab-produced molecules that act as substitutes for the body's own antibodies that fight infection. The covid treatments are designed to block the SARS-CoV-2 virus that causes infection from attaching to and entering human cells. Such treatments are usually prohibitively expensive, but for the time being the federal government is footing the bulk of the bill, though patients likely will be charged administrative fees.
Nationwide, nearly 4,000 sites offer the infusion therapies. But for patients and families of people most at risk — those 65 and older or with underlying health conditions — finding the sites and gaining access has been almost impossible, said Brian Nyquist, chief executive officer of the National Infusion Center Association, which is tracking supplies of the antibody products. Like Herritz, many seeking information about monoclonals find themselves on a lone crusade.
"If they're not hammering the phones and advocating for access for their loved ones, others often won't," he said. "Tenacity is critical."
Regeneron officials said they're fielding calls about covid treatments daily to the company's medical information line. More than 3,500 people have flooded Eli Lilly's covid hotline with questions about access.
As of this week, all states are required to list on a federal locator map sites that have received the monoclonal antibody products, HHS officials said. The updated map shows wide distribution, but a listing doesn't guarantee availability or access; patients still need to check. It's best to confer with a primary care provider before reaching out to the centers. For best results, treatment should occur as soon as possible after a positive covid test.
Some health systems have refused to offer the monoclonal antibody therapies because of doubts about the data used to authorize them. Early studies suggested that Lilly's therapy, bamlanivimab, reduced the need for hospitalization or emergency treatment in outpatient covid cases by about 70%, while Regeneron's antibody cocktail of casirivimab plus imdevimab reduced the need by about 50%.
But those studies were small, just a few hundred subjects, and the results were limited. "A lot of doctors, actually, they're not impressed with the data," said Dr. Daniel Griffin, an infectious disease expert at Columbia University who co-hosts the podcast "This Week in Virology." "There really is still that question of, 'Does this stuff really work?'"
As more patients are treated, however, there's growing evidence that the therapies can keep high-risk patients out of the hospital, not only easing their recovery but also decreasing the burden on health systems struggling with record numbers of patients.
Dr. Raymund Razonable, an infectious disease expert at the Mayo Clinic in Minnesota, said he has treated more than 2,500 covid patients with monoclonal antibody therapy with promising results. "It's looking good," he said, declining to provide details because they're embargoed for publication. "We are seeing reductions in hospitalizations; we're seeing reductions in ICU care; we're also seeing reductions in mortality."
Banking on observations from Mayo experts and others, federal officials have been pushing for wider use of antibody therapies. HHS officials have partnered with hospitals in three hard-hit states — California, Arizona and Nevada — to set up infusion centers that are treating dozens of covid patients each day.
One of those sites went up in late December at El Centro Regional Medical Center in California's Imperial County, an impoverished farming region on the state's southern border that has recorded among the highest covid infection rates in the state. For months, the medical center strained to absorb the overwhelming influx of patients, but chief executive Dr. Adolphe Edward said a new walk-up infusion site has already put a dent in the covid load.
More than 130 people have been treated, all patients who were able to get the two-hour infusions and then recuperate at home. "If those folks would not have had the treatment, they would have come through the emergency department and we would have had to admit the lion's share of them," he said.
It's important to make sure people in high-risk groups know to seek out the therapy and to get it early, Edward said. He and his staff have been working with area doctors' offices and nonprofit groups and relying on word-of-mouth.
"On multiple levels, we're saying, 'If you've tested positive for the virus, come and let us see if you are eligible,'" Edward said.
Greater awareness is a goal of the HHS effort, said Dr. John Redd, chief medical officer for the assistant secretary for preparedness and response. "These antibodies are meant for everyone," he said. "Everyone across the country should have equal access to these products."
For now, patients like Herritz, the Mississippi liver transplant recipient, say reality is falling well short of that goal. If he hadn't continued to call in search of a referral, he wouldn't have been treated. And without the therapy, Herritz believes, he was just days away from hospitalization.
"I think it's horrible that if I didn't have Twitter, I wouldn't know anything about this," he said. "I think about all the people who have died not knowing this was an option for high-risk individuals."
California's telemetry nurses, who specialize in the electronic monitoring of critically ill patients, normally take care of four patients at once. But ever since the state relaxed California's mandatory nurse-to-patient ratios in mid-December, Nerissa Black has had to keep track of six.
And these six patients are really sick: Many of them are being treated simultaneously for a stroke and covid-19, or a heart attack and covid. With more patients than usual needing more complex care, Black said she's worried she'll miss something or make a mistake.
"We are given 50% more patients and we're expected to do 50% more things with the same amount of time," said Black, who has worked at the Henry Mayo Newhall Hospital in Valencia, California, for seven years. "I go home and I feel like I could have done more. I don't feel like I'm giving the care to my patients like a human being deserves."
As covid patients continue to flood California emergency rooms, hospitals are increasingly desperate to find enough staffers to care for them all. The state is asking nurses to tend to more patients simultaneously than they typically would, watering down what many nurses and their unions consider their most sacrosanct job protection: a law existing only in California that puts legal restrictions on the nurse-to-patient ratio.
"We need to temporarily — very short-term, temporarily — look a little bit differently in terms of our staffing needs," said Gov. Gavin Newsom, after he quietly allowed hospitals to adjust their nurse-to-patient ratios on Dec. 11. Usually, California law requires a hospital to first get approval from the state before tinkering with those ratios; Newsom's move gave hospitals presumptive approval to work outside the ratio rules immediately.
Since then, 188 hospitals, mainly in Southern California, have been operating under the new pandemic ratios: They can require ICU nurses to care for three patients instead of two. Emergency room and telemetry nurses may now be asked to care for six patients instead of four. Medical-surgical nurses are looking after seven patients instead of five.
Nurses have taken to the streets in protest, holding physically distanced demonstrations across the state, shouting and carrying posters that read: "Ratios Save Lives." The union, the California Nurses Association, says the staffing shortage is a result of bad hospital management, of taking a reactive approach to staffing rather than proactive — laying nurses off over the summer, then not hiring or training enough for winter.
