This time last year, the United States seemed stuck on a COVID-19 plateau. Although 1,300 Americans were dying from the disease every day, states had begun to reopen in a patchwork fashion, and an anxious nation was looking ahead to an uncertain summer. Twelve months later, the situation is very different. Cases are falling quickly. About half as many people are dying every day. Several vaccines were developed faster than experts had dared to predict, and proved to be more effective than they had dared to hope. Despite a shaky start, the vaccination campaign has been successful, and almost half of the country has received at least one shot, including 85 percent of people older than 65. As the pandemic rages on elsewhere in the world, the U.S. is eyeing a summer of reconnection and rejuvenation. But there is another crucial difference between May 2020 and May 2021: People have now lived through 14 months of pandemic life. Millions have endured a year of grief, anxiety, isolation, and rolling trauma. Some will recover uneventfully, but for others, the quiet moments after adrenaline fades and normalcy resumes may be unexpectedly punishing. When they finally get a chance to exhale, their breaths may emerge as sighs. “People put their heads down and do what they have to do, but suddenly, when there’s an opening, all these feelings come up,” Laura van Dernoot Lipsky, the founder and director of the Trauma Stewardship Institute, told me. Lipsky has spent decades helping people navigate the consequences of natural disasters, mass shootings, and other crises. “As hard as the initial trauma is,” she said, “it’s the aftermath that destroys people.” The COVID-19 pandemic has been a singular disaster—a recurring series of traumatic events that have eroded the very social trust and connections that allow communities to recover from catastrophes. Even now, with COVID-19 cases in the U.S. falling and vaccinations rising, many of the people whom Lipsky works with are struggling. Things are getting better, so why don’t they feel better? “A lot of them are really confused by it, because they feel like they made it through and can see a little light at the end of the tunnel,” she said. If you’ve been swimming furiously for a year, you don’t expect to finally reach dry land and feel like you’re drowning. A brief note on the word trauma: Psychologists and psychiatrists still debate its definition. Some feel that the word is used too loosely. Others argue that the official definition—which requires actual or threatened death, serious injury, or sexual violence—inappropriately excludes serious life events such as divorce, unemployment, or some chronic illnesses. Some argue that you cannot be traumatized by watching news coverage of disasters, and others say you can. Jessi Gold, a psychiatrist at the Washington University School of Medicine, in St. Louis, thinks in terms of “big-T trauma” (the officially defined term) and “little-t trauma” (its colloquial cousin). Both meaningfully affect one’s mental health. “We can be too nitpicky about where something ends and something else begins,” she told me. “If someone feels bad and it affects their day-to-day life, it’s a mental-health problem, and I don’t really care what you call it.” Even in the more restrictive big-T sense, the pandemic has produced trauma at enormous scale. Millions of COVID-19 long-haulers spent months with debilitating symptoms, and many are still sick. In one study, 30 percent of people with lab-confirmed COVID-19, most of whom had not been hospitalized, were still experiencing symptoms after an average of six months. Many are still struggling with the byzantine world of disability benefits and long-term diagnoses such as myalgic encephalomyelitis. Many Americans who were hospitalized with COVID-19 will still be affected too. At the height of the winter surge, 132,000 people filled U.S. emergency rooms. Based on evidence from Italy and from past coronavirus epidemics, about a third of those people—and the hundreds of thousands more who were hospitalized before and after that moment--will develop PTSD. At least 580,000 Americans have died from COVID-19, and this official tally probably omits hundreds of thousands of uncounted deaths. Because each death leaves an average of nine close relatives bereaved, roughly 5 million Americans have been grieving parents, children, siblings, spouses, or grandparents at a time when funerals, bedside goodbyes, and other rituals of mourning and loss have been disrupted. Some may feel guilt about surviving, as did New Yorkers who narrowly missed the 9/11 attacks, or gay men who were “spared at random” by HIV during the 1980s. Some grievers may not heal for a long time. In normal circumstances, about 10 percent of bereaved people develop prolonged grief, becoming incapacitated by intense, all-consuming grief that persists for more than a year and flattens their life. About half a million Americans will likely feel this way—roughly the population of Atlanta. Grief will germinate along the same societal cracks that the pandemic exploited and widened: Indigenous, Pacific Islander, Latino, and Black Americans were more than twice as likely to die from COVID-19 than white Americans, and are therefore more likely to have lost loved ones to the disease. Medical traumas were compounded by social stressors including unemployment, isolation, the rigors of full-time parenting without child care, and a year of lost opportunities. Against this grim backdrop, other tragedies unfolded: the killings of Breonna Taylor, George Floyd, and many other Black people by police officers; a record wildfire season; the insurrection at the U.S. Capitol; the Texas power crisis; and mass shootings in Atlanta and elsewhere. “This has been an ongoing set of cascading collective traumas that have really not abated,” says UC Irvine’s Roxane Cohen Silver, a psychologist who has studied trauma for decades. The pandemic itself has not fully abated, either. Even as Americans ponder “post-pandemic” life, 600 people are still dying of COVID-19 every day. Despite the historic success of the vaccination campaign, the rate of vaccinations is slowing, and is lowest among the most socially vulnerable communities. COVID-19 is burning with renewed ferocity through India, much of South America, and other countries. Globally, the pandemic is set to kill more people in 2021 than in 2020. A sweeping and continuous crisis produces two almost-paradoxical phenomena. First, people become inured and apathetic to suffering at a mass scale, experiencing what the psychologist Paul Slovic of the University of Oregon has called psychic numbing. But people also become sensitized to further traumas in their own life. Silver has repeatedly found this pattern among people who experience successive disasters, such as 9/11, Hurricane Sandy, and the Boston Marathon bombings. Many didn’t habituate: Each new blow brought more stress, not less. “Around the one-year anniversary of COVID, a number of journalists asked me, ‘It’s been a year; why aren’t we adjusted to this?’” Silver told me. “I found that question very unusual.” The pandemic hasn’t been a one-off disaster but “a slow, recurrent onslaught of worsening things,” adds Tamar Rodney, from the Johns Hopkins University School of Nursing, who studies trauma. “We can’t expect people to go through that and for everyone to come out the other side being fine. People suffered in between, and those effects must be addressed, even if we’re walking around maskless.” In 1969, the psychiatrist Elisabeth Kübler-Ross wrote that people with terminal illnesses go through five emotional stages: denial, anger, bargaining, depression, and acceptance. This influential model etched itself into the public consciousness and has been applied to every flavor of grief and loss, including that of COVID-19. But it is deeply misleading, and always has been. Grief isn’t predictable. It doesn’t involve clearly defined stages. It doesn’t unfold linearly. It doesn’t necessarily end in acceptance. It carves long, meandering, and varied paths that popular myths do little to prepare us for. People who endure long bouts of stress often collapse when they get a chance to be calm. Soldiers who return to the everyday world “describe it as boring, which gives them more time to think about what happened in the theater of war,” Steven Taylor, a psychiatrist at the University of British Columbia, told me. Similarly, he predicts that, in the quieter moments after COVID-19 infections wane, health-care workers may remember the patients they lost, or the morally challenging decisions they had to make about apportioning care. And that’s if they get quiet moments between dealing with surgeries that were rescheduled during surges and patients who are coming in sicker than usual because they deferred care. “You’re just frayed, but you have to do everything that didn’t get done,” Saskia Popescu, an infection preventionist at George Mason University, told me last summer. “You don’t get a mental break.” Even Americans who were spared the big-T traumas of the emergency room still experienced a year of fear, uncertainty, and disruption. They too might experience jarring moments of unexpected reflection, even as the national outlook begins to brighten. “When you get a chance to realize that your safety or your family’s safety is no longer at risk, you think, What was this experience like for me?” said Gold, the Washington University psychiatrist. “Your answer could be I haven’t slept in months, or I feel miserable, or My kid is really angry and upset all the time. I think the curve [of mental-health problems] is likely to go up exponentially once people have time to even realize that mental health is part of the equation.” Such problems can be especially disquieting at times when people are expecting to feel renewed. Lipsky, the trauma specialist, told me that she has worked with many people who are “struggling with the struggle.” They might be nurses, doctors, judges, activists, or parents—hypercompetent individuals who are used to handling a constant baseline of stress, and who act as bedrocks and caregivers for their teams, communities, and families. The added burdens of the pandemic overwhelmed them, and rocked their identities. “People don’t recognize themselves,” Lipsky said. “They say, ‘I used to be the person who dealt with really hard things.’ I had parents questioning whether they were even meant to be a parent.” Not everyone will feel this way. Perhaps most Americans won’t. In past work, Silver, the UC Irvine psychologist, found that even communities that go through extreme traumas, such as years of daily rocket fire, can show low levels of PTSD. Three factors seem to protect them: confidence in authorities, a sense of belonging, and community solidarity. In the U.S., the pandemic eroded all three. It reduced trust in institutions, separated people from their loved ones, and widened political divisions. It was something of a self-reinforcing disaster, exacerbating the conditions that make recovery harder. “I don’t feel that we’re doomed,” Silver told me. “I do still believe that we will get through this.” She and other experts I talked with noted that people are resilient, and often more so than they realize. But they also agreed that the rhetoric of individual resilience can often be used to plaster over institutional failures: the shortage of mental health-care providers, the labyrinthine insurance system, the lack of support from employers, the stigma around seeking care at all, and the societal tendency to bottle grief. “I don’t know anyone who looks to the U.S. as a model for grieving and mourning,” Lipsky told me. “We don’t talk about loss. By and large, it’s all about consumption to help numb you out.” Lori Peek, a sociologist at the University of Colorado at Boulder, told me that recovery from disasters is usually gauged in terms of dollars regained, jobs restored, and infrastructure rebuilt. Mental health is harder to measure, and so easier to ignore. She is worried that the understandable societal desire to move past the pandemic will further alienate people who are still dealing with grief or symptoms. “What if someone is truly suffering and reaches out for help six months from now, and is told, ‘What are you talking about? The pandemic was ages ago,’” Peek said. Loss can linger longer than expected. The time frame for recovering from disasters “is measured not in months, but in years or decades,” Peek said. In many cases, it lasts beyond the lifespan of human compassion. In late 2005, the people who were displaced by Hurricane Katrina initially found an outpouring of support, including meals, clothes, furniture, money, and music. But by early 2006, goodwill gave way to what disaster-relief workers called Katrina fatigue, and what the evacuees just called discrimination. “People were like, ‘Aren’t these people going home?’” Peek said. “And they had no homes.” Similar tendencies are apparent now, as commentators wonder why many Americans are still anxious and risk averse, even as the U.S. begins to wake from its pandemic nightmare. “I think some people believe we pressed ‘pause,’ and we’ll go back to the way things were before, as if we didn’t have all the intervening experiences, as if 2020 didn’t happen, as if getting a vaccine erases your memory,” Gold said. Consider the latest phase of the ceaseless discourse around masks. The SARS-CoV-2 virus spreads primarily through shared indoor air, the vaccines are extremely effective, and breakthrough infections among vaccinated people are rare. It is reasonable, then, for the CDC to advise that fully vaccinated people don’t need to wear masks outdoors. (The agency’s surprising move to extend those guidelines indoors is more debatable.) But it is also reasonable for people to want to continue wearing masks, to feel anxious that others might now decide not to, or to be dubious that strangers will be honest about their vaccination status. People don’t make decisions about the present in a temporal vacuum. They integrate across their past experiences. They learn. Some have learned that the CDC can be slow in its assessment of evidence, or confusing in its proclamations. They watched their fellow citizens rail against steps that would protect one another from infections at a time when the U.S. had already weathered decades of eroding social trust. They internalized the lessons of a year in which they had to fend for themselves, absent support from a government that repeatedly downplayed a crisis that was evidently unfolding. “We had no other protections all year,” Gold said. “We had masks. No one else protected us. It’s understandable that people would be hesitant about taking them off.” For some people, taking off a mask will mean just exposing the bottom half of their face. But for others, it signifies that they must reevaluate their