Category: From California Healthline.org

La primavera pasada, Maritza Beniquez, enfermera de una sala de emergencias de Nueva Jersey, fue testigo de “una oleada tras otra” de pacientes enfermos, cada uno con una mirada aterrada que se volvió familiar a medida que pasaban las semanas.

Pronto, fueron sus colegas del Hospital Universitario de Newark, enfermeras, técnicos y médicos con los que había estado trabajando codo con codo, quienes se presentaban en la emergencia luchando por respirar. “Muchos de nuestros propios compañeros de trabajo se enfermaron, especialmente al principio; literalmente diezmó a nuestro personal”, contó.

A fines de junio, 11 de los colegas de Beniquez habían muerto. Como los pacientes que habían estado tratando, la mayoría eran de raza negra y latinos (que pueden ser de cualquier raza).

“Nos vimos afectados de manera desproporcionada por la forma en que nuestras comunidades se han visto afectadas de manera desproporcionada en cada [parte de] nuestras vidas, desde las escuelas hasta los trabajos y los hogares”, dijo.

El 14 de diciembre, Beniquez se convirtió en la primera persona en Nueva Jersey en recibir la vacuna contra el coronavirus, y fue una de los muchos trabajadores médicos de color destacados en los titulares.

Fue una ocasión alegre, que reavivó la posibilidad de volver a ver a sus padres y a su abuela de 96 años, quienes viven en Puerto Rico. Pero esas imágenes transmitidas a nivel nacional también fueron un recordatorio de aquéllos para quienes la vacuna llegó demasiado tarde.

Covid-19 se ha cobrado un precio enorme entre los afroamericanos y los hispanounidenses. Y esas disparidades se extienden a los trabajadores médicos que los intubaron, limpiaron sus sábanas y tomaron sus manos en sus últimos días, halló una investigación de KHN/The Guardian.

Las personas de color representan aproximadamente el 65% de las muertes en los casos en los que hay datos de raza y etnia.

Un estudio reciente encontró que los trabajadores de salud de color tienen más del doble de probabilidades que sus contrapartes caucásicas de dar positivo para el virus. Son más propensos a tratar a pacientes diagnosticados con covid, y a trabajar en hogares de adultos mayores, los principales focos de coronavirus; y también a reportar un suministro inadecuado de equipo de protección personal, según el informe.

En una muestra nacional de 100 casos recopilados por KHN/The Guardian en los que un trabajador de salud expresó su preocupación por la insuficiencia de EPP antes de morir por covid, tres cuartas partes de las víctimas fueron identificadas como negras, hispanas, nativas americanas o asiáticas.

“Es más probable que los trabajadores de salud de raza negra quieran ir a atenderse al sector público donde saben que tratarán de manera desproporcionada a las comunidades de color”, dijo Adia Wingfield, socióloga de la Universidad de Washington en St. Louis, quien ha estudiado la desigualdad racial en el industria del cuidado de salud. “Pero también es más probable que estén en sintonía con las necesidades y desafíos particulares que puedan tener las comunidades de color”, dijo.

Wingfield agregó que muchos miembros del personal de atención médica afroamericanos no solo trabajan en centros de salud de bajos recursos, sino que también son más propensos a sufrir muchas de las mismas comorbilidades que se encuentran en la población negra en general, un legado de décadas de inequidades sistémicas.

Y pueden ser víctimas de estándares de atención más bajos, agregó la doctora Susan Moore, pediatra de raza negra de 52 años de Indiana, quien fue hospitalizada con covid en noviembre y, según un video publicado en su cuenta de Facebook, tuvo que pedir repetidamente pruebas, remdesivir y analgésicos. Dijo que su médico (caucásico) desestimó sus quejas de dolor y fue dada de alta, solo para ser internada en otro hospital 12 horas después.

Numerosos estudios han encontrado que los afroamericanos a menudo reciben peor atención médica que sus contrapartes blancas: en marzo, una empresa de biotecnología de Boston publicó un análisis que mostraba que era menos probable que los médicos remitieran a pacientes negros sintomáticos para pruebas de coronavirus que a los blancos sintomáticos.

Los médicos también son menos propensos a recetar analgésicos a pacientes negros.

“Si fuera blanca, no tendría que pasar por eso”, dijo Moore en el video publicado desde su cama de hospital. “Así es como matan a los negros, cuando los envías a casa, y no saben cómo luchar por sí mismos”. Moore murió el 20 de diciembre por complicaciones de covid, dijo su hijo Henry Muhammad a los medios de comunicación.

Junto con las personas de color, los trabajadores de salud inmigrantes han sufrido pérdidas desproporcionadas a causa de covid-19. Más de un tercio de los trabajadores de salud que mueren por covid en el país nacieron en el extranjero, desde Filipinas y Haití, hasta Nigeria y México, según un análisis de KHN/The Guardian de casos registrados. Representan el 20% del total de trabajadores de salud de los Estados Unidos.

El doctor Ramon Tallaj, médico y presidente de Somos, una red sin fines de lucro de proveedores de atención médica en Nueva York, dijo que los médicos y enfermeras inmigrantes a menudo ven a pacientes de sus propias comunidades, y muchas comunidades inmigrantes de clase trabajadora han sido devastadas por covid.

“Nuestra comunidad son trabajadores esenciales. Tuvieron que ir a trabajar al comienzo de la pandemia, y cuando se enfermaban, iban a ver al médico de la comunidad”, dijo. Doce médicos y enfermeras de la red Somos han muerto por covid, dijo.

El doctor Eriberto Lozada era médico de familia de 83 años en Long Island, Nueva York. Todavía estaba viendo pacientes fuera de su consulta cuando los casos comenzaron a aumentar la primavera pasada. Originario de Filipinas, un país con un historial de envío de trabajadores médicos calificados a los Estados Unidos, estaba orgulloso de ser médico y “de haber sido un inmigrante próspero”, dijo su hijo James Lozada.

Los miembros de la familia de Lozada lo recuerdan como estricto y de voluntad fuerte; lo llamaban cariñosamente “el rey”. Inculcó a sus hijos la importancia de una buena educación. Murió en abril.

Dos de sus cuatro hijos, John y James Lozada, son médicos. Ambos fueron vacunados el mes pasado. Considerando todo lo que habían pasado, dijo John, fue una ocasión “agridulce”. Pero pensó que era importante por otra razón: ser un ejemplo para sus pacientes.

Las desigualdades en las infecciones, y las muertes, por covid podrían alimentar la desconfianza en la vacuna. En un estudio reciente del Pew Research Center, alrededor del 42% de los encuestados de raza negra dijeron que “definitivamente o probablemente” recibirían la vacuna en comparación con el 60% de la población general.

Esto tiene sentido para Patricia Gardner, enfermera nacida en Jamaica y gerenta en el Centro Médico de la Universidad de Hackensack, en Nueva Jersey, quien contrajo el coronavirus junto con familiares y colegas. “Mucho de lo que escucho es, ‘¿Cómo es que no fuimos los primeros en recibir atención, pero ahora somos los primeros en vacunarnos?’”, dijo.

Al igual que Beniquez, se vacunó el 14 de diciembre. “Para mí, dar un paso al frente y decir: ‘Quiero estar en el primer grupo’, espero que eso envíe un mensaje”, dijo.

Beniquez dijo que sintió el peso de esa responsabilidad cuando se inscribió para ser la primera persona en su estado en recibir la vacuna. Muchos de sus pacientes han expresado escepticismo, impulsado, opinó, por un sistema de salud que les ha fallado durante años.

