HOUSTON — Two weeks after Valery Martinez’s 41-year-old cousin was rushed to a hospital with severe symptoms of COVID-19, Martinez wrote a post on Facebook, thanking the doctors and nurses at Memorial Hermann Southeast Hospital in Houston who were working to save him.
“You are the real heroes putting your life on the line in this difficult time,” Martinez wrote. “May God continue to cover and protect you and your families.”
Afterward, she started getting messages from friends — nearly all of them Hispanic, like her — who said their loved ones were also sick with the coronavirus. One friend’s aunt was in intensive care at Memorial Hermann Southeast.
The friend’s family was planning a prayer vigil outside the hospital that weekend, so Martinez asked to join. Then members of another family they knew came forward, asking if they, too, could come pray for a loved one hospitalized there with COVID-19.
Martinez choked back tears that Sunday afternoon this month as she and 40 others stood in a parking lot outside Memorial Hermann Southeast, faces covered with masks, hands lifted in prayer for the three patients hospitalized in ICU rooms 2, 11 and 22 — all Hispanic, all connected to ventilators.
The moment made Martinez feel like she wasn’t alone, she said, and helped her realize just how rapidly the virus was spreading through her community.
“Pretty much everyone who I know has had coronavirus or has a family member who’s been sick or is in the hospital,” said Martinez, who by early this week could list 45 Hispanic friends, family members and acquaintances who’ve been sick with the virus in the Houston area — including four who’d died.
As the coronavirus tears disproportionately through Latino communities in Texas, data released this week by state health officials reveals that an outsized share of these residents are also suffering the worst outcomes. Hispanic Texans make up about 40% of the state’s population but 48% of the state’s 5,952 confirmed COVID-19 deaths, according to Department of State Health Services data.
In the Houston region, where COVID-19 hospitalizations surged in June before beginning to decline in recent days, data released by the Harris County health department showed a disproportionate share of those requiring hospital care — as high as 65% of newly hospitalized patients during some weeks in June — were Hispanic, despite the fact they are 44% of the population.
At Memorial Hermann Health System, one of the Houston region’s largest hospital chains, an analysis of emergency room visits shows that far more Hispanics in their 20s, 30s and 40s have showed up at its hospitals with COVID-19 compared with other ethnicities, an indication that the virus is spreading widely among young Hispanic residents and that they may be waiting until they are sicker to seek care, officials said.
There are numerous reasons for these disparities, experts say. Hispanic residents are more likely to work in service jobs or live in multigenerational households that make social distancing difficult. They are less likely to have health insurance. And they are more likely to have health problems, including diabetes and high blood pressure, leaving them more vulnerable to serious illness.
These factors are more pronounced in Texas, one of the first states to reopen after initial coronavirus shutdown orders, with Gov. Greg Abbott urging people to get back to work beginning in May — including at restaurants, bars and hotels — even as the number of COVID-19 cases continued to grow.
Texas is also the largest state in the nation that refused to expand health insurance for low-income residents under the Affordable Care Act, and it is home to a rapidly growing Latino population. Nearly a third of adults under 65 in Texas lack health insurance, the worst uninsured rate in the country, and more than 60% of those without health insurance in the state are Hispanic.
Dr. Esmaeil Porsa, Harris Health System’s president and CEO, oversees Houston’s two public safety-net hospitals. He said COVID-19 is amplifying the existing inequalities of “a health care infrastructure that is faulty by design.” At Porsa’s hospitals, where a majority of patients lack health insurance, the medical staff has run out of ICU space and key drugs needed to treat COVID-19, leaving many patients to linger in emergency room beds for days before being transferred to hospitals outside the city.
Nationally and in parts of Texas, the coronavirus has also disproportionately sickened and killed Black residents, another group with unequal access to health care.
“And what is happening today really is that faulty design coming out in terms of certain hospital systems becoming overwhelmed, and one segment of the population being disproportionately harmed by it,” Porsa said. “These problems are all coming to a head after decades of not paying attention to the health care infrastructure.”
Another problem: People who lack health insurance often wait too long to seek medical care, leading to worse outcomes, said Dr. Amelia Averyt, a primary care physician at Legacy Community Health, a federally funded center whose patients are about 60% Hispanic.
For those without legal status, Averyt said, there’s also the worry about being able to stay in the country and how to pay medical bills without health insurance.
“I think fear is keeping them at home more than anything,” she said.
The pandemic’s disproportionate toll can be seen in dozens of desperate postings on GoFundMe by Latino families in the Houston region, each pleading for help paying for COVID-19 medical bills or funeral expenses. Several said their loved ones lacked health insurance; others said the virus had hospitalized multiple members of the same family, leaving nobody healthy enough to earn money for rent.
Leonor Quiroz’s friends set up a fundraiser for her after she and her husband of nearly 10 years were hospitalized with COVID-19 in May. Leonor, 47, thinks her husband, Valentin, 52, brought the virus home from a construction site. He couldn’t afford to take time off work.
She was hospitalized first; Valentin, who continued going to work even as his symptoms worsened, followed her into HCA Houston Healthcare Tomball days later. She got better and was discharged; he got worse and was connected to a ventilator.
Each day, Leonor would call and sing Valentin one of their favorite songs in Spanish, “A Puro Dolor” — “Sheer Pain” — while a nurse held the phone to his ear.
“Give me back my fantasies … The courage that I need to live … The air that I breathe.“
Valentin died May 23, leaving Leonor with more than $25,000 in out-of-pocket medical and funeral expenses.
“A lot of my Hispanic friends and family believed the coronavirus was a conspiracy until I actually lost my husband,” Leonor said. “Now they realize it’s not ... after it cost me everything.”
Harris County Judge Lina Hidalgo, the top elected official in the county that includes Houston, called a news conference this month after county data began showing a surge in COVID-19 cases among Hispanic residents. She called the data “a wake-up call,” and not just for those communities already reeling.
“We should care about what’s happening to our most vulnerable residents right now and not just because it’s the right thing to do,” said Hidalgo, the first Latina elected to her position. “We are all interconnected. … If some among us are sicker than the rest of us at the moment, guess what? Sooner or later it’s going to catch up with all of us.”
“He Can’t Catch His Breath”
Cristobal Onofre, 22, has a framed photo of his father in his living room, taken on Benito’s 44th birthday in February. It shows Benito Onofre in his northwest Houston apartment, smiling with cake frosting on his lips, standing in front of a “Happy Birthday” banner and colorful balloons.
He was healthy, his son said.
Five months later, on July 3, Benito was found dead in his apartment after suffering from an untreated case of COVID-19. He was part of a wave of people who’ve died at home in Houston this summer as coronavirus infections surged.
Benito had gone to great lengths to protect himself from the virus, his son Cristobal said. He wore a mask at the restaurant where he worked as a dishwasher and gloves when shopping for groceries. If Benito saw too many people inside a store, he would turn back. But there was only so much he could do.
Sometime in late June, he started feeling ill, with an aching throat that kept him awake at night. After a few days, he decided to get tested for COVID-19 at the Mexican Consulate in Houston. But the test results would take days. In the meantime, Benito continued to treat it as a common cold, drinking hot tea and taking cough syrup.
By the end of the week, his symptoms worsened. “My uncle called and said: ‘Your dad is not doing very well. He can’t catch his breath,’” Cristobal said in Spanish.
His family called an ambulance but said Benito refused to get in when it arrived. Cristobal was told that his father, who still doubted he had COVID-19, was afraid of catching the virus in the hospital. There was also the question of how he would pay for hospital care. Like nearly half of Hispanics in Harris County, Benito lacked health insurance.
Later that night, after the ambulance left, Cristobal’s uncle, who lived with Benito, found him sprawled on the bathroom floor. Paramedics declared him dead, and the medical examiner later determined COVID-19 was the cause, listing high blood pressure and obesity as contributing factors.
Data from the Houston Fire Department shows a 45% jump between February and June in the number of cardiac arrest calls that ended with paramedics declaring people dead upon their arrival at the scene. In March, the department recorded about 250 dead-on-arrival calls, the most of any month in the past two years up until that point. In June, the number grew to nearly 300. And during the first 23 days in July, the most recent data available, the department had already surpassed that number, a new record, fire officials said.
Among the small subset of these at-home deaths later tested and confirmed to be the result of COVID-19, an overwhelming majority of people have been Hispanic, according to Harris County Institute of Forensic Sciences data. In the first two weeks of July, the medical examiner attributed the at-home deaths of 22 people in Harris County to the coronavirus — already surpassing the total number for the month of June. Sixteen of the dead, 73%, were Hispanic.
Benito left a wife and four children in his native Mexico. He hadn’t seen them in 13 years and was recently talking about heading back for good, becoming more anxious about being here without legal status.
In Houston, it was only father and son. They used to play soccer together and grab a bite at their favorite Mexican restaurant every Friday. A typical dad, Benito would scold Cristobal for not calling his mother or for changing lanes without signaling.
“He was my dad but also my friend,” Cristobal said.
“If you are sick, go to the hospital,” is his message to others. “We don’t know if it can be a common cold or the coronavirus. This illness is nothing to play around with.”
“Not Giving Up on Him”
Beginning in June, Dr. Jamie McCarthy, an executive vice president at Memorial Hermann Health System and an emergency room physician, was hearing anecdotes from colleagues suggesting that the coronavirus was hitting Hispanics harder than other groups in the Houston region.
This week, the hospital system ran an analysis of emergency room visits that confirmed those observations. More than 37% of nearly 9,000 patients who’ve tested positive for the virus at Memorial Hermann hospitals identified themselves as Hispanic, a greater share than the hospital system’s typical patient mix, McCarthy said. Another 4,000 patients who tested positive for the virus declined to share their ethnicity with the hospital, but a significant number of them came from majority-Hispanic ZIP codes.
Although the system’s Hispanic COVID-19 patients have been younger — more in their 20s, 30s and 40s than other age groups — McCarthy said a similar percentage of them, about 4%, end up requiring admission to an intensive care unit compared with patients of other ethnicities, who tend to be older. Part of the reason, McCarthy said, are the underlying health conditions experts have said can lead to poor outcomes even for young people in otherwise good health.
“Most people who are 40 and have a little bit of diabetes or a little bit of hypertension or maybe who are carrying a little bit of extra weight don’t feel like they should be at increased risk for this,” McCarthy said. “But that’s certainly what we’re seeing. People who think they’re healthy because their chronic conditions are well managed are still increasingly at risk and requiring hospitalization.”
A lack of health coverage, language barriers and bad past experiences may be leading many Hispanic residents to avoid emergency rooms until it’s too late, McCarthy said.
“I’m sure there are many people who have the story of, ’My loved one went to the hospital and I never talked to them again, and they died,” McCarthy said. “And that’s just scary. And so if you’re non-English speaking, from a limited socioeconomic background, are you going to call 911 when the other people who did that never came home?”
After noticing the trends, Memorial Hermann launched Spanish-language education initiatives targeting majority Latino communities, including billboards and TV segments, urging residents to social distance and to seek medical care when they begin to feel ill.
Weeks before holding the prayer vigil in the parking lot outside Memorial Hermann Southeast Hospital, Valery Martinez got a distressing call from her aunt. Her cousin, Arturo “Tudy” Valles Jr., 41, had been sick for days before his mother noticed him straining for air in the middle of the night on June 26 and finally called 911. The ambulance rushed him from his home in Pasadena, a majority-Hispanic city southeast of Houston, to the hospital, where he was soon connected to a ventilator.
In the days before being hospitalized, when he first noticed the pain in his throat, Valles made four attempts to get tested for COVID-19 at a free testing site near his home. But each day, his family said, the clinic ran out of tests before he reached the front of the line.
Valles’ mother, Nilda De La Peña, tested positive not long after calling paramedics for her son. Then a week later, Martinez caught the virus, too, forcing her to move out of her home to avoid infecting her elderly grandmother.
“Basically everyone I know has been impacted, and people are dying,” said Martinez, who by then could tally four people in her life who’d died of COVID-19.
A single father who lived with his mother and his 13-year-old daughter, Valles worked at a chemical plant until his diabetes worsened several years ago, forcing him to have one leg amputated. Despite being only 41, his underlying health troubles put him at higher risk once he became sick with the coronavirus.
Last week, after Valles had spent three weeks on a ventilator, doctors at Memorial Hermann warned that he might not survive another night, prompting Martinez to organize a video chat. Eighteen of Valles’ closest loved ones took turns telling him how much they loved him.
“We’re not giving up on him,” Martinez said last Thursday, two days after the video call. “God has the last word, not doctors or nurses.”
Her family hosted a fundraiser Saturday, selling Tex-Mex plates in the parking lot of a Pasadena restaurant to help pay for Valles’ mounting medical bills. A week after the doctors’ warning, Valles was still alive, giving Martinez and her family hope that he might pull through.
But on Tuesday, the hospital called with a devastating update. The number of people in Martinez’s life who’d been killed by the coronavirus had grown to five.
Utah prioritized the health of businesses over keeping coronavirus case counts down. As case counts rise, the state will now allow indoor gatherings of up to 3,000 people.
This article was first published on Tuesday, July 21, 2020 in ProPublica.
Back in April, when public health officials were still helping lead Utah's response to the coronavirus, the spread of the disease had slowed, stabilizing at fewer than 200 reported cases a day.
Then came a shift in power, and priorities.
State legislators who felt Gov. Gary Herbert was not moving quickly enough to lift restrictions on businesses created a commission to set guidelines to reopen. "It's not meant to give economic outcomes a higher weight, but it is time to give them some weight," said Sen. Daniel Hemmert, a Republican who sponsored the bill and took his seat on the commission alongside other politicians, bureaucrats and business leaders.
Email correspondence and interviews with more than a dozen state and local officials in Utah show that the health of the state's businesses was prioritized over the health of the public, as officials stopped slowing the spread of the virus and instead calculated how many sick people its health system could bear.
Dr. Joseph Miner, executive director of the Utah Department of Health, told ProPublica that state leaders originally planned to relax restrictions as cases decreased. But "because of the concern that you can't keep the economy closed this long," they reopened before that happened and shifted their attention to how many cases hospitals and contact tracers could handle.
"We know there's going to be increased cases. We just said, amongst ourselves, this is really what we're addressing: our capacity to respond rather than decreasing numbers."