understanding of risk and danger yet again, with fewer emotional reserves at hand. “I feel more clingy towards the routines I’ve established,” Whitney Robinson, a social epidemiologist at the University of North Carolina at Chapel Hill, told me. “Summer feels like an unknown, and kind of exhausting. [It means] navigating new situations, reestablishing relationships, and deciding on COVID norms. It feels tiring.” Nicolette Louissaint was tired when I first spoke with her last June, and she is tired still. Louissaint is the executive director of Healthcare Ready, a nonprofit that works to prepare for disasters by strengthening medical supply chains. She and her team started working full tilt in January 2020, well before most of the U.S. took COVID-19 seriously. The work has taken a toll, and isn’t over. “Our personal lives are stabilizing, but there is still this fatigue from our professional lives,” she told me. “And we’re less than a month from hurricane and wildfire season.” Those who work in emergency preparedness talk about panic-neglect cycles, where people and politicians lose interest in a crisis once it abates, withdrawing attention and resources that are needed to prevent the next one. Louissaint worries that the U.S. is set to go through that cycle again. “There’s a sense that political will and energy is now there, and might not be in a year,” she said. “At some point, no one’s going to want to hear about this anymore, so we’ll be fighting for infrastructure and investment, and we’ll be right back to where we are. Even now, when we do our normal trainings to get communities prepared for natural disasters, the feedback we often get is, ‘Oh my God, I can’t even think about that right now,’” Louissaint told me. “So what happens when we have to face it?” I asked her what she says to people who have just had enough, who feel that they’ve maxed out on their quota of catastrophe, who just want to move on from the pandemic, or who equate talk of preparedness with fearmongering. “I think there’s a difference between sitting around fearing that the worst will come, and actually understanding the things we must be prepared for,” she said. “If we were more prepared, we wouldn’t have to worry as much.” “If you don’t want to have this conversation anymore, I understand. I don’t either,” she added. “My challenge is: How do we get to a position where we can afford not to?” from https://ift.tt/2RxvxOG Check out http://natthash.tumblr.com
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Restaurants are back, baby! Head over to that reopened neighborhood joint, and snag a table with some friends you haven’t seen in a year. Overpriced cocktails have never sounded so good. Sit on the patio, and take in late May for all it’s worth. Oh, the waiter’s coming over; have you decided on drinks yet? Sorry, what’s that? I can’t hear you. Can you shout a little louder? Uh ... did something just fly into your face? The cicadas are back, baby! From Illinois to Washington, D.C., trillions of horny, red-eyed critters are just about to burst out of their 17-year slumber to blast mating calls as loud as rock concerts. And if that’s not annoying enough, Brood X will envelop everything in its path--lawn-mower operators, beware—before the bugs’ remnants turn your afternoon stroll into crunchapalooza. For a few excruciating weeks, all of this could make outdoor dining in some areas feel like a Hitchcockian hellscape. Some restaurants squarely in the path of the cicada-nado are already anticipating fewer customers at their rooftop bars and umbrella-shaded tables: Last week, Little Pearl, a wine bar in Washington, made the call to halt all service for a month, in part to spare diners the pesky cicada screeches. Lots of industries have had it tough during the pandemic, but the past 14 months have been what-in-holy-hell-is-happening bad for restaurants. Last March and April, nearly half of workers in the business lost their jobs when cities first shut down. By the end of 2020, more than 110,000 restaurants had closed for good. The survivors are lucky to merely be in the red. Now that more and more Americans are getting vaxxed up and are eager to eat out, restaurants, at long last, have their big chance to get back on track. The problem is that angsty teen insects might have something else in mind. [Read: The biggest party of 2021 is about to start] If any establishment in America knows what cicada season does to a diner’s inclination to eat outside, it’s Arnold’s. The Cincinnati bar and restaurant opened in 1861 and has withstood nine Brood X cicada swarms. Ronda Breeden, the former owner, told me that in 1987, “the cicadas were terrible in our courtyard, on the sidewalks, everywhere. There were definitely fewer people eating on the courtyard then. People just couldn’t deal.” (Another Cincinnati restaurant had a weirder problem that summer: Two men armed with nothing but a single cicada used the bug to spook a cashier before running off with $25.) There are three things to keep in mind for outdoor dining in the middle of cicada season, says Gene Kritsky, a cicada expert at Mount St. Joseph University: trees, trees, and trees. “That’s the ideal habitat they want,” he told me. During the last Brood X assault, in 2004, he ate outside in a wooded patch of northern Kentucky, and the cicada noise was so all-consuming that it took the fun out of outdoor dining. Restaurants in tree-starved city centers might be spared the absolute worst, but those in even slightly less concrete-laden places could be in for that frustrating buzzing din. Every summer, Baltimore’s Blue Pit BBQ fills up with customers who come to chill out on the tree-lined patio, often with their dogs in tow. But this summer, Cara Bruce, a co-owner, is nervously eyeing the cicada holes in her neighborhood. “I’m worried about them falling into people’s food,” she told me. “I’m worried about them being so loud that people can’t hear each other. I’m worried about cicada rain flying in people’s faces.” Daniel Souder, a co-owner of Pleasantry in Cincinnati, told me that the restaurant and wine bar had reopened full-service dining last week. Rebounding from the pandemic, he said, hinges on making use of every table he has this summer—including some on the patio and a handful along the street. “Cicadas are definitely another punch,” he said. [Read: Cicadas have an existential problem] What is so perversely devastating about cicada season this year is that the darn insects are poised to make outdoor dining a nuisance right after restaurants spent so much time and money perfecting their outdoor-dining game. Baltimore’s La Cuchara installed a tricked-out 60-foot tent, and even tried adding a 10-foot-by-10-foot fan, until it blew customers out of their chairs. A survey by OpenTable found that from March 2020 to March 2021, the percentage of total dining that happened outside four walls jumped by a factor of 12, buoyed by relaxed rules that let restaurants make use of city sidewalks and parking spaces. Those “streeteries” will continue to be a substantial part of restaurants’ revenue equation this summer, according to David Henkes, a restaurant-industry analyst at Technomic. A chunk of outdoor-or-bust Americans still aren’t quite comfortable eating inside after a year in which that was among the riskiest things you could do. And even if indoor dining rooms fill up, a few tables outside will help restaurants avoid turning away would-be customers. “Summers are always important for restaurants, but doubly so this summer after the past 15 months,” Henkes told me. [Read: An extinction event for America’s restaurants] Naturally, restaurants are doing everything they can to prepare for the coming bug tsunami. Ben and Amy Lefenfeld, who co-own La Cuchara, have considered renting out a forklift to cicada-proof their giant tent with nets. “Certainly we can replace anyone’s food if a cicada flies into it,” Amy told me. Bruce, of Blue Pit BBQ, has resigned herself to firing up a leaf blower and de-cicadaing her patio at the end of each day. Other restaurateurs were, dare I say, excited. I heard about plans for “Brewed X” beer, cicada dust that “tastes like asparagus,” and “cicada lemonada,” made with gin, raspberries, basil, and, thankfully, no actual cicadas. Tobias Padovano, a chef at Cocina on Market in Leesburg, Virginia, hopes diners on his rooftop will get a glance at some live cicadas as they’re munching on his foraged-cicada tacos, served with radishes and an avocado salsa verde. Whatever havoc the cicadas wreak, your favorite brasseries and neighborhood cafés likely have bigger problems right now. Barry Lowenthal, the general manager of the Brass Tap in Baltimore, can’t find enough craft beer to fill up the taps in his bar. Bruce posted a job listing for Blue Pit BBQ and expected as many as 100 applicants; she got two. “Why couldn’t the cicadas just have come last year?” she said. After everything the industry has been through, a mass invasion of prehistoric-looking banshees just as things are looking up is not exactly the chef’s kiss that restaurants were hoping for. from https://ift.tt/3fyZANI Check out http://natthash.tumblr.com If you have been fortunate enough to receive a COVID-19 vaccine, you also possess an essential, high-tech tool for proving your immunity to others. Just kidding, it’s a piece of cardstock. On the flimsy rectangle that all Americans get with their shots, doctors and pharmacists record dates of administration, vaccine type, and lot number. Some scrawl the information by hand with a pen; others apply a preprinted sticker. The cards offer no special marker to prove their authenticity, no scannable code to connect to a digital record. At three by four inches, they’re even too awkwardly sized to fit in a wallet. A mid-century polio-vaccine card doesn’t look too different from today’s COVID-19 vaccination records. Distributed by the CDC to those administering the vaccines, these cards are supposed to help recipients get the correct second dose, if needed, and offer a personal record, Jason Schwartz, a Yale public-health professor, told me. But they’ve taken on a considerably grander importance as pandemic restrictions have eased in the United States—especially now that the CDC has okayed vaccinated people going maskless in most places—because they’re the only thing available to all Americans that shows someone has been vaccinated. When you get a COVID-19 shot, the information goes into a digital record kept by the state where it was administered, and that’s the end of the road. The CDC does not hold records of individual vaccinations, and the White House has indicated that it has no plans for a federal database. (Neither the CDC nor the Department of Defense, which ran the Operation Warp Speed vaccine program, responded to my requests for comment.) This setup has made things complicated for businesses, employers, universities, restaurants, concert halls, airlines, and any other institutions that want to verify people’s vaccination status as the country reopens. It’s easy to say that customers, employees, or students need to be vaccinated, but it’s much more difficult to check that someone really is. A few states have created or promised more technical “vaccine passport” systems—usually smartphone apps connected to state databases—that could confirm people have been vaccinated against COVID-19. But many Republican-led states, including Texas, Florida, and Arizona, have opposed or even banned the implementation of any sort of vaccine verification system, mostly citing government overreach. The verification methods that places choose, if any, will certainly influence people’s behavior. At the same time, what requiring an immunization means is easy to misconstrue. America is simply past the point when any system could reasonably offer a foolproof, fraud-proof, universal method of confirming that someone has gotten a COVID-19 shot—flimsy cards and scattered apps included. Instead, we are bound to rely on the same method Americans have always had when it comes to proving vaccination: an honor system built on mutual trust. In many cases, the imminent future of vaccine verification will probably follow the model of a cashier who asks for ID when you present a credit card. In the same way that the cashier looks to see that it is an ID, or that the photo matches your face, a vaccination gatekeeper might glance at a piece of paper or your phone screen to check that some sort of documentation exists—and not, for instance, scan anything to confirm that the document is legitimate and that antibodies are indeed coursing through your tissue and blood. Especially in verification-shy states, things might not even go that far; citizens will “prove” their status by simple attestation. But for any place that decides to require a vaccine card or passport for entry, the cashier method won’t validate much either. Given the political animus and misinformation surrounding COVID-19 policies of all kinds, it’s no surprise that some opponents of vaccination realized they could abuse that trust by buying or stealing blank vaccination cards. Earlier this month, the owner of a bar in California was charged with selling fraudulent cards. In The Washington Post’s coverage of the arrest, a security expert estimated that forgery “is more widespread than we even think at this point.” Digital vaccine-passport systems overcome vaccine cards’ awkward physicality, but just as hygiene theater turned cleaning into a false sense of pandemic security, vaccine passports risk becoming verification theater, especially if deployed in only a small number of states. In March, New York launched Excelsior Pass, a free app that claims to provide secure vaccine verification for entry into venues such as theaters and stadiums. Hawaii plans to introduce a system backed by the same company, and California has adopted a policy that seems to require a similar app. Excelsior Pass does plug into state databases to produce a screen or printout with a barcode that can be scanned by another app. But this is all limited by the fact that the database records only shots administered in New York State. And the app isn’t magic; not much is stopping someone from sharing their own screenshots or printouts with someone else. [Read: A better solution than laminating your vaccine card] When I asked an Excelsior Pass help-desk agent how a business could confirm that a pass actually belonged to its holder, she said it was the first time anyone had asked that question. “As far as I know, there is no way,” she said. A vaccine-scanning agent could check the pass against a holder’s ID, but only a name and date of birth appear on the Excelsior Pass anyway. The New York governor’s office told me that hundreds of thousands of New Yorkers are downloading Excelsior Pass each day, and that “passes must be verified against a photo ID.” In a high-traffic environment