Nurses warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen healthcare for all.
Pennsylvania's Mifflin County offers a snapshot into how one hard-hit community, with more than 300 dead, is coping.
This article was published on Friday, April 1, 2022 in Kaiser Health News.
McVEYTOWN, PA — Connie Houtz didn't think COVID would be that bad.
She'd seen many people in this rural hamlet in central Pennsylvania get infected yet recover within a few days. She did not get vaccinated because she worried about how a new vaccine, developed in record time, might affect her heart condition.
Last October, her youngest son, 45-year-old Eric Delamarter, developed a chest cold. He put off going to the doctor because he had customers waiting at his shop where he repaired cars, she said. When he finally went to the emergency room at Geisinger Lewistown Hospital, he was diagnosed with pneumonia and COVID.
Within a few days, Houtz's oldest son, 50-year-old Toby Delamarter, had also been admitted to the hospital with the virus and shortness of breath.
Less than two weeks later, both of her sons were dead. Neither had been vaccinated.
"Even though it does not seem fair and does not seem right, down the road we will find a reason for why things happen," said Houtz, 71, as she sat at her kitchen table.
Eric and Toby Delamarter are two of the roughly 300 people who have died of COVID in Mifflin County, where cows grazing in pastures and Amish horse and buggies are frequent sights. The county 60 miles northwest of Harrisburg leans heavily Republican — 77% of votes cast in 2020 were for Donald Trump — and the former president's downplaying of COVID-19 found fertile ground there.
Mifflin has one of the highest COVID death rates among U.S. counties with at least 40,000 people, according to government data compiled by Johns Hopkins University — 591 deaths per 100,000 residents as of mid-March, compared with 298 deaths nationally.
The United States is nearing 1 million deaths from COVID — a number that few thought possible when the pandemic began.
In March 2020, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said that based on modeling of the pace of the coronavirus's spread in the U.S. at that time, "between 100,000 and 200,000" people may die from COVID.
Reaching a million deaths seemed even more improbable when safe and effective vaccines came onto the market in December 2020. More than 60% of the 977,000 deaths have occurred since then.
Mifflin County offers a snapshot into how one hard-hit community moved from skepticism about the scientific reality of the COVID virus, and then about the vaccine, to coping with unbearable loss and processing the trauma. Roughly 8 in 10 deaths nationwide from April to December 2021 were among the unvaccinated, according to the latest analysis of data from 23 states and New York City and Seattle by the Centers for Disease Control and Prevention.
Mifflin County Coroner Daniel Lynch isn't over the stress of COVID even as deaths have declined this year. As of mid-March, his office had counted 337 COVID deaths in the county — about 60 more than the official tally kept by the state. That's because the coroner counts anyone who dies in the county, including those who lived in other counties. Among the people in the coroner's count, 311 hadn't received even one COVID shot. Few residents wore masks even when cases were high nationally and locally.
"It was pure hell," Lynch said. "I have been a coroner since 1996 and never got calls from nurses reporting deaths crying on the phone or facilities reporting two or three deaths at one time."
In Lewistown, the county seat, finding people who knew some of the dead is easy.
At the Corner Lunchbox on a recent afternoon, hands of all five employees and customers quickly shot up when asked whether they knew anyone killed by COVID. Sheila Saurbeck, 65, a manager, said she had lost two friends. And she had COVID herself last year, recovering after a couple of weeks.
Behind the counter was owner Lorrie Sirgey, 56. She said she was hospitalized with COVID for four days last spring before she got vaccinated. "It's been a scary time," she said.
As elsewhere in the country, Mifflin County has seen COVID cases fall dramatically since January. It's unusual to see anyone wearing masks. Health experts point to several factors behind Mifflin County's high death rate:
A low COVID vaccination rate (51% of residents are fully vaccinated, compared with 63% statewide).
The prominent Amish and Mennonite populations; Amish people make up over 8% of county residents. Members of those communities largely did not get vaccinated and often gathered for large weddings and funerals during the past two years, according to county officials. Amish, in particular, have low rates of vaccination because they are leery of government intervention and rely on family traditions for preventive medicine.
Mifflin County Commissioner Kevin Kodish also blames politics.
"We are very rural here," he said. "It's heavy Republican and heavy in Trump support, so in the beginning people were skeptical of COVID because he downplayed the disease. And I think that carried over with skepticism with vaccines."
Having so many deaths in the county of about 45,000 people is difficult to comprehend, he added. His 94-year-old mother, who was living in a nursing home, died last year not long after her own bout with COVID.
Kodish, the only Democrat on the three-member County Commission, said COVID split the community, between people who took the disease seriously and got vaccinated, practiced physical distancing, and wore masks and others who just wanted to live their regular lives.
Although COVID has been devastating to many families, the Republican mayor of Lewistown, Deborah Bargo, acknowledged the death toll but focused on how her town's economy is improving.
"It's been hard for those who have lost loved ones, and that pain never goes away," said Bargo, who has been mayor for 15 years. "But, economically, we've bounced back."
Bargo pointed out that nearly every storefront in the downtown square is occupied, a century-old theater is being restored, and a young Mennonite entrepreneur has recently opened a cafe-bakery.
She said she is worried that many older people who stayed in their homes because of fears about COVID have been forever changed by the isolation. In her church, she said, people who wear masks still sit away from everyone else.
Noah Wise, 59, a road supervisor in Burnham, just north of Lewistown, said he's not coping well. His wife, Lisa, a nurse at Geisinger's outpatient care department, died of COVID in December. She was 58 and not vaccinated because she was worried how the vaccine would affect a chronic health condition — even though health experts say people with chronic health issues are more likely to suffer severe consequences and death from COVID.
Wise said Lisa likely caught the virus from him after he was infected in October. "She had no regrets about not being vaccinated," Wise said. "She thought she would pull through."
His wife's death has not persuaded him to get vaccinated because he believes his earlier infection has given him immunity. Natural immunity does confer some resistance to catching the disease but is highly variable in strength, so health experts urge those who have been infected to get vaccinated.
Jenny Barron Landis, executive director of the Juniata River Valley Visitors Bureau, which covers Mifflin County, said many community members were not interested in taking orders from government scientists. "We have a lot of independent farmers and business owners that didn't agree with or honor the mandates, and that has played a big role here in the number of deaths and the number of cases," she said.
Against that backdrop, Geoff Burke, a local funeral director, recalled weeks when his Lewistown funeral home would handle up to 17 deaths, many of them from COVID — triple its average. "We were overwhelmed," he said. "COVID just ravaged our town as it went from nursing home to nursing home."
On March 15, Geisinger Lewistown, a 133-bed hospital, had just two COVID patients, down from 50 earlier this winter, said Dr. Michael Hegstrom, chief medical officer for the region of Geisinger that includes Mifflin County. Geisinger refused to disclose what percentage of its employees at the Lewistown hospital have been vaccinated for COVID. It would say only that all its employees are either vaccinated or received an exemption. Geisinger also refused to disclose how many of its employees in Lewistown died of COVID.
Yet the hospital is still being affected by the virus. It is running above capacity because of high numbers of patients with medical issues such as heart disease and cancer who put off care during the pandemic, Hegstrom said.