"What we're seeing in these hospitals is their just-in-time response to a pandemic that they never prepared for — just-in-time staffing, just-in-time resources, not staffing up, calling nurses in on a shift at the very last minute — to boost profits," said Stephanie Roberson, government relations director for the California Nurses Association. "And we're seeing how nurses are being stretched even thinner."
But hospitals say this is an unprecedented crisis that has spiraled beyond their control. In the current surge, four times as many Californians are testing positive for the coronavirus compared with the summer's peak. As many as 7,000 new patients could soon be coming to California hospitals every day, according to Carmela Coyle, who heads the California Hospital Association.
"This is catastrophic and we cannot dodge this math," she said. "We are simply out of nurses, out of doctors, out of respiratory therapists."
The state has asked the federal government for staff, including 200 medical personnel from the Department of Defense, and it's tried to reactivate the California Health Corps, an initiative to recruit retired health workers to come back to work. But that has yielded few people with the qualifications needed to care for hospitalized covid patients.
Hiring contract nurses from temporary staffing agencies or other states is all but impossible right now, Coyle said.
"Because California surged early during the summer and other parts of the United States then surged afterward," she said, "those travel nurses are taken."
The next step for hospitals is to try "team nursing," Coyle said — pulling nurses from other departments, like the operating room, for example, and partnering them with experienced critical care nurses to help care for covid patients.
Joanne Spetz, an economics professor who studies health care workforce issues at the University of California-San Francisco, said hospitals should have started training nurses for team care over the summer, in anticipation of a winter surge, but they didn't, either because of costs — hospitals lost a lot of revenue from canceled elective surgeries that could have paid for that training — or because of excessive optimism.
"California was doing so well," she said. "It was easy for all of us to believe that we kind of got it under control, and I think there was a lot of belief that we would be able to maintain that."
The California Nurses Association has good reason to be defensive regarding the integrity of the patient-ratio law, Spetz said. It took 10 years of lobbying and activism before the bill passed the state legislature in 1999, then several more years to overcome multiple court challenges, including one from then-Gov. Arnold Schwarzenegger.
"I'm always kicking their butt, that's why they don't like me," Schwarzenegger famously said of nurses, drawing broad ire from the nurses union and its allies.
Nurses prevailed in the court of public opinion and in law; rules that put a legal cap on the number of patients per nurse finally took effect in 2004. But the long battle made nurses fiercely protective of their win. They've even accused hospitals of using the pandemic to try to roll back ratios for good.
"This is the exercise of disaster capitalism at its finest, where [hospital administrators] are completely maximizing their opportunity to take advantage of this crisis," Roberson said.
Hospitals deny they want to change the ratio law permanently, and Spetz said it's unlikely they'd succeed if they tried. The public can see that nurses are overworked and burned out by the pandemic, she said, so there would be little support for cutting back their job protections once it's over.
"To go in and say, 'Oh, you clearly did so well without ratios when we let you waive them, so let's just eliminate them entirely,' I think, would be just adding insult to moral injury," Spetz said.
Surveys in North Carolina and across the nation show that about one-third of transgender people have been refused treatment or suffered verbal or physical abuse from a medical provider.
This article was published on Wednesday, January 20, 2021 in Kaiser Health News.
When Allison Scott came out as a trans woman in 2013, she told not only family and friends, but also her primary care physician.
She didn't need his help with hormone therapy. She had another doctor for that. But she wanted to share the information with her doctor of more than 10 years in case it affected other aspects of her health.
She was shocked when he told her he would no longer treat her.
"It was humiliating," said Scott, now director of policy and programs for the Campaign for Southern Equality, an LGBTQ advocacy organization based in North Carolina. "It's not because the provider doesn't have the knowledge they need, but because the provider isn't comfortable with who you are."
Surveys in North Carolina and across the nation show that about one-third of transgender people have been refused treatment or suffered verbal or physical abuse from a medical provider.
Such concerns have become more worrisome during the covid-19 pandemic, when being denied health care — or avoiding it due to fear of discrimination and previous negative experiences — can have deadly consequences.
But Scott and other advocates in North Carolina now see an opening to push for city and county laws prohibiting this type of treatment. A state ban preventing local governments from enacting nondiscrimination ordinances expired on Dec. 1.
The ban was a remnant of the controversial 2016 "bathroom bill," which catapulted North Carolina into the national spotlight by making it the first state to require transgender people to use the bathroom of the gender on their birth certificate. Although public backlash and economic repercussions forced the state to repeal that law, the legislature replaced it with one that blocked local governments from passing nondiscrimination ordinances.
Now new laws could address discrimination in employment, housing, public places and more. Scott said health care should be among the top considerations, whether that means banning discrimination on the basis of gender identity and sexual orientation in hospitals and clinics or preventing someone from being fired for their identity and losing health insurance as a result.
So far, the towns of Carrboro, Hillsborough and Chapel Hill, along with Orange County, jointly announced this month new nondiscrimination ordinances that will protect LGBTQ individuals in workplaces and in public. At least two other cities are drafting ordinances and plan to vote on them later this month.
These local actions take on added significance in view of efforts during the past four years to roll back federal protections for LGBTQ people. The Trump administration has tried to expand the interpretation of religious liberty and civil rights laws to protect medical providers who refuse to provide services for religious or moral reasons. Last summer, the administration reinterpreted the Affordable Care Act's nondiscrimination requirements to remove Obama-era protections for LGBTQ people. This month, it removed explicit provisions that prohibited social service providers who receive Department of Health and Human Services grants from discriminating on the basis of sexual orientation and gender identity, among other characteristics. Sasha Buchert, a senior attorney with Lambda Legal, said the change affects a wide array of programs, from Meals on Wheels to child welfare agencies, HIV/AIDS services and more.
Although many of these actions have been blocked by courts, and the incoming Biden administration has promised to reverse several of Trump's policies, LGBTQ advocates and legal experts say those processes take time and are not guaranteed.