With key health experts cut out of the decision-making process, including the state epidemiologist and local officials who were stripped of their ability to issue their own restrictions, the governor and the commission quickly swept aside restrictions meant to slow the virus's advance in Utah. You can now hold indoor events with up to 3,000 people and outdoor events with up to 6,000. You can drink at bars, eat in restaurants and go to the movies.
People in Utah are going back to work; new unemployment claims from early July dropped 78% since the peak from early April, when most businesses were closed, and its unemployment rate is just above 5%, which is under half of the national average. Utah was considered one of the states best-prepared to weather the pandemic's economic downturn. But experts say that rising infections could threaten any state's recovery.
And in Utah, infections are rising. The percentage of tests that come back positive is at 10% as of July 13, compared with 3% to 5% in April. On July 14, the state reported its highest number of deaths on a single day since the pandemic began. Since late May, the seven-day average of daily case counts statewide has quadrupled.
Utah's story is mirrored in states across the country, where leaders sidelined public health experts and forged ahead without meeting criteria scientists say are necessary to reopen. In Florida, the governor loosened restrictions as cases rose; Miami is now the national epicenterof the virus. Georgia left it up to businesses to decide how much to scale back service in the middle of a pandemic; South Carolina let the hospitality industry write its own reopening guidelines. The virus is now spreading uncontrolled in those two states, with some of the highest ratesin the country. Texas, whose governor took advice on reopening from a panel stacked with corporate executives and business leaders, reopened restaurants and malls after reaching a record in daily deaths; its hospitals are now stretchedto the brink.
Herbert's office did not respond to questions about how he's managed the pandemic. In an emailed statement, Jefferson Burton, the commission's co-chair, said the group regularly reviews Utah's reopening guidelines and makes changes based on new data, federal guidance and input from stakeholders. Decisions on when to lift restrictions are based on hospital utilization, infection growth rates and the number of tests performed, among other factors, the statement said. "There are not hard-and-fast data points that automatically trigger a move. … Rather, individual geographic areas are evaluated looking at their specific trends over time."
Dr. Michael Good, CEO of University of Utah Health and the only physician on the commission, said the "goal has always been to slow the spread of the virus." The commission is trying to balance decisions on reopening in a way that keeps infections low while not inadvertently causing other social and economic problems, he said.
Epidemiologists say that one of the biggest risks of reopening prematurely is that it suggests formerly banned activities are now safe. The family of a diabetic man who died after going to a party in Riverside County, California, saidhe had been careful until the government eased restrictions.
The timing of Utah's spikes in cases clearly overlaps with the loosening of restrictions, said Dr. Emily Spivak, an infectious disease physician at University of Utah Health. People assumed the risk was over. Spivak has seen group barbecues and young people taking party trips to Lake Powell with "full-on 20-year-old summer social behavior." Of course case numbers went up, she added. "It's not rocket science."
A Shift in Power
Initially, Utah acted decisively to try and stop the spread of the coronavirus. In March, working with health advisers, Herbert decided to shut down schools days before New York City and restricted businesses based on their level of risk. Restaurants could not offer dine-in service; gyms and salons were closed.
While Herbert refused to issue a statewide shutdown, saying he didn't want to overrestrict less affected areas, mayors and local health officials wrote their own stay-at-home orders, which came with fines and even criminal penalties for violations. The state was a patchwork of legally binding rules, as The Salt Lake Tribune reported. "We give local control for the regional differences," Herbert said at the time, "and I think we've struck the right balance."
Doctors treating coronavirus patients were supposed to be allowed into the U.S. But hundreds of young doctors have their visas put on hold indefinitely.
Senate President Stuart Adams, a Republican businessman, disagreed. On April 8, he confirmed that lawmakers would convene to address the pandemic and consider limiting the power of local governments, saying their rules were creating confusion. It was time, he told the local paper in Ogden, for "a new phase" focused on the economy.
Sen. Hemmert and Rep. Mike Schultz co-sponsored a bill to establish the Public Health and Economic Emergency Commission, a 10-member team that would guide the reopening and advise Herbert. Staff from the Governor's Office of Management and Budget would provide support.
Apart from two healthcare system CEOs, none of the members had a medical or public health background. Among them: Adams, the two Republican legislators who sponsored the bill, the president and CEO of the Salt Lake Chamber of Commerce and the CEO of the Larry H. Miller Group of Companies, which includes sports teams such as the Utah Jazz as well as a chain of Megaplex Theatres across the state.
By the time the commission assembled, there was a new leader in charge of the state's coronavirus response.
Miner, a physician who had headed the state Health Department since 2015, has a lung condition and had been unable to attend in-person meetings. To be the "boots on the ground" for the the virus response, the governor appointed Burton, a retired military leader with no medical training who had experience in disaster management. Burton once headed Utah's National Guard and is running for a seat in the state House of Representatives. While Miner said he has remained "very much involved," he was not present, even virtually, for key decisions ProPublica asked about. He said he was briefed on outcomes by Burton's deputy.
During the time that Burton has served as co-chair of the commission, the three legislators on the commission have donated (either personally or through their campaigns) a total of $4,000 toward his run for state office, one-fifth of what his campaign has raised. He won the Republican primary in June and has no Democratic challenger in the general election.
The governor's office and a large team of advisers had createda color-coded system for reopening that could be turned up or down like a dial "based on the health risk." The system had four levels that dictated how businesses could operate, labeled red ("high risk"), orange ("moderate risk"), yellow ("low risk") and green ("new normal risk"). All of Utah was under the red designation in late April; each successive level would open more businesses and ease limitations.
The commission took the governor's guidelines and added specific rules for every industry, including restaurants, schools, entertainment venues and religious services. Five days after the group was created, it recommended moving the state to orange.
Herbert accepted the plan and moved Utah to the "moderate risk" level on May 1. Hotels and gyms opened. Groups of 20 could congregate with masks and social distancing.
Another Shift in "Risk"
Guidelines from the Centers for Disease Control and Prevention say one of the key factors for relaxing restrictions is evidence of a 14-day decline in new cases.
By May 12, cities and counties were expressing an interest in moving into the yellow, "low risk" level. Cases had plateaued, but had not dropped. Dr. Angela Dunn, the state epidemiologist, told KSL News Radio that on an "optimistic" timeline, some parts of the state might be ready to move into yellow on June 1.
But on May 14, just 13 days after moving the state into orange, the governor and the commission announced they were moving most of the state into the "low risk" level, on May 16. It was impossible to see, at that point, the full effects of the orange phase after half a month, because of the incubation period of the virus and the lag between symptoms, testing and test results.
Jenny Wilson, the mayor of Salt Lake County, petitioned to keep her county in orange; she noted that the active positive case rate there was several times higher than the state's. She could have kept the restrictions before the bill creating the commission passed, but now she needed the governor's approval. Herbert denied the appeal, but he approved similar petitions from the two largest cities in her county — Salt Lake City and West Valley City — and three other counties.
The rest of the state relaxed further into the phase labeled "low risk." All businesses could resume with certain precautions. Public swimming pools opened; close-contact team sports were allowed with temperature checks. Restaurants could serve buffets.
"Speaking [with] my public health voice, I feel that this is a mistake," Jennifer Dailey-Provost, a Democratic state representative who's pursuing a doctorate in public health, tweeted in reaction. "To say I'm frightened is an understatement. I hope I'm wrong."
Two weeks later, on May 27, cases began to surge.
A spokesman from the Salt Lake County Health Department said it's hard to say if the county would have fewer cases today if the entire county (and not just two cities) had stayed in orange. Commuting patterns make it impossible to separate different municipalities, and the piecemeal approach left some streets orange on one side and yellow on the other.
Hospitalization data is important to understanding the coronavirus's spread and impact. But after the Trump administration changed its reporting rules, the CDC removed the data from its site, and only added it back after a public outcry.
County data shows that throughout June, on days with a particularly high number of new cases, more than half came from areas that went yellow before the mayor felt they were ready.
Salt Lake City Mayor Erin Mendenhall said the commission has made it more cumbersome for local leaders to pass their own rules, but she gives the governor credit for allowing her city to remain in orange and approving the county's mandate for wearing face masks in public.
One of the counties Herbert had allowed to stay in orange was Grand County, home to Arches National Park. But that changed on May 28. When local officials asked to maintain extra protections as they moved to yellow — such as leaving hotel rooms empty for 24 hours between bookings — the governor's office denied the request.
The rural county has logged few cases, though it is impossible to tell how many tourists may have caught the virus there before returning home. Bradon Bradford, director of the Southeast Utah Health Department, which covers Grand County, said the local numbers started going up in July.
The commission's top-down approach is "uncharacteristic" of Utah, said Kirk Benge, who leads the Public Health Department for San Juan County in the southeastern corner of the state. "Most politicians claim that they like local authority and they like local decisions. In an emergency, to immediately strip that … I felt, was a mistake at the time."
A Mysterious Decision
Top health officials and other legislators have little insight into the commission's actions. Miner told ProPublica he has never attended a meeting. Nor has Dunn, the state epidemiologist. Both are part of a work group that provides input on what activities are allowed under each phase, but they aren't involved in the final decisions of when and how restrictions are loosened.
Dailey-Provost, the legislator with public health training, said her offers to help and suggest health experts went nowhere. She co-authored a study in April that predicted how coronavirus cases would peak in Utah. Reality has outstripped the study's worst projections.
One of the commission's most significant decisions occurred in late May, when they suggested redefining the yellow phase, which capped gatherings at 50 people, to allow indoor gatherings of 3,000 and outdoor gatherings of 6,000.
The proposal caught Dunn and other health officials off guard. They discussed it at their work group meeting of health and business experts. Burton's deputy, Richard Saunders, who often attends commission meetings, was also present.
Benge, the health officer for San Juan County, said he was "100% against" the change. Many businesses were still transitioning into the yellow phase and hadn't had time to open up, Benge said, so it was too early to loosen the guidelines any further. Dunn and Miner shared similar concerns.
Miner said he recalls the group was being asked to figure out how to implement the change as safely as possible. He said they concluded that if the venues were required to track where everyone sat, at least they could do contact tracing if anyone got sick.
The numbers were headed in the wrong direction. A day earlier, on May 28, the Tribunereported the biggest single-day spike in new cases statewide, as well as an outbreak in a nursing facility that infected more than half the residents. One county in northern Utah saw a 33% increase in cases.
Health officers fretted about the decision in emails released to ProPublica.
"This change happened on a timeline contrary to my recommendations and the recommendations of the state epidemiologist and other health officers," Benge wrote to his county health board.
"I don't think we'll need to move to Green because it's all being phased into Yellow," Bradford wrote to other local health officials.
"So who is going to count to see when they reach 6001 participants?" another officer replied.
Herbert accepted the commission's changes in June.
Jordan Mathis, the officer for the TriCounty Health Department that oversees Daggett, Duchesne and Uintah counties, said the numbers seemed arbitrary. "Why 3,000? Why 6,000? Where'd we pull those from?"
Good, the commission member, said he doesn't recall the exact reasons behind those numbers, but those discussions "were occurring at a time when 999 out of 1,000 Utahns did not have a coronavirus infection," he said. Today, the situation is more serious, with four times as many active cases as there were back then, he said. "Those are not the conversations we would be having today."
Brian Hatch, the health officer for Davis County, sits on a medical team that is supposed to advise the commission. He doesn't recall the commission ever asking for its advice on the phase guidelines. The medical team has focused on recommendations for high-risk residents who are especially vulnerable to COVID-19.
Hatch said the idea for 6,000 people outdoors might have come from his county. When the state moved to yellow, there was no reopening plan for Lagoon Amusement Park, the only amusement park in the state. The park owners worked with Hatch. They settled on 6,000 people, which is 15% of its usual capacity. With social distancing, mandated masks and other precautions like timed tickets, they could operate safely, Hatch said.
Dozens of New York nursing homes didn't see their first COVID-19 case until sick patients were sent there, many under Andrew Cuomo's state policy. To date, 6% of the state's nursing home population, or roughly 6,500 residents, have died.
The park reopened Memorial Day weekend with the governor's approval, a week before the commission meeting on May 29. A spokesman for the park said it reached the 6,000-person limit only a few times since opening. Hatch said there have been no outbreaks connected to the park, and having a large crowd dispersed outdoors is very different from cramming 3,000 spectators indoors. Since the risk of infection is much higher inside, "I'm concerned with 20 people together," he said.
Hatch said he doesn't know where the 3,000 number came from. Health officials couldn't point to any recent events with thousands gathered indoors. A spokeswoman for the Larry H. Miller Group, whose CEO sits on the commission, said the company's movie theaters have kept indoor crowds at 50 and have not hosted any sporting events at their large venues.
The indoor guidelines require assigned seating (to enable contact tracing) and masks whenever social distancing isn't possible.
Dunn and Benge said masks alone aren't enough. Masks need to be used in concert with distancing and hand washing, said Dr. Georges Benjamin, executive director of the American Public Health Association. "(The commission is) using the masks as an excuse to break all the other science rules."
The High Risk of "Low Risk"
Shortly after the May 29 meeting where the work group discussed the changes to the yellow guidelines, the commission held its own meeting.
According to meeting minutes, the commission wanted to determine how and when the state could switch to green, the "new normal." One of the people present was Burton's deputy, Saunders, who had just attended the work group meeting with Dunn and Miner.
Saunders told commission members that the potential impact from recent events — including Memorial Day celebrations and the opening of the amusement park — would become clear in the coming week. He said epidemiologists in the state Health Department advised staying at yellow until June 30.
Adams motioned to move most of the state to green by June 5, as long as the data supported it. The transition meant large crowds could gather without assigned seating. Religious services would no longer require 6 feet of space between families and sports competitions could resume.
The six commission members who were present voted unanimously for the idea. They waited several days to announce the news.
Utah had cycled through two phase changes in one month. Dunn worried residents saw it as permission to abandon precautions like masks. After all, the yellow phase was labeled "low risk."
"I am concerned that we are providing the public with false information regarding their risk for contracting COVID-19," she wrote to Miner, Burton and others on June 1. "Our % positive is at 7%, just a short jump away from the 8% positive at the beginning of this outbreak when we were only testing hospitalized patients. Our growth rate is sharply increasing."
The very next day, the commission said the state was ready to go to green.