Connie Houtz said that the deaths of Eric and Toby — two of her three children — had been hard but that she was thankful for family and friends and strong faith. She remembers Toby — who had some health problems, including cancer of the small intestine a few years ago — as "easygoing and a big teddy bear." Eric, who had high blood pressure, loved spending time with his daughter and taking the teenager fishing, Houtz said.
Both brothers rode Harley-Davidson motorcycles and would hang out with friends at a bar near her house. "It still hits you at times that they are really gone," she said.
Hundreds of millions of dollars were supposed to go to building a community health workforce after the American Rescue Plan Act was signed into law last March, but much of the money is being quickly spent on health departments or national initiatives, not local, community-based organizations.
This article was published on Thursday, March 31, 2022 in Kaiser Health News.
GRANITE CITY, Ill. — As a community health worker, 46-year-old Christina Scott is a professional red-tape cutter, hand-holder, shoulder to cry on, and personal safety net, all wrapped into one.
She works in an office in the shadow of the steel mill that employed her grandfather in this shrinking city in the Greater St. Louis area. Gone with many of the steel jobs is some of the area’s stability — almost a fifth of Granite City’s residents live in poverty, far higher than the national average.
Then another destabilizer — covid-19 — hit. And so Scott stepped in: She knows how to access rental assistance for those out of work as they isolate at home with covid. She can bring people cleaning supplies or food from a local food bank. She’ll stay on the phone with clients, helping them budget their finances to keep the lights on. And the calls keep coming because people know she understands.
“I’ve been hungry. I’ve not had a car,” Scott said. “I’ve been through those things.”
Scott is one of the over 650 community health workers the Illinois Department of Public Health hired through local, community-based organizations starting last March. This Pandemic Health Navigator Program workforce was made possible by a nearly $55 million grant from the Centers for Disease Control and Prevention through the federal pandemic relief passed by Congress. The team has completed at least 45,000 assistance requests, which were referred to them through contact tracing of covid cases.
As the workers have gained the community’s trust, Scott said, new requests have poured in from people who have heard about the catch-all program, which does more than what many people may think of as public health work.
But the money is set to run out at the end of June. Workers such as Scott are uncertain about their futures and those of the people they help each day. Dr. Georges Benjamin, executive director of the American Public Health Association, said that’s the tragedy of the boom-bust nature of public health funding in the United States.
“As the dollars go away, we’re going to see some people falling off the cliff,” he said. The problem, as Benjamin sees it, is the country’s lack of a systematic vision for public health. “If you did this with your army, with your military, you could never have a sound security system.”
Community health workers were positioned as key to President Joe Biden’s public health agenda. Ideally, they are one and the same as those they serve — like a neighbor who can be trusted when help is needed. Popular in countries such as Costa Rica, Liberia, and Brazil, community health workers have been difficult to maintain in the United States without consistent ways to pay them.
Hundreds of millions of dollars were supposed to go to building a community health workforce after the American Rescue Plan Act was signed into law last March, said Denise Smith, the founding executive director of the National Association of Community Health Workers. But, she said, much of the money is being quickly spent on health departments or national initiatives, not local, community-based organizations. And a lot of it has been going to AmeriCorps workers who may not be from the communities they work in — and make poverty-line salaries, Smith said.
“For bills and a car note, rent, or children, that’s just not sustainable,” she said. “We can’t do it for free.”
By contrast, Illinois’ program tries to hire workers from within communities. Two-thirds of its workers identify as Latino/Hispanic or Black. About 40% were previously unemployed, and hiring them injects money into the communities they serve. The jobs pay $20 to $30 an hour, and almost half include health insurance or a stipend toward it.
That’s by design, said Tracey Smith, who oversees the Pandemic Health Navigator Program for the Illinois Department of Public Health and is not related to Denise Smith. She believes paying for such workers is a necessity, not a luxury, in helping people navigate the nation’s broken health care system and disjointed government assistance programs.
Angelia Gower, a vice president of the NAACP in Madison, Illinois, is now one of those paid community health workers. “They see you out there week after week and month after month and you’re still there, they start trusting,” she said. “You’re making a connection.”
But as covid cases have waned, the number of Illinois’ pandemic health workers has decreased by nearly a third, to roughly 450, in part because they have found other opportunities.
Smith is optimistic the program will secure money to keep an estimated 300 community health workers on staff and then use the goodwill they’ve built up in communities to focus on disease prevention. The fragmented American health care system — and its systemic inequities — won’t disappear with covid, she said. Plus, millions of people are poised to lose their Medicaid coverage as pandemic benefits run out, Benjamin said, creating a hole in their safety net.
Part of the long-term funding challenge is quantifying what workers like Scott do in a day, especially if it doesn’t relate directly to covid or another communicable disease. How do you tabulate the difference made in a client’s life when you’re securing beds for their children, laptops for them to go to school, or tapping into Federal Emergency Management Agency funds to pay funeral costs after a loved one dies of covid? How do you put a dollar amount on wraparound services that may keep a family afloat, especially when a public health emergency isn’t occurring?
As Scott likes to point out, most of the time she’s helping people use resources already available to them.
The National Association of Community Health Workers’ Denise Smith is worried that even though programs like Illinois’ are doing the work to help with health inequities, they may go the way that many Affordable Care Act grants did. In 2013, she was working as a community health worker in Connecticut, helping cut the uninsured rate in her area by 50%. But the money ran dry, and the program disappeared.
She said North Carolina is an example of a state that has designed its pandemic-inspired community health worker program to be more permanent. But, nationally, Congress has yet to approve more money for covid testing and vaccines — much less for longer-term public health investments.
Meanwhile, Scott can’t help but worry about people such as 40-year-old Christina Lewis.
As she leaves Lewis’ mobile home after dropping off a load of groceries, Scott reminds Lewis to keep wearing her mask even as other people are shedding theirs. Scott used her own family as an example, saying they all wear their masks in public even though people “look at me like I’ve got five heads.”
Lewis said Scott’s help — bringing over groceries, talking through budgeting — has been invaluable. Lewis has stayed home throughout the pandemic to protect her 5-year-old daughter, Briella, who was born prematurely and has chronic lung disease. The struggle to make ends meet is far from over amid rising inflation. Briella knows to turn off the lights as soon as she’s out of a room. And now they are eyeing rising gasoline prices.
“I already know I’m going to have to get a bike,” Lewis said.
Over the past months, Scott has listened and consoled Lewis as she cried over the stress of staying afloat and losing family members to covid. Scott isn’t sure what will happen to all her clients if her support disappears.
“What happens to people when it goes away?” Scott asked.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
When Reyna or Justin Ansley or one of their three kids feels sick and needs to be tested for strep throat or flu, there’s a good chance they’ll head to their local pharmacy in Hemingford or Alliance, Nebraska. Dave Randolph, the proprietor of both locations of Dave’s Pharmacy, can do a rapid test, give them medicine if they need it, and send them on their way.
“I’m a cattle rancher,” said Reyna Ansley, whose family lives about 15 miles outside Hemingford. “You don’t necessarily have the time to drive to the doctor and sit in the waiting room. It’s really quicker through Dave.”