"To put it plainly, having protections at the local level sometimes offers more protection, particularly as laws are being contested at the federal level," said Lindsey Dawson, a researcher who studies LGBTQ issues at KFF. (KHN is an editorially independent program of KFF.)
A Path Forward
In recent decades, protections for LGBTQ Americans have emerged as a cultural flashpoint, often triggering debates about religious liberties versus civil rights and involving anything from marriage and parenting to offices and bakeries.
Critics of nondiscrimination laws say they squash valid debate in health care about what constitutes ethical treatment.
Ryan Anderson, a senior research fellow with the conservative think tank the Heritage Foundation, said no one should be turned away from medical care because of their identity, but laws need to distinguish between that type of discrimination and medical providers who disagree on a certain treatment plan.
"If there's an adult who wants to transition and a doctor and health care plan who want to support that, they can do that," Anderson said. "But if the doctor or health plan don't want to support that, they should also be free not to do that."
For advocates who work with LGBTQ people daily, the need for nondiscrimination laws is clear. Ames Simmons, policy director for Equality NC, recounted the experiences of people he knows: One trans woman was threatened with arrest if she didn't leave a hospital in the western part of the state, while another was denied care at a dialysis clinic in eastern North Carolina after she complained about harassment.
Research shows that LGBTQ people in states with nondiscrimination laws experience fewer disparities in employment, education and health care than those living in states without such laws. And city- and county-level actions may provide a road map for broader efforts. Christy Mallory, legal director at the Williams Institute at UCLA, pointed to the example of Utah, where a series of local ordinances eventually led the traditionally conservative state to pass a nondiscrimination law in 2015.
The laws don't automatically change people's beliefs, Mallory said, but they provide a starting point to build momentum toward statewide and cultural changes.
Pandemic Urgency
Advocates cite an added imperative to protect LGBTQ rights because the covid pandemic has highlighted shortcomings and disparities in the nation's health care system. A report by the Movement Advancement Project, a Colorado-based think tank, found 1 in 8 LGBTQ people have lost insurance coverage during the pandemic — twice the rate of non-LGBTQ people. Many are unable to afford hormone therapy or counseling. In some parts of the country, transgender people have reported mistreatment at covid testing sites.
Even before covid, transgender patients who came to Dr. Jennifer Abbott, a family physician at Western North Carolina Community Health Services in Asheville, often told her they had called as many as 10 other providers before finding someone willing to treat them. Abbott, who heads the clinic's transgender health program, said about one-third of its approximately 400 patients come from rural areas across the western part of the state.
For some, the promise of nondiscrimination laws reaches beyond questions of access. The laws can also temper discriminatory behavior by sending a clear message about what is acceptable in a community, said Michael Hoeben, who coordinates services for transgender and HIV patients at the clinic and is a transgender man.
Once, when Hoeben was having a cervical polyp removed, the doctor asked him what it meant to be transgender. The doctor and nurse proceeded to laugh at Hoeben's response while performing the procedure, he said. Hoeben was so mortified that he avoided seeing a doctor for the next seven years.
A law may not have prevented that experience, Hoeben said, "but without the law, it's like open season."
"For your local government to pass a law that says we see you, we recognize you and we include you," Hoeben said, "that is a level of safety you're constantly seeking as a trans person."
t's in the nature of presidential candidates and new presidents to promise big things. Just months after his 1961 inauguration, President John F. Kennedy vowed to send a man to the moon by the end of the decade. That pledge was kept, but many others haven't been, such as candidate Bill Clinton's promise to provide universal health care and presidential hopeful George H.W. Bush's guarantee of no new taxes.
Now, during a once-in-a-century pandemic, incoming President Joe Biden has promised to provide 100 million covid-19 vaccinations in his first 100 days in office.
"This team will help get … at least 100 million covid vaccine shots into the arms of the American people in the first 100 days," Biden said during a Dec. 8 news conference introducing key members of his health team.
When first asked about his pledge, the Biden team said the president-elect meant 50 million people would get their two-dose regimen. The incoming administration has since updated this plan, saying it will release vaccine doses as soon as they're available instead of holding back some of that supply for second doses.
Either way, Biden may run into difficulty meeting that 100 million mark.
"I think it's an attainable goal. I think it's going to be extremely challenging," said Claire Hannan, executive director of the Association of Immunization Managers.
While a pace of 1 million doses a day is "somewhat of an increase over what we're already doing," a much higher rate of vaccinations will be necessary to stem the pandemic, said Larry Levitt, executive vice president for health policy at KFF. (KHN is an editorially independent program of KFF.) "The Biden administration has plans to rationalize vaccine distribution, but increasing the supply quickly" could be a difficult task.
Under the Trump administration, vaccine deployment has been much slower than Biden's plan. The rollout began more than a month ago, on Dec. 14. Since then, 12 million shots have been given and 31 million doses have been shipped out, according to the Centers for Disease Control and Prevention's vaccine tracker.
This sluggishness has been attributed to a lack of communication between the federal government and state and local health departments, not enough funding for large-scale vaccination efforts, and confusing federal guidance on distribution of the vaccines.
The same problems could plague the Biden administration, said experts.
States still aren't sure how much vaccine they'll get and whether there will be a sufficient supply, said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials, which represents state public health agencies.
"We have been given little information about the amount of vaccine the states will receive in the near future and are of the impression that there may not be 1 million doses available per day in the first 100 days of the Biden administration," said Plescia. "Or at least not in the early stages of the 100 days."
Another challenge has been a lack of funding. Public health departments have had to start vaccination campaigns while also operating testing centers and conducting contact tracing efforts with budgets that have been critically underfunded for years.
"States have to pay for creating the systems, identifying the personnel, training, staffing, tracking people, information campaigns — all the things that go into getting a shot in someone's arm," said Jennifer Kates, director of global health & HIV policy at KFF. "They're having to create an unprecedented mass vaccination program on a shaky foundation."
The latest covid stimulus bill, signed into law in December, allocates almost $9 billion in funding to the CDC for vaccination efforts. About $4.5 billion is supposed to go to states, territories and tribal organizations, and $3 billion of that is slated to arrive soon.