such as a stadium or even a restaurant, though, it’s hard to believe that everyone will take the time to do so. None of this is to say that lying and forgery will necessarily be as big of a problem as some coverage has suggested. Millions and millions of Americans have received a shot or are eager to get one. And just because faking it is possible doesn’t mean that most people who oppose vaccinations will happily leap into deceit. (In March, the FBI warned that producing or purchasing vaccine cards is illegal.) But any practical consideration of COVID-19 vaccination requirements in the U.S. has to contend with the fact that hopes to require vaccinations in the first place only go so far. Other countries may not be better off. Some have devised a variety of high- and low-tech solutions to provide universal vaccination verification, including a European Union–wide digital pass and printable QR codes in Israel, which have limitations similar to those of the U.S. systems. But America’s scattershot, state-specific approach makes meaningful widespread verification all the more a fantasy. Don’t we confirm vaccination status all the time, and for much less scary diseases? No, we do not. Vaccine mandates can effectively increase immunization rates, but mandate has mostly meant encouragement, not requiring demonstrable evidence. Vaccine verification in America has been janky from the start. Vaccinations have always been recorded primarily on paper, and evidence of immunity has always been based largely on trust. Real verification of any vaccination remains, at the most basic level, pretty difficult. Every state maintains an immunization registry that records new vaccinations, but no matter the state, these systems record only vaccines administered in the state. If you move, your new physician could record your earlier shots on a paper record, but not an electronic one. In this way, digital vaccination records are typically less complete than paper ones. And nearly all states allow citizens to opt out of the vaccine registry anyway. Citizens usually can’t access their own records, and when they can, the process is not fast or easy. In some states, only medical offices can access digital vaccine records; in others, select agencies such as child-care facilities and schools are authorized to access them. Many companies are planning to mandate COVID-19 vaccines, which is perfectly legal under certain conditions, but these mandates can’t amount to much more than asking employees if they’ve gotten a shot. Even then, exemptions would likely be in place for reasons of disability or religion—and medical inquiries of certain kinds might run afoul of the Americans With Disabilities Act. The most common reason to need an immunization record is to enroll in school. In Georgia, where I live, new students must file a document, Form 3231, before they can register. A physician is supposed to fill out this form, which amounts to little more than a series of blank fields for various immunization dates. An FAQ from the Georgia Department of Public Health indicates that “only health departments and physicians licensed in Georgia can obtain blank immunization certificates,” presumably to control access to this official record in order to prevent misuse. But when I performed a simple Google search for Form 3231, the third result linked to exactly that, a blank immunization form. If someone wanted to, they could easily falsify the dates and claim inoculations they hadn’t really gotten. (The Georgia Department of Public Health didn’t respond to my request for comment.) [Listen: The crime of refusing vaccination] One big difference between an immunization record and a COVID-19 vaccination card is that the official record is signed by a health-care provider. Forging this signature could amount to committing a felony in all 50 states. This appears easy enough to get around: Some vaccine-record fraud has been perpetrated by complicit doctors. But also, the data on these forms might hardly be verified in the first place. Schwartz, whose research at Yale focuses on the history and public policy of vaccination, suspects that these documents are checked to see if they look like medical records, but not for much else. “If it passes that very low bar of looking plausibly accurate, I suspect that is considered good enough,” he said. Even international verification faces similar limitations. In the case of vaccines recommended or required for travel abroad (such as those for yellow fever, typhoid, and rabies), most countries rely on the International Certificate of Vaccination or Prophylaxis, provided by the World Health Organization. That instrument is—wait for it—a yellow card with written inoculation records accompanied by medical stamps or signatures. America’s resolutely patchwork approach to vaccine verification is not a failure of imagination. Schwartz noted that the technical hurdle is relatively surmountable; given verifiable vaccine billings to Medicare, Medicaid, and private insurers, along with the state databases, you could get a pretty comprehensive accounting. Eventually, in theory, some aggregation of state immunization registries could make the fantasy of a countrywide vaccine passport a reality. But the U.S. has already chosen a different path. Introducing a universal vaccine passport would not change the cultural, psychological, and civil-libertarian resistance to a national medical-certification system. When vaccination becomes an amorphous, cosmic battle of national political division, getting people to accept inoculations—which is the goal—becomes even harder. The existing recordkeeping system has worked well enough over the years, and so it will likely persist: Scribbles on sheets of paper, some signed and some not, will corroborate protection. COVID-19 vaccination cards will give way to … more cards or papers, probably. Perhaps signed by a doctor this time. Perhaps with a barcode that systems such as Excelsior Pass might read. The honor system will persist too, like it does with most documents and identification. If you’re a vociferous vaccine advocate, this can easily sound disheartening. But that shouldn’t necessarily be the case. Remember that mandates have mostly meant strong, official encouragements, not verifications. On the one hand, it’s understandable to be wary of going much further: In China, COVID-19 tracking has expanded the nation’s already concerning use of health data for citizen monitoring. On the other hand, the solutions currently on offer in the U.S. overlook the fact that the main hurdles to vaccine mandates are not technological. The whole vaccination apparatus just hasn’t sought this level of verifiable confirmation before. But verifiable confirmation is exactly what vaccine passport implies. That makes it a wrongheaded way to understand vaccine record-keeping. Vaccination records aren’t even trying to be secure, official documents, like driver’s licenses and passports. Instead, they are more like paper contracts—documents whose contents become “true” given a medical professional’s imprimatur or review. A “passport” suggests a universal infrastructure for recording, documenting, retrieving, and analyzing changing vaccination information in real time. That is not our actual situation. For Schwartz, the core challenge for vaccines as a part of public health doesn’t have much to do with verifying inoculations. Rather, it has to do with striking an appropriate balance between carrots and sticks. Without widespread support for vaccination, and the COVID-19 vaccines in particular, the ability to enforce its uptake will fail. “I worry about passports and permission to travel becoming the focal point,” Schwartz said, “when we really need to focus on helping to sell these vaccines.” To do that, it might be better to reframe what a “vaccine mandate” really means. Instead of an impersonal, technical ratification infrastructure, it boils down to asking people if they would please get vaccinated, and trusting that they have if they say they have. To accomplish that goal, Schwartz has a decidedly low-tech suggestion: “Focus on the preexisting communities where we have relationships and bonds.” Workplaces and schools, where people are already bound to others in an organic way, are a good place to start. According to Schwartz, if an organization you trust, such as your office or school, leads the charge from the grass roots in encouraging its community to get shots, more people are likely to do so, even if the documentation is imperfect. Extra incentives, whether in the form of free donuts, cash lotteries, or mask-free living, can also help. From there, the immunity conferred by a commitment to act safely among schoolmates or work colleagues would carry over to restaurants, airplanes, and concert venues. It’s more manageable than a top-down system of compliance, to which Americans respond poorly. No matter the appeal of a universal certification that would give businesses, airlines, theaters, and the public who uses them peace of mind about the vaccination status of those around them, Schwartz considers the cultural barriers to implementing such a system “insurmountable.” Establishing and relying on real mutual trust among citizens shouldn’t feel silly or foolish. That is not the current condition in America, to be sure. But we would be remiss to give up its possibility or dream of replacing it for good with an app. from https://ift.tt/3tHhR0w Check out http://natthash.tumblr.com The United States is rapidly encasing itself in a bubble of immunity. Heading into a quite possibly wonderful summer, more than half of adults are at least partly vaccinated against COVID-19, and their masks are coming off. Some will be rewarded with a million-dollar prize. The rest can wander into any CVS when they feel so moved. Soon that luxury will extend to tweens. By July 4, according to President Joe Biden, the bubble will be near completion. AsAmericans celebrate their independence, though, all indications suggest that the coronavirus pandemic will be raging. Only about 3 percent of adults are vaccinated in India, where a dangerous variant is spreading and tens of thousands of people are lost every day (based on very rough estimates from overloaded crematoria). In parts of Africa, almost no one is protected. The virus is tearing across South America. The contrast with the U.S. could not be starker. And we are doing very little about it. This has always been a tale of two pandemics: One for the rich people who can work anywhere while others bring provisions to their door; another for the poor who must work in risky conditions if they are to keep food on their own table. But until now, the fates of entire countries didn’t clearly track on the basis of wealth. The U.S., for example, has the most expensive health-care system in the world, and was also the hardest hit in 2020, while many countries with far fewer resources suffered far less. Writing in The New Yorker in February, Siddhartha Mukherjee pondered how India, by contrast, could have spent so little money (and done relatively little locking down), and yet seemed, at that point, to have escaped the worst of COVID-19. Was it something to do with the climate? Genetics, lifestyle, hygiene, immune-system differences? [Read: A simple rule of thumb for knowing when the pandemic is over] The answer turned out to be: no. These factors almost certainly play some role in determining the scope of outbreaks from place to place and community to community. But the biggest variable may have beenwas luck. And that luck was always temporary. Not until many months after New York City became the global epicenter of the pandemic did certain parts of the U.S.—especially in the Midwest—experience a first surge in cases. But ultimately no state was spared. And the virus is more likely to keep coming back to places where people think the pandemic is over without decisive action to drive down the virus everywhere. This is the point we continually fail to grasp. Since the day President Biden took office, and much more frequently of late, he has taken to repeating this sentiment. In January, he promised to lead a global effort to eradicate the virus: “History is going to measure whether we’re up to the task. I believe we are.” But no plan for eradication has been proposed. Instead, we’ve tried to have it both ways: saying that we care about global health and are doing everything we can to protect it, while at the same time hoarding hundreds of millions of vaccine doses, as well as the technologies and information necessary to produce more. We have even struggled to admit that Biden’s vaccine policy so far has largely amounted to a continuation of Donald Trump’s: America first. The amorality of this tack is clearer by the day. In the early pandemic, when little was known about how to prevent or treat the disease, countries with material resources weren’t at quite as much of an advantage. A dearth of ICU beds could be compensated for by conscientious individuals. The countries that got by were those where citizens took basic preventive measures, governments supported people who needed to stay home, and robust, depoliticized lines of communication existed between health officials and the public. Vaccines have changed the equation. Now even the U.S. is doing okay. Soon we will be vaccinating healthy 12-year-olds, while high-risk people in many countries continue to fill hospitals. Yet it’s uncouth to even mention this. After I tweeted this sentiment last week, the newscaster Mehdi Hasan cited my tweet in an interview with Anthony Fauci, who gave the administration’s standard line. He would “look at it another way,” he said, wherein we try to protect ourselves and those in other countries at the same time. “We’ve got to do everything we can to get people in low- and middle-income countries vaccinated as quickly as we possibly can,” Fauci said. That’s unrelated to the need to vaccinate kids in our own country. Vaccinating kids is urgent. We obviously need to pursue vaccination both at home and abroad. But we are not. In April, the Biden administration announced that the U.S. would give away 60 million AstraZeneca vaccine doses (which we didn’t need) to other countries. Even that is enough to cover only about 4 percent of India’s population. Giving away surplus doses won’t solve the problem, any more than shipping unsold grocery-store blueberries back around the globe would solve world hunger. Waiting for a few wealthy countries to supply the world with vaccines in future pandemics would doom us to repeat tragedies such as the current horror in India. Meaningful action would focus on building up production capacity and supply chains everywhere, not simply to honor the basic sanctity of human life, but because the emergence of variants and new viruses threatens us all, everywhere, constantly. That threat could be