The Ansleys don’t have health insurance and using the pharmacy, where Randolph charges $50 to $60 to do the tests, is cheaper than paying up to $200 for an office visit with a local doctor, Ansley said. If the test is positive, the medications generally cost $20 to $30.
Randolph’s ability to provide treatments for flu and strep throat is somewhat unusual. He can do so in Nebraska because he has an annual collaborative practice agreement with a local doctor that is subject to state approval.
The easy availability of pharmacists also helped propel them into a key role during the pandemic as they became a go-to resource for covid-19 testing and vaccines. Yet even before covid engulfed the country, many states were giving pharmacists a bigger role in consumers’ health.
According to the National Alliance of State Pharmacy Associations, more than a dozen states have expanded what pharmacists can do to include testing and treating people for illnesses such as strep throat, flu, and urinary tract infections and preventing HIV. Some states allow pharmacists to prescribe oral contraceptives or drugs to help people quit smoking. Typically, pharmacists have prescribing authority under agreements with doctors or rules called statewide protocols.
But a limited number of states have gone further, allowing pharmacists to prescribe medications on their own to treat a broad range of conditions for which there are rapid point-of-care tests, if it’s appropriate based on clinical guidelines.
“We’re seeing more states looking at direct prescribing authority now as opposed to collaborative practice agreements,” said Allie Jo Shipman, director of state policy at the National Alliance of State Pharmacy Associations. The alliance offers point-of-care testing and point-of-care treating training programs for pharmacists and pharmacy students.
The Biden administration, which has leaned on pharmacies to help battle the covid pandemic by administering vaccines and tests, is now calling for a limited number of pharmacies with retail clinics that employ doctors or other health care workers with prescribing authority to directly provide medication rapidly to people who test positive for the virus. The “test-to-treat” program is designed to make sure that people with covid get a course of antiviral medication quickly because it is most effective if used within five days of when someone shows symptoms.
Pharmacists say their expanded efforts on covid have helped raise their profile.
“One of the big things that came out of covid is that consumers understand that pharmacies do offer these services that are high-quality and convenient and support their health,” said B. Douglas Hoey, CEO of the National Community Pharmacists Association, which represents the interests of independent pharmacists.
But physicians don’t necessarily welcome this development. Doctor groups have long objected to the taking on of certain types of patient care by pharmacists, nurse practitioners, physician assistants, and other nondoctors unless it is overseen by or approved by physicians.
In November, the American Medical Association, which represents doctors, announced that since 2019, it had successfully opposed more than 100 legislative actions that would have expanded nonphysicians’ scope of practice, called scope creep. The group also issued a statement criticizing the Biden administration’s plan to allow pharmacy-based clinics to prescribe covid antiviral medications, saying that the program poses a danger to patient safety and risks negative health outcomes. And the AMA unsuccessfully opposed a federal decision to let pharmacists give covid vaccines to children younger than 18.
Meanwhile, the American College of Physicians, which represents internists, announced it “opposes independent pharmacist prescriptive privileges and initiation of drug therapy outside of a collective practice agreement, physician standing order or supervision, or similar arrangement.”
The AMA didn’t respond to questions about independent pharmacist prescribing, and the ACP declined to comment on its policy.
But are physicians correct that patient safety is at risk if a doctor isn’t involved in prescribing decisions? Pharmacists say that they want to provide care in line with their training and skills and that they know their limits. And they note that timely prescribing is vital for treating covid and other infectious diseases.
They also note that pharmacists are increasingly part of the multidisciplinary clinical teams that direct patient care at hospitals and in health care systems.
“Pharmacists are the professionals that are the most trained to deal with drug interactions,” said Rita Jew, a pharmacist who is president of the Institute for Safe Medication Practices, a nonprofit that focuses on preventing medication errors. “We monitor patients for both efficacy and side effects. So from that perspective, it’s not a safety concern. Delay in treatment is a concern.”
Many pharmacists are eager to expand their menu of patient services, but payment remains a problem. Pharmacists aren’t generally recognized as service providers under Medicare and don’t typically receive payment when they spend time evaluating, testing, or treating patients. Many private insurers follow Medicare’s lead on payment.
For many people, pharmacies are convenient and familiar. More than 90% of people in the United States live within 5 miles of a community pharmacy, and Medicare beneficiaries visit the pharmacy nearly twice as often as they do their primary care physician.
Dr. Jeffrey Singer, a general surgeon and a senior fellow at the libertarian Cato Institute, wrote a recent blog post suggesting that doctors who object to nonphysician prescribing may be more worried about competition than patient safety.
“Rather than work to prevent laws that could meet the needs of patients, the onus is on the profession to persuade people that they need to see a doctor,” Singer said in an interview, adding that he has relied on pharmacists’ expertise in his practice. “I ask them, ‘Is there any particular problem with this drug?’ They have the software. And that’s what they’re trained to do.”
In Arkansas, a 2021 law gave pharmacists the authority to treat conditions for which there are point-of-care tests, as long as they follow statewide protocols established by the state board of pharmacy and the state medical board.
“There are myriad tests that are on the market now that are quick and inexpensive and that can really increase access dramatically for folks who don’t have time or resources to go to a primary care provider,” said Scott Pace, a pharmacist and co-owner of Kavanaugh Pharmacy in Little Rock, Arkansas.
But pharmacists aren’t interested in replacing physicians, said Shipman. “We want to come alongside physicians,” she said. “We want to be another health care provider. In the middle of the pandemic, we need more help. The burden is too great to be carried by any one provider.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Some people aren't convinced about the value of a third shot, a hesitancy fueled by evolving scientific understanding of the virus and a distrust of the federal government entrenched in tribal communities.
This article was published on Thursday, March 31, 2022 in Kaiser Health News.
When covid-19 vaccines first became available, Native Americans acted swiftly and with determination to get their shots — as though they had everything to lose.
Covid hospitalization and death rates for American Indians and Alaska Natives had skyrocketed past those of non-Hispanic whites. Leveraging established systems like the Indian Health Service and tribal organizations, Native Americans urgently administered vaccines. Data from the Centers for Disease Control and Prevention showed they achieved the highest vaccination rates of any race or ethnicity.
Yet, tribal health officials said, they eventually ran up against the challenges that broadly stalled the U.S. vaccination campaign, particularly in persuading people to get booster shots.
Nationally, 72% of American Indians and Alaska Natives of all ages had received at least one dose of a covid vaccine as of March 28, and 59% were fully vaccinated — having received two doses of Moderna’s or Pfizer-BioNTech’s vaccine or one dose of Johnson & Johnson’s. A much smaller share had received booster shots — 44% of fully vaccinated Native Americans ages 12 and up, below the booster rates for whites, Asian Americans, and Native Hawaiians and Pacific Islanders.
Tribal health experts say data problems may be partly to blame, but there are other factors. It’s proved more difficult in recent months to find shots and book appointments. Some people weren’t convinced about the value of a third shot, a hesitancy fueled by evolving scientific understanding of the virus and a distrust of the federal government entrenched in tribal communities.
“Sometimes I think the people I talk to see it as, ‘Hey, we got our first and second shot. You guys have told us that’s what we need, and we’re going to be OK,’” said Angie Wilson, who until recently served as tribal administrator of the Reno-Sparks Indian Colony, a federally recognized tribe in Nevada with about 1,200 members.