But it's not clear that level of funding can sustain mass vaccination campaigns as more groups become eligible for the vaccine.
Biden released a $1.9 trillion plan last week to address covid and the struggling economy. It includes $160 billion to create national vaccination and testing programs, but also earmarks funds for $1,400 stimulus payments to individuals, state and local government aid, extension of unemployment insurance, and financial assistance for schools to reopen safely.
Though it took Congress almost eight months to pass the last covid relief bill after Republican objections to the cost, Biden seems optimistic he'll get some Republicans on board for his plan. But it's not yet clear that will work.
There's also the question of whether outgoing President Donald Trump's impeachment trial will get in the way of Biden's legislative priorities.
In addition, states have complained about a lack of guidance and confusing instructions on which groups should be given priority status for vaccination, an issue the Biden administration will need to address.
On Dec. 3, the CDC recommended health care personnel, residents of long-term care facilities, those 75 and older, and front-line essential workers should be immunized first. But on Jan. 12, the CDC shifted course and recommended that everyone over age 65 should be immunized. In a speech Biden gave last week detailing his vaccination plan, he said he would stick to the CDC's recommendation to prioritize those over 65.
Outgoing Health and Human Services Secretary Alex Azar also said Jan. 12 that states that moved their vaccine supply fastest would be prioritized in getting more shipments. It's not known yet whether the Biden administration's CDC will stick to this guidance. Critics have said it could make vaccine distribution less equitable.
In general, taking over with a strong vision and clear communication will be key to ramping up vaccine distribution, said Hannan.
"Everyone needs to understand what the goal is and how it's going to work," she said.
A challenge for Biden will be tamping expectations that the vaccine is all that is needed to end the pandemic. Across the country, covid cases are higher than ever, and in many locations officials cannot control the spread.
Public health experts said Biden must amp up efforts to increase testing across the country, as he has suggested he will do by promising to establish a national pandemic testing board.
With so much focus on vaccine distribution, it's important that this part of the equation not be lost. Right now, "it's completely all over the map," said KFF's Kates, adding that the federal government will need a "good sense" of who is and is not being tested in different areas in order to "fix" public health capacity.
Today marks the launch of The Biden Promise Tracker, which monitors the 100 most important campaign promises of President Joseph R. Biden. Biden listed the coronavirus and a variety of other health-related issues among his top priorities. You can see the entire list – including improving the economy, responding to calls for racial justice and combating climate change – here. As part of KHN's partnership with PolitiFact, we will follow the health-related issues and then rate them on whether the promise was achieved: Promise Kept, Promise Broken, Compromise, Stalled, In the Works or Not Yet Rated. We rate the promise not on the president's intentions or effort, but on verifiable outcomes. PolitiFact previously tracked the promises of President Donald Trump and President Barack Obama.
While millions wait for a lifesaving shot, the U.S. death count from covid-19 continues to soar upward with horrifying speed. On Tuesday, the last full day of Donald Trump’s presidency, the death toll reached 400,000 — a once-unthinkable number. More than 100,000 Americans have perished in the pandemic in just the past five weeks.
In the U.S., someone now dies of covid every 26 seconds. And the disease is claiming more American lives each week than any other condition, ahead of heart disease and cancer, according to the Institute for Health Metrics and Evaluation at the University of Washington.
“It didn’t have to be like this, and it shouldn’t still be like this,” said Kristin Urquiza, whose father, Mark, died of covid in June, as the virus was sweeping through Phoenix.
Urquiza described it as “watching a slow-moving hurricane” tear apart her childhood neighborhood, where many people have no choice but to keep going to work and risking their health.
“I talk to dozens of strangers a day who are going through what I did in June, but the magnitude and the haunting similarities between our stories six months later is really hard,” said Urquiza, who addressed the Democratic National Convention in August. She co-founded Marked By COVID, to organize grieving families and supporters. The group calls for a faster government response and a national memorial for pandemic victims.
Given its large population, the U.S. death rate from covid remains lower than the rate in many other countries. But the death toll of 400,000 now exceeds any other country’s count — close to double what Brazil has recorded, and four times the toll in the United Kingdom.
“It’s very hard to wrap your mind around a number that is so large, particularly when we’ve had 10 months of large numbers assaulting our senses and really, really horrific images coming out of our hospitals and our morgues,” said Dr. Kirsten Bibbins-Domingo, chair of epidemiology at the University of California-San Francisco.
Scientists had long expected that wintertime could plunge the country into the deadliest months yet, but even Bibbins-Domingo wasn’t ready for the sheer pace of deaths, or the scale of the accumulated losses. The mortality burden has fallen heavily on her own state of California, which was averaging fewer than 100 deaths a day for long stretches of the pandemic, but has ranged up to more than 500 in recent days.
She said California followed the science with its handling of the pandemic, yet the devastation unfolding in places like Los Angeles reveals just how fragile any community can be.
“It’s important to understand virology. It’s important to understand epidemiology. But ultimately, what we’ve learned is that human behavior and psychology is a major force in this pandemic,” she said.
The U.S. in mid-January has averaged more than 3,300 deaths a day — well above the most devastating days of the early spring surge, when daily average deaths hovered around 2,000.
“At this point, looking at the numbers, for me the question is: Is there any way we can avoid half a million deaths before the end of February?” said Dr. Ashish Jha, dean of the Brown University School of Public Health.
“I think of how much suffering as a nation we seem to be willing to accept that we have this number of people getting infected and dying every day.”
How Did U.S. Go From 300,000 Deaths to 400,000?
The path to 400,000 deaths was painfully familiar, with patterns of sickness and death repeating themselves from earlier in the pandemic.
A shocking number of people in nursing homes and assisted living facilities continue to die each week — more than 6,000 in the first week of January.
Deaths linked to long-term care account for more than a third of all covid deaths in the U.S. since the beginning of the pandemic. In a handful of states, long-term care contributed to half the total deaths.
Certain parts of the country have a disproportionately high death rate. Alabama and Arizona, in particular, have experienced high rates, given their populations. The virus continues to kill Black and Indigenous Americans at much higher rates than whites.