eliminated by ensuring that rapid vaccination is available worldwide. If we don’t establish a better system of production and distribution, every future pandemic will split us in two. In this moment, disparities may seem inevitable. To some degree, they are. We can’t simply ship excess doses of the mRNA vaccines around the world, for example, on account of their cold-storage requirements and relatively short shelf lives. Vaccine doses that Americans opt not to take won’t end up being flown to Africa; they’ll go to waste. It’s also true that vaccines are being produced by dozens of companies around the world, and if these companies could simply ship more doses, they would. Pharmaceutical companies don’t intentionally leave money on the table. The big pharmaceutical companies, as well as Bill Gates, have made exactly this argument: Vaccines are already being produced as quickly as possible. But if we’re maxed out on production, this is by design. It’s the result of decisions that the U.S. has made throughout the pandemic—most notably Trump’s refusal last September to sign on to a global coalition to ensure the equitable distribution of vaccines, known as COVAX—that have perpetuated a system of pharmaceutical sales that we have built over decades. Taxpayer money is used to fund basic science research, and then pharmaceutical companies develop products based on this research and sell them back to the government. (Medicare is the largest drug buyer, and it is not allowed to negotiate what it pays.) U.S. taxpayers have already, under Trump, contributed some $14 billion to the development and manufacturing of patented COVID-19 vaccines. That’s in addition to the billions spent over decades on the NIH-funded research these technologies are based on. The drug industry claims that if companies such as Pfizer didn’t stand to profit in the billions, they wouldn’t have invested to advance the technologies involved in developing and producing vaccines. But this same argument also illustrates the danger of such a system: Our emergency-preparedness plan for a global disaster depends on an industry that will not come to the rescue unless it stands to cash in. To rely on a handful of private companies to end the next pandemic, too, amounts to a cosmic roll of the dice—especially when those companies will not make guarantees of equitable distribution, or of production past the point at which a profit can be made. [Read: America’s patchwork pandemic is fraying even further] Adapting this system would bring us much closer to doing “everything we can” to get the world vaccinated, as Fauci suggested is the goal. Biden announced last week that his administration would take measures to waive patents for COVID-19 vaccines. This is an important, if incremental step. As the pharmaceutical industry has pointed out, making vaccines—particularly mRNA vaccines—is technologically difficult and requires investment. On its own, releasing patent rights is sort of like Tesla publishing its design secrets on Reddit. If other car companies wanted to produce exact replicas of Teslas, they could … eventually. But getting started would take a lot of time and money, and these companies wouldn’t make that investment unless they thought they could sell enough Tesla knockoffs to make it worth their while. Vaccines are more like fire trucks than Teslas, though. When your house is on fire isn’t the time to start building a fire truck. If your neighbors see the blaze and hand you plans for how to build an aerial ladder platform, you are not grateful. Global manufacturing and distribution systems for vaccines cannot be built immediately, and the release of IP at this point does not constitute a plan of action. The world stands waiting to see whether Biden will push the World Trade Organization to waive the patents—and do so in a way that encourages countries and governments to invest in long-term production. (Moderna has voluntarily shared its IP only “for the remainder of the pandemic.”) We’ll need to fortify and maintain supply chains, facilitate technology transfers, and build up genomic-sequencing capacities around the world so that new viruses or variants can be identified and boosters or new vaccines adapted accordingly. This is not a small task. But this moment could forever change precedents for how vaccines and even other drugs are produced and sold—who can and can’t afford them. One of the few things on which Trump and Biden ostensibly agree is that drug prices are far too high. The issue has long had broad, bipartisan support among nearly 80 percent of Americans. It’s in everyone’s interest to set up sustainable systems for development and production everywhere—of vaccines, at the very least—that can kick into action as soon as a new virus or variant emerges. The components of this system should function more like fire departments than factories for luxury goods. Vaccine production needs to happen in emergencies regardless of profit or shareholder interests. Vaccines could be seen as public goods that are vital to global security, not as part of a humanitarian cause or charity issue. If the past year has taught us nothing else, it’s that every human has a personal interest in a world where every other human has quick and ready access to vaccines against emerging pandemic viruses. An effective global strategy would allocate vaccines to the places where they would do the most to stop transmission, minimize death, and halt the spread of a dangerous virus before it can turn into a pandemic—let alone two pandemics. Such a system could stand as the enduring legacy of the Biden administration. If he’s willing to stand up to the industry. from https://ift.tt/3onT00H Check out http://natthash.tumblr.com When the Biden administration announced support for waiving COVID-19 vaccine patents last week, it was met with praise, relief, skepticism, and alarm by different groups—but surprise all around. Pharmaceutical giants have long fought efforts to have their intellectual property released to meet international needs. And they’ve backed it up with immense political muscle. Could this time be different? Would it discourage future research, as critics such as Bill Gates claim? And how much (and how quickly) could it help? To understand the issue, James Hamblin and Maeve Higgins are joined on the podcast Social Distance by Julie Rovner, the chief Washington correspondent for Kaiser Health News. Listen to their conversation here: Subscribe to Social Distance to receive new episodes as soon as they’re published. What follows is a transcript of their conversation, edited and condensed for clarity: James Hamblin: What was your reaction to that news last week when the Biden administration indicated that they would be backing patent waivers? Julie Rovner: Well, of course, because I cover politics, my first inclination was political. It was like, Wow, the Biden administration is doing something that the drug industry really doesn’t want them to do. And, of course, the drug industry is flying high right now. Everybody loves them because they brought us these miraculous vaccines. But someone reminded me that [President Joe] Biden did, in fact, promise to do this patent waiver back last summer. So it was a campaign promise. Maeve Higgins: I’m over in Ireland and some of the E.U. leaders have said this isn’t going to make the biggest difference. Do you think they have a point? Rovner: I think it’s not going to make a difference right away. And, in fact, the CEOs of the companies making the vaccines are worried about competition for the raw ingredients that they need to continue to make the vaccines. I was at a meeting with the ambassador of one of the E.U. countries ... [and] he did say that it was really important that less-developed countries not just get vaccines from more-developed countries but that they actually manufacture their own vaccines. I had not heard that before. This was a month ago [and] this was a country that makes its own vaccines. He thought this waiver was really important. He really wanted to get the rest of the world up and running. Obviously, it will take a very long time. It’s not going to help India with its current crisis. India needs vaccines. India has lots of vaccine manufacturing. So I think it may be a long-run thing. The other question is: Is this the first nose under the camel’s tent about intellectual property and waiving patents? Particularly for the very powerful drug industry, which I know is powerful, not just in the U.S. but also in other parts of the world, including the E.U. Hamblin: So, just to clarify the terms, these patent waivers would mean Pfizer would kind of upload its plans ... Higgins: It would put them on TikTok and anybody could screenshot them ... Rovner: It would be a recipe. It would be like Tasty for vaccines. Hamblin: Yeah, but not everyone can just go make a vaccine in their kitchen. It still requires a lot of overhead, and time to ramp up, and technology. And so the question is: Are there actually companies out there that would make that investment if they could get the IP? And hasn’t Moderna already shared theirs, and not a lot of people took them up on it? Rovner: I would think the companies would want to, but these are not easy vaccines to make, particularly the mRNA ones. I don’t think it would be that simple for even some of the countries that have vaccine-manufacturing capabilities to necessarily do these quickly. But it’s definitely an interesting prospect, assuming the World Trade Organization goes ahead and does this. Remember: This is just us supporting it. The W.T.O. actually has to do it. Assuming that they do, it’ll be interesting to see what happens with it. Higgins: Is Biden just potentially really upsetting the pharmaceutical industry, while not necessarily taking a meaningful step to actually help the countries that desperately need vaccines? Rovner: The U.S. is also doing other things to help countries that desperately need vaccines. There’s been a lot of concern about the U.S. [being] slow to help India. And there is this lingering irritation of “Why are we vaccinating 12-to-15-year-olds when there are so many countries in the world that can’t vaccinate anybody yet?” What obligation does the U.S. and all the developed countries that now have these vaccines have to less-developed countries? And [there’s a] continual reminder that people don’t appreciate that: Nobody is safe until everybody is safe. There are countries that are basically on fire and creating new variants that could undermine all of the vaccinating that we’re doing now. Hamblin: Do you have concerns about the argument people like Bill Gates have made, that if we set a precedent now that vaccine patents can just be made public, that there will be even less investment from the industry in vaccines we might need for future pandemics? Rovner: Well, my impression is that most of the investment was made by the government. (Laughs.) Higgins: (Laughs.) Yes! Hamblin: In point of fact, yeah. Rovner: Drug companies are still not investing that much. And drug companies not investing in vaccines is not a new thing. I’ve been writing about it for 20 years. And there is this whole argument—and I’ve been covering drug prices since the 1980s when we first started complaining about them, maybe before that, but that was when I started—and drug companies have always said, “If you don’t let us make big profits, we won’t have money to invest into the next lifesaving medicines. Drug companies have been investing in things that are not vaccines for a really long time, so I’m not sure how much of a precedent this sets for intellectual property on other drugs, but certainly it’s something that the drug industry is not thrilled about. I was amazed at how quickly the reaction started flooding into my inbox when this was announced last week. I mean, within seconds. Hamblin: And the argument is like, “This is going to destroy access to so many medications.” Or, “We won’t be able to do our jobs if we don’t have a billion dollars in profit.” Rovner: Basically, yes. “You take away the incentive for us to sink money into it if you’re just going to give away what we discover.” And this is not a new argument. This has been the argument about drug prices too. “If we can’t earn unlimited profits, then we won’t have money to put into R&D.” That’s effectively what they’ve been saying since the 1980s. Hamblin: Yeah. But it’s an effective argument. Rovner: It’s an extremely effective argument. I always say: The two industries we’re forever haranguing are the drug industry and the tobacco industry. And, unlike the tobacco industry, the drug industry makes things we want and need. Hamblin: Is it a bundling issue? Could we just have companies that just make vaccines? That way they wouldn’t be able to say, “We’re not going to make vaccines because we need the money to invest in cancer research.” It becomes very muddled and complicated. Rovner: It does. I mean, there were not enough companies making childhood vaccines for a while. This is not a new thing. They don’t make as much money off of vaccines, which you give once ... Well, the flu vaccine you give every year, but generally, childhood vaccines you give once, maybe twice, rather than a statin drug that a lot of adults will take every day for 20 or 30 years. Vaccines are sort of the least-profitable piece of the drug industry. Hamblin: Because they work so well. Rovner: That’s right, yeah. We have problems with antibiotics for the same reason. Which is to say: You don’t take them constantly. You just take them when you’re sick. Hamblin: Does the kind of pandemic matter here? This is a global emergency for everyone in the world. Do you think the kind of emergency we’re seeing now incentivizes research for another disease that could pop up? Rovner: We’ve obviously never had this kind of a global pandemic before. And that’s part of the problem. Even when we had Ebola, we could send everything to the one place where it was. This is a true pandemic. And I do think that things are different. Although a lot of scientists are expecting that this will not be the last pandemic, [and] that as we have these diseases that jump from animals to people that people have no resistance to, it could happen again. And it could conceivably happen again with something that’s even more deadly than this one. I mean, it’s definitely uncharted territory, but I think people are kind of looking at it to see [whether] we’re going to have a different feeling for how public health and the medical system work. I was interested at the beginning to see how the nation’s various health systems were able to deal with this. And I realized very quickly that it wasn’t so much a test of health systems as it was a test of public-health systems, and that places that had good, very robust public-health systems were better able to deal with it than places that