Reno-Sparks provides a glimpse into what it takes to increase vaccinations. Before the omicron variant arrived in early December, vaccinations had plateaued, and many members were expressing apathy about getting additional shots, she said. After omicron caused a sharp rise in cases, Reno-Sparks mandated that its employees be fully vaccinated and boosted. It also used money provided by the American Rescue Plan Act to offer cash to members: $1,000 for getting the initial doses and $500 for a booster, regardless of whether they lived on or off the reservation.
Those incentives and rising counts of breakthrough infections sparked renewed interest and persuaded roughly 130 people to get boosters within six weeks. Thirty-five percent of eligible Reno-Sparks’ tribal members had been boosted as of late March. The rates of first and second shots rose, too: 60% of members 5 and older had received an initial dose, while 56% were fully vaccinated.
The tribal land is in an urban area in Reno, and the reservation has a Walmart Supercenter. Nevada lifted its statewide mask mandate abruptly Feb. 10.
With precautions to limit covid’s spread falling by the wayside, tribal officials fear what any gaps in vaccination will mean for their communities. American Indians and Alaska Natives have been hospitalized for covid at three times the rate of white Americans and have died of covid at double the rate of whites, according to the CDC. Nationally, as of March 28, fewer than half of booster-eligible Native residents had received them.
“I can see where we’re heading, which is concerning,” Wilson said. “I worry about our tribal population, especially with our risk factors.”
The challenges were evident even before the FDA on March 29 authorized a second booster dose of the Pfizer-BioNTech and Moderna vaccines for anyone 50 or older and certain immunocompromised people. Tribal members and health experts see several reasons that booster rates have not been higher, despite employing more aggressive vaccination measures than surrounding states and counties.
Virginia Hedrick, executive director of the California Consortium for Urban Indian Health, said, “I do think that IHS really rose to the occasion when it came to the pandemic and vaccine rollout.” Still, “any time we have something change,” she said of the vaccine, “it raises questions for folks.”
In the fall, Hedrick said, her mother-in-law saw ads for booster shots all over the place but still couldn’t get an appointment. “There was a general sense of frustration,” she said.
Another problem, which likely masks the true share of Native Americans who have gotten booster shots: data inconsistencies. Race data on Native Americans has long been hindered by accuracy issues, including misclassifications of people. With covid vaccines, the CDC receives data from a hodgepodge of systems that generally don’t communicate with one another: state immunization registries, pharmacy chains, and federal vaccine providers, including IHS. And race and ethnicity information is missing from a significant share of vaccination records.
The agency acknowledges that it can overestimate initial vaccines given and undercount subsequent doses because the data does not include personally identifiable information. As a result, different doses may not be connected back to the same person.
If a Native American receives the first two doses through the IHS but gets a booster elsewhere, the booster dose could be misclassified as a first dose. Many instances of this could create the impression that booster rates among Native Americans are lower than they really are.
“The counting might get confused because there’s no central system,” said Dr. Meghan O’Connell, a tribal medical epidemiologist with the CDC Foundation who works at the Great Plains Tribal Leaders Health Board in South Dakota.
Accurate federal data is crucial for assessing Native American vaccinations because of the large role played by the IHS, a federal agency through which 355 facilities, tribal health programs, and urban Indian organizations received vaccine shipments. State-level data on vaccination does not include administered shots from all federal vaccine providers, including the IHS.
Native Americans get vaccinated in and outside of tribal health facilities, but access to IHS facilities can affect overall rates.
IHS publishes the number of vaccine doses that have been delivered and administered in 11 IHS areas but not the number of people per area who have received those doses. The lone exception is Alaska, where tribes received vaccines from the state.
“Something I’m very interested in is knowing how these rates may differ between tribal communities so that we can learn more about best practices,” O’Connell said.
IHS received $9 billion to respond to the pandemic, the bulk of it from the American Rescue Plan. It did not respond to questions about efforts to increase booster rates among tribal populations and whether they differed from outreach done to encourage people to get the initial shots.
When asked how often Native American vaccination data is checked for errors, CDC spokesperson Kate Grusich said the agency “regularly provides feedback on data quality” and works to remove duplicate or incorrect records. “This is an ongoing process and includes strategies to improve the accuracy of all COVID-19 vaccination related data, including race and ethnicity data,” she said in an email.
Agnes Attakai, a member of the Navajo Nation who lost six relatives to covid, got her first two vaccine doses easily, through a university drive-thru clinic. But when it came to her booster shot, she said, she had two options — CVS and Walgreens pharmacies, which had “a month- to two-month-long waits,” or her local public health department about 10 miles away. A resident of rural Pima County, Arizona, she chose the latter and got her shot in November.
Attakai, director of health disparities outreach and prevention education at the University of Arizona’s public health school, said she observed high uptake of booster shots. But there have been some clear differences compared with the early vaccine rollout.
Shots were “more accessible at the very beginning where there was a mass effort, a communitywide effort,” Attakai said. “When the boosters rolled out … [folks had to] actually find out where to get their booster shots and which was the closest location, when they were open. And, of course, some of them were open only during the daytime.”
The Navajo Nation, the largest tribe in the U.S., in January required its employees to get booster shots, building on an earlier mandate that they be fully vaccinated. As of March 4, 66% of Navajo Nation residents had received the first two doses, according to spokesperson Jared Touchin, above the U.S. rate at the time.
As officials brace for future covid surges, Wilson said tribal officials are trying to figure out how to best educate people on how to protect themselves. “If we don’t do that, I think that the issue’s going to be, ‘Well covid’s over, everything’s opened up, we don’t have to deal with this anymore, I’m back to living my life,’ without realizing that the danger is still there,” she said.
The hardship for the national pandemic response is that “there’s a validity in the fear in tribal communities,” Wilson said, “centered around the distrust of the federal government, rightfully so.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Sen. Tim Scott, a rising star in the Republican Party with broad popularity in his home state of South Carolina, is getting showered with drug industry money before facing voters this fall.
Scott was the top recipient of pharma campaign cash in Congress during the second half of 2021, receiving $99,000, KHN's Pharma Cash to Congress database shows, emerging as a new favorite of the industry. Though Scott has been a perennial recipient since arriving in Congress in 2011, the latest amount is nearly twice as much as his previous highest haul.
Why Tim Scott? South Carolina's junior senator is someone widely viewed as destined for greater things during his political career. And this is an existential moment for the American pharmaceutical industry when securing allies is critical.
Congress is under intense pressure to rein in the high prices of medicines in the U.S., which are often several times those in other developed countries. Roughly 1 in 4 adults report difficulty affording their prescription drugs, according to KFF polling. Further, 83% of Americans support the idea of Medicare negotiating with pharmaceutical firms to lower prices for both its beneficiaries as well those with private insurance — that's 95% of Democrats, 82% of independents, and 71% of Republicans.
The industry needs people like Scott, who has introduced several health-related bills in recent years and maintains drug industry-friendly positions, in its corner. He opposes proposals introduced in legislation backed by most Democrats in Congress to let Medicare negotiate prices. In 2019, when the Senate Finance Committee considered a drug pricing bill crafted by Sen. Chuck Grassley (R-Iowa) and Sen. Ron Wyden (D-Ore.), Scott voted against a measure that would have amended the legislation to allow Medicare drug price negotiation. (Scott himself was absent but registered his opposition through a proxy vote.)