The chance of dying of covid remains much higher in rural America than in the urban centers.
People over 65 make up the overwhelming majority of deaths, but Jha said more young people are dying than earlier in the pandemic, simply because the virus is so widespread.
In this newest and grimmest chapter of the pandemic, the virus has preyed upon a public weary of restrictions and rules, and eager to mix with family and friends over the holiday season.
Like many other health workers, Dr. Panagis Galiatsatos at Johns Hopkins Hospital is now witnessing the tragic consequences in his daily rounds.
“My heart breaks, because we could have prevented this,” said Galiatsatos, an assistant professor of medicine who cares for covid patients in the intensive care unit.
“A lot of what we saw during the holiday travel was the inability to reach our loved ones or family members — not like a public service announcement, but one on one, talking to them [about the exposure risks]. … I really felt like we failed.”
Galiatsatos still recalls a grandmother who was transported six hours from her home to his hospital — because there were no beds anywhere closer. On the phone, he heard her family’s shock at her sudden passing.
“They said, ‘But she was so healthy. She cooked us all Thanksgiving dinner and we had all the family over,’” he said. “They were saying it with sincerity, but that’s probably where she got it.”
Light at the End of a Very Long Tunnel
The enormous loss of life this winter has happened, paradoxically, at a time that many hope marks the start of the final chapter of the pandemic.
A quarter of all covid deaths have happened during the five weeks since the Food and Drug Administration authorized the first vaccine.
Markel, who has written about the 1918-19 flu pandemic, said it’s estimated it killed upward of 700,000 Americans.
Of the covid pandemic, he said, “I hope we’re not talking … 600,000 or more.”
At this point, about 3 in 100 people have been vaccinated, placing America ahead of many other countries but behind the optimistic promises made in the early days of the rollout. Given the current pace of vaccination, experts warn, Americans cannot depend solely on the vaccine to prevent a crushing number of additional deaths in the coming months.
UCSF’s Bibbins-Domingo worries that the relief of knowing a vaccine will eventually be widely available — the light at the end of the tunnel — may actually lull millions more Americans into a false sense of safety.
“This tunnel is actually a very long tunnel, and the next few months, as the last few months have been, are going to be very dark times,” she said.
The emergence of more contagious variants of SARS-CoV-2, the covid virus, complicates the picture and makes it all the more imperative that Americans spend the coming months doubling down on the very same tactics — masks and physical distancing — that have kept many people safe so far.
But Jha, of Brown University, says the country now faces a different task from that of the fall, when “big behavioral changes and large economic costs” were required to prevent deaths.
“Right now what is required is getting people vaccinated with vaccines we already have,” he said. “The fact that’s going super slow still is incredibly frustrating.”
It is this dichotomy — the advent of lifesaving vaccines as hospitals are filled with more dying patients than ever before — that makes this moment in the pandemic so confounding.
“I can’t help but feel this immense somberness,” said Kristin Urquiza. “I know that a vaccine isn’t going to make a difference for the people that are in the hospital right now or who will be in the hospital next week or even next month.”
This story is from a reporting partnership with NPR.
Marketing experts say public health advertising often falls short because it incites people's worst fears rather than providing clear steps viewers can take to save lives.
This article was published on Tuesday, January 19, 2021 in Kaiser Health News.
ST. LOUIS — The public service announcement showed a mother finding her teenage son lifeless, juxtaposed with the sound of a ukulele and a woman singing, "That's how, how you OD'd on heroin."
It aired locally during the 2015 Super Bowl but attracted national attention and has been viewed more than 500,000 times on YouTube.
"You want to tap into a nerve, an emotional nerve, and controversy and anger," said Mark Schupp, whose consulting firm created the ad pro bono. "The spot was designed to do that, so we were happy with it."
But like other ads and PSAs seeking to move the needle on public health, it went only so far.
Marketing experts say public health advertising often falls short because it incites people's worst fears rather than providing clear steps viewers can take to save lives. They say lessons from opioid messaging can inform campaigns seeking to influence behavior that could help curb the coronavirus pandemic, such as wearing masks, not gathering in big groups and getting a covid-19 vaccine.
The Super Bowl ad was produced and aired by the St. Louis chapter of the National Council on Alcohol and Drug Abuse using $100,000 from an anonymous donor. Then-director Howard Weissman said a top priority for his group was for Missouri to start a prescription drug monitoring program.
Five years later, Missouri remains the only state without a statewide program. And the number of opioid deaths has steadily increased in that time, state data shows, up from 672 in all of 2015 to 716 deaths in just the first six months of 2020.
The national council, now called PreventEd, is one of many nonprofits and government agencies that invest millions in messaging aimed at curbing the opioid epidemic. People who study such advertisements said it's difficult to measure their impact, but if the metric is the number of overdose deaths, they have not yet succeeded. The country set a record for overdose deaths in 2019 that it was on pace to break in 2020.
"You have to give them a solution, especially in a health context, like with opioids, because similar to with cigarette smoking, if you increase fear and don't give a solution, they are just going to abuse more because that's their coping mechanism," said Punam Anand Keller, a Dartmouth College professor who studies health marketing.
To address public health issues, marketers often use images of diseased lungs to discourage smokers or the bloody aftermath of car crashes to prevent drunken driving. But these can provoke "defensive responses" that may be avoided by giving people ways to take action, said a 2014 International Journal of Psychology review of campaigns that use fear to persuade people.
Missouri's state health and mental health departments, with the help of federal funds, spent at least $800,000 on advertising in 2019 to curb the opioid epidemic through their Time 2 Act and NoMODeaths campaigns, according to data from advertising agencies and partner organizations.
Mac Curran, a 34-year-old social media influencer, described his struggles with opioid addiction in a number of videos for Time 2 Act, one of which was viewed more than 100,000 times on Facebook. In another recent video, Curran used storytelling to highlight the benefits of getting treatment for his addiction. He talked about strangers cheering for him when he returned to a friend's streetwear store after getting out of the recovery program, and discussed how he learned coping skills he could use throughout life.