necessarily had universal health care. Hamblin: If you could take politics out of it, how should we get the global vaccine supply into a more sustainable place where we’re not having to rely on hoping that companies come through for us next time? If companies won’t do so unless they can be guaranteed a large profit, how do we get around that to have a sustainable plan for the future? Rovner: Well, you know, if we had a functioning U.N. and a functioning World Health Organization ... and that’s what COVAX [COVID-19 Vaccines Global Access] is. I mean, that’s the idea that the wealthier countries are going to come together and help fund vaccines for the poorer countries who can’t do it themselves. Because, as I said, no one is safe until everyone is safe. So, there is self-interest in this too. One would hope that self-interest would help this along. Hamblin: We have that in abundance. Rovner: Yes, we definitely have that in abundance. But I think people don’t see it. This is the constant: “Why do we give money to other countries? Our foreign-aid budget must be huge. Why should we give money? Why do we care if the rest of the world is at war?” Well, we get a lot of our stuff from the rest of the world, which I think we’re discovering now. The disrupted supply chains are an eye-opener to a lot of people. Hamblin: How much can you see the influence playing out of the money that Big Pharma donates to politicians? Do you kind of see that happening like clockwork in your work, or is it more subtle? Rovner: With the drug companies, it’s not that subtle. They do give a lot of money to lawmakers, and lawmakers tend to do their bidding. And it’s not just Republicans. They give money to Democrats, and there are Democrats who are kind of loath to cross the drug industry. This is why Congress has been fighting about drug prices for 40 years and still hasn’t really done anything about it. They haven’t even done some of the very low-hanging fruit, like letting drug companies buy off their generic competition temporarily, which helps the generic company because they’re getting paid, and it helps the brand-name company because they don’t have competition. And the only people who aren’t helped are the people actually trying to buy the drugs. That’s been one of these things that just about everybody agrees on. And yet Congress has had great difficulty doing even the easy stuff, much less the hard stuff that might actually do something about the price of prescription drugs. Higgins: I just keep thinking about insulin. I have friends who, immediately, when Biden made his announcement, they were just like, How about insulin? Rovner: Insulin is such a good example because the original patent for insulin was sold for $1. The whole idea was that insulin wasn’t supposed to make money. And yet all of these little variations on insulin now cost hundreds and thousands of dollars. And we’re seeing people in the United States literally dying because they’re diabetics and can’t afford their insulin. Hamblin: And this is coming off of a presidency where Donald Trump said many times that we need to do something about drug prices. He would get cheers at his rallies for it, and Biden has said the same thing. It would seem like there’s bipartisan support for this to happen. And Americans certainly want lower drug prices. And yet here we are. Well, what I would love to hear you say that this is a big, significant move and it’s one you think is really going to change things, waiving these patents. But unfortunately ... Rovner: I will believe it when I see it. Waiving the patents for vaccines is an important step, but I don’t know that it gets followed by anything else. I’d love to be proven wrong, but I have grown cynical about drug prices over almost 40 years of covering them. from https://ift.tt/3uL6h61 Check out http://natthash.tumblr.com When the third coronavirus surge hit the U.S. last fall, the midwestern states were among the worst affected. Thousands of people in the region were being hospitalized with the virus every day. It was at this inauspicious time that a team of transplant doctors at University Hospital in Ann Arbor, Michigan, received a pair of healthy-seeming lungs. According to a published case report, the donor had been in an automobile accident, and died from her injuries a few days later. She’d shown no signs of being sick, according to her family, nor had she been knowingly exposed to anyone with COVID-19. A radiologist did find an abnormality in her right lung but chalked it up to damage from the accident. Meanwhile, a nasal swab, taken at the hospital, confirmed her infection status: She was negative. The patient for whom those lungs were meant to be lifesaving—a woman with chronic obstructive lung disease—also tested negative for COVID-19, in a nasal swab taken 12 hours before her surgery. But three days later, the recipient was in severe distress: She was feverish, with plummeting blood pressure, and she experienced such difficulty breathing that she had to be placed on a ventilator. Now she tested positive for the coronavirus. (One of the transplant surgeons, too, would end up sick.) In the weeks that followed, the transplant patient received the best available COVID-19 treatments, including remdesivir and convalescent plasma, but doctors couldn’t save her. Two months after the procedure, she was dead. A reexamination of respiratory fluid taken from her donor before surgery revealed the source of the infection: The transplanted lungs that doctors sewed inside her body had been teeming with the coronavirus. I’m a physician who specializes in diagnostics, so one quirk of my pandemic experience has been getting lots of text messages from my friends about the polymerase chain reaction. PCR is used in laboratories to identify everything from genetic conditions to infections to cancers, though you probably know it as the “gold standard” method for detecting SARS-CoV-2, the virus that causes COVID-19. The friends who texted me had gotten COVID-19 tests, and they wanted help interpreting their results. A COVID-19 test result seems straightforward on its face: You’re either positive or negative. But questions often follow: What if you feel a little sick, but your test has come up empty—can you risk going back to work? Or what if your test is positive, but you feel completely fine—should you repeat it later to confirm that you’ve recovered? How much later? In the early months of the pandemic, I muddled through giving advice to friends based on what was already known about the technology, and on the preliminary data coming out of China. Probably not, I said. Maybe so. A week or two? I couldn’t say very much with certainty. A year later, my colleagues and I have more and better facts to help us through this diagnostic slop. Now we know that a positive result on a PCR test won’t tell you whether you’re currently contagious, but it can say—with 99.9 percent accuracy—that you’ve been infected with SARS-CoV-2. As for false negatives, larger analyses suggest that about one in eight infections could be missed. There’s one specific branch of medicine where even these modest risks of error simply cannot be abided. For the more than 107,000 Americans who are now waiting for an organ transplant—and for those who have already received an organ—the stakes of COVID-19 testing are amplified many times over. It’s easy to understand how a missed infection in a donor could lead to deadly complications for the transplantee, as in the tragedy last fall. But a false-positive result—a COVID-19 case that isn’t real or is long-recovered—may be fatal too, when it delays or prevents an organ from reaching a desperate patient. It’s hard enough for frontline doctors to interpret a surprising test result. For those who work in transplant medicine, decisions made under this uncertainty could be irreversible. “It’s my worst nightmare,” Joshua Lieberman, a pathologist at the University of Washington who works on transplantation testing, said when I asked about the case in Michigan. He was particularly struck by the extent of infection found in the donated lungs. “There’s not a little bit of COVID in there. It is rip-roaringly positive,” he said of the PCR results—“like, a million times more virus” than he usually sees. How could that infection have been missed? Even at the start of the pandemic, we knew that patients could be admitted to a hospital with severe breathing problems but get a negative COVID-19 test result. One very early study, done in China, found that sick patients might test negative in samples taken from the nose, but positive in fluid from the lungs; it’s since been confirmed that a lung sample can catch about 13 percent more infections than a regular, nasopharyngeal swab. That’s why the American Society of Transplantation recommends this form of testing for every lung donation. Still, organ-procurement organizations have held off on mandating this. Not every lab can process fluids from the lung, Lieberman told me, so adding this one requirement might end up reducing patients’ access to a scarce resource. Lifesaving surgeries could be delayed. The problem is that even a very modest COVID-19 infection in a patient who has received a new organ has profound implications, Ajit Limaye, an infectious-disease physician at the University of Washington, told me. Patients who catch the coronavirus around the time of any sort of surgery are at a tripled risk of death. Those who have received new organs are still more susceptible, on account of their being sick enough to need a new organ, and their being on powerful immunosuppressive drugs to prevent rejection of that organ. One review found that among transplant recipients who became infected with the coronavirus, 81 percent needed to be hospitalized. (That hospitalization rate for the general U.S. population is estimated to be about 5 percent.) Even the usual rule of thumb for how long someone might remain actively infected are thrown out the window for transplant patients. While a case of COVID-19 typically lasts about two weeks, live virus has been recovered from immunosuppressed people more than two months after their initial infection. [Read: The audacious plan to save this man’s life by transplanting his head] But being overcautious about potentially infected donors can be deadly too. There is no safe option for patients in the medically fragile state of organ failure: A recent study found that people waiting for a kidney during the pandemic have been at a 37 percent greater risk of dying than people who were on the list before. Because the queue for kidneys is so long—about 90,000 people—this finding could mean “a substantial number of additional deaths,” the authors wrote. This is the catch-22 of COVID-19. The sickest people, such as those in organ failure, are at risk whether they choose to avoid the health-care system or to interact with it. Medical decisions involving organ donation are made all the more challenging by the time constraints involved. In the hours it takes to sort out an intended transplant recipient’s true infection status after a first, positive result—by repeating the test on a different PCR machine, for example, or scrutinizing how much viral material was detected—an organ may need to be diverted to someone else or discarded entirely. Limaye knows of transplants that have been canceled because doctors didn’t have a quick (enough) way to determine whether a patient’s infection as picked up by PCR actually posed a risk to them or others. Could the test have spotted a case of COVID-19 that was already resolved? Were the doctors willing to bet someone’s life on that presumption? Laboratory experts have developed some helpful ways to pick up false positives and false negatives on COVID-19 tests, from transplant patients and others, too. One thing they look for is an incongruent result. PCR machines check a sample for matches to multiple elements of the virus’s genetic code. When only one of those elements is detected, doctors might repeat the test to make sure it’s accurate. A microbiologist named April Abbott has also pointed out that, in rare cases, a sample’s viral load is so high as to be literally off the charts—and thus invisible to laboratory software. That problem can be solved, she said, by looking at the analyzer’s raw data, not just its automated result. Beyond a few simple improvements, though, there are no easy answers for doctors overseeing transplants. In these situations, a test result may serve as the basis for a life-or-death decision. Taking a careful medical history can help mitigate the risk of misdiagnosis, when combined with a physical examination and the results of other laboratory or imaging studies that have already been performed. Doctors then pull together all of this information to estimate a patient’s “pre-test probability” of infection—how likely they might have been to have COVID-19 before their swabs were sent off for testing. A probability isn’t a certainty, however. The Michigan doctors had been using just this logic when they decided to forgo any further testing on the lung donor: Because her initial swab was negative and she lacked any known symptoms or exposures, they determined that the risk of missing an actual infection was very low. Organs from deceased donors, which make up the majority of transplants in the United States, present a unique challenge for this careful clinical interpretation. Doctors cannot take a medical history from a patient who suffered brain death after a car accident or drug overdose. (In the case of the Michigan donor, the medical history was provided by the family.) Many of these potential donors are young and relatively healthy, so if they had been sick with COVID-19, they’re more likely to have had a mild case—and therefore to have been unaware of it. “They may have never been tested or had any symptoms,” Limaye said. “So we’re left with limited information.” Meanwhile, any positive test result from a deceased donor will probably mean their organs are removed from the system for good. Limaye worries that this “COVID Zero” approach may not be the right one for transplant medicine. There are circumstances, he argues, in which it would be worth the risk to allow an organ donation even from someone with a known infection. (The rules are more relaxed for living donors, who are generally allowed to share their organs three weeks after initial signs of COVID-19, even if follow-up testing still registers as positive.) For example, a patient who may not survive without a rapid transplant could benefit from receiving an organ from a deceased donor who had experienced only a mild or asymptomatic infection. One published case series looked at transplants drawn from six deceased donors who had tested positive for COVID-19 at some point before their death; none ended up transmitting the virus. [Read: Two doctors say it’s far