When Benge heard the news, he told colleagues he was "concerned that the current 'Phased Health Guidelines' have gradually shifted at the state level, from being focused on protecting health to being more focused on protecting the economy."
The commission acknowledged coronavirus cases "may continue to rise" as restrictions are lifted. But case numbers are "a poor indicator of health risk for all Utahns," as 99% of COVID-19 patients recover, they said in a press release that cited low hospitalization rates, low death rates and increased testing and contact tracing. They called for a "smart" green level where everyone should still wear masks and stay socially distant.
They didn't mention the racial disparities that persisted throughout the pandemic. Fourteen percent of Utah's population is Latino, but they make up 40% of cases. The proportion of patients who die from the virus is three times as high for Native Americans as it is for white residents. Navajo Nation, which extends into Utah, Arizona and New Mexico, recently imposed stay-at-home orders over several weekends because of the worsening situation in surrounding areas. Most of the roads leading to Utah's national parks go through the reservation, said Pete Sands, a spokesman for Utah Navajo Health Systems. So when residents or visitors refuse to take precautions, it directly affects Navajo citizens.
Too many states are letting their cases grow based only on healthcare capacity, said Benjamin, the American Public Health Association director. "Why open the economy and allow needless death and illness and disability … [when] this single-minded strategy is eroding the economy in the long term?" he said. "Sick people can't work. People who are afraid to go out and shop [or] eat aren't going to go out."
Experts say there's more at play than ensuring hospital beds; workers face personal protective equipment shortages and burnout. There's no surefire way to prevent COVID-19 deaths, and many survivors are left with heart damage, scarred lungs, neurological problems and other long-term effects doctors are just beginning to understand.
A day after the commission's announcement on June 2, Dunn told reporters that no community in Utah was ready for green.
Nearly 8,000 ventilators are destined for foreign countries as part of Trump's plan to make the U.S. "king of ventilators." But public health experts worry the machines are crowding out more urgently needed aid.
Herbert waited until June 12 before moving one county to green. A week later, he approved requests from nine other counties to do the same.
As Herbert finalized the partial shift to green, Dunn sent an urgent memo to state and local health officials, which the Tribunepublished several days later on June 22.
"If we do not reach a rolling 7-day average of 200 [cases] per day by July 1, we need to move the entire state to orange," Dunn wrote. "This will send the message to Utahns that this outbreak continues to be a serious problem."
"This might be our last chance for course correction," she warned. "Contact tracing and testing alone will not control this outbreak."
Dunn recommended a statewide requirement for face masks. If that wasn't possible, she wrote, "we need to be clear with the public about why decisions are being made lessening restrictions — economic, not health."
Herbert said he appreciated Dunn's analysis but would not close down the economy. The seven-day average stood at 485 cases per day.
Beyond Capacity
By mid-July, the seven-day average had reached 650 cases per day.
A growing number of health and business interests want a statewide mask mandate. That includes the Salt Lake Chamber of Commerce and the Larry H. Miller Group, whose leaders sit on the commission. Adams has come out against the idea.
Herbert has required masks in state buildings and in K-12 schools starting this fall but stopped short of a blanket rule, citing individual freedom and local control. The issue has become so politicized in Utah that one county commissioner compared the idea of a mask mandate to Nazism. In Provo, residents crowded into a county commission meeting to protest the school mask requirement.
Darin Mellott, a real estate executive who serves on a separate economic task force on the pandemic, describes himself as an establishment Republican. But he personally feels masks are an easy way to stem the tide. "I think future generations, if we do nothing, are going to look back and say, 'Why did you subject so many people … to this threat, because of some imagined threat to our liberty?'"
Mellott said Herbert has a tough balancing act — "I think we would be in a much worse situation if it weren't for him" — but that the governor and other state leaders need to give more health professionals a seat at the table. "This is a war against the virus, and the medical professionals are the generals," he said. "So listen to the generals."
In a recent press conference, Herbert acknowledged that labeling the different phases based on risk might have given the public a false sense of security. He challenged residents to voluntarily wear masks and set a goal to keep average new cases below 500 a day by August 1. Herbert cited 800 a day as the absolute maximum the state can handle.
Dunn told ProPublica she suggested 200 cases a day because it allows the state to do contact tracing within 24 hours. Because of the lag time between infections and hospitalizations, any preventative measures taken today won't have an effect for another two to four weeks, so there's no time to lose. "You can't wait until you're already underwater," she said.
The state is hiring more contact tracers, but can now handle only 300 cases a day.
Doctors treating coronavirus patients were supposed to be allowed into the U.S. But hundreds of young doctors have their visas put on hold indefinitely.
This article was first published on Friday, July 17, 2020 in ProPublica.
As hospitals across the United States brace for a difficult six months — with the first wave of the coronavirus pandemic still raging and concerns about a second wave in the fall — some are acutely short-staffed because of an ill-timed change to immigration policy and its inconsistent implementation.
A proclamation issued by President Donald Trump on June 22, barring the entry of most immigrants on work visas, came right as hospitals were expecting a new class of medical residents. Hundreds of young doctors were unable to start their residencies on time.
Trump's order included the H1-B visa for highly skilled workers, which is used by some practicing doctors abroad who get U.S. residency slots. The proclamation stated that doctors "involved with the provision of medical care to individuals who have contracted COVID-19 and are currently hospitalized" should be exempt from the ban, but it delegated the issuing of guidance to the departments of State and Homeland Security. That guidance has been slow and inconsistent.
Many consulates started approving doctors' visas on Thursday, after ProPublica asked the State Department about the delay. Others say they're still awaiting guidance.
At hospitals where many incoming residents are visa holders, even a delay of a few weeks in arriving in the U.S. creates a staffing crisis. Doctors and administrators are afraid that the repercussions will last for the rest of the year — leaving them overworked and ill-prepared even before a second wave of the virus hits.
ProPublica has heard from 10 would-be medical residents stuck abroad because of H1-B visa issues. Six of them had gotten emergency consulate appointments for visa approval, but when they arrived for meetings they were told their visas could not be approved. Three were still waiting on DHS approval for their visas, a necessary step before a visa gets a consulate stamp. One resident had application approval but was denied an emergency consulate interview appointment because of the ban. All were destined for hospital positions treating COVID-19 patients.
The State Department told ProPublica on Tuesday that it, "in conjunction with the Department of Homeland Security and interagency partners, is establishing and implementing procedures" for the visa ban, and that it "has communicated and will continue to communicate implementation procedures" to consulates abroad.
On Thursday, the State Department'swebsite posted guidance, spelling out that doctors treating COVID-19 patients were exempt from the ban. On that day, many of the residents ProPublica spoke to said they had suddenly received visa approvals. "A quite remarkable turnaround, given that I received a rejection email three days ago," one said. In at least five countries, however, consulates were still not processing doctors' visas.
The Committee of Interns and Residents, an affiliate of the Service Employees International Union, has heard from over 250 interns stuck abroad. Over 150 of them are on H-1B visas.. (The others are on visas that weren't covered in Trump's ban, but can't get approval because their consulates are still closed due to the pandemic.) Union president Jessica Edwards pointed out to ProPublica that while that number may sound small, each intern is responsible for the care of thousands of patients.
As of 2017, there were 2,532 medical residents on H1-B visas, according to the Journal of the American Medical Association — though the Trump administration's continued restrictions to legal immigration may have made it less appealing for hospitals to sponsor visas in the last few years. But the impact on hospitals is highly concentrated in the less-prestigious hospitals that tend to rely on residents from overseas.
At one New York City hospital serving low-income residents, nearly half the incoming class is still stuck abroad, multiple sources confirmed to ProPublica. One hospital in a large Midwestern city told ProPublica that "roughly half" of its first-year doctors started on time. In the Deep South, a region now overwhelmed by COVID-19 cases, a doctor who was set to start told ProPublica he was among 10 residents still awaiting visa approval as of early July. All hospitals and doctors spoke to ProPublica on the condition of anonymity because they worried about jeopardizing their visa applications.
ProPublica has also spoken to more-experienced doctors facing the same issue — including an infectious-disease specialist blocked from starting a job in an area of the Western U.S. where COVID-19 cases are rising.
When there aren't enough incoming residents to replace departing third-year residents, staffing crunches result.
At the New York City hospital, a doctor told ProPublica that after only 10 days of short-staffing, one resident had called in sick from exhaustion. The doctor recounted a recent shift in which there had only been two junior residents on call, compared with the typical six. Even by having residents work individually instead of in teams of two, they couldn't keep up with new patient admissions.
"The patients had to just stay there waiting in the (emergency department) for the residents to finish their first admission, in order to see them," the doctor said. "When the shift was over, I logged into the computer and I would see notes written at 10 p.m., 11 p.m. And these residents are expected to go home and then come back again at 6:30 a.m."
Even at hospitals with decreasing COVID-19 caseloads, short-staffing is a bigger problem than it was in pre-pandemic times. Some hospitals are seeing a "surge of non-COVID patients" who were unable to get care for chronic conditions like heart disease during lockdown and are now deteriorating, a doctor at a short-staffed hospital told ProPublica. And because protocols prevent doctors from switching back and forth between COVID-19 and non-COVID-19 patients, the hospital needs to keep more doctors on-call to maintain staffing levels in both wards.
"If someone is getting acutely ill, who will see them?" a hospital administrator told ProPublica. "I've got my poor residents running around trying to make sure everyone is seen in a timely manner. And residents are great, but they can only be in one place at one time."
Some of these problems will be fixed as residents receive delayed visa approvals and are able to come. But it will take weeks, if not months, to successfully onboard them. The Midwestern hospital anticipates that arriving residents may not be able to start until mid-August. In the meantime, they're understaffing services and using fourth-year medical students in place of residents.
Hospitals are used to a summertime efficiency gap, as new interns learn the ropes. This year, it could persist into fall — when a second wave of coronavirus infections is expected.
"I'm really worried that in three months," said the medical administrator, "we're going to have a bunch of residents who are just exhausted and just getting into the worst part of the fall, flu and COVID season."
These doctors already had to push themselves through the first wave of COVID-19 this spring. Furthermore, at hospitals hardest hit by the visa ban, the residents picking up the slack are often themselves H1-B visa holders whose futures are now uncertain. Trump's ban didn't revoke visas for anyone currently in the U.S., but if they leave the country — which they will have to do if they change jobs — their ability to return is unclear. Some of the doctors interviewed by ProPublica were living in the U.S. before the pandemic and returned home partly to get visa approval for their new jobs. One doctor ended up stuck in India while her husband was unable to travel there from the U.S.
Hospitalization data is important to understanding the coronavirus's spread and impact. But after the Trump administration changed its reporting rules, the CDC removed the data from its site, and only added it back after a public outcry.
Another doctor from India, now working in the U.S., told ProPublica: "My parents, they're (in India) by themselves, and both of them are about 70. At some point, probably, they will catch the infection." If that happens, the doctor plans to leave the U.S. to care for them — "and if I don't come back, I don't come back. At this point, I really don't care."
The feeling that the U.S. doesn't value them is compounded among residents who've already lived through the first wave of COVID-19 and who are now facing overwork and visa uncertainty. Some said other countries are making it easier for doctors to immigrate, while the U.S. leaves them in limbo.
"We feel underappreciated for what we're doing," the New York City resident said. "And what else can you do, more than sacrificing your life?"
Tightly regimented residency schedules can be tricky for H1-B visa holders even in the best cases. Doctors find out in mid-March if they are "matched" with a U.S. hospital, where they'll be expected to start at the beginning of July. DHS often takes longer than that to approve H1-B applications. Employers can pay for expedited processing to guarantee a decision within five days — but DHS shut down its expedited processing on March 22 because of COVID-19 and didn't reopen it until June 8.
Shortly afterward, Trump issued his proclamation banning entries on many visa types, including the H1-B.
Most people coming to the U.S. for residencies arrive on a different kind of visa, the J-1, and aren't covered by Trump's ban, though some have had issues getting consulate appointments because of the COVID-19 pandemic. But doctors do identical work regardless of their visa types. If anything, doctors with H1-Bs are more qualified than those with J-1s, since they're required to have completed all three phases of the taxing U.S. Medical Licensing Exam before starting residencies. Residents with H1-B visas were practicing doctors in their home countries, working alongside new medical-school grads from the U.S.
An earlier immigration ban targeting permanent immigrants, which passed in March, contained a broad medical worker exemption. When rumors of a work-visa ban started swirling in late spring, immigration lawyers and hospitals expected it would include the same language. Instead, the June proclamation mentioned only doctors working with hospitalized COVID-19 patients.
Every resident who spoke with ProPublica had provided evidence to the U.S. government that they met that description. Some were told by consular officers that they were probably exempt. But until they received State Department guidance, they had to place their visas in "administrative processing" — an indefinite holding pattern.
ProPublica saw an image of a form given to one visa applicant informing them of a hold. The form is typically used to request more information from the applicant. In this case, though, a consular officer had modified the form to say that processing would not begin until "implementation procedures" for the visa-ban exemption had been provided.
Doctors in limbo have formed WhatsApp groups to share information and support, but the dialogue has shown inconsistencies in the ban's implementation. Some consulates, such as those in Serbia, Russia and the United Arab Emirates, have approved doctors' H1-B visas as exempt. Asked about the discrepancy, the State Department told ProPublica: "Applicants who believe they qualify for an exemption from Presidential Proclamation 10052 should check the website of the closest U.S. Embassy or Consulate regarding the current status of services. How appointment systems are managed can vary depending on the consular section."
One applicant who reached out to the State Department for assistance received an email reply from an employee on July 10. The employee said that as far as they knew, the Office for Consular Affairs had given guidance to consulates and embassies to process visas that were exempt from the ban. (The agency declined to comment on that email.)
On Thursday, that applicant received a second email from the same employee. Guidance had been slow in coming, the employee admitted, but it had finally come through.
But some countries still haven't changed their practices. One doctor stuck abroad told ProPublica they'd sent a follow-up email to the consulate on Thursday morning. "He gave me the same reply," the doctor said, "that they are still waiting for guidance from Department of State."
For the world's best-known corporate-management consultants, helping tackle the pandemic has been a bonanza. It's not clear what the government has gotten in return.
This article was first published on Wednesday, July 15, 2020 in ProPublica.