“Recordamos los juicios de Tuskegee. Recordamos las ‘apendicectomías’ ”: informes de mujeres que fueron esterilizadas a la fuerza en un centro de detención del Servicio de Inmigración y Control de Aduanas de Georgia. “Estas son cosas que le han sucedido a esta comunidad, a las comunidades negras y latinas durante el último siglo. Como trabajadora de salud, tengo que reconocer que sus temores son legítimos y explicarles ‘Esto no es lo mismo’”, dijo.

Beniquez dijo que su alegría y alivio por recibir la vacuna se ven atenuados por la realidad del aumento de casos en la sala de emergencias. La adrenalina que ella y sus colegas sintieron la primavera pasada se ha ido, reemplazada por la fatiga y la cautela de los meses venideros.

Su hospital colocó 11 árboles en el vestíbulo, uno por cada empleado que murió de covid; han sido adornados con recuerdos y obsequios de sus colegas.

Hay uno para Kim King-Smith, de 53 años, el amable técnico de EKG, que visitaba a amigos de amigos, o a familiares cada vez que terminaba en el hospital.

Uno para Danilo Bolima, 54, el enfermero de Filipinas que se convirtió en profesor y era el jefe de servicios de atención al paciente.

Otro para Obinna Chibueze Eke, de 42 años, asistente de enfermería nigeriano, que pidió a sus amigos y familiares que oraran cuando estuvo hospitalizado con covid.

“Cada día, recordamos a nuestros colegas y amigos caídos como los héroes que nos ayudaron a seguir adelante durante esta pandemia y más allá”, dijo el doctor Shereef Elnahal presidente y director ejecutivo del hospital, en un comunicado. “Nunca olvidaremos sus contribuciones y su pasión colectiva por esta comunidad y por los demás”.

Justo afuera del edificio, está el árbol número 12. “Será para otro u otra que perdamos en esta batalla”, dijo Beniquez.

Esta historia es parte de “Lost on the Frontline”, un proyecto en curso de The Guardian y Kaiser Health News que tiene como objetivo documentar las vidas de los trabajadores de  salud de los Estados Unidos que mueren a causa de COVID-19, e investigar por qué tantos son víctimas de la enfermedad. Si tienes un colega o un ser querido que deberíamos incluir, por favor comparte su historia.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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COLUMBIA, Mo. — A memory haunts Christina Fuhrman: the image of her toddler Pearl lying pale and listless in a hospital bed, tethered to an IV to keep her hydrated as she struggled against a superbug infection.

“She survived by the grace of God,” Fuhrman said of the illness that struck her oldest child in this central Missouri city almost five years ago. “She could’ve gone septic fast. Her condition was near critical.”

Pearl was fighting Clostridium difficile, or C. diff, a type of antibiotic-resistant bacteria known as a superbug. A growing body of research shows that overuse and misuse of antibiotics in children’s hospitals — which health experts and patients say should know better — helps fuel these dangerous bacteria that attack adults and, increasingly, children. Doctors worry that the covid pandemic will only lead to more overprescribing.

A study published in the journal Clinical Infectious Diseases in January found that 1 in 4 children given antibiotics in U.S. children’s hospitals are prescribed the drugs inappropriately — the wrong types, or for too long, or when they’re not necessary.

Dr. Jason Newland, a pediatrics professor at Washington University in St. Louis who co-authored the study, said that’s likely an underestimate because the research involved 32 children’s hospitals already working together on proper antibiotic use. Newland said the nation’s 250-plus children’s hospitals need to do better.

“It’s irresponsible,” Fuhrman added. Coupled with parents begging for antibiotics in pediatricians’ offices, it’s “just creating a monster.”

Using antibiotics when they’re not needed is a long-standing problem, and the pandemic “has thrown a little bit of gas on the fire,” said Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School.

Although fears of covid-19 mean fewer parents are taking their children to doctors’ offices and some have skipped routine visits for their kids, children are still getting antibiotics through telemedicine visits that don’t allow for in-person exams. And research shows more than 5,000 children infected with the coronavirus were hospitalized between late May and late September. If symptoms point toward a bacterial infection on top of the coronavirus, Schleiss said, doctors sometimes prescribe antibiotics, which don’t work on viruses, until tests rule out bacteria.

At the same time, Newland said, the demands of caring for COVID patients take time away from what are known as “stewardship” programs aimed at measuring and improving how antibiotics are prescribed. Often such efforts involve continuing education courses for health care professionals on how to use antibiotics safely, but the pandemic has made those more difficult to host.

“There’s no doubt: We’ve seen some extra use of antibiotics,” Newland said. “The impact of the pandemic on antibiotic use will be significant.”

Habits Drive Superbug Growth

Antibiotic resistance occurs through random mutation and natural selection. Those bacteria most susceptible to an antibiotic die quickly, but surviving germs can pass on resistant features, then spread. The process is driven by prescribing habits that lead to high levels of antibiotic use.

A March study in the journal Infection Control & Hospital Epidemiology found that the rates of antibiotic use on patients at 51 children’s hospitals ranged from 22% to 52%. Some of those medications treated actual bacterial infections, but others were given in hopes of preventing infections or when doctors didn’t know what was causing a problem.

“I hear a lot about antibiotic use for the ‘just in case’ scenarios,” said Dr. Joshua Watson, director of the antimicrobial stewardship program at Nationwide Children’s Hospital in Ohio. “We underestimate the downsides.”

Newland said each specialty in medicine has its own culture around antibiotic use. Many surgeons, for example, routinely use antibiotics to prevent infection after operations.

Outside of hospitals, doctors have long been criticized for prescribing antibiotics too often for ailments such as ear infections, which can sometimes go away on their own or can be caused by viruses that antibiotics won’t counter.

Dr. Shannon Ross, an associate professor of pediatrics and microbiology at the University of Alabama at Birmingham, said not all doctors have been taught how to correctly use antibiotics.

“Many of us don’t realize we’re doing it,” she said of overuse. “It’s sort of not knowing what you’re doing until someone tells you.”

All this drives the growth of numerous superbugs in the very population served by these hospitals. Numerous studies, including one published in the Journal of Pediatrics in March, cite the rise among kids of C. diff, which causes gastrointestinal problems. A 2017 study in the Journal of the Pediatric Infectious Diseases Society found that cases of a certain type of multidrug-resistant Enterobacteriaceae rose 700% in American children in just eight years. And a steady stream of research points to the stubborn prevalence in kids of the better-known MRSA, or methicillin-resistant Staphylococcus aureus.

Superbug infections can be extremely difficult — and sometimes impossible — to treat. Doctors often must turn to strong medicines with side effects or give drugs intravenously.

“It’s getting more and more worrisome,” Ross said. “We have had patients we have not been able to treat because we’ve had no antibiotics available” that could kill the germs.

Doctors say the world is nearing a “post-antibiotic era,” when antibiotics no longer work and common infections can kill.

A Monster Unleashed

Superbugs spawned by antibiotic overuse put everyone at risk.

Like her daughter, Fuhrman also suffered through a C. diff infection, getting sick after taking antibiotics following a root canal in 2012. While killing harmful germs, antibiotics can also destroy those that protect against infection. Fuhrman cycled in and out of the hospital for months. When she finally got better, she tried to avoid using antibiotics and never gave them to her daughter.

That’s because antibiotics affect your microbiome by wiping out bad germs but also the good germs that protect your body against infections.

Pearl’s first symptoms of C. diff arose about three years later, at around 20 months old. Fuhrman noticed her daughter was having lots of bowel movements. The mom eventually found pus and blood in her daughter’s stools. One day, Pearl was so pale and weak that Fuhrman took her to the emergency room. She was discharged, then spiked a fever and returned to the hospital.