too hard for terminal patients to donate their organs] The complexity of these clinical judgments is likely to persist, even as more Americans are vaccinated. More than half of all U.S. adults have now received at least one dose of a COVID-19 vaccine, but transplant patients are in a special group, left to navigate the pandemic with added uncertainty. Studies of both the Pfizer and Moderna vaccines excluded people who are on immunosuppressive medications, so we don’t yet know how effective the shots might be at preventing illness in an organ recipient. Johnson & Johnson did include some transplant recipients in its clinical trial, but only a handful. One study looked at 658 organ-transplant recipients who had been fully vaccinated with either the Pfizer or Moderna vaccine, and found that only about half of them produced detectable levels of the relevant antibodies—in contrast to nearly 100 percent of healthy people. That’s not the only “data void,” as Limaye describes it, for transplant doctors. They don’t know exactly when it’s safe to transplant an organ after a donor’s positive COVID-19 test, and they don’t know whether some organs from infected donors might be safer to transplant than others (a lung from someone with a respiratory virus might be more dangerous, for example, than a kidney or a liver). Until those gaps in knowledge can be filled with rigorous, unbiased research, doctors can only keep a broad perspective on the stakes involved. What would be the consequences of approaching a test result with too much caution—or with too much chutzpah? Deciding whether it’s more important to guard against false negatives or false positives, as one transplant doctor put it, may be a matter of deciding “what scares you more.” A COVID-19 diagnosis is powerful, and the downstream consequences can’t always be predicted. Diagnostic labels, like medical interventions, may be lifesaving or life-threatening in themselves. It’s likely that more intense screening of transplant patients has prevented other tragedies like the Michigan case, but it may also have cost some people a new organ. Practicing medicine means imperfect answers and inevitable trade-offs. “There’s nothing sacred about COVID tests,” Limaye said. “We’re learning that they have challenges of interpretation, like virtually every single test we do.” from https://ift.tt/3xZvYSe Check out http://natthash.tumblr.com Unless you’re extraordinarily wealthy (congrats on that), your experience of working through the pandemic has probably been miserable. If you’ve had to work in person, your days have been dangerous and precarious. If you’ve been able to work from home, you’ve had an enormous privilege. But devoid of choice and novelty, remote work has lost some of its romance for office workers who previously dreamed of ending their commute. In home offices around the country, the wallpaper has begun to yellow. WFHers have been working longer hours and more weekends than before the pandemic, and they’re more likely to report loneliness, depression, and anxiety than people working in person, according to Gallup. At the end of April, nearly 66 percent of respondents to a Morning Consult poll said they wanted to return to the office as soon as possible. Half of remote workers even miss their commute. But these data aren’t as conclusive as they might look. In the same Morning Consult poll, 84 percent of respondents said they enjoyed remote work. Gallup found that remote workers reported better overall well-being and higher engagement than those in the office. Many office workers also seem to be more productive at home, even in the middle of a disaster. All of this has been enough to make some employers reconsider their future. Much attention has been paid to a small number of influential companies such as Facebook and Twitter, which have announced their elective remote-work policies, as well as to those such as Goldman Sachs, which insisted in February that remote work is a temporary anomaly and not a new normal. But rumors of the office’s death have been greatly exaggerated, as have those of its triumphal return. Most companies are still deciding exactly what their post-pandemic workspaces look like, which means many office-going Americans are about to enter a few months of relative freedom during phased, attendance-capped reopenings. Employers are trying to figure out what they can get away with down the line, and workers are trying to figure out what they can demand. What would be best for most office workers—and what’s most likely to happen for many of them—is something between the extremes of old-school office work and digital nomadism. What’s right for you might end up being a little further in either direction, depending on how social or siloed your job is, or if you’re a particularly extreme introvert or extrovert. But I’m here to argue for a particular baseline: three days in the office, and two at home. Working from home certainly can have perks. You can sleep later and sit on your couch. Your boss probably can’t monitor your every move. Even if you have hated remote work during the pandemic, WFH advocates are quick to point out that the experience of the past year is not at all a good barometer of what your remote-work future could be, especially if you’ve had kids at home all day who would otherwise be at school. In a post-pandemic world, even a couple of days a week at home will let people with substantial commutes, for instance, win back a few hours of their time—for sleep, for exercise, for reading a book in the morning, for avoiding after-school child-care fees, for whatever. [Read: 6 Questions for the Boss Who Wants You Back in Your Cubicle] Working from home also gives you more control of marginal time in the workday itself. At the office, if you need a break from your computer, that might mean going to stand in line to buy a salad or yet another coffee. At home, it could be washing dishes or folding laundry or doing a grocery run—stuff that would otherwise eat away at personal time. Remote workers can walk their dogs and make sure their packages don’t get snatched off their porch, and they have more flexibility to travel. Working from home can also open up new choices about where to live; even if you’re commuting two or three days a week, you might be able to opt for a more affordable neighborhood, or a town that offers more outdoorsy activities that’s farther away from the office. But working from home is also not what most people say they want to be doing full-time in the near future. In a 2020 survey from Gensler, an architecture and design firm, more than half of respondents said that they’d ideally split their time between home and the office. (Only 19 percent said that full-time remote work was their ideal setup.) Many people benefit from working and living in separate places. Commutes can have upsides. Last year, I was somewhat embarrassed to realize that I was among the half of American office workers who missed mine; the time I used to spend walking and riding the train every morning provided a psychological in-between, when all I needed to do was let my brain transition into work mode while I listened to a podcast. Once you’re actually at work, seeing others there can be valuable, even if you have a robust outside social life. In-person communication provides texture and detail that Zoom can’t re-create, and can make working with your colleagues feel less transactional and more humane—listening to your boss say something absolutely wild in a meeting isn’t quite as bad if you can make eye contact with a friend across the conference table and then run out for a coffee afterward to vent. That effect is particularly strong for early-career workers, who need opportunities to learn from older colleagues, network with people in their industry, and figure out the internal politics of their workplace—a set of office advantages that would be tricky for even the most well-meaning employers to offer for a fully dispersed workforce, and not all employers are well meaning. Maintaining access to an office also helps ensure that the financial burden of work stays with employers. Your company has to find space for you, instead of you renting a bigger place with an extra bedroom to make room for your job. Your company has to provide you with the equipment necessary to complete your work, instead of you furnishing your own home office. (I can’t be the only one who was dismayed last year to find out how much a decent desk chair costs.) The company pays the power bill to climate-control your workplace all week, and it provides internet access that’s good enough to have multiple people using video services at once. The term American office worker might conjure images of lawyers and accountants, but according to the Bureau of Labor Statistics, the most common type of job in the country is office administration and support. Receptionists, assistants, file clerks, mail-room attendants, and people who enter data and field customer-support calls do vital work, much of which is paid at significantly lower rates than their big-shot colleagues, and many of them can’t do their jobs fully remotely. For those who can, extra bedrooms and home-office equipment aren’t cheap. In an all-remote future, the wealthiest employers would probably provide stipends for these things to retain the people they see as the most valuable talent. If you’re outside that circle—or, worse, someone they see as support staff—good luck getting your gratis Aeron chair. [Read: Yes, the Pandemic Is Ruining Your Body] I’m sure you strenuously object to at least one of my descriptions of office or remote work. Maybe you hate having to share compulsory niceties with your co-workers just to refill your coffee. Maybe you are totally unable to complete work tasks anywhere but the office, and think anyone who says they can is lying. But the beauty of hybrid work is that to be engaged in it productively, no one has to see eye to eye with their co-workers about why either extreme is good or bad. By letting people choose their own office adventures, employees can gain back some of what’s sorely missing in American work culture: self-determination. Need to plow through a task that will take you a full day? Stay home. Need to talk through some plans with a few co-workers? Everyone goes in. Kid got the sniffles? Expecting a delivery? Have dinner plans near the office? Do what you need to do to manage your life. Being constantly forced to ask permission to have needs outside your employer’s Q3 goals is humiliating and infantilizing. That was true before the pandemic, but it’s perhaps never been as clear as it is after a year in which many employers expected workers not to miss a beat during a global disaster unlike anything in the past century. Now that many American companies have been forced to adapt to remote-work life, there are good reasons to demand continued flexibility from your employer—and good reasons to believe you could get it. “There's this new realization and awareness of how you work best, what's important in life, and how you want to spend your time,” says Janet Pogue McLaurin, the global-research principal at Gensler, the architecture firm. “People are going to shift to align with that.” Employers, she told me, know that the genie is not going all the way back in the bottle, and some will see this switch as a win-win. They get to reduce their office footprint and brag about providing a highly sought-after benefit that saves them money. At the other end of the spectrum, though, are the office traditionalists—bosses who didn’t believe in remote work before the pandemic, and who steadfastly refuse to let a massive catastrophe change anything about their worldview. Even these people might be wrestled into acquiescence this year if enough of your co-workers needle them. If you’re new to hybrid working and are trying to figure out what might work best for you, start your demands at three days in person, and two days remote. You’ll still be in the majority of the week, which might help a reluctant boss come around, but you’ll have enough flexibility to make a real difference in your work life. We’re in a rare moment when American office workers are likely to have significant leverage over their working conditions—in a recent survey, well over half of middle-income workers said they were considering switching jobs this year, and for most of them, remote flexibility would be a factor. Companies that don’t want to spend a fortune replenishing their ranks in a hot labor market will need to make concessions. They can start with two days a week. from https://ift.tt/3ewCojV Check out http://natthash.tumblr.com Had Johnson & Johnson’s COVID-19 vaccine been the first to get the FDA’s green light, it might have been hailed from the get-go for what it actually is: a scientific and technological marvel. It requires just one injection to confer full immunity—a boon for needlephobes and tough-to-reach populations who can’t easily access a second dose. It’s relatively cheap and has forgiving refrigeration requirements, making it a breeze to ship and store. And clinical trials showed that it’s a knockout at guarding against hospitalization and death, and 66 percent effective at preventing moderate to severe cases of COVID-19, even amid the rise of antibody-dodging coronavirus variants. Johnson & Johnson accomplished all this in less than a year, granting the world a safe and effective vaccine crucial to hastening the pandemic’s eventual end. That’s not how the J&J story played out. By the time the authorization for the J&J vaccine went through, its mRNA-based counterparts, boasting clinical-trial efficacies of roughly 95 percent, had been in the field for months. Experts cautioned that differences in trial design and timing made the trio of vaccines impossible to accurately compare. But people pitted them against one another all the same, and time and time again, J&J appeared to lose out. The shot was labeled “second class” just as it surged into some of the disadvantaged populations hit hardest by the pandemic, raising discomfiting questions about whether the rich and privileged were hoarding the top-tier vaccines for themselves. Manufacturing snafus that compromised millions of doses quickly added to the ire. Last month’s 10-day hiatus, when the CDC and FDA linked the vaccine to a rare and unusual blood-clotting disorder, dealt the shot yet another blow, spurring a noticeable dip in confidence in the J&J formulation. As vaccine supply starts to exceed demand in the U.S., researchers and health workers across the country are steeling themselves for what could be a rough rescue mission. A vaccine that’s thought of as “shitty,” experts told me, has little chance at being seen as truly equitable, and some of them worry that J&J’s product has already been snared in that trap. “I think it’s going to be hard to dig