In the middle of March, as the coronavirus pandemic was shutting down the country, McKinsey & Co., the giant management consulting firm, saw opportunity. The firm sprang into sales mode, deploying its partners across the country to seek contracts with federal agencies, state governments and city halls. Government organizations had been caught unprepared by the virus, and there was a lot of money to be made advising them on how to address it.
That month, a partner in McKinsey's Washington, D.C., office, Scott Blackburn, got in touch with an old colleague. Deb Kramer had just been promoted to become an acting assistant undersecretary at the Department of Veterans Affairs, where Blackburn, whom McKinsey declined to make available for an interview, had held senior roles between 2014 and 2018. During that period, the two had overseen a major overhaul of the agency called "MyVA," a project McKinsey had worked on as well. Blackburn had worked at McKinsey before going to the VA, and he returned to the firm afterward. He and Kramer were in touch repeatedly in the middle of March, according to a person familiar with the exchanges.
On March 19, Kramer made a highly unusual request: The VA, she said, needed to hire McKinsey within 24 hours. The VA runs a sprawling health care system that serves 9 million veterans, many of them older and plagued by chronic health problems, and typically takes many months to solicit and accept bids and vet bidders for a contract. The health system's leadership wanted to sign a multimillion-dollar contract with McKinsey to spend up to a year consulting on "all aspects" of the system's operations during the COVID-19 pandemic, Kramer told a VA contracting officer, Nathan Pennington. Pennington memorialized parts of the exchange in a public contracting document.
"There is no time to spare," the contracting document stated, "every day wasted by a lack of situational awareness down to the community level, and the inability to model scenarios and test alternative courses of action, increases the risk to the citizens of this nation, to include Veterans and our own employees." The VA, the document observed, needed help with "life-and-death decision-making today."
The exigent circumstances left no time to seek competing bids or to fully vet McKinsey's proposal, Kramer argued. It was the only contractor she and her colleagues were aware of that could provide the required services without needing "ramp-up" time the VA couldn't afford. Pennington conducted no market research and only a minimal review of the cost, "as there was no time," he wrote. Kramer approved the $12 million price tag. The contract was signed on March 20.
That would turn out to be just a down payment for McKinsey. Ten days later, the Defense Health Agency was added to the VA contract, upping its value to $22.5 million, and the week after, the Air Force hired McKinsey — also with a no-bid contract. The firm's assignment for the Air Force was to serve on a task force developing a strategy to get defense contractors, many of them McKinsey clients, to produce medical supplies during the pandemic. To justify the $12 million value of that contract, an Air Force contracting document cited what the VA had agreed to pay McKinsey. It did not mention the VA price tag's largely unvetted nature. Finally, in early May, the DHA expanded the scope of McKinsey's work, signing an additional contract worth up to $6.1 million.
A VA spokeswoman, Christina Noel, said that the agency "adhered to all federal contracting laws" in hiring McKinsey and that "no-bid contracts can help provide VA the flexibility needed during this national emergency to deliver the services required to support clinical needs and save lives." A DHA spokesman, Richard Breen, said McKinsey had "expertise needed and an existing contract with [the VA] for COVID-19 modeling support with a separate and distinct scope." An Air Force spokesperson did not respond to emailed questions.
In a matter of weeks, McKinsey had extracted a total of $40.6 million in no-bid contracts out of its initial agreement with one federal agency. The firm has continued to scoop up COVID-19-related contracts for various governments since then. Altogether, in the four months since the pandemic started, the firm has been awarded work for state, city and federal agencies worth well over $100 million — and counting.
Many of the most prominent government pandemic efforts have been staffed with battalions of McKinsey's trademark dark-suited young MBAs. The joint coronavirus task force operating out of the Federal Emergency Management Agency and Department of Health and Human Services enlisted McKinsey, on a pro bono basis, to help obtain medical supplies. New York Gov. Andrew Cuomo's team hired McKinsey to draw on existing epidemiological models to project hospital capacity and medical supply needs. The Food and Drug Administration retained the firm to do data analysis.
Among states, California, Illinois, Massachusetts, New Jersey, Tennessee and Virginia have worked with McKinsey. (Comprehensive contracting data is not yet available, and only some states have revealed the dollar value of their contracts. For example, the contracts for New York and New Jersey represent a combined $18 million in revenue for the firm.) Cities including Atlanta, Chicago, Los Angeles, New Orleans and St. Louis have also used the firm during the pandemic.
It's too early to fully judge these engagements, but a preliminary assessment shows mixed results. After early stumbles, New York state and New Jersey are doing relatively well. On the other hand, the FEMA/HHS task force has faced harsh criticism for a slow and dysfunctional effort to procure supplies. And project documents and interviews show that, at the VA, consultants have been slow to deliver urgently needed data. In other places, officials have denigrated McKinsey's contributions. "Basically, they are compiling data for us," a top official in Florida's Miami-Dade County wrote in an internal email obtained by ProPublica. "And putting it in pretty formats." That contract was for up to a month of work, with a price tag of up to $568,000, and the confusing set of reopening guidelines that emerged with McKinsey's help has been widely panned.
McKinsey defended its work in a written statement the firm sent in the name of Liz Hilton Segel, its managing partner for North America operations: "Like many other companies, we chose to engage and do our part in helping governments fight this pandemic." The statement noted that McKinsey "has the capabilities to support leaders and public servants who are navigating this humanitarian and economic crisis. … We are proud of the support we have provided to public sector leaders, front line staff and those engaged in fighting this pandemic."
Given that McKinsey consultants operate as advisers, with government officials charged with making final decisions, it can be hard to identify the firm's responsibility for any given decision. But the firm's government work has been steadily rising in the wake of a multidecade hollowing out of government (a trend McKinsey has promoted and ridden). Today, that increasingly means that if you examine the government's response to the pandemic, you're likely to find McKinsey's fingerprints.
Like countless organizations, McKinsey has been buffeted by the pandemic, encountering turbulence and uncertainty. For starters, the sputtering economy put many of its corporate clients under duress.
Then there was a bevy of self-inflicted problems.
McKinsey's bankruptcy practice, which would normally thrive during hard times, has been under a "black cloud," as a lawyer representing McKinsey put it in a court hearing in April. The firm's practice has been dogged by a federal investigation into potentially criminal self-dealing and tied up in litigation with the founder of a rival firm over whether McKinsey properly disclosed possible conflicts of interest. ("McKinsey's bankruptcy disclosure practices have always complied with the law," Gary Pinkus, chairman of the firm's North America operations, said in a written statement.)
More broadly McKinsey has seen its long-gilded reputation tarnished in recent years as government projects come under critical scrutiny. Media outlets, such as ProPublica, The New York Times and The Wall Street Journal, have investigated a variety of ethically and legally dubious actions. That included helping the Trump administration execute exclusionary immigration policies, corruption allegations against local companies McKinsey worked alongside in Mongolia and South Africa, and a pattern of hiring the children of high-ranking officials in Saudi Arabia. In each instance, McKinsey has denied wrongdoing. With $10 billion in annual revenues, the firm is now as big or bigger than many of its clients and has developed a culture that resists oversight.
Newly uncovered documents show the consulting giant helped ICE find "detention savings opportunities" — including some that the agency's staff viewed as too harsh on immigrants.
In April, McKinsey was penalized for running afoul of the federal government. The General Services Administration, which oversees federal procurement, canceled two government-wide contracts, one of which had earned the firm nearly $1 billion between 2006 and 2019. In a reportissued earlier by GSA's internal watchdog, investigators revealed that McKinsey had refused to comply with an audit. Instead, the firm went over the head of a contracting officer and found a GSA supervisor who was willing to accommodate the firm. That supervisor worked with McKinsey to improperly inflate the contract prices, the investigators found, part of a troubling pattern of favoritism the supervisor showed toward McKinsey.
For nine months, GSA negotiated with McKinsey to lower its rates. McKinsey's intransigence ultimately led officials to see cancellation as the best option, according to a statement from a senior GSA official, Julie Dunne. (DJ Carella, a spokesman for McKinsey, which denied wrongdoing, said in a statement, "We are disappointed with GSA's decision and look forward to potentially returning to the GSA schedule in the future.")
The fallout devastated the firm's U.S. public-sector practice, current and former consultants say. "The public-sector practice was already underutilized after the [GSA] report," one of them said. "And then it just stopped."
For McKinsey, the pandemic provided a new opportunity to regain its foothold in the federal government. Coordination from the White House was inconsistent at best, and many state, federal and city agencies were already short staffed. Years of budget cuts and anti-big government policies had left them dependent on outside contractors even in ordinary circumstances.
So dependent that McKinsey consultants on the FEMA-HHS task force ended up working in the procurement process, according to a federal official briefed on the task force's work. That was unfamiliar terrain for the McKinseyites. Crucial medical supplies from surgical masks to ventilators were scarce and the government had solicited offers from any vendors claiming to have access to the necessary supplies. As the offers came in, McKinsey consultants were among the task force members assigned to help vet them before forwarding them to federal procurement officers, the federal official said. Carella, the McKinsey spokesman, said the firm "did not 'vet' offers" of "PPE, ventilators or medical supplies," but rather "helped the client assess the availability of life-saving equipment," without making any decisions about what to pass on to contracting officers.
A FEMA spokeswoman, Janet Montesi, put it differently. The task force "vetted hundreds of leads for PPE that were passed along to FEMA and HHS," she said in a statement. Responding to questions about McKinsey's pro bono work for the task force, Montesi added that "the volunteers played an important role," but career contracting officers followed legally required processes before entering into any contracts.
McKinsey consultants struggled to understand the complicated government procurement rules, according to the federal official. The career procurement officers found themselves rejecting what seemed like every other offer forwarded by the consultants and other task force members, because they ran afoul of various rules. "Even though a career employee can spot the problems quickly, you still have to stop doing your regular procurement work," the official said. "That delays the whole process."
In the weeks just after McKinsey signed its $12 million contract with the VA, Richard Stone, who runs the agency's health care system, and his aides crowed about hiring the consultancy, according to federal officials who spoke with them at the time. Stone, a medical doctor who had worked as a consultant at Booz Allen Hamilton, seemed to lack faith in his own staff. The VA, he told one of the federal officials, was now "better prepared because we have private-sector capability."
His enthusiasm didn't last long. Kramer had insisted that only McKinsey could meet the VA's needs immediately. Yet more than three weeks after the consultants started, they still hadn't provided data and analysis on key parts of the VA health system. One of McKinsey's daily PowerPoint updates for VA officials, dated from mid-April and obtained by ProPublica, shows that the consultants had yet to analyze the pandemic's effect on two types of health care facilities most vulnerable to the coronavirus: VA-run nursing homes and VA facilities in rural parts of the country. The rural facilities alone serve 2.7 million veterans — more than a quarter of the veterans enrolled in the VA — and half of them are over 65 years old. These analyses, notes one of McKinsey's slides, would be added "in the coming days."
The federal government is spending billions of dollars to combat the coronavirus, and spending shows no sign of slowing down. Explore who the U.S. is buying from, what it's buying and how much it's paying.
Also absent was data on medical supply capacity across the VA health system. Slides assessing conditions in numerous regions — including those facing some of the country's worst outbreaks at the time, like New York City, Detroit and New Orleans — contained a placeholder for the missing data: "To be incorporated over the next few days." (Hilton Segel, the McKinsey partner, seemed to blame the VA. "We conducted the analyses as the data was available so the client could make decisions in real time with the best available information," she said in a written statement.)
Meanwhile, VA nurses and other front-line care providers were sounding the alarm about widespread shortfalls in personal protective equipment and other materials. With a complete void in McKinsey's slides where the relevant data should've been, VA officialsdisputed that there was a supply shortfall, delaying the agency's response. It wasn't until late April that Stone acknowledged in an interview with The Washington Post that medical supplies were at "austerity levels" at some VA hospitals.
Noel, the VA spokeswoman, defended the consultants' work. "McKinsey & Company is fully fulfilling the terms of its contract, providing timely, critical intelligence about capacity and utilization rates of non-VA health care facilities and other analytical services during VA's response to COVID-19. This is a capability that VA does not have, and these services are vital."
At congressional oversight hearings in recent weeks, questions about the sufficiency of the VA's medical supply stores have persisted. Meanwhile, infections have been rising sharply in its facilities. A month ago, there were about 1,685 VA patients and employees with active COVID-19 cases. As of July 14, that number had jumped to 5,887.
McKinsey's success cultivating government clients during the pandemic is, in many respects, the realization of a 70-year mission. The 1950s were when the firm began pushing the view that businessmen should supplant civil servants, particularly in the management positions tasked with putting policy into practice. The pitch was self-interested but well calibrated to appeal during the Cold War: The "free enterprise society" of the U.S. "dictates that industry should be given as extensive a role as possible," McKinsey wrote in a 1960 report to the fledgling National Aeronautics and Space Administration.
NASA soon relied almost exclusively on outside contractors. By 1961, almost $850 million of the agency's $1 billion budget went to aerospace contractors. NASA would become the template for "the emerging 'hollowed-out' structure of the contractor state," the historian Christopher McKenna wrote in "The World's Newest Profession," his 2006 book on the consulting industry.
Over decades, McKinsey's approach became self-reinforcing. As successive administrations chipped away at the civil service, politicians who advocate small government got the dysfunctional bureaucracy they had complained about all along, which helped them justify dismantling it further.
The upshot of this process can be seen throughout McKinsey's coronavirus consulting. Stone, the VA health system head, thought a consulting firm made the VA better prepared. The Defense Health Agency provided "no staff support" for the head of its COVID-19 task force, according to a contracting document, prompting the agency to outsource that work to McKinsey. A senior official in Miami-Dade County had a more jaundiced view. She wrote in an email to a colleague that the firm's consultants were merely "doing the research I am too burned out at this point to do" — adding that she was "quite flattered" that it took an entire team of high-priced consultants to replace her.
McKinsey's business model also generates a second round of revenue from its government work: The firm effectively sells data it obtains from one government project to other agencies. McKinsey generally retains in its central databases anonymized work product from its engagements, so future consulting teams can get a head start on similar projects. Ordinarily, the federal government might be expected to put together that type of clearinghouse and share it with state and city governments free of charge. But in the absence of such a clearinghouse, McKinsey has something state, city and federal government agencies need, and access to government data has formed a core part of McKinsey's COVID-19 pitch.