In September, as the top Republican on the Senate's Special Committee on Aging, he released a report arguing that HR 3, a sweeping measure from House Democrats to tamp down prices, would result in "shattered innovation" and "bankrupt businesses," echoing arguments made by pharma companies.
"Democrats propose the federal government should be in charge of deciding the price of treatments, instead of a competitive free marketplace sustained by companies driving innovation," the report stated. The bill would have allowed the federal government to negotiate prices for certain costly medicines and penalize drug companies that don't cooperate, among other provisions.
Scott has also been a member of the Senate Finance Committee since 2015, an assignment that gives him significant influence over legislation affecting the sector as well as a prominent perch for fundraising. In total, 27 drug and biotech companies or their powerful lobbying organizations in Washington contributed to his campaign accounts in the latter half of last year. Amgen, Vertex Pharmaceuticals, Merck & Co., AstraZeneca, BioMarin Pharmaceutical, and Genentech were his top donors, each giving between $5,000 and $10,500.
He also is a member of the Senate Health, Education, Labor, and Pensions Committee, which this year is set to consider an issue of great importance to pharma companies: reauthorization of user fees the industry pays to the FDA to help expedite the drug review and approval process. The law must be reauthorized by Congress every five years.
"I didn't know until you told me," Scott said when stopped by a KHN reporter in the Capitol and asked what the message was to his constituents as the member of Congress who has received the most money from pharmaceutical PACs in the last two quarters of 2021.
Stephen Billet, an expert on political action committees and associate professor at the Graduate School of Political Management at George Washington University, points to factors beyond his stances on pharma issues that contribute to his fundraising haul. Many of Scott's positions are aligned with his fellow Republicans in Congress who shun greater government intervention in controlling costs. Instead, the contributions may reflect the industry's bet that Scott has a promising political future.
He is a prolific fundraiser. Federal Election Commission records show that Scott has raised $38 million — the most of any GOP senator up for reelection in 2022 and the second highest among senators across both parties — and had $21.5 million in his campaign account at the end of 2021, fueling speculation about a future presidential run. "America, A Redemption Story," Scott's memoirs, is scheduled for release in August through Christian publisher Thomas Nelson.
Billet said pharmaceutical PACs will sit down at the beginning of a campaign cycle and take a close look at the upcoming races and what their budget is likely to be and then figure out who they want to help.
"So they'll say, Tim Scott is up, he's an up-and-comer, he's been a pretty good guy," Billet said. "It's a good idea to get out front and put some money in his pocket."
Pharmaceutical firms have a long tradition of strategic gift-giving to members to develop goodwill, the benefits of which typically emerge many years later.
Other Republican senators up for reelection didn't get nearly as much money from drug companies during the same period, KHN's analysis of Federal Election Commission data shows. For example, Sen. Michael Crapo (R-Idaho), the most senior Republican on the Senate Finance Committee, received $68,300. Fellow Finance panel member Sen. Todd Young (R-Ind.) took in $48,000. All three seats are considered safe for Republicans in November.
Scott has received money from drugmakers every year since coming to Congress as a member of the House in 2011, receiving $596,000 through the end of last year, according to the KHN analysis of FEC data. Scott joined the Senate in 2013 after then-Gov. Nikki Haley chose him to replace GOP senator Jim DeMint, who resigned from Congress to helm the conservative Heritage Foundation think tank. But this is his banner year; previously, the most he received was $54,000 during the second half of 2019.
The following year, Scott co-founded the congressional Personalized Medicine Caucus with a handful of other lawmakers, including fellow pharma darling Sen. Kyrsten Sinema (D-Ariz.). Personalized medicine — which is also referred to as precision medicine — promises to use genetics and other traits to develop individualized treatments for patients, often at a very steep price.
"We will take steps to nurture scientific advancements that may reverse the genetic and molecular causes of rare and common diseases, bringing new hope to American patients and lasting benefits to our healthcare system," Scott's prepared statement read at the time.
Scott's press secretary, Caroline Anderegg, shared that the senator has long held an interest in sickle cell disease, which is the most commonly inherited blood disorder in the U.S. and disproportionately strikes Black people. The disease, which affects roughly 100,000 Americans, is one that could benefit from the development of gene-based therapies, a form of precision medicine, she said.
The caucus's formation was hailed by the Personalized Medicine Coalition, a pharma-friendly group whose members consist of drugmakers donating to Scott — AbbVie, AstraZeneca, Eli Lilly, Genentech, Johnson & Johnson, and Merck, to name a few. The organization estimated that personalized medicines accounted for more than a quarter of new therapies the FDA had approved since 2015, underscoring the pharmaceutical industry's widespread work in the field.
Since 2019, Scott has introduced 17 health-related bills or resolutions about everything from food allergens and sickle cell disease to health disparities among racial and ethnic minorities. Last year, he sponsored a bill that would create tax incentives for drug and medical device companies to manufacture more of their products in the U.S. The legislation's framework loosely aligns with ideas from the Association for Accessible Medicines, which lobbies for generic drug companies.
Overall, from June to December, members of Congress received $3.5 million in their campaign coffers from pharmaceutical companies and their trade associations, according to the KHN analysis of industry contributions.
"There is kind of a cycle to giving and so the off year, 2021, is likely going to have less money than 2022, since it's an election year," said Paul Jorgensen, an associate professor at the University of Texas-Rio Grande Valley who studies campaign finance. "But there was a lot of money put into lobbying this cycle because of all of the initiatives that were being pushed in the House and with the Build Back Better plan, so in some ways your numbers just kind of mirror what one would expect."
Other top recipients of drug industry money in the second half of 2021 include Rep. Cathy McMorris Rodgers (R-Wash.), who was second behind Scott in contributions, receiving $97,300. McMorris Rodgers is the top Republican on the House Energy & Commerce Committee, which has significant sway over pharmaceutical issues, and could become chair of the powerful panel should Republicans retake the House majority in November as expected. Over the entirety of 2021, she received the most money from the sector of any lawmaker.
The pharmaceutical PACs are cognizant of who is up for committee leadership roles, said Billet: "They are 100% aware of who the next person in line is, making McMorris Rodgers an obviously easy target."
Sinema posted the third-highest haul — $74,800 despite not being up for reelection until 2024. It was a big gain over the first half of 2021, when she received $8,000. KHN reported in 2020 on Sinema's connections to the pharmaceutical industry.
Data analyst Elizabeth Lucas contributed to this report.
Biden's reforms don't address residents' rights to have contact with informal caregivers — family members and friends who provide emotional support and practical assistance.
This article was published on Tuesday, March 22, 2022 in Kaiser Health News.
When the Biden administration announced a set of proposed nursing home reforms last month, consumer advocates were both pleased and puzzled.
The reforms call for minimum staffing requirements, stronger regulatory oversight, and better public information about nursing home quality — measures advocates have promoted for years. Yet they don't address residents' rights to have contact with informal caregivers — family members and friends who provide both emotional support and practical assistance.