our way out,” Abraar Karan, an internal-medicine physician at Brigham and Women’s Hospital in Boston, told me. What the J&J shot now faces is a sort of branded vaccine reluctance, largely specific to one company’s product. But the reputation of other vaccines also hinge on this one, experts told me, making rehabilitation key. An important first step, they said, might be giving people the option not to take it at all. The Johnson & Johnson vaccine is not, experts repeatedly told me, a “worse” vaccine. Among the three options available to Americans—Pfizer-BioNTech, Moderna, and J&J—“the best vaccine you can get is the one you can get in your arm as soon as possible,” Chrissie Juliano, the executive director of the Big Cities Health Coalition, told me. But J&J’s vaccine is undeniably different, and its portability and convenience have prompted health departments to shuttle it into distinct populations, such as incarcerated individuals and people experiencing homelessness. In practice, this may be contributing to some unintended stratifications. David Lazer, a computer scientist at Northeastern University, told me his team has collected data showing that Black people are almost twice as likely to have received the J&J vaccine than white people, a disparity that doesn’t seem to be accounted for by preferences alone. The hustle to allocate J&J immediately raised questions about whether America’s “problematic” vaccine was being earmarked for communities who are already distanced from medical resources and disproportionately pummeled by the virus, says Rachel Hardeman, a health-equity expert at the University of Minnesota. That stigma rapidly began to reinforce itself. In early March, Detroit Mayor Mike Duggan rejected a batch of J&J doses, saying that he wished to provide his residents with only “the best” vaccines. One physician told me that she’d received calls from reporters asking her to comment on J&J “being the poor person’s vaccine.” “There’s this undercurrent of tension,” Taison Bell, a critical-care physician at the University of Virginia Health System, told me. Many of the populations described as good J&J candidates “feel, rightfully so, that they receive second-rate care.” This challenge, even if it has more to do with public perception than the vaccine’s intrinsic quality, can’t be dismissed: If people believe the vaccine is inferior, “that’s just as important as reality when people try to make healthy decisions for themselves,” Bell said. Rehabilitating the Johnson & Johnson vaccine, experts told me, will require honest acknowledgments of its shortcomings, and validating, not combatting, people’s concerns. The rare blood clots that have been tied to the vaccine are serious, they said, but extraordinarily uncommon—a risk that’s far outweighed by the benefits of immunity. The pause clearly did shake things up. Willie Bodrick II, a senior pastor of Twelfth Baptist Church in Boston, who’s heavily engaged in vaccine outreach to the city’s Black community, told me that, even before the pause, he had been fielding questions about the J&J shot for weeks. Some people who were unwilling to take a second dose, whether because of work constraints or wariness of side effects, saw the single injection as an ideal option; others “were really worried they would be receiving a subpar vaccine,” he said. Just days before the J&J halt, Bodrick felt he’d made progress. But news of the rare blood clots “resurfaced a hurdle I thought we were doing a good job moving beyond,” he said. Van Yu, a physician in New York City working to bring J&J vaccines to people experiencing homelessness, told me that, before the pause, many of his patients explicitly requested “the single-shot thing.” Now that J&J is available again, he and his colleagues have noticed that some people are citing the halt as a reason to turn it down. The risk of clots has persuaded a few people to forgo vaccination entirely. Earl Potts, a 60-year-old IT-security specialist in Maryland, told me that he’s been skeptical of receiving any vaccines for decades. Although constant coaxing from family initially nudged him and his wife, Lori Renee Potts, toward getting J&J “because it was just one shot,” the pause reignited their fear that the vaccine-making process had been rushed. “I need more data; I need more time,” he said. In many parts of the country, however, a simple message is still encouraging people to roll up their sleeves: Johnson & Johnson’s vaccine is “one of three excellent choices for protection against COVID-19,” as Hardeman puts it. In Columbus, Ohio, the health department’s on-site clinic vaccinates about 130 to 140 people each day, more than a third of whom are still queueing up for the one-and-done shot, Health Commissioner Mysheika Roberts told me. At another large site, where Pfizer and J&J doses are alternated throughout the week, “the J&J days are just as busy.” Still, the pause prompted Roberts and her team to switch up their outreach tactics. Before the halt, city officials had brought only one brand at a time when inoculating off-site, prioritizing J&J allocations for the residents of homeless shelters and homebound individuals. When the vaccine returned with a warning label, “we thought it was appropriate to offer a choice,” Roberts told me, so no one felt cornered. Porting mRNA vaccines around requires a mobile freezer, which is “tedious to maintain,” she said, but removes a barrier. “Now when we go out to any location, it’s, ‘Which do you want, Pfizer or J&J?’” This smorgasbord-of-shots strategy, experts told me, could be key to the next stage of the American rollout, especially as vaccine delivery moves past inoculating enthusiasts, and starts pointedly targeting those with reservations. The idea is to meet the unimmunized where they are, both literally and figuratively. And sending different brands of vaccines to different communities isn’t going to work in a culture set on believing one shot is “worse” than the rest. Biased allocation also puts the vaccination campaign as a whole at risk, Bell told me: If something should derail a shot that’s been doing most of the heavy lifting for certain demographics, those populations could be put in a sudden and irreversible bind. “There should be no community without a choice of vaccines available to it,” Camara Phyllis Jones, a family physician and epidemiologist based in Atlanta, told me. “Giving options is another way of signaling we value people equally.” Sending J&J to places that lack the infrastructure to store and administer Moderna and Pfizer, for instance, might seem easier or more expedient in the short term. But it sidesteps the actual inequities at play, she said. And she doesn’t consider a lack of a freezer a good excuse for snubbing an mRNA vaccine: “Bring a freezer.” An infrastructure of choice is now supporting the vaccine rollout among people experiencing homelessness in Los Angeles County, where close to 70,000 people are without stable housing. Heidi Behforouz, the medical director of Housing for Health, told me that her team has delivered doses to more than 3,500 people living in shelters or on the streets in the past three months. Most received the Moderna vaccine. The shot is cumbersome to trek into encampments, but with the help of specialized coolers and a vigilant follow-up protocol, “our second-dose return rate is about 93 percent,” she said. (The national average, meanwhile, is about 92 percent.) The team added J&J to its repertoire in early April, just days before the pause, and plans on offering both brands to all of its patients. Two of Housing for Health’s recent recipients, Candy Acuña Rodriguez and Daniel Gilbert Trujillo, told me they gladly selected the one-and-done shots last Friday, after health workers assuaged their concerns about the pause. “Why would we want to have to go back and take two doses?” Rodriguez told me. “It should be all in one.” None of these discussions are intended to erase the fact that the J&J may be well suited to, or preferred by, certain groups of people. Making assumptions about who those individuals are is what imperils a rollout. Roberts, in Columbus, told me that one of her region’s first outreach clinics brought J&J to a predominantly African American church, whose members rallied for the brand because it was familiar to them. “They said, ‘It’s a company we’ve heard of,’” she told me. In Los Angeles, however, Behforouz told me that some Black women regard J&J with reproach, citing concerns that the company had, in prior years, aggressively marketed baby powder to their demographic, even amid accusations of asbestos contamination. “It’s hard to predict which patients will want which vaccines,” Josh Banerjee, a physician working with the Street Medicine Program at USC, told me. As Yu, the New York physician, said: “It’s not like I can take a look at you and just guess.” A big asterisk still hangs on this discussion. While millions of Americans quibble over their glut of three spectacular shots, residents of other countries are wrapped into a far worse conundrum: a paucity of any vaccines at all. High-income countries have already laid claim to more than half the globe’s available doses. As things stand, the rest of the world doesn’t have the luxury of choice. The U.S. has taken some limited steps in rectifying global disparities, by shipping out doses of the AstraZeneca vaccine (which resembles J&J in formulation but has yet to be cleared by American regulators), and moving toward waiving intellectual-property protections on the vaccines. After failing to protect people for months, U.S. policies are finally reversing that trend with a successful vaccination campaign. The country now has another opportunity for global leadership: collectively opting back into a lifesaving shot. Choosing a J&J vaccine here doesn’t just benefit the person who receives it; it sends a reverberating message, Karar, of Brigham and Women’s, told me. “It highlights that perhaps this is not a worse vaccine at all.” from https://ift.tt/3er6Hst Check out http://natthash.tumblr.com What explains the strange constellation of symptoms that is “long COVID?” Will it ever go away? And why does vaccination seem to help? Writer F.T. Kola returns to the podcast Social Distance to recount her experience with long COVID with hosts James Hamblin and Maeve Higgins. They’re also joined by Dr. Akiko Iwasaki, an immunologist investigating long COVID at her Yale lab. She explains what we know about the condition—and how two theories about its root cause mean the difference between a cure and no clear end in sight. Listen to their conversation here: Subscribe to Social Distance to receive new episodes as soon as they’re published. What follows is a transcript of their conversation, edited for length and clarity: James Hamblin: This term, “long COVID”—or “long-haulers”—is used often. Is there a working definition or way that you describe it? Because it can encapsulate many different things, right? Akiko Iwasaki: There lies the problem already. There isn’t a universal definition of long COVID. But I think the medical community is coming to some consensus that it’s basically a post-acute viral syndrome that happens after a person has experienced infection with SARS-CoV-2 and has had symptoms for over two months—some people say three months. That definition, again, isn’t universal. [And] for most people to be considered to have long COVID, you need to have prolonged symptoms of certain severity. For instance, many of the long-haulers have fatigue—like, extreme fatigue. Maeve Higgins: F.T., you’ve mentioned your fatigue before. F.T. Kola: Yeah; it’s really interesting hearing Professor Iwasaki talk about this, because one of my anxieties this whole time has been that I feel relatively okay, and I know that there are people out there with very distressing and extreme symptoms. And do I qualify as long COVID if I’m basically up and around? The fatigue, which weirdly emerged later in 2020, meant that I would ration my week. I would have two or three days to get things done—and then two or three days I just had to black out on the calendar, because I won’t get anything done and I’ll probably just be in bed that whole time. That fatigue was surprising to me. It was a type I’d never experienced before. And I thought a lot about how, if I had had to go to a place of work or if most of my work was physical, I would not have been able to do that for over a year post-COVID. And that was mostly due to the fatigue. Iwasaki: Exactly. That is one of the most common symptoms that people with long COVID have—this very severe fatigue. Others report brain fog: an inability to think clearly and remember things, [along with] other cognitive issues as well. Higgins: And what about [losing] the sense of smell and taste? Is that a common long-COVID symptom, too? Iwasaki: That is also extremely common in people who had COVID. Some people only have a loss of taste or smell as the symptom. Others have it in addition to more serious symptoms. Higgins: What about vaccination helping people who have long COVID? F.T., didn’t [you] experience some alleviation after you got vaccinated? Kola: Yes, definitely. The long COVID kind of went in stages. It waxed and waned over time. [And it was] surprising to me how much things melted away post-vaccine. I have my fingers crossed as I’m saying this. The fatigue was one of those things. It’s like I got an energy boost. That [fatigue] has gone away, as well as things like particular kinds of chest pain and very bad headaches. I’m curious if Professor Iwasaki knows why some things might have seemingly gone away and some things are yet to resolve—like, for example, hyposmia and hormonal changes? Iwasaki: That’s exactly why we’re starting a study to investigate what might be underlying the symptom improvement in long COVID after vaccination. As you say, F.T., there are people reporting symptom improvements after the vaccine. And we don’t even have a handle on: What are the common things that people experience that improvement [with] after vaccination? But I do hear people saying they have energy, and they’re not as fatigued anymore. They can breathe better. The shortness of breath has gone away. They can walk again without shortness of breath. [Before the vaccine] people tend to not be able to even walk across the room, and [then] they can. So there are a lot of different symptoms that are apparently being lifted by the vaccine. Higgins: How do vaccines help? What is the mechanism that a vaccine would help with the symptoms of long COVID? Hamblin: It’s kind of counterintuitive. Iwasaki: Yeah, exactly. So in order to explain that, I think we need to introduce a couple of theories about long COVID. So, long COVID can be mediated by a persistent virus infection, stimulating inflammation in a person for an extended time period. Higgins: So would you still test positive for