McKinsey's data was one of the factors cited by VA officials to justify hiring the firm within 24 hours. As a contracting document explained: The firm "already possessed an immense amount of both global and community epidemiological data on COVID-19" the VA didn't otherwise have access to. McKinsey customers pay not only in cash but by adding new data that the firm will be able to sell to the next customer.
Hiring McKinsey is a famously expensive proposition, even when compared with its leading competitors. A single junior consultant — typically a recent college or business school graduate — runs clients $67,500 per week, or $3.5 million annually. For $160,000 per week, you get two consultants, the second one mid-level.
To alleviate the sticker shock, McKinsey has lately offered a coronavirus discount. In project proposals, the firm branded these COVID-19 rates "philanthropic prices." The reduced rates ranged from $125,000 per week (for the two-consultant package) to $178,000 (for five). In a separate column, a McKinsey pricing sheet played up pandemic-only add-ons, whose language read like action-figure packaging: "COVID team includes COVID analytics and best practices."
In her statement, Hilton Segal, the McKinsey partner, noted that, when the pandemic began, the firm reduced its fees to the public sector "as part of our commitment to help. We made our intellectual property and capabilities available widely, including by setting up a COVID Response Center that provides free public access to insights from our research. Thousands of McKinsey colleagues stepped up to help — through client work, pro bono service, developing and publishing insights on the pandemic, and more."
The firm's work for Miami-Dade County suggests some clients get little in return, according to interviews, as well as emails and project documents obtained by ProPublica through a public records request. On a Friday in late April, Jennifer Moon received an email from a senior McKinsey partner. Moon is the budget director and a deputy mayor for Miami-Dade, and her boss, the mayor, wanted to hire McKinsey to help finalize guidelines for reopening the county's economy, which he had shuttered over a month earlier. It fell to Moon to hammer out the details.
In his email, the McKinsey partner, Andre Dua, directed Moon's attention to a pricing sheet listing what he called "our special Covid 19 pricing" and outlined the anticipated scope of the firm's work. The proposal consisted largely of consulting buzzwords: variations on the word "analysis"; offers of "best practices," "perspectives" and "decision-support."
Moon could read between the lines, and she discerned a familiar set of tasks. "Here's what the consultants will be doing," she wrote, forwarding one of Dua's emails to the county lawyer reviewing McKinsey's contract. "Apparently, it takes 5 people with staff support to do what I've been doing myself." The $142,000 per week it would cost was more than the combined annual salaries of the two staffers who had been helping Moon prepare the reopening plan — very ably, she noted in an email.
The reopening plan's publication was imminent, and Moon didn't expect the project to last longer than a month. But as contract negotiations unfolded, Dua and Geoff Bradford, a McKinsey contract manager, resisted the county's attempts to limit the contract's duration to four weeks. They wanted to keep the agreement as open-ended as possible to "provide flexibility." What they meant by that, they explained in a series of emails, was the flexibility to expand the scope of the project and keep McKinsey's consultants around longer.
Dua and Bradford also resisted county officials' efforts to be transparent. McKinsey has a long-standing policy of refusing to reveal the names of its clients and demanding that clients likewise not reveal that they've retained McKinsey, unless they're legally obligated to. Amid the pandemic, the firm has taken confidentiality a step further. McKinsey's COVID-19 contracts still require that clients not disclose that they've hired the consultancy. But many of them now allow McKinsey to unilaterally "disclose that we have been retained by the Client and a general description of the Services." The firm has taken advantage of that clause to market its government work online.
When the officials in Miami-Dade objected to the confidentiality clause, Dua took a firm line: removing it "will be a show stopper on our end." Eventually Bradford allowed that the firm might budge, but only a little. McKinsey would consider letting county officials share its work product "with specific entities," he wrote in a markup of McKinsey's draft contract. But only "if we're able to define those entities and can attach guardrails to such disclosure." McKinsey insisted, in other words, that it should decide what the government could say — and to whom — about the advice it had been given.
As the project progressed, Moon's initial skepticism was borne out. There were non-intuitive and innovative recommendations among the "best practices" for reopening the county. But many of them were obvious or had already been suggested by county staffers: "install Plexiglass barriers between cashier and customer," for example. At times, it seemed as if the consultants were picking best practices at random: a slide on reopening construction sites recommended grouping workers into teams that not only work and eat together but "live" and "travel" together.
Myriam Marquez, communications director of the mayor of Miami-Dade County, didn't respond to a request for comment. McKinsey's statement noted that the firm's "work with Miami-Dade County was focused on sharing insights and observed practices from governments and businesses around the world, as leaders navigated the uncertainty of reopening major sectors of their economy."
In mid-May, Miami-Dade County issued its reopening plan, "The New Normal." The document, which stretched to 175 pages, was widely panned for its needless complexity, which sewed confusion among the public. The plan structured reopening around two overlapping schemes. Five different colored "flags" represented different phases of reopening. Separately, five "archetypes" — a McKinsey innovation, emails andproject documents show — grouped industry sectors and public spaces by how much human interaction they required: "can be performed remotely," "lower proximity" and so on. Yet the five flags and the five archetypes didn't align; one flag might cover two archetypes and vice versa. Imagine a stoplight where shapes have been added to the usual three-color scheme — a yellow square means something different from a yellow circle, which means something different from a red circle — and you'll start to get a sense for the confusion the systems provoked. As the Miami Herald put it, echoing the local reaction in Florida-appropriate terms: "They're just like the flags that lifeguards fly on their stands at the beach. Except more confusing."
Xavier Suarez, a longtime county commissioner and former mayor of Miami, didn't see what had been gained by pulling more than half a million dollars out of the county's pandemic-hit budget to hire McKinsey. "It just strikes me as a colossal waste of money," he told me. The firm's "archetypes" certainly hadn't added anything. "I remember reading about archetypes in psychology when we covered Carl Jung," Suarez said. "It sounds like just the right kind of" — and here he paused for effect — "sesquipedalian word a consultant would come up with to try and sound smarter than you."
Carlos Giménez, the mayor of Miami-Dade County and a political foe of Suarez, evidently came to agree. On June 19, his administration quietly posteda revised version of it. Notably scrubbed from the new "New Normal": McKinsey's archetypes. As of mid-July, COVID-19 cases continued to rise in Miami-Dade.
The busiest hospitals in Houston are increasingly telling emergency responders they cannot safely accept new patients as hundreds of coronavirus patients crowd emergency rooms, and hospitals scramble to open more intensive care space.
This article was first published on Friday, July 10, 2020 in ProPublica.
HOUSTON — Houston hospitals have been forced to treat hundreds of COVID-19 patients in their emergency rooms — sometimes for several hours or multiple days — as they scramble to open additional intensive care beds for the wave of seriously ill people streaming through their doors, according to internal numbers shared with NBC News and ProPublica.
At the same time, the region’s 12 busiest hospitals are increasingly telling emergency responders that they cannot safely accept new patients, at a rate nearly three times that of a year ago, according to data reviewed by reporters.
The increase in ambulance diversions, coupled with the spike in patients being held indefinitely in emergency rooms, are the latest indicators that Houston hospitals are straining to keep up with a surge of new coronavirus patients. ProPublica and NBC News have previously reported that a public hospital in Houston ran out of a medication to treat COVID-19 patients and that a spike in at-home deaths from cardiac arrest suggests that the death toll from the coronavirus may be higher than official statistics show.
On Thursday, 3,812 people were hospitalized with COVID-19 in the region, including more than 1,000 in intensive care units, a record since the pandemic began. At the same time, since Texas officials have not issued another stay-at-home order to slow the virus’s spread, hospitals are also still seeing a steady flow of patients in need of care as a result of car accidents, violent crime and heat-related medical emergencies.
Officials in Houston are warning that the situation could become a replay of what happened in New York City in March and April, when thousands of people died as hospitals struggled to keep up with the surge of patients, but without the same level of government intervention to stem the tide.
Typically when people arrive at a hospital emergency department, they’re evaluated and treated by the medical staff. Those sick or injured enough to require hospitalization are then moved to other areas of the hospital for specialized care. But increasingly in Houston, particularly for patients suffering from COVID-19, there’s nowhere for them to go.
“Normally that patient would just go to an ICU bed, but because there are no beds available, they continue to board in the emergency room,” said Harris Health System president and CEO Esmaeil Porsa, who oversees the city’s two public safety-net hospitals. “It is not an optimal level of care. This is not something we would choose to do. The only reason this is happening is because we are being forced to do it.”
Although hospital leaders say they are working to provide high-quality care for patients being held in emergency rooms — in part by bringing specialized medical staff and equipment to patients being treated there — studies done before the coronavirus pandemic show that the longer patients stay in ERs, the worse their outcomes.
ICUs and other hospital units are staffed with doctors, nurses and other support personnel who have specialized training and experience caring for critically ill patients in need of specific medical interventions, whereas the mission of emergency department medical workers is to quickly assess patients, stabilize them and get them to where they need to be.
“The problem is you can’t get them to where they need to be, and now it puts the ER doc in the position of having to function like the hospitalist or the intensive care doctor, and that’s not a role that we’re really supposed to be in,” said Dr. Cedric Dark, an emergency physician at Baylor College of Medicine in Houston. “The bad thing about having any patient boarded in the emergency department, regardless of the situation, is that it slows down the beginning of care for somebody who needs hospitalization, and the beginning of care for any medical condition is the most crucial period of time.”
The same scenario is playing out at hospitals across the Houston region.
A daily status report prepared Wednesday by the SouthEast Texas Regional Advisory Council, which coordinates the Houston region’s emergency medical response, showed multiple hospitals running out of immediately available nonsurgical ICU beds, including both of the city’s top-tier trauma centers, Ben Taub Hospital and Memorial Hermann’s flagship hospital in the Texas Medical Center.
As of Wednesday afternoon, about 145 patients were being held in emergency departments throughout the Memorial Hermann Health System, according to internal numbers provided separately by a Memorial Hermann physician and confirmed by a hospital executive. Several other Houston area hospitals have reported holding multiple patients in their ERs, including four with more than a dozen.
Dr. Jamie McCarthy, an executive vice president at Memorial Hermann Health System and an emergency room physician, acknowledged that the coronavirus crisis has forced his teams to hold more patients in ERs.
“All the hospitals are full,” McCarthy said. “All the hospitals in the city are boarding patients. We are expanding capacity, but we can’t turn those on immediately. It requires staffing. It requires nurses and doctors to come in. And so, as we’ve continued to expand our inpatient capacity, we’re just keeping up with the volume that’s coming in.”
It’s not unusual for a small number of patients to be held in ERs on busy days, especially during flu season, but three Houston ER physicians said they have never seen so many patients receiving prolonged care in emergency departments, or for such long periods of time.
Although treating patients in the ER for more than a few hours is “not ideal,” McCarthy said, Memorial Hermann has worked to mitigate the impact on patients by sending intensive care doctors and other specialists to emergency departments, to ensure patients are receiving quality care regardless of where they’re located.
But he warned that there’s a limit to what Houston hospitals can do to respond to the crisis.
“We are adding more capacity, but we are absolutely stretched now, and if it keeps going this way, we’re going to run out of room. We’re going to look like New York,” McCarthy said, emphasizing the need for Houston residents to stay home and avoid crowds to slow the virus’s spread.
One of Houston’s largest hospital systems, HCA Healthcare, also has been caring for dozens of COVID-19 patients in its emergency departments. In a statement, HCA spokeswoman Debra Burbridge said hospital officials have taken steps to reduce the impact on patients, including sending staff members who would normally be performing or assisting with elective surgeries — which have been suspended under an order by the governor — to treat patients with COVID-19.
Dr. Kusum Mathews, an assistant professor of critical care and emergency medicine at the Icahn School of Medicine at Mount Sinai in New York, said hospitals can take steps to reduce the risks of overcrowded ERs, including some of those described by Memorial Hermann and HCA officials.
Treating patients sickened by the virus “has outstripped every stretch of our imagination,” Mathews said. “We have had to put beds in hallways, double up patient rooms … just to allow for offloading the emergency department to get more patients in.”
While Houston’s top hospital executives have repeatedly said they can add hundreds of new intensive care beds to meet the demand, at least for the next couple of weeks, the number of patients being treated in emergency rooms demonstrates the difficulty of executing those plans in the midst of a rapidly growing crisis, officials say.
“Those things are not like a switch-key type of activity,” said Porsa, the Harris Health System CEO, noting that his hospitals have had to send patients to hospitals outside of Houston to make room. “The bottleneck to do that is really staffing. As you can imagine, ICU nurses are not a dime a dozen. They are very hard to come by, and it takes time to actually be able to do that.”
The logjam of patients being treated in ERs has also led to delayed emergency response times across the city, according to Houston Fire Department officials.
When hospitals get overloaded, they ask regional authorities to divert ambulances elsewhere. For example, Memorial Hermann’s northeast hospital was on diversion status just 2% of the time during an eight-day period in late June and early July last year; it was on diversion status 58% of the time during the same time period this year. At Houston’s busiest public hospital, Ben Taub, the number jumped to 81% from 58%.
The problem, said Houston Fire Department Assistant Chief Matt White, is that when every hospital is maxed out, ambulance crews have no choice but to take patients to emergency departments that are too busy to quickly receive them. And by law, hospitals must screen and stabilize any patient who arrives.
“When everyone is on diversion,” White said, “nobody is on diversion.”
Earlier coronavirus outbreaks inundated emergency rooms in New York City and Detroit, but lockdown orders in those cities led to fewer car accidents and a reduction in violent crime, freeing more space in ERs for COVID patients.
With most Texas businesses still open and no mandatory stay-at-home order, hospitals in Houston and other COVID-19 hot spots face the added challenge of making room for COVID patients while still dealing with a steady flow of patients seeking care for other medical emergencies.
And across the country, people with chronic health problems who delayed seeking care earlier in the pandemic are now showing up for treatment, taking up beds, said Dr. Marc Eckstein, medical director of the Los Angeles Fire Department and a professor of emergency medicine at Keck School of Medicine of the University of Southern California.
Despite these challenges, McCarthy, the Memorial Hermann executive, said it’s essential that people continue to come to the hospital for medical emergencies. He pointed to an NBC News and ProPublica report this week that showed a growing number of people are dying suddenly at home, before emergency responders can reach them.