Jay Winsten, a Harvard University scientist who spearheaded the U.S. designated-driver campaign to combat drunken driving, described Curran's videos as "really excellent because he comes across as genuine and well spoken. People remember stories more than they do someone simply lecturing at them."
Still, Winsten emphasized the importance of including actionable steps and would like to see Missouri and other groups focus on teaching friends of users "how to intervene and what language to use and not to use."
Others, including the libertarian Cato Institute, argue that PSAs on drug use just don't work and point to the history of failed campaigns to discourage teen marijuana use.
Yet agencies keep trying. Missouri's mental health department and the Missouri Institute of Mental Health at the University of Missouri-St. Louis convened focus groups in 2019 with drug users and their families and captured their words on billboards for the NoMODeaths campaign. One said, "Don't give up on treatment. It's worth the work," and gave a number to text for help with heroin, fentanyl or pill misuse.
In addition to giving information, the goal was "to let people who use drugs know that other people care if they live or die," said Rachel Winograd, a psychologist who leads the NoMODeaths group aimed at reducing harm from opioid misuse.
She said she understands the argument that PSAs are a waste of money, given that organizations like hers have limited funds and also try to provide housing for those in recovery and naloxone, used to revive people after overdoses.
But, Winograd said, some of the advertisements appeared to work. The organization saw a big increase after the ads ran in the number of people who visited its website or texted a number for information on treatment or obtaining naloxone.
Although federal funding rose for fiscal years 2021 and 2022, Winograd's team and state officials decided to cut NoMODeaths' advertising budget in half and instead spend the money on direct services like naloxone, treatment and housing.
Now health agencies are consumed by the coronavirus pandemic and are trying to craft messages that cut through politically charged discourse and get the public to adopt safety measures such as wearing masks, staying physically distanced and getting vaccinated.
Convincing people to wear masks has been difficult because messages have been mixed. Missouri's health department has tried to depoliticize mask-wearing and get people to view it as a public health solution, said spokesperson Lisa Cox.
But Missouri Gov. Mike Parson has appeared without a mask at public events and has declined to enact a statewide mask mandate. He also said at a Missouri Cattlemen's Association event in July, "If you want to wear a dang mask, wear a mask."
Cox would not comment on whether Parson's approach undermined the state's public health efforts, but Keller said it did.
Missouri's messaging about vaccines has been much more straightforward and clear. A website provides facts and answers to common questions as it encourages people to "make an informed choice" on whether to get the shots.
Keller praised the "unemotional, not-fear-arousing" approach to the vaccine messaging issued so far.
"It needs the right messengers: well-known individuals who have high credibility within specific population groups that currently are hesitant about taking the vaccine," Winsten said.
This time, Parson has been one of those messengers. When he announced the launch of the vaccine website in November, he said in a news release: "Safety is not being sacrificed, and it's important for Missourians to understand this."
In spite of the politicization of the virus crisis, Winsten, who serves on the board of advisers of the Ad Council's $50 million covid vaccine campaign, has "guarded optimism" that enough people will get vaccinated to curb the pandemic.
And he remains hopeful that PSAs could eventually help reduce the number of people who die from opioids.
"Look at the whole anti-smoking movement. That took over two decades," he said. "These are tough problems. Otherwise, they would be solved already."
Health care — and how much it costs — is scary. But you're not alone with this stuff, and knowledge is power. "An Arm and a Leg" is a podcast about these issues, and its second season is co-produced by KHN.
As we settle into the new year, we have two small doses of good news.
First, a new federal rule could help cut through one health care issue. Host Dan Weissmann talked about the rule — which requires hospitals to make public the prices they negotiate with insurers — in a short conversation with his former public-radio colleague, Niala Boodhoo, for the daily-news podcast "Axios Today."
You'll find more detail on that rule in this story from reporter Celia Llopis-Jepsen, whose reporting about a $50,000 "air ambulance" ride formed the core of a recent episode about how consumers get squeezed by insurers on one side and providers on the other.
Later in the episode, a listener describes how he used what he learned from "An Arm and a Leg" to head off an insurance nightmare.
The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that's typically racially diverse made up of physicians, hospital cafeteria workers, nurses and janitorial staffers.
This article was published on Sunday, January 17, 2021 in Kaiser Health News.
Black Americans are receiving covid vaccinations at dramatically lower rates than white Americans in the first weeks of the chaotic rollout, according to a new KHN analysis.
About 3% of Americans have received at least one dose of a coronavirus vaccine so far. But in 16 states that have released data by race, white residents are being vaccinated at significantly higher rates than Black residents, according to the analysis — in many cases two to three times higher.
In the most dramatic case, 1.2% of white Pennsylvanians had been vaccinated as of Jan. 14, compared with 0.3% of Black Pennsylvanians.
The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that’s typically racially diverse made up of physicians, hospital cafeteria workers, nurses and janitorial staffers.
If the rollout were reaching people of all races equally, the shares of people vaccinated whose race is known should loosely align with the demographics of health care workers. But in every state, Black Americans were significantly underrepresented among people vaccinated so far.
Access issues and mistrust rooted in structural racism appear to be the major factors leaving Black health care workers behind in the quest to vaccinate the nation. The unbalanced uptake among what might seem like a relatively easy-to-vaccinate workforce doesn’t bode well for the rest of the country’s dispersed population.
“My concern now is if we don’t vaccinate the population that’s highest-risk, we’re going to see even more disproportional deaths in Black and brown communities,” said Dr. Fola May, a UCLA physician and health equity researcher. “It breaks my heart.”
Dr. Taison Bell, a University of Virginia Health System physician who serves on its vaccination distribution committee, stressed that the hesitancy among some Blacks about getting vaccinated is not monolithic. Nurses he spoke with were concerned it could damage their fertility, while a Black co-worker asked him about the safety of the Moderna vaccine since it was the company’s first such product on the market. Some floated conspiracy theories, while other Black co-workers just wanted to talk to someone they trust like Bell, who is also Black.