COVID if that’s what it is? Iwasaki: Well, that’s the tricky thing. Such a reservoir of virus is not likely to be in your nose, so the nasopharyngeal swab people used to test for COVID is vastly negative in the long-COVID patients. And so if that reservoir were to exist, it must be deeper in the tissue somewhere. Higgins: So that could be hiding, and that’s what’s making you still really sick. And then is there another theory you were going to mention? Iwasaki: Yes. The second theory is that long COVID is created by autoreactive cells, or autoimmune cells, and antibodies. And if that were the case, then the vaccine may provide some temporary relief—but may not be a cure for long COVID, because all autoreactive cells are really difficult to get rid of. Hamblin: Is this something that you would anticipate might take years to go away, but should eventually—or might be with people indefinitely? Iwasaki: It’s hard to say how long the long COVID will last. Based on experience with other post-viral long-term symptoms, in some people this could last for a very long time. People with other viral syndromes after acute infection have been suffering for years or decades. Hopefully that’s not the case with long COVID, that it’s a more transient thing. But we just don’t know yet. And a lot of long-COVID people didn’t have the [COVID-19] diagnosis. Because back in early spring of last year when COVID was spreading, there were not enough tests. And so there are lots of people who are suffering from very similar symptoms as long COVID without the actual diagnosis of COVID. That’s leaving a lot of those people out of studies. And a lot of people like that are out there trying to get into post-COVID clinics and get therapy—but they don’t have the diagnosis and therefore are left out of the system. Hamblin: F.T., you got COVID-19 during the early days of the pandemic. I don’t think long COVID was known to be something to look for then. What were you told? How does that square with what you’re hearing now from physicians? Kola: It was so early on for me that I remember my doctors coming into my room and saying: “Well, we just got off the WHO call.” Things like that. It was changing day by day. At the very end, when I was out of the ICU and into the newly created COVID ward, I’d say something like: “I think something in my chest is weird” or “I don’t think I’m urinating in the way that I should be.” And the doctors would say what they would say for months and continue to say, really, which is: “We’re going to record everything, and we’ll test everything if you say something’s wrong”—which I greatly appreciate, because I think a lot of long-COVID patients haven’t had people believe them or haven’t had access to responsive health care, which was huge. So they would say: “We’ll look at it, and we’ll test it, and we’ll monitor it, and we’ll watch it.” And once I got home, it was: “Come back in this many weeks, and we’ll run bloodwork.” “Come back and do a brain MRI.” “Let’s do an echocardiogram.” And this is an extraordinary amount of luck and privilege to have that medical care. But they, understandably, can’t really tell me anything. I think the only thing that has changed is this understanding that long COVID is real. And, as Professor Iwasaki was saying, all these things are long COVID, but I still don’t know what they mean or what they are. I still don’t know why I’ve had chest pain. A few things were obvious, like having pneumonia. But most of it has been: “We don’t know why this is happening. We don’t know what that is. We believe you. We’re going to look at it, but we just have no way to know.” And something that has been my great psychological fear is what Professor Iwasaki mentioned—that there may be a reservoir of virus somewhere still in my body. I think that’s medically terrifying, but it’s also psychologically terrifying. Because it feels like you’re living with this thing, like can it reemerge at some time and you’re not free of it. It’s like being possessed or something. So those are the two areas of mystery: What exactly did it do to me? And is it really gone? Hamblin: Yeah, what about treatments? What’s the first step of treating long COVID? Iwasaki: We’re hoping that our new study of the immune response in long COVID will highlight some of the pathways that we can interfere [with] to make some of these symptoms go away. For example, if long COVID is driven by persistent infection, the vaccine may actually get rid of the source of the problem altogether—because it will induce a very robust antibody response and T-cell response. And that will be a permanent cure. But if it is autoimmunity, we need a completely different way of dealing with it—to sort of tamp down the autoreactive cells from becoming more activated. And that would require completely different kinds of therapy. Understanding the disease process itself is really important to coming up with the right therapy. Hamblin: Yeah; that’s the same tension at the heart of a lot of treatment of acute COVID-19, too. At what point are you trying to tamp down the immune system, and at what point do you just focus on trying to minimize the virus? Because sometimes you need your immune system to eradicate that virus, and sometimes the immune system is causing those symptoms. Iwasaki: Right—running on the theme that everything we do with COVID is about the timing. The therapy, for example, for late-stage disease is completely different from therapy against the early infection. And getting that timing right for each patient has been a real struggle. It’s something we’re learning on a daily basis. So I’m interested in whether we should enhance the immune response to get rid of the reservoir virus or tamp it down. And I believe the answer is going to be different for different individuals. If we can come up with some sort of biomarker to diagnose who has what kind of long COVID and what the best treatment is for that person, that would be my dream come true. And to get there, we really need to understand the disease itself. from https://ift.tt/3h8IFUE Check out http://natthash.tumblr.com At its peak, in late March, the mass-vaccination site at Nashville’s Music City Center was giving out 2,100 doses a day. It was all hands on deck: Local nurses, volunteers, FEMA employees, and even U.S. Forest Service EMTs were redeployed to help give COVID-19 shots. But last week, the number of daily doses dropped to less than 1,300—about 1,100 second doses and only 190 first doses. Imagine three weeks from now, when only 190 people are due back for dose two, says Brian Todd, a spokesperson for the local public-health department. At that point, the number “is going to be very low,” he told me. The Music City Center site will close for good on May 28. The era of mass vaccinations is ending: Although these big sites were key to speeding up vaccinations after a rocky start in the winter, many are beginning to find themselves idle as the country’s daily vaccination rate falls from its mid-April peak. “We are running out of eager, enthusiastic people who will chase down the vaccine wherever we put it,” says Kelly Moore, the deputy director of the nonprofit Immunization Action Coalition. But with more than half of Americans still unvaccinated, the COVID-19 immunization campaign is far from over. It is now entering a new phase. Instead of in convention centers and arenas, shots will be distributed across a larger number of smaller sites: pharmacies, doctors’ offices, churches, mosques, factory parking lots, barbershops, bars, breweries, even individual homes. This more tailored phase of the vaccination campaign introduces a new set of challenges, but by making vaccination as easy as possible, public-health officials hope to reach those who are hesitant, busy, or simply indifferent. To inch closer to the goal of vaccinating the whole population, the vaccines will have to go to the people, rather than requiring the people to go to the vaccines. [Read: What if we never reach herd immunity?] Mass-vaccination sites are shutting down partly because you no longer need to visit one to get a shot. Pharmacies in particular have stepped up their vaccine campaigns. “You can’t go into a grocery store here in town and not see signs up,” Todd told me. And the neighborhood pharmacy is a lot more convenient than a mass-vaccination site halfway across town. Vaccine supply is no longer a bottleneck in many places. Mecklenburg County, in North Carolina, originally had a vaccine waiting list 6,000 people long. Recently, Gibbie Harris, the director of the county’s health department, was discussing whether to keep the list when she realized, “No, there’s nobody on it.” Everyone eager enough to get on a waiting list had already found a vaccine. The county will also wind down its mass-vaccination site at Bojangles Coliseum, in Charlotte, at the end of May. Instead, it will divert staff and resources to taking the vaccine on the road with mobile vaccine clinics at events including a motorcycle rally and a food-truck festival. “We’re looking at anywhere and everywhere we can go,” she says. To reach people who physically cannot come to a clinic, the department also has a homebound program. Demand for mass-vaccination sites is falling faster in some parts of the country than others, though. In Orange County, California, appointments were full until just this past week; now they’re still 80 percent full, says Regina Chinsio-Kwong, a deputy health officer for the county. But she expects mass-vaccination sites to be phased out by the fall. By then, she told me, “we’ll have just more mobile or travel teams going out.” The county’s mobile teams will focus on vaccine equity; they are already working with groups such as the Multi-ethnic Collaborative of Community Agencies (MECCA) and Latino Health Access to get vaccines to underserved neighborhoods. Pharmacies, doctors’ offices, and clinics will help fill in the gap. This next phase will be slower and more laborious simply because it requires reaching people who are harder to reach. Instead of thousands of shots at once, it’s going to be a hundred doses here, a few dozen doses there. “We just have to adjust our expectations,” says Kirsten Johnson, the commissioner of the Milwaukee Health Department, which recently also announced the closing of the city’s mass-vaccination site. “Twenty vaccines in arms at a site is still a win.” The role of primary-care doctors has so far been limited in the vaccination process, but they will play an important part in what comes next. For months now, vaccine experts have been telling me that the established trust between patient and doctor is key to persuading people on the fence about vaccines to get one. “This is where the conversation happens,” says Saria Saccocio, a co-chair of the COVID-19-vaccine task force for Prisma Health, a large health-care system in South Carolina. Prisma is currently ramping down its mass-vaccination clinics to focus on giving vaccines through its primary-care doctors. But the COVID-19 vaccines have specific logistical requirements that make them uniquely hard to administer in doctors’ offices and other small settings. For example, Pfizer’s vaccine needs to be kept in ultracold freezers if stored for longer than two weeks, which small sites may not have. All three vaccines in the U.S. are packaged in multidose vials, and once punctured, the vials have to be used within six to 12 hours, depending on the manufacturer. Pfizer’s vials contain five to six doses, Johnson & Johnson’s five; and Moderna’s originally had 10, recently changed to 15. “If you would have asked me two months ago, I would have said, ‘That’s fantastic,’” says Johnson, the Milwaukee health commissioner, about the change to 15 doses. But now, the increase actually complicates vaccination in small settings. A small physician’s office simply might not have 15 patients who want vaccines in a given day, and last-minute leftover doses are only going to get harder to give away as more people are vaccinated. Several providers told me they are planning vaccine days at their office, so they can get patients vaccinated at the same time rather than opening one vial one day and another the next. But that still requires patients to make a special trip for the vaccine, instead of coming at their own convenience. [Read: We are turning COVID-19 into a young person’s disease] Rural areas have already been facing the challenges of vaccinating on a smaller scale. Heather Preuss, a family physician in Hot Springs, South Dakota, told me that there is only one place for the general public to get COVID-19 vaccines in her town, and it’s giving them out only once a week, on Wednesdays. Her own clinic has not gotten any vaccines, but she has had many patients ask about them while in for another appointment. “They were very disappointed that I could not give that to them while in the clinic,” she said. She worries that her patients who are elderly or unable to afford gas money for long trips won’t get vaccinated. Meanwhile, Susan Osborne, a family physician in Floyd, Virginia, who has been administering COVID-19 vaccines in her small town, says she sometimes can’t find enough takers after opening a vial. “People want to come on their own time right now,” she told me. “We really need to get a single-dose vial.” This is going to happen more and more as the U.S. moves toward smaller-scale vaccination. Should a vaccine provider open a new vial for two people at the end of the day, knowing that most of the doses will probably be spoiled? “We need guidance about how to balance vaccine waste and missed opportunities as we shift gears into a distributed system,” says Moore, of the Immunization Action Coalition, who is looking to the CDC for future guidelines. The dilemma is unlikely to go away soon. Even as the U.S. moves to smaller vaccination sites where single-dose vials would be helpful, vaccines are in short supply globally and still need to be made as efficiently as possible. Manufacturing single-dose vials would require five to 15 times as much glass and “fill and finish” capacity for bottling the vaccines, which the world currently can’t spare. If mass vaccination was the first, emergency phase of the COVID-19 vaccine campaign, Moore says, this current second phase is the awkward transition period before vaccines are given like any other routine shot. In that third and final phase, you will be able to get one by walking into any pharmacy or doctor’s office. Vaccines will come in single-dose vials or, better yet, prefilled syringes. The quicker we get there, the quicker we get out of this pandemic. By then, mass-vaccination sites will be a distant memory. Nashville’s Music City Center will be back to hosting country-music festivals and orthopedic conventions. from https://ift.tt/3vHebx4 Check out http://natthash.tumblr.com |
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