“If a patient believes they have a serious medical issue, they still need to come to the emergency department,” McCarthy said. “We will make the capacity to take care of them. Delaying care for time-sensitive emergencies is time we don’t get back. If they wait to call for help when they are having a heart attack, it will be worse than if they come in early.”
The federal government is essentially providing seed money to PPE startups, including some run by people accused of fraud. Mask brokers describe a simple blueprint for buying masks from China to get rich.
This article was first published on Saturday, July 11, 2020 in ProPublica.
Jason Cardiff didn’t want his new business to end up like his last one, an alleged pyramid scheme involving robocalling and selling unwitting customers bogus remedies to lose weight or quit smoking. One of his ventures, Prolongz, falsely claimed to offer men “increased ejaculation control.”
“I am not going to lose another company,” Cardiff told his lawyer in an April 5 email, just before detailing a fantasy list of people he wanted to place on the board of his new venture, VPL Medical Inc.
His wish list included Brian Travis Kennedy, a right-wing think tank leader and pundit with connections to the Trump administration, who Cardiff cryptically said could be the company’s “advisor to the White House.” That didn’t work out, Cardiff says.
He also wanted to make sure he had controlling stock of the company and the ability to buy out his business partner if he wanted, according to the email.
“As I (have) raised all the capital and done all the work once again,” Cardiff wrote in typo-laden prose, “I am not going to lose out on perhaps my biggest company to date. Further I have a group that wants to put in 10 mil this week.”
Seven days later, VPL was incorporated in California. Curiously, the former Mercedes Benz salesman left his name off of the business filings, which listed only his partner, Bobby Bedi, as the owner. Before ProPublica wrote about Cardiff’s work with VPL in June, the paperwork appears to have missed the gaze of the Federal Trade Commission, which had frozen his and his wife’s assets, and a court-appointed receiver who had taken over the family money.
Yet, just 12 days after Cardiff’s email, the untested company landed $20 million in contracts with two federal agencies to supply cheap surgical masks for health care workers.
That email exchange, along with financial records and contracts submitted to a federal court in California, provide a rare behind-the-scenes look at the nascent coronavirus mask trade, where just about anyone with who registers a corporation or limited liability company can get rich off the nation’s public health nightmare with help from a desperate government agency.
The filings illustrate how the federal government is essentially providing seed money to ambitious startups, including some run by people previously accused of fraud. Mask brokers interviewed by ProPublica described this basic blueprint:
Step One: Obtain a government purchase order. This has become startlingly easy after the Trump administration cut red tape so agencies could order personal protective equipment from nearly anyone who says they can deliver.
Step Two: Leverage that purchase order to get financing from private investors who can easily command exorbitant returns on a short-term, high-risk bet.
Step Three: Use the cash to buy masks from China.
Once the government accepts and pays, everyone involved gets a cut. And taxpayers pay inflated prices for essential personal protective equipment, or PPE, that is once again in short supply as the rate of COVID infection continues to rise.
“The tough part is not getting the government purchase order or the financing,” Cardiff explained in an interview. “The tough part is executing.”
Unlike many contractors who have failed, his company delivered the promised 8 million masks to the Department of Veterans Affairs, the agency confirmed. It shipped materials in from China and transported them by air to a VA warehouse in Chicago, records show.
“These all get fulfilled — that’s the difference,” he said. “As you can see, the government is desperate for its citizens, so it reaches out with a broad reach and says, ‘If you can get masks, I’ll pay you.’”
And VPL definitely got paid.
On the $5.4 million deal to provide masks to VA hospitals, court records show Cardiff’s personal profit was $420,000.
Bedi, the listed owner who a court receiver alleges is Cardiff’s equal partner, also walked away with $420,000.
Stacey Barker, a marketing consultant, earned a $250,000 commission just for arranging the deal with the VA.
A pending $14.1 million deal with the Department of Health and Human Services, which oversees the national stockpile, could net Cardiff and Bedi about $2 million in profit, according to court records.
Using a government order to get a loan to buy goods is not a new practice. Contractors routinely get what’s called purchase order financing from specialized lenders. But companies with little history and little credit, as is the case with many pop-up mask traders, often seek financing from private investors.
When VPL got its VA purchase order, documents show that it turned to a guy named Keith Langlands and a company registered in his name, Wave Crest Management, for a $3 million loan to buy masks from a Chinese vendor. But those details also have come under question.
A lawyer for Langlands said Friday that Langlands, a Las Vegas accountant who markets himself as a leading expert in the niche realm of setting up captive insurance firms, had nothing to do with VPL. Someone founded Wave Crest and used his name, said lawyer Michael Pariente.
“We didn’t know anything about this until we got your call,” Pariente said. “Keith never signed that contract. Keith never invested, and he didn’t sign that contract.”
The documents suggest that the lender was to be repaid an advance plus a cut on each of the 8 million masks bought by the VA. The first batch of masks would net 5 cents per mask, a hefty return for masks that, before the pandemic, cost only a few pennies. A second expected “tranche” would yield even more — 7.5 cents a mask, according to the documents.
The total return on the investment would be $500,000, the records show, or nearly 17% in just a few weeks.
Cardiff says the investment “just came about by calling to different people about who was doing different types of transactions in PPE financing.” They all charged high fees, he said.
“Look, it’s a high-risk transaction for anybody,” he explained. “You’re wiring money to China. You’re hoping the masks show up.’’
The investor’s fee cited in the documents is also high considering the type of masks ultimately delivered to the VA. ProPublica also reviewed similar broker-investor arrangements involving the far more effective N95 mask, which cost about $1 each before the pandemic. Agencies such as the Federal Emergency Management Agency have ordered N95s at six to seven times that price, yet broker fees on those much higher quality masks are also often about 5 to 10 cents a mask.
Today, an unscientific perusal of Amazon shows the less effective surgical masks pricing for anywhere from $7 to $25 for a box of 50 — often less than a quarter apiece, depending on quality, which varies widely. The VA paid about 68 cents.
This transaction is just one small example of the thousands of murky deals that have sprung from the Trump administration’s $17.7 billion — and counting — spending spree to address the pandemic. Of that, about $6.8 billion was spent on PPE and related equipment, a ProPublica data analysis shows.
More than 2,000 of those contracts, including two with VPL, were given without any competitive bidding. More than 470 contractors, including VPL, got contracts totaling $2.29 billion.
For the VA masks themselves, records show VPL paid a Chinese manufacturer just $2.26 million, less than half the total taxpayers would eventually pay. Another $1.2 million went to shipping and logistics. After overhead and their personal payouts, the company invested another $285,000 from the VA deal to purchase mask-making machines from China.
On its website the company is now taking orders for masks labeled “Made in USA by VPL Medical.” The new machines can spit out half a million masks a day, Cardiff said.
“It’s easy for you to go, ‘Oh, well, Cardiff is a fraud with the FTC, but we’re delivering masks. No one is absconding with anything,” Cardiff said. “We make masks in the United States and we do source the raw material from abroad, but only because no one makes these raw materials in the U.S.”
About $2.8 million remains in VPL bank accounts, according to the court receiver who convinced a federal court judge to also freeze that cash. But it owes more than it has on hand.
The latest freeze stems from an ongoing suit filed by the FTC, which shut down a different company operated by Cardiff and his wife, describing it as a pyramid scheme. It alleged that the firm engaged in robocalling people and making “false and unsubstantiated claims for dissolvable film strips advertised for smoking cessation, weight loss, and male sexual performance.”
A federal court issued an injunction, shutting down the Cardiffs’ business and freezing their assets. In March, Cardiff was found in contempt of court for hiding about a million dollars and funding a lavish lifestyle through an account he had opened in the name of his 90-year-old father.
Most recently, the court receiver alleged that Cardiff concealed his recent windfall by keeping his name off the official business records and cites a photo of a VPL organizational chart found at its office that shows him at the top with Bedi, as well as meeting minutes and contracts that suggest they’re equal partners.
Cardiff denies the allegation and said he’s getting paid the same amount as the official owner, but only as a consultant. Asked why he’s making the same amount as the owner, he pointed out that gifted professional athletes often earn more money than their coaches.
He dismissed the April email in which he laid out a vision for the company as “just rough thoughts and ideas.”
“It’s an email,” he argued. “It’s one email. It doesn’t detail my hope for anything. It details some rough thoughts.”
In an email, Barker, VPL’s own public relations and sales consultant, contradicted that defense.
“Jason Cardiff is the founder,” she told ProPublica.
Kennedy, who did not respond to a request for comment, was never added to the board, Cardiff said.
Cardiff says the FTC has unfairly targeted him and is now standing in the way of getting life-saving gear to people who need it.
“The bigger story here is — Why would you intervene in that?” he said.
With the mask business in receivership, it’s unclear if VPL will be able to deliver on its promise of 20 million American-made 3-ply masks to the national stockpile. Cardiff says he’s hopeful.
“Look, it’s a global pandemic right now,” he said. “People need PPE.”
In Houston more residents are dying before they can make it to a hospital. Medical examiner data shows that an increasing number of these deaths are the result of COVID-19.
This article was first published on Wednesday, July 8, 2020 in ProPublica.
HOUSTON — When Karen Salazar stopped by to check on her mother on the evening of June 22, she found her in worse shape than she expected. Her mother, Felipa Medellín, 54, had been complaining about chest pains and fatigue, symptoms that she attributed to a new diabetes treatment she'd started days earlier.
Medellín, who had seen a doctor that day, insisted she was fine. But Salazar, 29, noticed that when Medellín lay down, her chest was rising and falling rapidly — as if she couldn't catch her breath.
"I grabbed her hand and I said: 'I'm sorry. I know you don't want to go to the hospital, but I'm calling the ambulance,'" Salazar said.
While Salazar was on the phone with a 911 dispatcher, her mother suddenly passed out. Then she stopped breathing.
"Mom! Mom!" Salazar remembers shouting, trying to rouse her.
With the dispatcher on speaker phone, Salazar attempted CPR, repeatedly pressing her hands down on her mother's chest, silently praying for her to startle back to life. But by the time Houston paramedics arrived at her home in northwest Houston, Medellín was dead.
Days later, an autopsy revealed the primary cause: COVID-19.
"We never thought it was COVID," Salazar said. "We didn't even realize she had it."
Medellín's death is part of a troubling trend in Houston.
As coronavirus cases surge, inundating hospitals and leading to testing shortages, a rapidly growing number of Houston area residents are dying at home, according to an NBC News and ProPublica review of Houston Fire Department data. An increasing number of these at-home deaths have been confirmed to be the result of COVID-19, Harris County medical examiner data shows.
The previously unreported jump in people dying at home is the latest indicator of a mounting crisis in a region beset by one of the nation's worst and fastest-growing coronavirus outbreaks. On Tuesday, a record 3,851 people were hospitalized for the coronavirus in the Houston region, exceeding normal intensive care capacity and sending some hospitals scrambling to find additional staff and space.
The uptick in the number of people dying before they can even reach a hospital in Houston draws parallels to what happened in New York City in March and April, when there was a spike in the number of times firefighters responded to medical calls, only to discover that the person in need of help had already died. These increases also echo those reported during outbreaks in Detroit and Boston, when the number of people dying at home jumped as coronavirus cases surged.
While far more people died of COVID-19 in those cities than have died so far in Houston, researchers and paramedics say that the trend of sudden at-home deaths in Texas' largest city is concerning because it shows that the virus's toll may be deeper than what appears in official death tallies and daily hospitalization reports.
Many people who die at home are not tested for COVID-19, said Dr. Jeremy Faust, an emergency medicine physician at Brigham and Women's Hospital in Boston. In New York City, for example, only 16 percent of the 11,475 at-home deaths between February and June have been attributed to COVID-19, according to data from the U.S. Centers for Disease Control and Prevention.
"There's no reflexive testing," Faust said, noting that medical examiners are selective about the cases they take. "There's no pressure to call it a COVID death."
The rise in at-home deaths may also reflect people who are afraid to go to the hospital because of COVID-19, and who die of heart attacks, strokes, diabetes and other conditions not tied to the coronavirus, Faust said.
Ultimately, Faust said, public health experts trying to assess the toll from COVID will need to study how many excess deaths there are in a particular region and whether the demographics of those who died are different from what one might expect. "If there's a huge spike in at-home deaths but no real spike in overall deaths, it's just sort of rearranging deck chairs."
Such an analysis takes time, in part because death certificates are not submitted instantaneously.
Dr. Peter Hotez, dean of the National School of Tropical Medicine at the Baylor College of Medicine in Houston, said the surge in at-home deaths reflects the nature of the way COVID-19 attacks the body. Early on, he said, doctors were focused on respiratory symptoms, but case studies in New York and elsewhere showed the virus also causes serious heart problems that can lead to sudden deaths.
"And it seems to be happening both early and late in the course of the illness," Hotez said. "So patients are recovering and then they'll come home from the hospital and they'll die. Or they were never diagnosed, and the first manifestation is sudden death. So that's a very frightening aspect of COVID-19 and why we need to work so hard to slow the spread, because you don't even get the chance to seek medical attention."
In the Houston area, the trend can be seen in autopsies performed by the Harris County Institute of Forensic Sciences. In May, among people who had died unexpectedly at home, the county medical examiner attributed just six deaths to COVID-19. In June, the number jumped to 19, with most of those cases coming in the second half of the month, coinciding with a surge in the number of confirmed coronavirus cases locally. Because the medical examiner only performs autopsies in a fraction of cases, these numbers are not comprehensive.
More broadly, Houston emergency responders have also seen an increase in deaths during cardiac arrest calls.
Data from the Houston Fire Department shows a 45% jump since February in the number of cardiac arrest calls that ended with paramedics declaring people dead upon their arrival at the scene. In March, the department recorded about 250 dead-on-arrival calls, the most of any month in the past two years up until that point. In June, the number grew to nearly 300, more than 75 in excess of either of the previous two Junes. And on July 3, officials said the department experienced the most such calls on a single day in recent memory: 18.
This doesn't include cases in which responding firefighters have tried to resuscitate a person but were unsuccessful, which have also ticked up slightly since early this year.
Houston fire officials can't say for certain what's driving the increases, but Senior Capt. Isabel Sky-Eagle said it seems to be tied to the coronavirus crisis. Some of those found dead upon arrival had serious underlying health problems and didn't realize they were also sick with COVID-19, Sky-Eagle said. Others had simply delayed medical care for too long, she said, possibly because they'd seen news reports about overburdened hospitals.