Doctors treated Pearl with Flagyl, a broad-spectrum antibiotic. But two days after the last dose, she went downhill. The infection had returned. She recovered only after going to the Mayo Clinic in Rochester, Minnesota, for a fecal microbiota transplantation, in which she received healthy donor stool from her dad through a colonoscopy.

Since her family’s ordeal, Fuhrman has been trying to raise awareness of superbugs and antibiotic overuse. She serves on the board of the Peggy Lillis Foundation, a C. diff education and advocacy organization, and has testified before a presidential advisory committee in Washington, D.C., about superbugs and antibiotic stewardship.

In March, the Centers for Medicare & Medicaid Services began requiring all hospitals to document that they have antibiotic stewardship programs.

One approach, Schleiss said, is to restrict antibiotics by “saving our most magic bullets for the most desperate situations.” Another is to stop antibiotics at, say, 72 hours, after reassessing whether patients need them. Meanwhile, doctors are calling for more research into antibiotic use in children.

Fuhrman said hospitals must do all they can to stop superbug infections. The stakes are enormous, she said, pointing toward Pearl, now a 7-year-old first grader who likes to wear a pink hair bow and paint her tiny fingernails a rainbow of pastel colors.

“Antibiotics are great, but they have to be used wisely,” Fuhrman said. “The problem of superbugs is here. It’s in our backyard now, and it’s just getting worse.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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As the covid-19 pandemic heads for a showdown with vaccines it’s expected to lose, many experts in the field of emerging infectious diseases are already focused on preventing the next one.

They fear another virus will leap from wildlife into humans, one that is far more lethal but spreads as easily as SARS-CoV-2, the strain of coronavirus that causes covid-19. A virus like that could change the trajectory of life on the planet, experts say.

“What keeps me up at night is that another coronavirus like MERS, which has a much, much higher mortality rate, becomes as transmissible as covid,” said Christian Walzer, executive director of health at the Wildlife Conservation Society. “The logistics and the psychological trauma of that would be unbearable.”

SARS-CoV-2 has an average mortality rate of less than 1%, while the mortality rate for Middle East respiratory syndrome, or MERS — which spread from camels into humans — is 35%. Other viruses that have leapt the species barrier to humans, such as bat-borne Nipah, have a mortality rate as high as 75%.

“There is a huge diversity of viruses in nature, and there is the possibility that one has the Goldilocks characteristics of pre-symptomatic transmission with a high fatality rate,” said Raina Plowright, a virus researcher at the Bozeman Disease Ecology Lab in Montana. (Covid-19 is highly transmissible before the onset of symptoms but fortunately is far less lethal than several other known viruses.) “It would change civilization.”

That’s why in November the German Federal Foreign Office and the Wildlife Conservation Society held a virtual conference called One Planet, One Health, One Future, aimed at heading off the next pandemic by helping world leaders understand that killer viruses like SARS-CoV-2 — and many other less deadly pathogens — are unleashed on the world by the destruction of nature.

With the world’s attention gripped by the spread of the coronavirus, infectious disease experts are redoubling their efforts to show the robust connection between the health of nature, wildlife and humans. It is a concept known as One Health.

While the idea is widely accepted by health officials, many governments have not factored it into policies. So the conference was timed to coincide with the meeting of the world’s economic superpowers, the G20, to urge them to recognize the threat that wildlife-borne pandemics pose, not only to people but also to the global economy.

The Wildlife Conservation Society — America’s oldest conservation organization, founded in 1895 — has joined with 20 other leading conservation groups to ask government leaders “to prioritize protection of highly intact forests and other ecosystems, and work in particular to end commercial wildlife trade and markets for human consumption as well as all illegal and unsustainable wildlife trade,” they said in a recent press release.

Experts predict it would cost about $700 billion to institute these and other measures, according to the Wildlife Conservation Society. On the other hand, it’s estimated that covid-19 has cost $26 trillion in economic damage. Moreover, the solution offered by those campaigning for One Health goals would also mitigate the effects of climate change and the loss of biodiversity.

The growing invasion of natural environments as the global population soars makes another deadly pandemic a matter of when, not if, experts say — and it could be far worse than covid. The spillover of animal, or zoonotic, viruses into humans causes some 75% of emerging infectious diseases.

But multitudes of unknown viruses, some possibly highly pathogenic, dwell in wildlife around the world. Infectious disease experts estimate there are 1.67 million viruses in nature; only about 4,000 have been identified.

SARS-CoV-2 likely originated in horseshoe bats in China and then passed to humans, perhaps through an intermediary host, such as the pangolin — a scaly animal that is widely hunted and eaten.

While the source of SARS-CoV-2 is uncertain, the animal-to-human pathway for other viral epidemics, including Ebola, Nipah and MERS, is known. Viruses that have been circulating among and mutating in wildlife, especially bats, which are numerous around the world and highly mobile, jump into humans, where they find a receptive immune system and spark a deadly infectious disease outbreak.

“We’ve penetrated deeper into eco-zones we’ve not occupied before,” said Dennis Carroll, a veteran emerging infectious disease expert with the U.S. Agency for International Development. He is setting up the Global Virome Project to catalog viruses in wildlife in order to predict which ones might ignite the next pandemic. “The poster child for that is the extractive industry — oil and gas and minerals, and the expansion of agriculture, especially cattle. That’s the biggest predictor of where you’ll see spillover.”

When these things happened a century ago, he said, the person who contracted the disease likely died there. “Now an infected person can be on a plane to Paris or New York before they know they have it,” he said.

Meat consumption is also growing, and that has meant either more domestic livestock raised in cleared forest or “bush meat” — wild animals. Both can lead to spillover. The AIDS virus, it’s believed, came from wild chimpanzees in central Africa that were hunted for food.

One case study for how viruses emerge from nature to become an epidemic is the Nipah virus.

Nipah is named after the village in Malaysia where it was first identified in the late 1990s. The symptoms are brain swelling, headaches, a stiff neck, vomiting, dizziness and coma. It is extremely deadly, with as much as a 75% mortality rate in humans, compared with less than 1% for SARS-CoV-2. Because the virus never became highly transmissible among humans, it has killed just 300 people in some 60 outbreaks.

One critical characteristic kept Nipah from becoming widespread. “The viral load of Nipah, the amount of virus someone has in their body, increases over time” and is most infectious at the time of death, said the Bozeman lab’s Plowright, who has studied Nipah and Hendra. (They are not coronaviruses, but henipaviruses.) “With SARS-CoV-2, your viral load peaks before you develop symptoms, so you are going to work and interacting with your family before you know you are sick.”

If an unknown virus as deadly as Nipah but as transmissible as SARS-CoV-2 before an infection was known were to leap from an animal into humans, the results would be devastating.

Plowright has also studied the physiology and immunology of viruses in bats and the causes of spillover. “We see spillover events because of stresses placed on the bats from loss of habitat and climatic change,” she said. “That’s when they get drawn into human areas.” In the case of Nipah, fruit bats drawn to orchards near pig farms passed the virus on to the pigs and then humans.

“It’s associated with a lack of food,” she said. “If bats were feeding in native forests and able to nomadically move across the landscape to source the foods they need, away from humans, we wouldn’t see spillover.”

A growing understanding of ecological changes as the source of many illnesses is behind the campaign to raise awareness of One Health.

One Health policies are expanding in places where there are likely human pathogens in wildlife or domestic animals. Doctors, veterinarians, anthropologists, wildlife biologists and others are being trained and training others to provide sentinel capabilities to recognize these diseases if they emerge.