That's been a painful concern during the pandemic as nursing homes have locked down, caregivers have been unable to visit loved ones, and a significant number of residents have become isolated, discouraged, or depressed.
Thousands of residents died alone, leaving a trail of grief for those who couldn't be by their side. Altogether, more than 200,000 residents and staffers in long-term care facilities perished of COVID-19 in the first two years of the pandemic, according to an analysis by KFF.
"What we learned is that family members' support is absolutely essential to the well-being of residents," said Mairead Painter, Connecticut's long-term care ombudsman. (Ombudsmen are official advocates for nursing home residents.) "We need to make sure that the far-reaching restrictions put in place never happen again."
Although nursing home residents have a right to have visitors under federal law, this protection was "degraded" during the pandemic, said Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform. "I worry that facilities and public health departments will feel emboldened to cut visitation off at their discretion, whenever there's an infectious disease outbreak," he explained.
What's needed now, Chicotel suggested, is legislation stating that "even in a public health emergency, residents have a core right to support from [informal] caregivers that cannot be waived."
A new "essential caregivers" bill in California (AB-2546) would allow residents to designate two such informal caregivers, one of which would have access to a facility around-the-clock without advance scheduling. Caregivers would need to comply with the same safety and infection control protocols that apply to staffers. Laws with a similar intent have passed in 11 states, according to the Essential Caregivers Coalition, an advocacy group formed during the pandemic.
Nationally, the Essential Caregivers Act of 2021, another measure along these lines, is languishing in the House Ways and Means health subcommittee. Competing priorities, pandemic-related fatigue, and a sense that the COVID emergency "is behind us" are contributing to inaction, said Maitely Weismann, a co-founder of the Essential Caregivers Coalition.
If sweeping nursing home changes don't address the harm to residents when they are cut off from families, "we're only halfway where we need to be," she cautioned. The White House did not respond to requests for comment about whether it planned to address the issue.
Elizabeth O. Stern, 69, of Stonington, Connecticut, was unable to see her 91-year-old mother for eight months after her mother's nursing home shut its doors on March 10, 2020. Before the pandemic, Stern visited nearly every day with her mother, who had a stroke in 2016 and developed dementia.
"I did her laundry and cleaned and washed the windows in her room," Stern told me. "I took care of her fingernails and much of her personal care. I'd sing her to sleep at night."
Unable to see her family during the long pandemic-inspired lockdown, Stern's mother became anguished, and her health deteriorated. Two and a half days before she died in November 2020, Stern was finally able to get inside the nursing home to say her final goodbyes.
"So many family caregivers like me are scratching their heads and wondering why, after all the devastation we've suffered, are we again being overlooked in the [Biden administration's] proposed reforms," she said.
New research confirms the extent of assistance that family caregivers like Stern provide. Using national survey data from 2016, researchers from the University of Pennsylvania reported in a recent Health Affairs study that informal caregivers helped 91% of nursing home residents who needed aid with medications; 76% of residents who required assistance with self-care tasks such as bathing or dressing; 75% of residents who had problems such as getting in and out of bed or moving across a room; and 71% who required aid with household tasks, such as managing money. On average, this care from informal caregivers amounted to 37 hours a month.
In addition to the harmful effect on residents, the loss of this assistance during the pandemic placed extra burdens on already-stressed nursing home workers, contributing to the staffing crisis that afflicts long-term care, said Dr. Rachel Werner, co-author of the study.
"The discussion we should be having is how to support [informal] caregivers in long-term care facilities, whether we're in a pandemic or not, by acknowledging what they do, giving them more training, and making them part of care teams and the care planning process," Werner said.
Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, an advocacy organization, added a note of caution. "One of the things we're concerned about is that family members and the assistance they provide might be looked at, in some cases, as part of a solution to short-staffing in nursing homes," she told me.
"Yes, family members can help, and we want to make sure that their access to long-term care facilities is ensured. But they can't be seen as a substitute for staff."
In San Francisco, that line blurred for Dr. Teresa Palmer, a geriatrician, whose 103-year-old mother took to bed in her nursing home in March 2021 and wouldn't get up. Concerned, Palmer insisted on a "compassionate care" exception to the nursing home's lockdown rules and was able to see her mother inside the facility for the first time in a year.
"To the staff, my mother was just an old person who was acting old. But she was down to 90 pounds from a baseline weight of 105 and her bowel functions had changed," said Palmer, who took her mother to the hospital, where she was diagnosed with malnourishment, dehydration, and pancreatic cancer.
Palmer brought her mother home from the hospital, with hospice care, where she died 10 weeks later.
"Even in a very good nursing home such as my mother's, they really don't have time to make sure residents are eating enough or drinking enough or give the hands-on loving care that family members provide," Palmer said.
As for the nursing home industry, there are signs this lesson has hit home. In a statement about the national Essential Caregivers Act, the American Healthcare Association said, "We applaud this bill and welcome family members and friends taking an active role in the care of their loved ones." The statement was forwarded by Cristina Crawford, senior manager of public affairs.
Ruth Katz, senior vice president of public policy at Leading Age, another long-term care association, wrote in a statement that her group believes quality care "includes residents' ability to maintain regular connections to and contact with family and friends" and expects new federal rules to reinforce caregivers' efforts to support nursing home residents in emergencies in the future.
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Montana Gov. Greg Gianforte's office estimates that "thousands of healthcare workers" have obtained religious exemptions and "remain in the workforce."
This article was published on Tuesday, March 22, 2022 in Kaiser Health News.
Charlie O'Neill received part of her husband's liver in a 2013 living donor transplant and has been taking drugs that suppress her immune system ever since to prevent her body from attacking the organ.
"I frequently get infections," she said. "Just being an immune-compromised person, you are faced with just every little cold and flu."
O'Neill lives in the small town of Pony in southwestern Montana's Madison Valley. Despite living in an uncrowded rural setting, O'Neill said, the first year of the coronavirus pandemic was terrifying. She rarely left home, waiting for COVID-19 vaccines to become available.
Even now, after being vaccinated, O'Neill said the virus is always on her mind when she drives into nearby Bozeman for groceries and other basic needs. She wears a mask and avoids people as much as she can. While vaccinations provide robust protection against hospitalization and death for the typical individual, they are far less effective in those who are immunocompromised.
O'Neill developed abscesses on her liver, requiring daily visits to the Bozeman hospital for antibiotic infusions. In a state where the governor has encouraged health workers to seek vaccination exemptions, she worried about which of the many people involved in her care were instead putting her at risk: the people checking her in at the front desk, the traveling nurses, the imaging technicians?
Gov. Greg Gianforte's office estimates that "thousands of healthcare workers" have obtained religious exemptions and "remain in the workforce," according to a recent press release.
"I so boldly ask people often just if they're vaccinated, especially if I have to take my mask off for MRIs or something like that," O'Neill said. She said she'd request someone else if a worker told her he or she were unvaccinated or declined to answer, but that hasn't happened.
Most medical staffers across the U.S. are now required to be fully vaccinated against COVID under a federal Centers for Medicare & Medicaid Services rule. While, legally, requests for religious or medical exemptions must be allowed at every institution, in much of the country they are reviewed carefully and approved judiciously. In New York City's 12-hospital public system, for example, 100% of staff members inside the hospitals are vaccinated; the few who were granted exemptions are assigned outside tasks.
