Category: From California Healthline.org

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Imagine this: Your elderly mother, who has dementia, is in a nursing home and COVID-19 vaccines are due to arrive in a week or two.

You think she should be vaccinated, having heard the vaccine is effective in generating an immune response in older adults. Your brother disagrees. He worries that development of the vaccine was rushed and doesn’t want your mother to be among the first people to get it.

These kinds of conflicts are likely to arise as COVID vaccines are rolled out to long-term care facilities across the country.

“This is a highly politicized environment, not only with respect to vaccines but also over the existence of the virus itself,” said Michael Dark, a staff attorney with California Advocates for Nursing Home Reform. “It’s not hard to imagine disputes arising within families.”

About 3 million people — most of them elderly — live in nursing homes, assisted living centers and group homes, where more than 105,000 residents have died of COVID-19. They should be among the first Americans to receive vaccines, along with health care workers, according to recommendations from the Centers for Disease Control and Prevention and various state plans.

But long-term care residents’ participation in the fastest and most extensive vaccination effort in U.S. history is clouded by a significant complication: More than half have cognitive impairment or dementia.

This raises a number of questions. Will all older adults in long-term care understand the details of the vaccines and be able to consent to getting them? If individual consent isn’t possible, how will families and surrogate decision-makers get the information they need on a timely basis?

And what if surrogates don’t agree with the decision an elderly person has made and try to intervene?

“Imagine that the patient, who has some degree of cognitive impairment, says ‘yes’ to the vaccine but the surrogate says ‘no’ and tells the nursing home, ‘How dare you try to do this?” said Alta Charo, a professor of law and bioethics at the University of Wisconsin-Madison Law School.

Addressing these issues will occur against a backdrop of urgency. Deaths in long-term care facilities are rising dramatically, with new estimates suggesting that 19 residents die of COVID-19 every hour. With viral outbreaks increasing, already-overwhelmed staffers may not have much time to sit down with residents to answer questions or have conversations with families over the phone.

Meanwhile, CVS and Walgreens, the companies operating vaccine programs at most long-term care facilities, have aggressive timetables. Both companies have said the large-scale rollout of the Pfizer-BioNTech vaccine — the first one that the Food and Drug Administration has authorized — will begin on Dec. 21.But facilities in some states may get supplies earlier. Altogether, there are more than 15,000 nursing homes and nearly 29,000 assisted living residences in the U.S.

At a meeting of the federal Advisory Committee on Immunization Practices early this month, Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, acknowledged the agency was “very concerned” that information about vaccines be adequately explained to long-term care residents. “It’s very important for the frail elderly not only to ensure that they are understanding the vaccine that they’re getting but also that their family members do,” she said.

Each vaccine manufacturer will be required to prepare a fact sheet describing what’s known about benefits and risks associated with a vaccine, what’s not known, and making it clear that a vaccine has received “emergency use authorization” from the FDA — a conditional endorsement that falls short of full approval. A second vaccine, from Moderna, is poised to receive this kind of authorization after an FDA meeting on Thursday.

Something that will need to be made clear to residents: while vaccines have been tested on people age 65 and older, those tests did not include individuals living in long-term care, according to Dr. Sara Oliver, a CDC expert.

Some operators have crafted communication plans around the vaccines and already begun intensive outreach. Others may not be well prepared.

Juniper Communities operates 22 senior housing communities (a standalone nursing home, multiple memory care and assisted living facilities, and two continuing care retirement communities) in Colorado, New Jersey and Pennsylvania. This week, it is planning an hour-long town hall videoconferencing session for residents and families about coronavirus vaccines. Last week, it held a similar event for staffers.

Juniper has contracted with CVS, which is requiring that every resident and staff member fill out consent forms in triplicate before being inoculated. When written consent can’t be obtained directly, verbal consent, confirmed independently, may substitute. Walgreens has similar requirements.

For residents with memory impairment, two Juniper nurses will reach out by phone to whomever has decision-making authority. “One will ask questions and obtain verbal consent; the other will serve as a witness,” said Lynne Katzmann, Juniper’s founder and chief executive officer. Separately, emails, blog posts and prerecorded voice messages about the vaccines have gone out to Juniper residents and staffers, starting at the end of November.