But access issues persist, even in hospital systems. Bell was horrified to discover that members of environmental services — the janitorial staff — did not have access to hospital email. The vaccine registration information sent out to the hospital staff was not reaching them.
“That’s what structural racism looks like,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Those groups were seen and not heard — nobody thought about it.”
UVA Health spokesperson Eric Swenson said some of the janitorial crew were among the first to get vaccines and officials took additional steps to reach those not typically on email. He said more than 50% of the environmental services team has been vaccinated so far.
A Failure of Federal Response
As the public health commissioner of Columbus, Ohio, and a Black physician, Dr. Mysheika Roberts has a test for any new doctor she sees for care: She makes a point of not telling them she’s a physician. Then she sees if she’s talked down to or treated with dignity.
That’s the level of mistrust she says public health officials must overcome to vaccinate Black Americans — one that’s rooted in generations of mistreatment and the legacy of the infamous Tuskegee syphilis study and Henrietta Lacks’ experience.
A high-profile Black religious group, the Nation of Islam, for example, is urging its members via its website not to get vaccinated because of what Minister Louis Farrakhan calls the “treacherous history of experimentation.” The group, classified as a hate group by the Southern Poverty Law Center, is well known for spreading conspiracy theories.
Public health messaging has been slow to stop the spread of misinformation about the vaccine on social media. The choice of name for the vaccine development, “Operation Warp Speed,” didn’t help; it left many feeling this was all done too fast.
Benjamin noted that while the nonprofit Ad Council has raised over $37 million for a marketing blitz to encourage Americans to get vaccinated, a government ad campaign from the Health and Human Services Department never materialized after being decried as too political during an election year.
“We were late to start the planning process,” Benjamin said. “We should have started this in April and May.”
And experts are clear: It shouldn’t merely be ads of famous athletes or celebrities getting the shots.
“We have to dig deep, go the old-fashioned way with flyers, with neighbors talking to neighbors, with pastors talking to their church members,” Roberts said.
Speed vs. Equity
Mississippi state Health Officer Dr. Thomas Dobbs said that the shift announced Tuesday by the Trump administration to reward states that distribute vaccines quickly with more shots makes the rollout a “Darwinian process.”
Dobbs worries Black populations who may need more time for outreach will be left behind. Only 18% of those vaccinated in Mississippi so far are Black, in a state that’s 38% Black.
It might be faster to administer 100 vaccinations in a drive-thru location than in a rural clinic, but that doesn’t ensure equitable access, Dobbs said.
“Those with time, computer systems and transportation are going to get vaccines more than other folks — that’s just the reality of it,” Dobbs said.
In Washington, D.C, a digital divide is already evident, said Dr. Jessica Boyd, the chief medical officer of Unity Health Care, which runs several community health centers. After the city opened vaccine appointments to those 65 and older, slots were gone in a day. And Boyd’s staffers couldn’t get eligible patients into the system that fast. Most of those patients don’t have easy access to the internet or need technical assistance.
“If we’re going to solve the issues of inequity, we need to think differently,” Boyd said.
“We are missing the boat on equity,” he said. “If we don’t step back and address that, it’s going to get worse.”
While Plescia is heartened by President-elect Joe Biden’s vow to administer 100 million doses in 100 days, he worries the Biden administration could fall into the same trap.
And the lack of public data makes it difficult to spot such racial inequities in real time. Fifteen states provided race data publicly, Missouri did so upon request, and eight other states declined or did not respond. Several do not report vaccination numbers separately for Native Americans and other groups, and some are missing race data for many of those vaccinated. The CDC plans to add race and ethnicity data to its public dashboard, but CDC spokesperson Kristen Nordlund said it could not give a timeline for when.
Historical Hesitation
One-third of Black adults in the U.S. said they don’t plan to get vaccinated, citing the newness of the vaccine and fears about safety as the top deterrents, according to a December poll from KFF. (KHN is an editorially independent program of KFF.) Half of them said they were concerned about getting covid from the vaccine itself, which is not possible.
Experts say this kind of misinformation is a growing problem. Inaccurate conspiracy theories that the vaccines contain government tracking chips have gained ground on social media.
Just over half of Black Americans who plan to get the vaccine said they’d wait to see how well it’s working in others before getting it themselves, compared with 36% of white Americans. That hesitation can even be found in the health care workforce.
“We shouldn’t make the assumption that just because someone works in health care that they somehow will have better information or better understanding,” Bell said.
In Colorado, Black workers at Centura Health were 44% less likely to get the vaccine than their white counterparts. Latino workers were 22% less likely. The hospital system of more than 21,000 workers is developing messaging campaigns to reduce the gap.
“To reach the people we really want to reach, we have to do things in a different way, we can’t just offer the vaccine,” said Dr. Ozzie Grenardo, a senior vice president and chief diversity and inclusion officer at Centura. “We have to go deeper and provide more depth to the resources and who is delivering the message.”
That takes time and personal connections. It takes people of all ethnicities within those communities, like Willy Nuyens.
Nuyens, who identifies as Hispanic, has worked for Kaiser Permanente Los Angeles Medical Center for 33 years. Working on the environmental services staff, he’s now cleaning covid patients’ rooms. (KHN is not affiliated with Kaiser Permanente.)
In Los Angeles County, 92% of health care workers and first responders who have died of covid were nonwhite. Nuyens has seen too many of his co-workers lose family to the disease. He jumped at the chance to get the vaccine but was surprised to hear only 20% of his 315-person department was doing the same.
So he went to work persuading his co-workers, reassuring them that the vaccine would protect them and their families, not kill them.
“I take two employees, encourage them and ask them to encourage another two each,” he said.
So far, uptake in his department has more than doubled to 45%. He hopes it will be over 70% soon.
When Gwendolyn Davis received her husband's death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.
This article was published on Friday, January 15, 2021 in Kaiser Health News.
On Sundays, Bishop Bruce Davis preached love. Through his Pentecostal ministry, he organized youth parades and gave computers, bicycles and food to families in need.