But in Montana, the pendulum has swung in a different direction.
Gianforte, a Republican who opposed the federal mandate, encouraged health workers to seek religious exemptions before the Feb. 14 deadline to receive one dose of vaccine. His administration provided guidance to hospitals that said the validity of healthcare workers' religious beliefs shouldn't be questioned in seeking exemptions. Gianforte also told the state health department to create an application for religious exemptions, which is posted at the top of its website to download.
When asked for an interview with Gianforte, spokesperson Brooke Stroyke referred to the governor's open letter to health workers dated Feb. 10.
"The State of Montana will continue to press its claims that the mandate is unconstitutional or otherwise unlawful in the district and appellate courts," the letter read. "In the meantime, however, I urge those of you who are unvaccinated to consider using the religious and medical exemptions that your employers are required to offer, as well as talk to your colleagues or personal health provider about getting vaccinated."
The Equal Employment Opportunity Commission said that employers should assume a request for a religious exemption is based on sincerely held beliefs, but that if there is an objective basis for questioning the request, the employer is justified in making a limited factual inquiry.
There's no way of knowing just how many healthcare workers remain unvaccinated at any facility. Many hospitals across the state are unwilling to share the data.
Out of nearly 65 hospital facilities statewide, 11 shared their exemption rates with Montana Public Radio, Yellowstone Public Radio, and KHN. Those rates range from under 1% at two critical access hospitals operated by the U.S. Indian Health Service to 37% at Prairie Community Hospital in Terry. Four facilities reported that a quarter or more of their workers had exemptions.
Prairie Community Hospital CEO Burt Keltner said he didn't question exemption requests because losing nearly 40% of his staff would close the hospital.
"Some of the people that had made the choice that they did not want to get the vaccine were some of our best employees," he said.
Montana Hospital Association CEO Rich Rasmussen said one reason most hospitals are leery of sharing how many workers remain unvaccinated is a law passed last year prohibiting discrimination based on vaccination status. Hospitals fear that even providing percentages of unvaccinated workers could spell legal trouble for them, he said.
Centers for Disease Control and Prevention spokesperson Martha Sharan said the agency will soon publish national vaccination rates for medical staffers in CMS-certified acute care hospitals. She added that the dashboard could eventually include national data from other medical facilities participating in certain CMS programs.
CMS will post facility-level vaccination rates from those facilities on its Care Compare website in October, CMS spokesperson Beth Lynk said.
An analysis of voluntarily reported data by the CDC found that nationwide 70% of staff members at medical facilities were vaccinated as of mid-September but noted lower vaccination rates were likely in rural areas. That was before the Biden administration announced the CMS vaccine mandate, and rates have likely increased since.
Paul Conway, chair of policy and global affairs at the American Association of Kidney Patients, said the lack of transparency around COVID vaccination rates for medical workers puts immunocompromised patients in a bind.
"During COVID, if you're in a dialysis center where you're in there for hours, you're having blood exchanged, you're around a lot of different workers, you're around a lot of different patients, your susceptibility is very high," he explained.
A University of Michigan study found that a quarter of patients on dialysis died if they contracted COVID. That study used data from 2020, when vaccines weren't available until December.
Conway said the kidney patients' association wants CMS to make vaccination rates for hospitals and dialysis centers public to help patients make informed decisions. But for the time being, he said, they are on their own. That leaves them in the uncomfortable position of interrogating caregivers about their vaccination status at a time when that is a charged issue in much of the country.
"Patients always do have the right and the freedom to ask the question and, similarly, doctors and nurses also have the freedom to answer the question or not," said Joel Wu of the University of Minnesota's Center for Bioethics. "I think answering the question truthfully is important because I think it builds trust."
Roger Gravgaard, a 62-year-old kidney transplant recipient from Billings who serves as a patient advocate for kidney disease organizations, said unvaccinated staffers need to understand there are real consequences for patients like him. He is grateful all his providers have been forthcoming about being vaccinated without his even having to ask, he said.
"I feel better knowing that they're vaccinated and I would hope that they have the same feeling knowing that I've been vaccinated, because it's a two-way street," he said.
NASHVILLE, Tenn. — Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake.
The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient's breathing and left her brain-dead before the error was discovered.
Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became "complacent" in her job and "distracted" by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone.
"I know the reason this patient is no longer here is because of me," Vaught said, starting to cry. "There won't ever be a day that goes by that I don't think about what I did."
If Vaught's story followed the path of most medical errors, it would have been over hours later, when the Board of Nursing revoked her RN license and almost certainly ended her nursing career. But Vaught's case is different: This week she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, a 75-year-old patient who died at Vanderbilt University Medical Center on Dec. 27, 2017.
Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a healthcare worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught's loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day.
The Nashville district attorney's office declined to discuss Vaught's trial. Vaught's lawyer, Peter Strianse, did not respond to requests for comment. Vanderbilt University Medical Center has repeatedly declined to comment on Vaught's trial or its procedures.
Vaught's trial will be followed by nurses nationwide, many of whom worry a conviction may set a precedent even as the coronavirus pandemic leaves countless nurses exhausted, demoralized, and likely more prone to error.
Janie Harvey Garner, a St. Louis registered nurse and founder of Show Me Your Stethoscope, a nursing group with more than 600,000 members on Facebook, said the group has closely watched Vaught's case for years out of concern for her fate — and their own.
Garner said most nurses know all too well the pressures that contribute to such an error: long hours, crowded hospitals, imperfect protocols, and the inevitable creep of complacency in a job with daily life-or-death stakes.
Garner said she once switched powerful medications just as Vaught did and caught her mistake only in a last-minute triple-check.
"In response to a story like this one, there are two kinds of nurses," Garner said. "You have the nurses who assume they would never make a mistake like that, and usually it's because they don't realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda."
As the trial begins, the Nashville DA's prosecutors will argue that Vaught's error was anything but a common mistake any nurse could make. Prosecutors will say she ignored a cascade of warnings that led to the deadly error.
The case hinges on the nurse's use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. According to documents filed in the case, Vaught initially tried to withdraw Versed from a cabinet by typing "VE" into its search function without realizing she should have been looking for its generic name, midazolam. When the cabinet did not produce Versed, Vaught triggered an "override" that unlocked a much larger swath of medications, then searched for "VE" again. This time, the cabinet offered vecuronium.
Vaught then overlooked or bypassed at least five warnings or pop-ups saying she was withdrawing a paralyzing medication, documents state. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state.
Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to "look directly" at a bottle cap that read "Warning: Paralyzing Agent," the DA's documents state.
The DA's office points to this override as central to Vaught's reckless homicide charge. Vaught acknowledges she performed an override on the cabinet. But she and others say overrides are a normal operating procedure used daily at hospitals.
While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said at the time of Murphey's death that Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system.
Murphey's care alone required at least 20 cabinet overrides in just three days, Vaught said.
"Overriding was something we did as part of our practice every day," Vaught said. "You couldn't get a bag of fluids for a patient without using an override function."
Overrides are common outside of Vanderbilt too, according to experts following Vaught's case.
Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital.
Cohen and Brown stressed that even with an override it should not have been so easy to access vecuronium.
"This is a medication that you should never, ever, be able to override to," Brown said. "It's probably the most dangerous medication out there."
Cohen said that in response to Vaught's case, manufacturers of medication cabinets modified the devices' software to require up to five letters to be typed when searching for drugs during an override, but not all hospitals have implemented this safeguard. Two years after Vaught's error, Cohen's organization documented a "strikingly similar" incident in which another nurse swapped Versed with another drug, verapamil, while using an override and searching with just the first few letters. That incident did not result in a patient's death or criminal prosecution, Cohen said.
Maureen Shawn Kennedy, the editor-in-chief emerita of the American Journal of Nursing, wrote in 2019 that Vaught's case was "every nurse's nightmare."
In the pandemic, she said, this is truer than ever.
"We know that the more patients a nurse has, the more room there is for errors," Kennedy said. "We know that when nurses work longer shifts, there is more room for errors. So I think nurses get very concerned because they know this could be them."
When Pfizer CEO Albert Bourla said March 13 that all Americans would need a second booster shot, it struck many COVID experts as a self-serving remark without scientific merit. It also set off spasms of doubt over the country's objectives in its fight against the coronavirus.
The decision on how often and widely to vaccinate against COVID-19 is part science, part policy, and part politics. Ultimately it depends on the goals of vaccination at a time when it's becoming clear that neither vaccines nor other measures can entirely stop the viral spread.
On March 15, Pfizer made a more limited request of the FDA, seeking authorization of a second booster only for people 65 and older. Advisers for the FDA and the Centers for Disease Control and Prevention are likely to approve a fourth shot for people in that age group because they're the group most likely to be hospitalized or die of COVID. Pfizer competitor Moderna on March 17 also filed for a second booster shot, although its application extended to all adults.
The vaccines' protection against COVID infection generally wanes within several months in all age groups. But experts disagree on whether frequent boosters, especially for younger people, can do anything about that. Two or three vaccinations protect most people from serious disease — but do relatively little to prevent infection, which is generally mild or asymptomatic, after three or four months.
Statements like Bourla's create public pressure for a fourth dose that could force the Biden administration's hand before government experts have time to assess the evidence, said John Moore, professor of microbiology and immunology at Weill Cornell Medical College.
It appears to be based on a yet-to-be-peer-reviewed Israeli study that examined patients only a few weeks after they had received their fourth dose of vaccine. The limited scope of the data raises questions about the duration of that protection, said Dr. Phil Krause, a former deputy director of the FDA's biologics center. Krause helped lead the agency's COVID vaccine reviews before resigning last fall.
Throughout the pandemic, repeated public proclamations by pharmaceutical company executives — broadcast widely via the media, often without supporting data — have created pressure for politicians and their scientific advisers to act.
Last summer, Bourla announced the likely need for an initial booster in April 2021, then, in August, President Joe Biden promised the first booster shots would be available to all adults starting the following month. "That created an expectation that everyone would get their slice of yummy chocolate cake," Moore said. "Who wants to be 'the cake nazi' and say, 'No cake for you?!'"
Although FDA and CDC expert panels, and some federal scientists, were hesitant about recommending the first booster for younger populations, the agencies overrode their advice and approved boosters for everyone 12 and older. That continues to be a sore point with many immunologists and infectious disease specialists.
''The last thing we need is to have corporate CEOs in March saying this is what you need in December because 'we know,'" Moore said. "How do you know?" CEO announcements have often been made before scientific evidence supporting the claims has been publicly released, meaning scientists have not had time to evaluate their validity.
The desire to react to growing signs of infection is understandable but may be futile in the face of a virus that seems to infect even the well-vaccinated. If we keep chasing the virus with boosters, "we're going to be making the drug companies very happy, since our antibodies will go down every four months," said Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia.
But whether those levels are a good measure of protection — especially against serious disease, and in which populations — is an open question. The answer is important because, like all vaccines, there is a small risk of adverse reactions from each shot.
There's some disagreement among experts on how well COVID vaccines to date have prevented serious disease in healthy young people, and whether and how often they should be boosted.
While a recent CDC study showed an increased risk of hospitalization among people ages 18 to 49 several months after second and third vaccine doses, the data categories in the study aren't fine-grained enough to show whether many of those who suffered severe disease had comorbidities such as chronic disease or obesity, Offit said.
But others argue there's enough evidence to show that yearly vaccines, perhaps in combination with influenza vaccinations, would be the best solution. "Given how safe the vaccines are and how effective they are, I think it probably does make sense for people to get a booster, and the most convenient would be once a year," said Dr. Otto Yang, an infectious disease specialist at UCLA. If COVID turns out to be seasonal, peaking in winter months, vaccination in the fall would provide decent protection, he said.
"We are bound to need another booster. We just don't know when or for which variant," said Dr. Daniel Douek, chief of the human immunology section at the National Institute of Allergy and Infectious Diseases.
The coronaviruses that cause about a third of all common colds appear to infect people as frequently as once a year on average, said Stanley Perlman, a coronavirus expert at the University of Iowa. Vaccines could never prevent all those infections, yet the federal approach has largely acted as if this were feasible, Offit said.
"We're coming off two years where we treated this virus like smallpox, isolating anyone with mild illness, even asymptomatic people," he said. "That's going to have to change. Because neither vaccination nor natural infection is going to protect you from mild illness for a longer period of time."
It's important for U.S. health officials to have and share with the public some clarity about the goals of the vaccination program, said Dr. Luciana Borio, a former FDA and National Security Council official who is now a senior fellow for global health at the Council on Foreign Relations. "We need people to understand that protection against all illness is not long-lasting, instead of thinking the vaccine is not working."
"The goal is not to stop transmission, it's mainly to protect the vulnerable at this point," said Dr. Norman Hearst, a family physician and public health researcher at the University of California-San Francisco.
How, in the absence of perfect vaccines, we will protect the vulnerable remains a conundrum. Borio argues that we need systems to rapidly test elderly and immunocompromised people for COVID and quickly give them treatment if their results are positive.
But this is more easily said than done, Hearst said, since people rarely seek medical help for upper respiratory diseases until the illness is too developed for antiviral drugs to work; antivirals generally work best, sometimes only, if they are taken within a few days of onset of symptoms.
For the time being, all debate on a second booster is moot, said John Wherry, chair of the Department of Systems Pharmacology and Translational Therapeutics at the University of Pennsylvania. Unless Congress reverses itself and decides to give the administration more money to fight COVID, there won't be any free vaccines — or free COVID treatments — available to the public next fall.
"We have an acute budgetary problem and we're not yet out of the woods," Wherry said. COVID numbers are spiking in Europe again, and concentrations of the virus in wastewater are starting to multiply in some areas of the U.S., indicating that a loosening of COVID restrictions may be causing spread among those who weren't infected during the omicron wave in December and January.
Offit, a vaccine inventor and longtime champion of vaccination, cautions against leaning too hard on COVID boosters for answers.
"What's our response going to be if we have another variant like omicron that sweeps across people who got two or three doses?" he asked. "Will we accept this, and say, 'OK, calm down?'"