A key message is “we’ve done this before, not at this scale, mind you, and not at this level of import, but we do flu vaccinations annually,” said Katzmann, who plans to be the first Juniper employee to get the Pfizer vaccine when it comes to New Jersey.

At Genesis Healthcare, crucial messages are “these vaccines have been studied thoroughly, tens of thousands of people have received them already, they’re very, very effective, and no steps have been skipped in the scientific process,” said Dr. Richard Feifer, executive vice president and chief medical officer. Genesis, the nation’s largest long-term care company, operates more than 380 nursing homes and assisted living residences in 26 states, with about 45,000 employees and more than 30,000 residents.

Medical directors at each Genesis facility have been scheduling video conferences with families, residents and staffers during the past few weeks to address concerns. They’ve also distributed a letter and a question-and-answer document prepared by the Society for Post-Acute and Long-Term Care Medicine, in addition to getting information out through closed-circuit TV channels and social media.

In partnership with Brown University researchers, the company will monitor daily the side effects that its long-term care residents experience after getting coronavirus vaccines. Most reactions are expected to be mild or moderate and resolve within a few days. They include fatigue, pain at the injection site, headaches, body aches, fever and, rarely, allergic responses.

Administering the vaccine will occur over three visits for all long-term care facilities. At the first, all Genesis residents and staffers will get inoculations. At the second, three to four weeks later, those same people will get a second dose, and new staffers and residents will get a first dose. At the third, those who still qualify for a second vaccine dose will get one.

What will happen if lots of people experience uncomfortable side effects and employees don’t come in for a couple of days while recovering? “It’s a very difficult problem and we’re making contingency plans to address it,” Feifer said.

And what about continuing care retirement communities — also known as “life plan communities” — where residents in skilled nursing, assisted living and independent living can reside in close proximity?

That’s the case at Bayview in Seattle, which houses 210 residents in a 10-story building. For the moment, independent living residents aren’t on the priority list but “I know there will be a contingent of residents and staff who won’t want to be vaccinated and we’ll see if we can use those vaccines for our independent living people instead,” said Joel Smith, Bayview’s health services administrator.

Logistical challenges are sure to arise, but many operators have an acute sense of mission. “It is critical that we lead the way out of this crisis,” Feifer of Genesis said. “Nursing homes need to go first and be the first ones to address vaccine hesitancy head-on and be successful at generating a high level of acceptance. There is no alternative, no Plan B right now. We have to be successful.”

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MINNEAPOLIS — Gloria Torres-Herbeck gets the flu vaccine every year, but the 53-year-old teacher in Rochester, Minnesota, isn’t yet convinced she wants to be first in line for a potential COVID-19 vaccine.

“I’m not super old, but I’m not as strong as other people,” she said. “So, I need to be realistic on my own situation. Do I want to participate in something that might be a big risk for me?”

This month, the Food and Drug Administration gave emergency use authorization for one vaccine and is weighing approval of another. So, public health officials around the country are gearing up for what might be as challenging as figuring out how to store a vaccine at 70 degrees below zero Celsius. They need to persuade people who are part of communities that have been hit hard by the virus — those in low-income families and some minority populations, especially Black and Latino residents — to take a vaccine developed in less than a year and approved under emergency use authorization.

Yet there are a few places where officials think they have a head start. Rochester, Minnesota, home of the Mayo Clinic, is one of them. The Rochester Healthy Community Partnership has been working to reduce health disparities in the area’s immigrant communities, including Somali, Hispanic, Cambodian, South Sudanese and Ethiopian residents, for 15 years.

The partnership is composed of Mayo health providers and researchers, county public health officials and community volunteers like Torres-Herbeck, who immigrated to the U.S. 27 years ago from Mexico. One of the first of its kind, other similar efforts have sprung up around the country, but no one officially tracks such partnerships.