Sky-Eagle said she and her crewmates first noticed more people dying before paramedics arrived weeks ago, before internal data confirmed the trend.
"Normally these patients would have called us earlier on, and now they are waiting too long because maybe they don't want to be transported to a hospital," Sky-Eagle said. "Now we're catching them when they're already in cardiac arrest, and it's too late."
Three companies including Gate Gourmet, a global provider of airline meals, received $338 million in relief money for workers — and laid workers off anyway.
After nearly three decades on the job, Sky-Eagle said she's gotten used to the fact that many of the people she's called on to help won't survive. But it's frustrating, she said, when the call comes so late that there's nothing she can do once she arrives.
"And then you put the stress of the COVID situation on top of that, where we're left wondering, 'Is this person dying because of COVID?' It adds another layer of fear to the job that, day after day, starts to add up," Sky-Eagle said, referring to the fear of contracting the virus or passing it to others.
Dr. Dario Gonzalez, deputy medical director of the New York City Fire Department, said the number of cardiac arrest calls that the department had to respond to in March and April was overwhelming. At the peak of the New York outbreak, the Fire Department was responding to more than 300 cardiac arrest calls per day, compared with a daily average of just 65 calls the previous year.
"The psychological toll on the providers is significant," Gonzalez said. "You can lose one or two but when it's constantly going, going, going. … It just seemed like it went on and on."
Gonzalez said he worries about first responders with post-traumatic stress disorder.
"If we get hit with a second wave, that's going to be a huge issue for us and the hospitals," Gonzalez said. "Can the people — the nurses, the doctors, the EMTs and the medics — do it all over again? Everybody likes to say they'll rise to the challenge, but there's just so much challenge you can deal with."
After her mother died so suddenly, Salazar said she and her siblings have been in a constant state of panic, worried that their father or another loved one could be next. Salazar's mother had health problems before she contracted COVID-19, but none that were immediately life threatening.
Salazar told her dad that, after trying and failing to revive her mother with chest compressions, she wanted to take CPR lessons.
"At least then I will know what to do if this ever happens again to someone else I love," she said. "Because right there in the moment, you just go blank."
As Houston's coronavirus crisis deepens — with area hospitals reporting baseline ICU beds filled beyond capacity — Salazar has been warning friends and relatives to take the virus seriously. She's terrified that she might contract the virus and pass it to her father, who lived with her mother but tested negative last week.
That's left her father, Jose Salazar, 51, to grieve alone.
"I told my dad, 'I can't be at your house right now,'" Karen Salazar said. "'I know you feel alone, alone in the house where my mom passed away. We already lost our mother, we can't lose you, too.'"
Court records show the federal government gave $20 million in contracts to a company partly controlled by a man with a history of shady business practices.
This article was first published on Thursday, July 9, 2020 in ProPublica.
Desperate to acquire masks to slow the spread of the novel coronavirus, two federal agencies gave nearly $20 million in contracts to a newly formed California company without realizing it was partly run by a man whose business activities were under sanction by the Federal Trade Commission, court records show.
On Tuesday, a U.S. District Court judge froze the company's assets, most of which had come from the Department of Veterans Affairs in a $5.4 million mask deal. A story by ProPublica revealed Jason Cardiff's role in operating VPL Medical LLC in June.
Cardiff was sued by the FTC in 2018 in connection with an alleged fraudulent scheme involving smoking cessation strips and male sexual enhancement pills and was under court order to report his income to a receiver. Cardiff was recently held in contempt for violating that court order. By not disclosing his involvement with VPL, court records allege Cardiff was essentially hiding information from the FTC about money his company was getting from another federal agency, the VA.
California business filings show that VPL was incorporated just four days before it won the VA deal in April, and it went on to win a $14.5 million no-bid contract the next day from the federal office in charge of the national stockpile. Those filings do not mention Cardiff as a company owner. The FTC alleges in court records that Cardiff and a partner, Bobby Bedi, were equal partners and had each paid themselves at least $420,000 from the VA money.
In May, when ProPublica asked VPL officials about Cardiff's role, Bedi said Cardiff was "a consultant." In a recent filing, the court receiver said that characterization "strains credibility" and included photos of a company organizational chart showing the two co-leading VPL.
When the VA signed the VPL deal, the agency had been told by a company representative that Cardiff was the CEO of the company, according to emails included in the FTC's latest court filings.
That VPL representative, Stacey Barker, was paid more than $257,000 for helping to close the VA deal.
While the company is not on the list of banned federal contractors, a quick Google search reveals Cardiff had been repeatedly accused of fraudulent schemes.
The attorney representing Cardiff and VPL, James B. White, argued that the FTC filings are the agency's perception, not the truth, and said corporate filings do not include Cardiff's name.
"What I'm suggesting to you is that is not the only interpretation of the documentary trail," White told ProPublica. "Is it not possible in your world that the payments to Mr. Cardiff were for a consultancy?"
The VA, which has struggled to provide protective equipment to medical workers at the largest hospital system in the country, said the company successfully provided 8 million surgical masks. VPL has yet to deliver under its separate contract with the U.S. Department of Health and Human Services, according to the company's lawyer and court records.
The federal government and states have fueled an unregulated, chaotic market for masks ruled by oddballs, ganjapreneurs and a shadowy network of investors.
Cardiff and Bedi did not respond to requests for comment. A VA spokeswoman said VPL met basic criteria for a contract award.
"If you have concerns about the federal laws governing the federal contracting process, you should direct them to the relevant congressional committees of jurisdiction," said the spokeswoman, Christina Noel.
In 2018, the FTC sued to shut down Cardiff and a different company operated by him and his wife, describing it as a pyramid scheme. It alleged that the firm involved robocalling people and making "false and unsubstantiated claims for dissolvable film strips advertised for smoking cessation, weight loss, and male sexual performance."
A federal court issued an injunction, shutting down the Cardiffs' business and freezing their assets. In March, Cardiff was found in contempt of court for, among other things, hiding 1.5 million Canadian dollars (about $1.1 million) in assets. The case is ongoing, with the most recent injunction freezing VPL assets.
The FTC alleged that Cardiff was funding a lavish lifestyle through an account he had opened in the name of his 90-year-old father.
"The Cardiffs are spending nearly $17,000 per month," court records state. "On Bentley, Porsche, and Range Rover lease payments, private elementary school tuition, restaurants, phone and cable bills, salons and spas, pet grooming, a 5-star hotel in New York City, music lessons, taekwondo lessons, ride shares, movie theaters, and other lavish expenditures."
After months of asserting pregnant women were not at high risk for the coronavirus, the CDC recently released a study with sobering findings for expectant mothers. Experts say the data gaps are almost as worrisome as the results.
This article was first published on Monday, July 6, 2020 in ProPublica.
By Nina Martin
In late June, after three months of near silence on the topic, the Centers for Disease Control and Prevention finally weighed in on a question of critical importance to millions of American women and families: How dangerous is the coronavirus for pregnant women and new mothers?
The CDC had been asserting that pregnant women don't seem to be at higher risk for severe complications from the virus. As recently as late May, a spokesperson told ProPublica, "Current evidence shows pregnant women have the same risk of severe illness from COVID-19 as adults who are not pregnant."
Then, the agency abruptly changedits tone. In its first examination of U.S. data on COVID-19 in pregnancy, the CDC found that expectant mothers with the virus had a 50% higher chance of being admitted to intensive care and a 70% higher chance of being intubated than nonpregnant women in their childbearing years.
Pregnant Latina and Black women were infected at significantly higher rates than white women, researchers reported. As of July 2, at least 30 expectant and new mothers with the virus had died.
That news was sobering enough. But what many experts found really worrisome were the glaring gaps in data that the study exposed.
The CDC acknowledged that crucial health information was missing for about three-quarters of pregnant women with the virus, including whether they had preexisting conditions or required an ICU stay or mechanical ventilation. For the vast majority of U.S. women of reproductive age who tested positive — about 326,000 women through June 7 — there was no information about pregnancy status at all.
Researchers couldn't even say how many of the hospitalized mothers-to-be — 31.5% of the pregnant women in the study — had been admitted because of COVID-19, versus how many were in the hospital for other reasons, such as giving birth.
The flawed CDC report highlights a problem that OB-GYN providers and researchers in the U.S. have been fretting about since the pandemic began. Because emerging diseases can have catastrophic consequences for pregnant women and their babies, close monitoring of new illnesses in this vulnerable population is important. So is rapid communication with providers trying to keep their patients safe.
But the U.S. public health system's efforts to understand the impact of the coronavirus in mothers and babies have been flat-footed, scattershot and agonizingly slow.
The holes in the CDC's data are "startling. I won't lie," said Cindy M. P. Duke, an OB-GYN who runs the Nevada Fertility Institute in Las Vegas. "It's shocking to realize that we do not have a uniform system in place" for collecting and analyzing basic maternal and infant health information during times of crisis.
"By the time we get the best data available," said Christina Han, a maternal-fetal specialist who is on the clinical faculty at the University of California, Los Angeles, medical school, "this pandemic will be over."
To track the coronavirus in pregnant women and their babies, the CDC is instructing local health departments to check a box on the standard Case Report Form if a patient is currently pregnant. Jurisdictions can also complete an "optional, supplemental form" providing information about disease severity and outcomes in mothers and babies, a spokeswoman said.
It's a system that guarantees there will be huge data inconsistencies, time lags and gaps. "We're talking about millions of cases that are having to be reported back to the CDC right now," Han said, "And the clinicians who are taking care of these patients don't have the time to be filling out the full case report forms."
The CDC has "initiated COVID-19 pregnancy surveillance," according to its study, working with local health departments to improve data collection going forward. But researchers didn't give any details.
"We need to be set up prior to an outbreak to capture information about how any new or emerging or reemerging pathogen affects pregnant women and their infants," said Denise Jamieson, who spent 20 years at the CDC studying reproductive infectious disease and now heads the OB-GYN department at Emory University medical school in Atlanta. "And I think it's clear … that [the CDC] are not well poised to do that."
It Doesn't Have to Be This Bad
When COVID-19 arrived in Europe this winter, researchers in the United Kingdom were ready.
Caught unprepared by the H1N1 outbreak of 2009, and determined not to let that happen again, the National Institute for Health Research issued a call for studies in 2011 that could be up and running as soon as the next pandemic hit. Nine proposals were chosen, all focusing on flu but adaptable to other types of outbreaks; then they were "hibernated" — put on hold, the protocols periodically reviewed and revised, pending government action.
When the sirens began blaring this February, eight of the studies launched, including one by the U.K. Obstetric Surveillance System, a research platform devoted to rare disorders of pregnancy. "I was told to activate [it] on a Friday," said Marian Knight, a professor of maternal and child population health at the University of Oxford, "and by Monday, we were collecting the data."
The UKOSS design was ambitious — a comprehensive, prospective study of COVID-19-infected pregnant women at the National Health Service's 194 obstetric hospitals; it was also straightforward, based on a two-page electronic form, with all patient information kept anonymous. The careful planning allowed researchers to move quickly without being overly rushed, Knight wrote in a blog post for The BMJ journal, "minimizing the risks of publication of, at best, misleading, or, at worst, erroneous, information" — problemsthat have bedeviled other high-profile COVID-19 studies.
By mid-May, UKOSS releasedits first findings from an analysis of every pregnant woman hospitalized in Britain from March through mid-April who tested positive for the virus, 427 in total. Mothers-to-be did not seem to get as sick overall from COVID-19 as they had from H1N1 flu and SARS, but Black and Middle Eastern women were far likelier to be hospitalized with the virus than white women were. About 1 in 10 women became so ill they required respiratory support. Five mothers and five babies died.
The study provided the kind of high-quality data that doctors and policymakers value most: populationwide, scientifically rigorous, immediately actionable. British medical organizations quickly issued new guidance about the heightened risks for women of color.
Medical groups alsoreaffirmed earlier recommendations that women in their third trimester should avoid job settings, such as working as a doctor or nurse on the front lines, that could expose them to the virus. That's a much more conservative position than American medical organizations and employers have taken, citing a lack of research that would suggest a different approach. Knight said the UKOSS findings support stringent social distancing in late pregnancy. "That's where we see the majority of women with critical disease. The good news is that women now know when they should start to be particularly vigilant."
Public health experts say UKOSS' proactive, big-picture approach is exactly what was needed in the U.S., which has nearly 4 million births annually — about five times as many as Britain — and wide racial disparities in maternaland infant outcomes that COVID-19 has likely only widened. By one estimate, more than 16,000 American women could be infected with the coronavirus when they give birth this year.
But the U.K. has universal health care, which gives the government access to vast amounts of patient data, making large-scale research like the UKOSS study more feasible. The U.S. health care system is fragmented and inefficient, much of its data hidden in black boxes.
The two nations also have very different approaches to maternal health, exemplified by how they confront pregnancy-related complications and deaths. The U.K. treats every mother's death like a public health disaster; the U.S. can barelykeep track of its maternal mortality problem.
Women's health in general tends to be an afterthought for American researchers and policymakers, said Barbara Levy, former vice president for health policy at the American College of Obstetricians and Gynecologists, now a consultant in the Washington, D.C., area. In a public health system that's beenunderfunded for decades, pregnancy-related issues get especially short shrift.
"If we're not seeing a red-hot button to raise our concern, then we just aren't particularly curious about what might be going on." Yet the stakes of this kind of population-based research couldn't be higher, Levy said. "This is the future of our world. This is the next generation."
Patching Together a View
Starting with the first, very limited case reports from China, there's been a deluge of studies seeking to fill the information void about COVID-19 and pregnancy. In the U.S., much of the research has come from hot spots like New York City,Seattle and Chicago, where physicians in the throes of the pandemic have reported on their own patients and pushed out their findings with breakneck speed.
The general trend has been somewhat reassuring: COVID-19 can make pregnant women very sick, but many seem to remain asymptomatic or become only mildly ill. There have only been a few cases of suspected "vertical transmission" — mothers passing the virus to their babies in the womb — but those remain under investigation, and most infants born to COVID-19-positive women have done fine. Some red flags have also emerged: A couple of cases of heart-related complications, indications ofplacental abnormalities and reports of asymptomatic women who spiraled after giving birth.