The scale of preventive efforts is far smaller than the threat posed by these pathogens, though, experts say. They need buy-in from governments to recognize the problem and to factor the cost of possible epidemics or pandemics into development.

“A road will facilitate a transport of goods and people and create economic incentive,” said Walzer, of the Wildlife Conservation Society. “But it will also provide an interface where people interact and there’s a higher chance of spillover. These kinds of costs have never been considered in the past. And that needs to change.”

The One Health approach also advocates for the large-scale protection of nature in areas of high biodiversity where spillover is a risk.

Joshua Rosenthal, an expert in global health with the Fogarty International Center at the National Institutes of Health, said that while these ideas are conceptually sound, it is an extremely difficult task. “These things are all managed by different agencies and ministries in different countries with different interests, and getting them on the same page is challenging,” he said.

Researchers say the clock is ticking. “We have high human population densities, high livestock densities, high rates of deforestation — and these things are bringing bats and people into closer contact,” Plowright said. “We are rolling the dice faster and faster and more and more often. It’s really quite simple.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Funeral director Kevin Spitzer has been overwhelmed with covid-related deaths in the small city of Aberdeen, South Dakota.

He and his two colleagues at the Spitzer-Miller Funeral Home have been working 12-15 hours a day, seven days a week, to keep up with the demand in the community of 26,000. The funerals are sparsely attended, which would have been unthinkable before the pandemic.

“We had a funeral for a younger man one recent Saturday, and not 20 people came, because most everyone was just afraid,” he said.

As covid-19 has spread from big cities to rural communities, it has stressed not only hospitals, but also what some euphemistically call “last responders.” The crush has overwhelmed morgues, funeral homes and religious leaders, required ingenuity and even changed the rituals of honoring the dead.

Officials in many smaller cities and towns learned from seeing the overflow of bodies during last spring’s first wave of covid deaths in places such as Detroit, where nurses at Detroit Medical Center Sinai-Grace Hospital alerted the media to bodies accumulating in hospital storage rooms. They watched as New York hospitals and funeral homes marshaled refrigerated trucks to store bodies. More than 600 bodies of people who died in the spring COVID surge remain in freezer trucks on the Brooklyn waterfront because officials can’t find next of kin, or relatives are also sick or unable to pay for burial.

People like Dr. Robert Kurtzman, Montana’s chief medical examiner, took heed. Last spring, he worked with funeral directors and others to study the state’s morgue capacity. After looking at covid projections, the state arranged with the Montana National Guard to have 13 refrigerated semitrucks ready to dispatch anywhere in the state.

“We are already in a precarious position, and the projections present a scary proposition,” he said. “We need to be ready for worst-case scenarios.”

Chad Towner, CEO of St. Joseph Health System, which has two hospitals in northern Indiana, ordered two refrigerated semitrailers in April. For a time, things were relatively quiet. But the pandemic has hit.

“I told a friend who was a covid doubter that if my wife needed a bed today, I could not arrange one. That’s the dire situation we face here,” Towner said. “All our competitors in the area are in the same boat, and we’re working together instead of competing.”

Although the freezer trucks have not yet been needed, he worries that the sharp increase in cases, and those anticipated from holiday gatherings, will make last-resort measures necessary.

“We recently had four deaths in one afternoon,” said Towner. “A priest approached me to say he’d been asked to provide last rites to three patients in one hour.”

Moving bodies from the hospital morgue is a slower process than usual, he said. “Morticians and funeral homes are overflowing as well. Families that are sick or quarantined at the time of the loved one’s death often can’t work with us on a transfer, meaning bodies are here longer. The entire system is stressed to the tipping point,” said Towner.

Private enterprise has created a solution for smaller communities. In Bozeman, Montana, a specialty truck company has retrofitted trailers that can be pulled by an SUV or a pickup.

Acela Truck Co. has already sold hundreds of the pull-behind refrigerated units created in response to the covid pandemic. They range from 9 to 53 feet and have racks that each hold four body trays. “We’re very busy and have orders in all of the lower 48 states,” said CEO David Ronsen. Acela has partnered with Mopec, a Michigan autopsy supply company, to help sell and deliver the new product.

Billings Clinic in Montana also anticipated a flood of deaths last spring by reserving a semitrailer for delivery, if needed. The clinic, which has just two morgue spaces, has dealt with 80 covid deaths, including seven on the weekend after Thanksgiving.

Chief Nursing Officer Laurie Smith said the hospital is at capacity, despite adding beds by converting office space and building an addition. The hospital, which currently has 335 beds, so far has handled the additional deaths through what she calls a “sad partnership” with funeral homes, which have been quickly picking up bodies the hospital cannot store.

The hospital does its best to allow relatives to say goodbye, but that often involves family members standing at an interior window outside the patient’s room, using a computer tablet to communicate their last words.

That is just one way in which the rituals of grieving have changed during the covid pandemic.

Typical congregational hymns are pretty much gone, as are choirs.

“We are using mostly recordings, sometimes a soloist,” said Spitzer.

Funeral home directors who pride themselves on spending time comforting grieving families say they are so busy that some days they have to rush out from one funeral to begin the next one.

“Families are being robbed of the whole funeral rite experience and losing the support of having friends and family around them,” said Shauna Kjos-Miotke of Fiksdal Funeral Home in Webster, South Dakota.

Native communities have not only been among the hardest hit with covid illnesses and deaths, but their grieving rituals have been among the most seriously disrupted.

“Normally a funeral is a two- or three-day process with hundreds of people,” said Josiah Hugs, a Crow tribal member who is the outreach coordinator for Billings Urban Indian Health and Wellness Center. “Now there is no time to tell stories about the person, not a lot of singing and praying. I’ve been to three recent covid funerals, and everything was at the burial site, with maybe 30 people sitting in their cars and not getting out.”

Covid has even affected body disposal. A survey by the National Funeral Directors Association found that more than half of their members reported increased cremation rates due to covid. The NFDA also found that half its members have clients who have postponed services to hold a memorial later.

In the largely impoverished Hidalgo County, a Texas border area, county officials began using covid funds to help cover the burial costs for struggling families. Then they begin hearing of the emotional costs, including the anguish of videoconferenced funerals, such as for a family that had lost a husband, a mother and an aunt in one month. They wondered if there would be interest in an alternative way to honor the dead.

“We sent out a social media post asking if anyone wanted to post a photograph of a relative who died of covid if we created a county memorial page,” said county spokesperson Carlos Sanchez, who himself barely survived a bout with covid in July. “Within minutes, we got more than 20 emails. Several sent photos of multiple relatives. They want them to be remembered.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Ted Howard started taking Truvada a few years ago because he wanted to protect himself against HIV, the virus that causes AIDS. But the daily pill was so pricey he was seriously thinking about giving it up.

Under his insurance plan, the former flight attendant and customer service instructor owed $500 in copayments every month for the drug and an additional $250 every three months for lab work and clinic visits.

Luckily for Howard, his doctor at Las Vegas’ Huntridge Family Clinic, which specializes in LGBTQ care, enrolled him in a clinical trial that covered his medication and other costs in full.

“If I hadn’t been able to get into the trial, I wouldn’t have kept taking PrEP,” said Howard, 68, using the shorthand term for “preexposure prophylaxis.” Taken daily, these drugs — like Truvada — are more than 90% effective at preventing infection with HIV.

Starting this month, most people with private insurance will no longer have to decide whether they can afford to protect themselves against HIV. Most health plans must begin to cover the drugs then without charging consumers anything out-of-pocket (some plans already began doing so last year).