During the week, Bruce practiced what he preached, caring for prisoners at a Georgia hospital. On March 27 he began coughing, and on April 1 he was hospitalized. He’d tested positive for covid-19. The virus swept through his household, infecting his wife and daughter and hospitalizing their disabled son. Ten days after landing in the hospital, Bruce died.
But when Gwendolyn Davis received her husband’s death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.
“He wouldn’t have had kidney failure if he didn’t have covid,” Gwendolyn said.
After Bruce died, his wife applied to two pandemic relief programs seeking help with $1,500 in missed payments on a truck and an electricity bill. But, she said, she was denied because his death certificate didn’t mention covid-19.
“I think it’s wrong,” Gwendolyn said. “It’s almost like we didn’t count.”
The count has profound implications for families and the country. Omitting covid-19 on death certificates threatens to undercount the toll of the pandemic nationwide. For Davis’ family and others, it can pile financial hardship onto emotional despair, as death benefits and other covid-19 relief programs are withheld. Interviews with families across the U.S. shed light on reasons covid deaths are being undercounted — and the consequences loved ones have endured.
When covid patients die, the “immediate” cause of death is always something else, such as respiratory failure or cardiac arrest. Residents, doctors, medical examiners and coroners make the call on whether covid was an underlying factor, or “contributory cause.” If so, the diagnosis should be included on the death certificate, according to the Centers for Disease Control and Prevention.
Even beyond the pandemic, there is wide variation in how certifiers describe causes of death: “There’s just no such thing as an objective measure of cause of death,” said Lee Anne Flagg, a statistician at the CDC’s National Center for Health Statistics.
Partly because of a lack of training in how to fill them out, “the quality of the death certificates is not good,” said Dr. James Gill, vice president of the National Association of Medical Examiners. And in cases in which people had other chronic conditions, it can be difficult to determine whether covid was a contributing cause of death, he said. That was especially true early on, when reliable testing was not widely available.
Since early in the pandemic, the CDC has encouraged certifiers who suspect covid as a cause of death to list it on the death certificate as “probable” or “likely.”
Still, some clinicians are “reluctant to certify a death as a covid death without a test in hand,” Gill said.
It’s not clear how Bruce Davis’ case slipped under the radar. His death was certified by William Ken Garland, deputy coroner in Baldwin County. Reached by phone, Garland said the causes of death were provided by Dr. Joseph Coppiano, a medical resident who pronounced Davis dead at Augusta University Medical Center, about 90 miles away. No autopsy was done.
“I did certify the record, but that’s about all I did,” Garland said.
Hospital spokesperson Danielle Harris declined to comment on the case, citing patient privacy. She said the hospital follows Georgia Department of Public Health guidelines.
In the absence of certainty, the CDC has encouraged coroners to document the virus. “We’re not worried that we’re overcounting the number of [covid-19] deaths,” Farida Ahmad, epidemiologist and mortality surveillance team leader at NCHS, said in April.
Missed cases are one reason that experts agree covid deaths are being undercounted nationwide. As evidence for that, they point to the vast number of excess deaths — additional deaths compared to what would be expected based on prior-year numbers and demographic trends.
Over the past year, the U.S. had endured up to 431,792 excess deaths as of Jan. 6, with 68% directly attributed to covid, according to the CDC.
These excess deaths “tend to track pretty closely with covid cases, trailing by a couple of weeks,” said Daniel Weinberger, an epidemiologist at Yale School of Public Health who has published on this topic. “This strongly suggests that a large proportion of these uncounted deaths are due to covid but not recorded as such.”
We may never know how many covid deaths went uncounted: Postmortem tests can detect the virus, but it’s “unlikely that this type of testing will be performed at a [sufficient] scale,” Weinberger said. Early in the pandemic, especially in the Northeast, many of those who were treated clinically for covid and then died were not tested for the virus — so they never made it into the statistics.
Testing Troubles Affect Lawsuits, Hospital Bills
Inaccurate death certificates can make it harder to pursue a lawsuit or win a workers’ compensation case when a loved one dies after contracting covid on the job. Gwendolyn Davis did win workers’ compensation death benefits from Bruce’s employer, a state psychiatric facility in Milledgeville, by providing medical records. But problems with covid testing can complicate the process.
Bruce’s supervisor at work, Mark DeLong, also died after contracting covid, but it did not appear on his death certificate with the other causes: cardiopulmonary arrest, respiratory failure and diabetes.
The omission on DeLong’s certificate seemed to stem from a delay in test results: His covid-positive results didn’t arrive until three days after he died, according to his widow, Jan DeLong. She has asked the local coroner to correct the record.
In New Jersey, attorney Paul da Costa represents 75 family members who lost loved ones at veterans homes in Menlo Park and Paramus in April and May. He said he knows of at least five patients whose death certificates did not list covid-19 despite evidence suggesting it killed them.
The root problem, he said, was a “complete dearth of testing.” Patients were transferred to hospitals, or dying in the veterans facilities, without ever being tested, he said.
The gap between excess deaths and confirmed covid deaths has “narrowed over time as testing has increased,” Weinberger said.
Early testing inaccuracy may also have led to undercounting, which creates a different burden: hospital bills. Without a diagnosis, families can be on the hook for thousands of dollars in charges that otherwise would have been covered under the CARES Act.
Correcting the Record
In some cases, families have sought to have death certificates changed to reflect covid. Dorothy Payton, 95, who lived in the ManorCare nursing home in Denver, first showed covid symptoms April 5. Five days later, Payton — known as “Nana Dee” — tested positive for it. And on April 13, her husband, Edward Benjamin, received a call that she had died.
The death certificate offered a litany of causes: vascular dementia, atrial fibrillation, congestive heart failure, gait instability, difficulty swallowing and “failure to thrive.”
But not covid-19. So it “seemed logical to fight for listing her cause of death under her cause of death,” Benjamin said.
After a few calls, her husband was able to get the certificate amended. ManorCare could not be reached for comment.
For Benjamin, it wasn’t about public health statistics or financial considerations. It simply offers a sense of closure.
“I want her life and death remembered the way it was, and I’m glad we set the record straight,” he said. “It’s the first step towards moving on.”
This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.