The underlying data in many of these case reports is overlapping and confusing, with little or no peer review to vet the findings. "In none of these series can we be certain of the underlying population denominators nor the degree to which they are affected by the biases" inherent in small-scale studies conducted in a single hospital or city, Knight wrote in her BMJ commentary. "The results are thus almost impossible to interpret."
As coronavirus spread through the nursing home where Molly Baldwin is a social worker, management wouldn't let her work remotely. That forced her to choose between staying safe while in her third trimester and getting her paycheck.
Meanwhile, numerous efforts are underway to do larger scale, longer-term, more scientifically meticulous studies that could give a fuller picture of how the virus affects pregnant women and babies in different parts of the U.S. (which is likely to be different from how it affects women in the U.K. or Sweden or Iran). In late May, the National Institute of Child Health and Human Development announced a sweeping initiative, a series of studies at the 12 academic institutions in its Maternal-Fetal Medicine Units Network, the preeminent obstetric research collaborative in the U.S. The network, which dates to the mid-1980s and stretches from the Rhode Island to Utah, is "a very well-oiled machine that can put protocols into place very quickly," said Diana Bianchi, a prenatal geneticist who heads the NICHD, which is one of the National Institutes of Health.
One big study will compare women who delivered at the various sites between March and December of this year with women who delivered in the same hospitals in the same period in 2019, Bianchi said. "They're asking, first of all, is there a difference in the number of deaths? Is there a difference in the number of cesarean sections that have been performed? Is there a difference in terms of the maternal near misses?... If we see any increased incidence of complications, death, whatever, then the presumption is the difference is due to COVID." Another study will follow 1,500 COVID-19-positive pregnant women to understand the course of the disease and its treatment.
A different approach, the PRIORITYstudy, originates at the University of California, San Francisco, and UCLA. The idea is to build a large nationwide registry of women who contracted COVID-19 at any point in their pregnancy and to follow them for at least a year after they give birth, miscarry or have an abortion. A key goal is to make the registry more geographically, racially and economically diverse than is typical of many academic-based studies, "because we want the results to accurately reflect the true representation of pregnant people that are being impacted by COVID 19," said Vanessa Jacoby, an associate professor at UCSF who is one of the lead investigators. To that end, the researchers are working with birth advocates in communities of color around the country to get the word out to potential participants directly; they don't need a doctor or hospital to take part. In the first few weeks, many of the women enrolled were pregnant health care workers.
Another UCSF-based study, the ASPIRE registry, will focus on early pregnancy, when the risks are greatest for birth defects and miscarriages, and aims to eventually enroll 10,000 participants.
"This disease is so humbling because it's new to humans, and we keep learning more and more about its manifestations in real time," Bianchi said. "We have not gone through a nine-month cycle with pregnant women. And so I'm very concerned about the consequences of infection in the first trimester." She points to Zika, a mosquito-borne virus that was once thought to be harmless because the symptoms in men and nonpregnant women were often quite mild. Only after newborns exhibited devastating neurological disabilities did researchers realize how dangerous the virus really was.
Recent reports of COVID-19's unexpected effects — like a life-threatening inflammatory syndrome in children — have intensified providers' unease. On a Facebook group for OB-GYNs with 4,400 members, doctors have recently been trading stories about an alarming, if highly anecdotal, increase in miscarriages and stillbirths in some of their practices. But the OB-GYNs didn't know whether what they were seeing was a real spike caused by COVID-19, an increase caused by something else or a statistical fluke magnified by their own anxiety. And what, they worried, might the reports about clotting disorders in younger, nonpregnant adults mean for expectant and new mothers, who are already more susceptible to life-threatening blood clots?
"The gap in knowledge — it's chilling," said Jane van Dis, a Los Angeles-area OB-GYN who is the medical director at theMaven women's health telemedicine platform and helps administer the Facebook group. "It's very distraught-provoking to be expected to be an expert on a topic that we've spent our whole lives dedicated to, but for which we don't have the answers right now, and they're really important answers to be able to have."
The truth is, answers may be elusive for a long time. "This virus keeps surprising us," said Sonja Rasmussen, former director of the CDC's Office of Infectious Diseases, now a professor of pediatrics and epidemiology at the University of Florida medical school. "That was true for Zika and Ebola, too." One of the most important lessons of past outbreaks, she said, is that "you can't be too confident early on. It just shows the importance of collecting data and not being too sure about what you think you're going to see before you collect those data. You've got to keep an open mind."
Texas was one of the first states in the nation to ease social distancing mandates. In Houston, the number of patients hospitalized with COVID-19 has quadrupled since Memorial Day. "It's time to be alarmed," one expert said.
This article was first published on Wednesday, July 1, 2020 in ProPublica.
HOUSTON — At Lyndon B. Johnson Hospital on Sunday, the medical staff ran out of both space for new coronavirus patients and a key drug needed to treat them. With no open beds at the public hospital, a dozen COVID-19 patients who were in need of intensive care were stuck in the emergency room, awaiting transfers to other Houston area hospitals, according to a note sent to the staff and shared with reporters.
A day later, the top physician executive at the Houston Methodist hospital system wrote to staff members warning that its coronavirus caseload was surging: “It has become necessary to consider delaying more surgical services to create further capacity for COVID-19 patients,” Dr. Robert Phillips said in the note, an abrupt turn from three days earlier, when the hospital system sent a note to thousands of patients, inviting them to keep their surgical appointments.
And at The University of Texas MD Anderson Cancer Center, staff members were alerted recently that the hospital would soon begin taking in cancer patients with COVID-19 from the city’s overburdened public hospital system, a highly unusual move for the specialty hospital.
These internal messages highlight the growing strain that the coronavirus crisis is putting on hospital systems in the Houston region, where the number of patients hospitalized with COVID-19 has nearly quadrupled since Memorial Day. As of Tuesday, more than 3,000 people were hospitalized for the coronavirus in the region, including nearly 800 in intensive care.
“To tell you the truth, what worries me is not this week, where we’re still kind of handling it,” said Roberta Schwartz, Houston Methodist’s chief innovation officer, who’s been helping lead the system’s efforts to expand beds for COVID-19 patents. “I’m really worried about next week.”
What’s happening in Houston draws eerie parallels to New York City in late March, when every day brought steep increases in the number of patients seeking care at overburdened hospitals — though, so far, with far fewer deaths. But as coronavirus cases surge in Texas, state officials here have not reimplemented the same lockdown measures that experts say helped bring New York’s outbreak under control, raising concern among public health officials that Houston won’t be able to flatten the curve.
“The time to act and time to be alarmed is not when you’ve hit capacity, but it’s much earlier when you start to see hospitalizations increase at a very fast rate,” said Lauren Ancel Meyers, a professor of integrative biology who leads the University of Texas at Austin COVID-19 Modeling Consortium. “It is definitely time to take some kind of action. It is time to be alarmed.”
Even as new cases and hospitalizations soar, the number of daily deaths in Texas has remained relatively low. On Tuesday, the state reported nearly 7,000 new cases, a record, but only 21 new deaths. All told, New York state has reported nearly 25,000 confirmed deaths from COVID-19. Texas has recorded fewer than 2,500, including 378 in Harris County, which includes Houston.
But experts caution that rising hospitalizations today will likely result in a spike in deaths in the coming weeks, and those who require ICU care for COVID-19 but recover often leave the hospital with lasting health problems.
Meyers and others said that while hospitals across the United States generally are more prepared than they were in March and April — personal protective equipment is more plentiful, advances in therapeutics have helped patients and ventilators aren’t in short supply — the lack of government measures to slow the spread in Texas and other states puts them at a disadvantage.
Texas was one of the first states in the nation to ease social distancing mandates, beginning two months ago when daily coronavirus cases remained relatively low compared with some states. Restaurants reopened first, with gradually loosening capacity restrictions; bars, hair salons, bowling alleys and other businesses soon followed. In Houston, where Gov. Greg Abbott had until recently blocked local officials from issuing public mask requirements, it was common to see the majority of people shopping at neighborhood supermarkets or big-box hardware stores with no face coverings.
But to date, Abbott has resisted a return to the lockdown, other than an order last week closing bars and further limiting the capacity at restaurants. This week, after the top elected leader in Dallas County asked for the authority to issue a new stay-at-home order locally, Abbott dismissed the idea, saying the official was asking to “force poverty” on people.
“Closing down Texas again will always be the last option,” the governor said last week, emphasizing his commitment to protecting the state’s economy.
Experts noted that it can take two weeks or longer for social distancing measures to lead to decreases in cases and hospitalizations.
“The hospitalizations you see today, they’re not just going to linearly increase in the next two weeks,” said Dr. Clay Johnston, dean of the Dell Medical School at the University of Texas at Austin. “They’re going to accelerate. When you overwhelm the hospitals, you’re in big trouble. That to me is the impossible task that the governor faces. It’s like steering a giant tanker through a tiny strait without any maps.”
Although hospital executives in Houston stress that they have the ability to add additional intensive care beds in the region to meet the growing demand — for a few more weeks, at least — the strain on hospitals is already being felt in other ways.
Houston Fire Chief Samuel Peña said his paramedics sometimes have to wait for more than an hour while emergency room workers scramble to find beds and staffers to care for patients brought in by ambulance — a bottleneck that’s tying up emergency medical service resources and slowing emergency response times across the region.
Part of the problem, Peña said, is that when his crews arrive at a hospital with a patient suspected of having COVID-19, the hospital may have a physical bed open for them, but not enough nurses or doctors to staff it. That’s a problem that’s likely to deepen as a growing number of medical workers have been testing positive for the virus, according to internal hospital reports. Just as New York hospitals did four months ago, some Houston hospitals have posted on traveling nurse websites seeking nurses for “crisis response jobs.”
“If they don’t have the nursing staff, then you can’t place the patient,” Peña said. “Then our crews have to sit with the patient in the ER until something comes open. It has a huge domino effect.”
The crisis in Houston has accelerated rapidly in recent weeks, at times resulting in muddled messaging from both hospital leaders and public officials.
On June 24, several hospital executives affiliated with the Texas Medical Center — a sprawling medical campus that’s home to most of Houston’s major hospital systems — issued a statement warning that COVID-19 hospitalizations were growing at an “alarming rate” and could soon put an unsustainable strain on hospital resources.
But the following day, after Abbott issued an executive order directing hospitals to limit elective surgeries — a measure intended to preserve hospital capacity but one that also hurts hospital revenues — the CEOs of four hospitals in the medical center abruptly dialed back their earlier warnings at a hastily organized news conference. They said they hadn’t meant to alarm the public. The hospitals still had room to add ICU beds, they said, both to treat COVID-19 and to continue caring for other patients.
“I think the Texas Medical Center’s purpose was to really urge people to do the right things in the community, and do so by talking about capacity, but really ended up unintentionally sounding an alarm bell too loudly,” Dr. Marc Boom, president and CEO of Houston Methodist, which is part of the Texas Medical Center, said at the news conference. “We clearly do have capacity.”
The shifting messages upset Harris County Judge Lina Hidalgo, the county’s top elected official. She vented her frustrations Monday during a virtual news conference from her home, where she’s on self-quarantine after a member of her staff tested positive for the coronavirus. Hidalgo said the “diluted” messaging from some hospital leaders “weakens our community’s ability” to stop the virus.
“The goal is not to have doctors and nurses that we’re bringing in from out of town,” Hidalgo said. “The goal is not to have basic general population beds that we need for dialysis and heart attacks and strokes and pregnant women who need to give birth turned into ICU beds. The goal is not to see how much room we can make for people to go and be there and die in a hospital bed. That is not the point of any of this.”
In an interview Tuesday, Boom said he didn’t intend to suggest that there wasn’t reason to be deeply concerned about the number of COVID-19 patients filling hospital wards. He said he and other executives were trying to thread the needle between sounding the alarm about the growing but still manageable strain on hospital resources, while trying to reassure people who might need to come to the hospital for other ailments.
“Honestly, in a way, it’s backfired, and I’m very sorry for that because what has happened has actually been the exact opposite of what we were trying to accomplish,” he said of his attempt to clarify the earlier warning about hospital capacity. “I never wanted to confuse the public. The message really was, ‘Hey guys, we don’t want panic, because when people panic, bad things happen.’”
Hospitals in Houston and elsewhere in the country temporarily halted outpatient visits and elective surgeries in March and April as the coronavirus pandemic took hold on the East Coast — a move that not only hurt hospital revenues, Boom said, but also forced many patients to delay critical procedures, including heart surgeries.
Boom and other hospital leaders said the earlier restrictions also led some patients to avoid going to the hospital after suffering symptoms of heart attacks or strokes, leading to potentially deadly delays in care.
Vivian Ho, an economics professor at Rice University, said hospitals want to protect their fiscal health and the health of patients, both those with COVID-19 and those with other conditions, while also preventing themselves from becoming overwhelmed down the line.
Elective surgeries deliver a far better financial return than ICU wards full of patients with COVID-19.
“They would prefer to tell the public that this is extremely dangerous,” she said, “but they can’t, in part, because they have to keep performing these elective surgeries, and for the most part, that is safe.”
Not all hospitals are equally equipped to respond to a surge in COVID-19 demand, accompanied by a loss of more profitable business, Ho said. Hospital systems like Houston Methodist have “the financial resources to sort of convert anything into an ICU just because they have more money, more cash on hand,” she said.
Houston’s public hospitals, Ben Taub and Lyndon B. Johnson, don’t have those same resources.
“The problem is that, of course, there are going to be more patients who are going to be going to Ben Taub” because the virus is disproportionately affecting Black and Latino people in low-income communities, and Ben Taub is traditionally the safety net for those without health insurance, Ho said. “I don’t know to what extent they are able to send patients to the other hospitals.”
The Sunday note to the staff at Lyndon B. Johnson said that the hospital had reached maximum occupancy in its COVID-19 units. That day, nearly 50% of the patients tested for the virus had it, more than double the rate from a week before. The hospital had run out of remdesivir, an antiviral drug that’s shown some effectiveness in treating COVID-19. And for now, all elective surgeries were being canceled to preserve bed and staffing capacity.
There appeared to be no letup in sight; the note to the staff warned that Monday would likely be worse.
“Sunday,” it said, “is typically a lower volume day.”