Drugs in this category — Truvada, Descovy and, newly available, a generic version of Truvada — received an “A” recommendation by the U.S. Preventive Services Task Force. Under the Affordable Care Act, preventive services that receive an “A” or “B” rating by the task force, a group of medical experts in prevention and primary care, must be covered by most private health plans without making members share the cost, usually through copayments or deductibles. Only plans that are grandfathered under the health law are exempt.

The task force recommended PrEP for people at high risk of HIV infection, including men who have sex with men and injection drug users.

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In the United States, more than 1 million people live with HIV, and nearly 40,000 new HIV cases are diagnosed every year. Yet fewer than 10% of people who could benefit from PrEP are taking it. One key reason is that out-of-pocket costs can exceed $1,000 annually, according to a study published in the American Journal of Public Health last year. Required periodic blood tests and doctor visits can add hundreds of dollars to the cost of the drug, and it’s not clear whether insurers are required to pick up all those costs.

“Cost sharing has been a problem,” said Michael Crews, policy director at One Colorado, an advocacy group for the LGBTQ community. “It’s not just getting on PrEP and taking a pill. It’s the lab and clinical services. That’s a huge barrier for folks.”

California officials have already sought to address the problem, including guarantees that PrEP drugs and care provided along with the drugs are covered without cost sharing for patients. The state also bans requiring prior approval from insurers to take the drugs and restrictions on the use of some of the drugs if cheaper ones are available.

“California did go further issuing the guidance to cover ancillary services with no cost sharing and we also have the bill preventing [prior authorization] and step therapy for PrEP meds,” said Anne Donnelly, director of state health care policy at the San Francisco AIDS Foundation.

The California requirements, however, apply only to health insurance policies regulated by the state. Employers that pay their workers’ claims directly, rather than buying health insurance, don’t have to comply with the California rules.

Whether you’re shopping for a new plan during open enrollment or want to check out what your current plan covers, here are answers to questions you may have about the new preventive coverage requirement.

Q: How can people find out whether their health plan covers PrEP medications without charge?

The plan’s list of covered drugs, called a formulary, should spell out which drugs are covered, along with details about which drug tier they fall into. Drugs placed in higher tiers generally have higher cost sharing. That list should be online with the plan documents that give coverage details.

Sorting out coverage and cost sharing can be tricky. Both Truvada and Descovy can also be used to treat HIV, and if they are taken for that purpose, a plan may require members to pay some of the cost. But if the drugs are taken to prevent HIV infection, patients shouldn’t owe anything out-of-pocket, no matter which tier they are on.

In a recent analysis of online formularies for plans sold on the ACA marketplaces, Carl Schmid, executive director of the HIV + Hepatitis Policy Institute, found that many plans seemed out of compliance with the requirement to cover PrEP without cost sharing this year.

But representatives for Oscar and Kaiser Permanente, two insurers that were called out in the analysis for lack of compliance, said the drugs are covered without cost sharing in plans nationwide if they are taken to prevent HIV. Schmid later revised his analysis to reflect Oscar’s coverage.

Coverage and cost-sharing information needs to be transparent and easy to find, Schmid said.

“I acted like a shopper of insurance, just like any person would do,” he said. “Even when the information is correct, [it’s so] difficult to find [and there’s] no uniformity.”

It may be necessary to call the insurer directly to confirm coverage details if the information on the website is unclear.

Q: Are all three drugs covered without cost sharing?

Health plans have to cover at least one of the drugs in this category — Descovy and the brand and generic versions of Truvada — without cost sharing. People may have to jump through some hoops to get approval for a specific drug, however. For example, Oscar plans sold in 18 states cover the three PrEP options without cost sharing. The generic version of Truvada doesn’t require prior authorization by the insurer. But if someone wants to take the name-brand drug, they have to go through an approval process. Descovy, a newer drug, is available without cost sharing only if people are unable to use Truvada or its generic version because of clinical intolerance or other issues.

Q: What about the lab work and clinical visits that are necessary while taking PrEP? Are those services also covered without cost sharing?

That is the thousand-dollar question. People who are taking drugs to prevent HIV infection need to meet with a clinician and have bloodwork every three months to test for HIV, hepatitis B and sexually transmitted infections, and to check their kidney function.

The task force recommendation doesn’t specify whether these services must also be covered without cost sharing, and advocates say federal guidance is necessary to ensure they are free.

“If you’ve got a high-deductible plan and you’ve got to meet it before those services are covered, that’s going to add up,” said Amy Killelea, senior director of health systems and policy at the National Alliance of State & Territorial AIDS Directors. “We’re trying to emphasize that it’s integral to the intervention itself.”

A handful of states have programs that help people cover their out-of-pocket costs for lab and clinical visits, generally based on income.

There is precedent for including free ancillary care as part of a recommended preventive service. After consumers and advocates complained, the Centers for Medicare & Medicaid Services (CMS) clarified that under the ACA removing a polyp during a screening colonoscopy is considered an integral part of the procedure and patients shouldn’t be charged for it.

CMS officials declined to clarify whether PrEP services such as lab work and clinical visits are to be covered without cost sharing as part of the preventive service and noted that states generally enforce such insurance requirements. “CMS intends to contact state regulators, as appropriate, to discuss issuer’s compliance with the federal requirements and whether issuers need further guidance on which services associated with PrEP must be covered without cost sharing,” the agency said in a statement.

Q: What if someone runs into roadblocks getting a plan to cover PrEP or related services without cost sharing?

If an insurer charges for the medication or a follow-up visit, people may have to go through an appeals process to fight it.

“They’d have to appeal to the insurance company and then to the state if they don’t succeed,” said Nadeen Israel, vice president of policy and advocacy at the AIDS Foundation of Chicago. “Most people don’t know to do that.”

Q: Are uninsured people also protected by this new cost-sharing change for PrEP?

Unfortunately, no. The ACA requirement to cover recommended preventive services without charging patients applies only to private insurance plans. People without insurance don’t benefit. Gilead, which makes both Truvada and Descovy, has a patient assistance program for the uninsured.

This story also ran on Fortune. It can be republished for free.

Sharon Clark is able to get her life-sustaining cancer drug, Pomalyst — priced at more than $18,000 for a 28-day supply — only because of the generosity of patient assistance foundations.

Clark, 57, a former insurance agent who lives in Bixby, Oklahoma, had to stop working in 2015 and go on Social Security disability and Medicare after being diagnosed with multiple myeloma, a blood cancer. Without the foundation grants, mostly financed by the drugmakers, she couldn’t afford the nearly $1,000 a month it would cost her for the drug, since her Medicare Part D drug plan requires her to pay 5% of the list price.

Every year, however, Clark has to find new grants to cover her expensive cancer drug.

“It’s shameful that people should have to scramble to find funding for medical care,” she said. “I count my blessings, because other patients have stories that are a lot worse than mine.”

Many Americans with cancer or other serious medical conditions face similar prescription drug ordeals. It’s often worse, however, for Medicare patients. Unlike private health insurance, Part D drug plans have no cap on patients’ 5% coinsurance costs once they hit $6,550 in drug spending for this year (rising from $6,350 in 2020), except for very low-income beneficiaries.

President-elect Joe Biden favors a cap, and Democrats and Republicans in Congress have proposed annual limits ranging from $2,000 to $3,100. But there’s disagreement about how to pay for that cost cap. Drug companies and insurers, which support the concept, want someone else to bear the financial burden.

That forces patients to rely on the financial assistance programs. These arrangements, however, do nothing to reduce prices. In fact, they help drive up America’s uniquely high drug spending by encouraging doctors and patients to use the priciest medications when cheaper alternatives may be available.

Growing Expense of Specialty, Cancer Medicines

Nearly 70% of seniors want Congress to pass an annual limit on out-of-pocket drug spending for Medicare beneficiaries, according to a KFF survey in 2019. (KHN is an editorially independent program of KFF.)

The affordability problem is worsened by soaring list prices for many specialty drugs used to treat cancer and other serious diseases. The out-of-pocket cost for Medicare and private insurance patients is often set as a percentage of the list price, as opposed to the lower rate negotiated by insurers.

For instance, prices for 54 orally administered cancer drugs shot up 40% from 2010 to 2018, averaging $167,904 for one year of treatment, according to a 2019 JAMA study. Bristol Myers Squibb, the manufacturer of Clark’s drug, Pomalyst, has raised the price 75% since it was approved in 2013, to about $237,000 a year. The company believes “pricing should be put in the context of the value, or benefit, the medicine delivers to patients, health care systems and society overall,” a spokesperson for Bristol Myers Squibb said via email.

As a result of rising prices, 1 million of the 46.5 million Part D drug plan enrollees spend above the program’s catastrophic coverage threshold and face $3,200 in average annual out-of-pocket costs, according to KFF. The hit is particularly heavy on cancer patients. In 2019, Part D enrollees’ average out-of-pocket cost for 11 orally administered cancer drugs was $10,470, according to the JAMA study.

The median annual income for Medicare beneficiaries is $26,000.

Medicare patients face modest out-of-pocket costs if their drugs are administered in the hospital or a doctor’s office and they have a Medigap or Medicare Advantage plan, which caps those expenses.

But during the past several years, dozens of effective drugs for cancer and other serious conditions have become available in oral form at the pharmacy. That means Medicare patients increasingly pay the Part D out-of-pocket costs with no set maximum.

“With the high cost of drugs today, that 5% can be a third or more of a patient’s Social Security check,” said Brian Connell, federal affairs director for the Leukemia & Lymphoma Society.

This has forced some older Americans to keep working, rather than retiring and going on Medicare, because their employer plan covers more of their drug costs. That way, they also can keep receiving financial help directly from drugmakers to pay for the costs not covered by their private plan, which isn’t allowed by Medicare.

‘This Is a Little Nuts’

All this has caused financial and emotional turmoil for people who face a life-threatening disease.

Marilyn Rose, who was diagnosed with chronic myeloid leukemia three years ago, until recently was paying nothing out-of-pocket for her cancer drug, Sprycel, which has a list price of $176,500 a year. That’s because Bristol Myers Squibb, the manufacturer, paid her insurance deductible and copays for the drug.

But the self-employed artist and designer, who lives in West Caldwell, New Jersey, recently turned 65 and went on Medicare. The Part D plan offering the best deal on Sprycel charges more than $10,000 a year in coinsurance for the drug.

Rose asked her oncologist if she could switch to an alternative medication, Gleevec, for which she’d pay just $445 a year. But she ultimately decided to stick with Sprycel, which her doctor said is a longer-lasting treatment. She hopes to qualify for financial aid from a foundation to cover the coinsurance but won’t know until sometime this month.

“It’s just strange you have to make a decision about your treatment based on your finances rather than what’s the right drug for you,” she said. “I always thought that when I get to Medicare age I’ll be able to breathe a sigh of relief. This is a little nuts.”

Given the sticker shock, many other patients choose not to fill a needed prescription, or delay filling it. Nearly half of patients who face a price of $2,000 or more for a cancer drug walk away from the pharmacy without it, according to a 2017 study. Fewer than half of Medicare patients with blood cancer received treatment within 90 days of their diagnosis, according to a 2019 study commissioned by the Leukemia & Lymphoma Society.

“If I didn’t do really well at scrounging free drugs and getting copay foundations to work with us, my patients wouldn’t get the drug, which is awful,” said Dr. Barbara McAneny, an oncologist in Albuquerque, New Mexico, and past president of the American Medical Association. “Patients would just say, ‘I can’t afford it. I’ll just die.’”

The high drug prices and coverage gaps have forced many patients to rely on complicated financial assistance programs offered by drug companies and foundations. Under federal rules, the foundations can help Medicare patients as long as they pay for drugs made by all manufacturers, not just by the company funding the foundation.

But Daniel Klein, CEO of the PAN Foundation, which provides drug copay assistance to more than 100,000 people a year, said there are more patients in need than his foundation and others like it can help.

“If you are a normal consumer, you don’t know much about any of this until you get sick and all of a sudden you find out you can’t afford your medication,” he said. Patients are lucky, he added, if their doctor knows how to navigate the charitable assistance maze.

Yet many don’t. Daniel Sherman, who trains hospital staff members to navigate financial issues for patients, estimates that fewer than 5% of U.S. cancer centers have experts on staff to help patients with problems paying for their care.

Sharon Clark, who struggles to cover her cancer drugs, works with the Leukemia & Lymphoma Society counseling other patients on how to access helping resources. “People tell me they haven’t started treatment because they don’t have money to pay,” she said. “No one in this country should have to choose between housing, food or medicine. It should never be that way, never.”

This article is part of a series on the impact of high prescription drug costs on consumers made possible through the 2020 West Health and Families USA Media Fellowship.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Yolanda Coar was 40 when she died of COVID-19 in August 2020 in Augusta, Georgia. She was also a nurse manager, and one of nearly 3,000 frontline workers who have died in the U.S. fighting this virus, according to an exclusive investigation by The Guardian and KHN.

Read more of the health workers’ stories behind the statistics — their personalities, passions and quirks. “Lost on the Frontline” examines: Did they have to die?

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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ERIE, Colo. — Whenever Larry Kelderman looks up from the car he’s fixing and peers across the street, he’s looking across a border. His town of 28,000 straddles two counties, separated by County Line Road.

Kelderman’s auto repair business is in Boulder County, whose officials are sticklers for public health and have topped the county website with instructions on how to report COVID violations. Kelderman lives in Weld County, where officials refuse to enforce public health rules.

Weld County’s test positivity rate is twice that of its neighbor, but Kelderman is pretty clear which side he backs.

“Which is worse, the person gets the virus and survives and they still have a business, or they don’t get the virus and they lose their livelihood?” he said.

Boulder boasts one of the most highly educated populations in the nation; Weld boasts about its sugar beets, cattle and thousands of oil and gas wells. Summer in Boulder County means concerts featuring former members of the Grateful Dead; in Weld County, it’s rodeo time. Boulder voted for Biden, Weld for Trump. Per capita income in Boulder is nearly 50% higher than in Weld.

Even their COVID outbreaks are different: In Boulder County, the virus swirls around the University of Colorado. In Weld County, some of the worst outbreaks have swept through meatpacking plants.

It’s not the first time County Line Road has been a fault line.

“I’ve been in politics seven years and there’s always been a conflict between the two counties,” said Jennifer Carroll, mayor of Erie, once a coal mining town and now billed as a good place to raise a family, about 30 minutes north of Denver.

Shortly before the coronavirus hit Colorado, Erie’s board of trustees extended a moratorium on new oil and gas operations in the town. Weld County was not pleased.

“They got really angry at us for doing that, because oil and gas is their thing,” Carroll said.

Most of the town’s businesses are on the Weld side. To avoid public health whiplash, Carroll and other town leaders have asked residents to comply with the more restrictive stance of the Boulder side.

The feud got ugly in a dispute over hospital beds. At one point, the state said Weld County had only three intensive care beds, while Weld County claimed it had 43.

“It made my job harder, because people were doubting what I was saying,” said Carroll. “Nobody trusted anyone because they were hearing conflicting information.”

Weld’s number, it turned out, included not just the beds in its two hospitals, but also those in 10 other hospitals across the county line, including in the city of Longmont.

Longmont sits primarily in Boulder County but spills into Weld, where its suburbs taper into fields pockmarked with prairie dog holes. Its residents say they can tell snow is coming when the winds deliver a pungent smell of livestock from next door. Longmont Mayor Brian Bagley worried that Weld’s behavior would deliver more than a stench: It might also deliver patients requiring precious resources.

“They were basically encouraging their citizens to violate the emergency health orders … with this cowboy-esque, you know, ‘Yippee-ki-yay, freedom, Constitution forever, damn the consequences,’” said Bagley. “Their statement is, ‘Our hospitals are full, but don’t worry, we’re just going to use yours.’”

So, “for 48 hours, I trolled Weld County,” he said. Bagley asked the city council to consider an ordinance that could have restricted Weld County residents’ ability to receive care at Longmont hospitals. Bagley, who retracted his proposal the next day, said he knew it was never going to come to fruition — after all, it was probably illegal — but he wanted to prove a point.

“They’re going to be irresponsible? Fine. Let me propose a question,” he said. “If there is only one ICU bed left and there are two grandparents there — one from Weld, one from Boulder — and they both need that bed, who should get it?”

Weld County commissioners volleyed back, calling Bagley a “simple mayor.” They wrote that the answer to the pandemic was “not to continually punish working-class families or the individuals who bag your groceries, wait on you in restaurants, deliver food to your home while you watch Netflix and chill.”

“I know we’re all trying to get along, but people are starting to do stupid and mean things and so I’ll be stupid and mean back,” Bagley said during a Dec. 8 council meeting.

In another Longmont City Council meeting, Bagley (who suspects the commissioners don’t know what “Netflix and chill” typically means) often referred to Weld simply as “our neighbors to the East,” declining to name his foe. The council shrugged off his statement about withholding medical treatment but demanded that Weld County step up to fight the pandemic.

“We would not deny medical care to anybody. It’s illegal and it’s immoral,” said council member Polly Christensen. “But it is wrong for people to expect us to bear the burden of what they’ve been irresponsible enough to let loose.”

“They’re the reason why I can’t be in the classroom in front of my kids,” said council member and teacher Susie Hidalgo-Fahring, whose school district straddles the counties. “I’m done with that. Everybody needs to be a good neighbor.”

The council decided Dec. 15 to send a letter to Weld County’s commissioners encouraging them to enforce state restrictions and to make a public statement about the benefits of wearing masks and practicing physical distancing. They’ve also backed a law allowing Democratic Gov. Jared Polis to withhold relief money from counties that don’t comply with restrictions.

Weld County Commissioner Scott James said his county doesn’t have the authority to enforce public health orders any more than a citizen has the authority to give a speeding ticket.

“If you want me as an elected official to assume authority that I don’t have and arbitrarily exert it over you, I dare you to look that up in the dictionary,” said James, who is a rancher turned country radio host. “It’s called tyranny.”

James doesn’t deny that COVID-19 is ravaging his community. “We’re on fire, and we need to put that fire out,” he said. But he believes that individuals will make the right decisions to protect others, and demands the right of his constituents to use the hospital nearest them.

“To look at Weld County like it has walls around it is shortsighted and not the way our health care system is designed to work,” James said. “To use a crudity, because I am, after all, just a ranch kid turned radio guy, there’s no ‘non-peeing’ section in the pool. Everybody’s gonna get a little on ’em. And that’s what’s going on right now with COVID.”

The dispute is not just liberal and conservative politics clashing. Bagley, the Longmont mayor, grew up in Weld County and “was a Republican up until Trump,” he said. But it is an example of how the virus is tapping into long-standing Western strife.

“There’s decades of reasons for resentment at people from a distance — usually from a metropolis and from a state or federal governmental office — telling rural people what to do,” said Patty Limerick, faculty director at the Center of the American West at the University of Colorado-Boulder, and previously state historian.

In the ’90s, she toured several states performing a mock divorce trial between the rural and urban West. She played Urbana Asphalt West, married to Sandy Greenhills West. Their child, Suburbia, was indulged and clueless and had a habit of drinking everyone else’s water. A rural health care shortage was one of many fuels of their marital strife.

Limerick and her colleagues are reviving the play now and adding COVID references. This time around, she said, it’ll be a last-ditch marriage counseling session for high school classes and communities to adopt and perform. It likely won’t have a scripted ending; she’s leaving that up to each community.

Nine months into the pandemic that has killed more than 320,000 people in the U.S., Kim Larson is still trying to convince others in her northern Montana county that COVID-19 is dangerous.

As Hill County Health Department director and county health officer, Larson continues to hear people say the coronavirus is just like a bad case of the flu. Around the time Montana’s governor mandated face coverings in July, her staffers saw notices taped in several businesses’ windows spurning the state’s right to issue such emergency orders.

For a while, the county with a population of 16,000 along the Canadian border didn’t see much evidence of the pandemic. It had only one known COVID case until July. But that changed as the nation moved into its third surge of the virus this fall. By mid-December, Hill County had recorded more than 1,500 cases — the vast majority since Oct. 1 — and 33 people there had died.

When Larson hears people say pandemic safety rules should end, she talks about how contagious the COVID virus is, how some people experience lasting effects and how hospitals are so full that care for any ailment could face delays.

“In public health, we’ve seen the battle before, but you typically have the time to build your evidence, research showing that this really does save lives,” Larson said. “In the middle of a pandemic, you have no time.”

Public health laws typically come long after social norms shift, affirming a widespread acceptance that a change in habits is worth the public good and that it’s time for stragglers to fall in line. But even when decades of evidence show a rule can save lives — such as wearing seat belts or not smoking indoors — the debate continues in some places with the familiar argument that public restraints violate personal freedoms. This fast-moving pandemic, however, doesn’t afford society the luxury of time. State mandates have put local officials in charge of changing behavior while general understanding catches up.

Earlier this month, U.S. Surgeon General Jerome Adams stood next to Montana’s governor in Helena and said he hopes people wear masks because it’s the right thing to do — especially as COVID hospitalizations rise.

“You don’t want to be the reason that a woman in labor can’t get a hospital bed,” Adams said, adding a vaccine is on the way. “It’s just for a little bit longer.”

He spoke days after state lawmakers clashed over masks as a majority of Republican lawmakers arrived for a committee meeting barefaced and at least one touted false information on the dangers of masks. As of Dec. 15, the Republican majority hadn’t required masks for the upcoming legislative session, set to begin Jan. 4.

And now a group opposed to masks from Gallatin and Flathead counties has filed a lawsuit asking a Montana judge to block the state’s pandemic-related safety rules.

Public health laws typically spark political battles. Changing people’s habits is hard, said Lindsay Wiley, director of the health law and policy program at American University in Washington, D.C. Despite the misconception that there was universal buy-in for masks during the 1918 pandemic, Wiley said, some protesters intentionally built rap sheets of arrests for going maskless in the name of liberty.

She said health officials realize any health restrictions amid a pandemic require the public’s trust and cooperation for success.

“We don’t have enough police to walk around and force everyone to wear a mask,” she said. “And I’m not sure we want them to do it.”

Local officials have the best chance to win over that support, Wiley said. And seeing elected leaders such as President Donald Trump rebuff his own federal health guidelines makes that harder. Meanwhile, public shaming like calling unmasked people selfish or stupid can backfire, Wiley said, because if they were to give in to mask-wearing, they would essentially be accepting those labels.

In the history of public health laws, even rules that have had time to build widely accepted evidence weren’t guaranteed support.

It’s illegal in Montana to go without a seat belt in a moving car. But, as in 13 other states, authorities aren’t allowed to pull people over for being unbuckled. Every few years, a Montana lawmaker, backed by a collection of public health and law enforcement organizations, proposes a law to allow seat belt traffic stops, arguing it would save lives. In 2019, that request didn’t even make it out of committee, squelched by the arguments of personal choice and not giving too much power to the government.

Main opposition points against public health laws — whether it’s masks, seat belts, motorcycle helmets or smoking — can sound alike.

When Missoula County became the first place in Montana to ban indoor smoking in public spaces in 1999, opponents said the change would destroy businesses, be impossible to enforce and violate people’s freedom of choice.

“They are the same arguments in a lot of ways,” said Ellen Leahy, director of the Missoula City-County Health Department. “Public health was right at that intersection between what’s good for the whole community and the rights and responsibilities of the individual.”

Montana adopted an indoor smoking ban in 2005, but many bars and taverns were given until 2009 to fall in line. And, in some places, debate and court battles continued for a decade more on how the ban could be enforced.

Amid the COVID pandemic, Missoula County was again ahead of much of the state when it passed its own mask ordinance. The county has two hospitals and a university that swells its population with students and commuters.

“If you have to see it to believe it, you’re going to see the impact of a pandemic first in a city, most likely,” Leahy said.

Compliance hasn’t been perfect and she said the need for strict enforcement has been limited. As of early December, out of the more than 1,500 complaints the Missoula health department followed up on since July, it sent closure notices to four businesses that flouted the rules.

In Hill County, when the health department gets complaints that a business is violating pandemic mandates, two part-time health sanitarians, who perform health inspections of businesses, talk with the owners about why the rules exist and how to live by them. Often it works. Other times the complaints keep coming.

County attorney Karen Alley said the local health officials have reached out to her office with complaints of noncompliance on COVID safety measures, but she has not seen enough evidence to bring a civil case against a business. Unlike other health laws, she said, mask rules have no case studies yet to offer a framework for enforcing them through the Montana courts. (A handful of cases against businesses skirting COVID rules were still playing out as of mid-December.)

“Somebody has to be the test case, but you never want to be the test case,” said Alley, who is part of a team of three. “It’s a lot of resources, a lot of time.”

Larson, with the Hill County Health Department, said her focus is still on winning over the community. And she’s excited about some progress. The town’s annual live Nativity scene, which typically draws crowds with hot cocoa, turned into a drive-by event this year.

She doesn’t expect everyone to follow the rules — that’s never the case in public health. But Larson hopes enough people will to slow down the virus. That could be happening. By mid-December, the county’s tally of daily active cases was declining for the first time since its spike began in October.

“You just try to figure out the best way for your community and to get their input,” Larson said. “Because we need the community’s help to stop it.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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WASHINGTON — Even before there was a vaccine, some seasoned doctors and public health experts warned, Cassandra-like, that its distribution would be “a logistical nightmare.”

After Week 1 of the rollout, “nightmare” sounds like an apt description.

Dozens of states say they didn’t receive nearly the number of promised doses. Pfizer says millions of doses sat in its storerooms, because no one from President Donald Trump’s Operation Warp Speed task force told them where to ship them. A number of states have few sites that can handle the ultra-cold storage required for the Pfizer product, so, for example, front-line workers in Georgia have had to travel 40 minutes to get a shot. At some hospitals, residents treating COVID patients protested that they had not received the vaccine while administrators did, even though they work from home and don’t treat patients.

The potential for more chaos is high. Dr. Vivek Murthy, named as the next surgeon general under President-elect Joe Biden, said this week that the Trump administration’s prediction — that the general population would get the vaccine in April — was realistic only if everything went smoothly. He instead predicted wide distribution by summer or fall.

The Trump administration had expressed confidence that the rollout would be smooth, because it was being overseen by a four-star general, Gustave Perna, an expert in logistics. But it turns out that getting fuel, tanks and tents into war-torn mountainous Afghanistan is in many ways simpler than passing out a vaccine in our privatized, profit-focused and highly fragmented medical system. Gen. Perna apologized this week, saying he wanted to “take personal responsibility.” It’s really mostly not his fault.

Throughout the COVID pandemic, the U.S. health care system has shown that it is not built for a coordinated pandemic response (among many other things). States took wildly different COVID prevention measures; individual hospitals varied in their ability to face this kind of national disaster; and there were huge regional disparities in test availability — with a slow ramp-up in availability due, at least in some part, because no payment or billing mechanism was established.

Why should vaccine distribution be any different?

In World War II, toymakers were conscripted to make needed military hardware airplane parts, and commercial shipyards to make military transport vessels. The Trump administration has been averse to invoking the Defense Production Act, which could help speed and coordinate the process of vaccine manufacture and distribution. On Tuesday, it indicated it might do so, but only to help Pfizer obtain raw materials that are in short supply, so that the drugmaker could produce — and sell — more vaccines in the United States.

Instead of a central health-directed strategy, we have multiple companies competing to capture their financial piece of the pandemic health care pie, each with its patent-protected product as well as its own supply chain and shipping methods.

Add to this bedlam the current decision-tree governing distribution: The Centers for Disease Control and Prevention has made official recommendations about who should get the vaccine first — but throughout the pandemic, many states have felt free to ignore the agency’s suggestions.

Instead, Operation Warp Speed allocated initial doses to the states, depending on population. From there, an inscrutable mix of state officials, public health agencies and lobbyists seem to be determining where the vaccine should go. In some states, counties requested an allotment from the state, and then they tried to accommodate requests from hospitals, which made their individual algorithms for how to dole out the precious cargo. Once it became clear there wasn’t enough vaccine to go around, each entity made its own adjustments.

Some doses are being shipped by FedEx or UPS. But Pfizer — which did not fully participate in Operation Warp Speed — is shipping much of the vaccine itself. In nursing homes, some vaccines will be delivered and administered by employees of CVS and Walgreens, though issues of staffing and consent remain there.

The Moderna vaccine, rolling out this week, will be packaged by the “pharmaceutical services provider” Catalent in Bloomington, Indiana, and then sent to McKesson, a large pharmaceutical logistics and distribution outfit. It has offices in places like Memphis, Tennessee, and Louisville, which are near air hubs for FedEx and UPS, which will ship them out.

Is your head spinning yet?

Looking forward, basic questions remain for 2021: How will essential workers at some risk (transit workers, teachers, grocery store employees) know when it’s their turn? (And it will matter which city you work in.) What about people with chronic illness — and then everyone else? And who administers the vaccine — doctors or the local drugstore?

In Belgium, where many hospitals and doctors are private but work within a significant central organization, residents will get an invitation letter “when it’s their turn.” In Britain, the National Joint Committee on Vaccination has settled on a priority list for vaccinations — those over 80, those who live or work in nursing homes, and health care workers at high risk. The National Health Service will let everyone else “know when it’s your turn to get the vaccine ” from the government-run health system.

In the United States, I dread a mad scramble — as in, “Did you hear the CVS on P Street got a shipment?” But this time, it’s not toilet paper.

Combine this vision of disorder with the nation’s high death toll, and it’s not surprising that there is intense jockeying and lobbying — by schools, unions, even people with different types of preexisting diseases — over who should get the vaccine first, second and third. It’s hard to “wait your turn” in a country where there are 200,000 new cases and as many as 2,000 new daily COVID deaths — a tragic per capita order of magnitude higher than in many other developed countries.

So kudos and thanks to the science and the scientists who made the vaccine in record time. I’ll eagerly hold out my arm — so I can see the family and friends and colleagues I’ve missed all these months. If only I can figure out when I’m eligible, and where to go to get it.