“What we realized when the pandemic hit in spades in March was that with long-established partnerships we were uniquely positioned to leverage” trust built up over the years between Mayo experts and their community partners, said Dr. Mark Wieland, who helps direct the group and studies the impact of such partnerships. “We realized we were obligated to jump in with two feet.”

Although only preliminary evidence has been gathered so far, there are indications that since the efforts began, Rochester has increased COVID-19 testing, improved contact tracing and boosted preventive behaviors such as mask-wearing, hand-washing and physical distancing in these vulnerable communities, he said. The group is hoping those early successes portend well for vaccine acceptance.

Learning From a Measles Outbreak

The Rochester partnership is banking on a commonsense approach that focuses on shared values, transparency and clear communication.

It’s a strategy that has succeeded in the past.

When a measles epidemic hit the large Somali population in Minneapolis-St. Paul in 2017, the Mayo Clinic reached out to community leaders among the 25,000 Somali immigrants in the Rochester area. Many had been frightened of the measles vaccine by baseless claims that it could cause autism, and vaccination rates were low in the community. Medical experts held town hall meetings in mosques and community centers, answering questions about vaccine safety and reassuring people that there was no scientific evidence of a link to autism. Somali actors created YouTube videos to help address common concerns. In the end, there were no recorded cases of measles in Olmsted County, home to Rochester.

About a year ago, Dr. Robert Jacobson, medical director for the Population Health Science Program at Mayo Clinic, at the request of a rabbi visited an Orthodox Jewish community in New York in which vaccine refusal was fueling another measles outbreak. He helped health care leaders there allay concerns.

“The Orthodox Jews in that community were refusing that vaccine for the same reason we were recommending it,” Jacobson said. “They were trying to protect their children.”

Efforts by Jewish leaders, public health experts such as Jacobson and lawmakers who tightened up laws on vaccine exemptions helped quell the outbreak.

Since March, the Rochester partnership has broadcast similar messages about COVID-19 to diverse audiences. Fear or misunderstanding was an issue at the beginning of the pandemic. Health leaders found that members of the immigrant communities were hanging up when the public health department called. So, the partnership developed messaging in several languages to explain the importance of the phone calls. They worked around problems, including that other languages don’t always have terms that mesh with English words for illnesses. For example, the word for “cold” and “flu” is the same in Somali.

Now fewer people hang up.

At the same time, these public health teams report back to the medical experts on what the community needs. “They’re the experts on the subtleties of their communities,” Wieland said.

So when the group learned that many immigrants were intimidated by COVID-19 testing and unsure of the logistics, the group recommended simplifying the process: Now, videos featuring community leaders on social media direct people to testing sites. Once there, anyone who doesn’t speak English automatically gets tested — no identification or insurance card necessary.

“We think that’s part of the reason that, as a county, we have overtested minority populations in relation to white populations,” Wieland said.

The ‘Why’ Was Missing

Only 40% of older Black adults and 51% of older Hispanics said they are somewhat or very likely to get the COVID-19 vaccination — compared with 63% of older white people, a University of Michigan poll shows. Their concerns mirror Torres-Herbeck’s: how well will the vaccine work or how safe it will be.

An even more recent survey of people of all ages for the COVID Collaborative, an advocacy group of national and state health and economic leaders, the NAACP and other groups shows trust in vaccine safety is as low as 14% in Black Americans and 34% in Latinos.

Older adults said they would like recommendations from doctors, health officials, or family and friends — people they trust, according to the Michigan poll. And Black Americans are twice as likely to trust Black messengers versus white messengers, the other survey showed.

“Even if people don’t trust doctors in general, they trust their own doctor,” said Dr. Preeti Malani, one of the authors of the Michigan survey and chief health officer of the university.

The advantage of groups like the Rochester partnership is that its members are also trusted messengers.

Several weeks ago, Torres-Herbeck said, she talked to a landscaper who didn’t wear a mask while working with his business partner. She told him that COVID-19 is a virus and explained how it spreads. He was surprised, and Torres-Herbeck understood. “When I came here 27 years ago, we were not as educated on that,” she said. “When I grew up, it was believed that if you walk barefoot you will catch a cold.”

Often, she said, public health officials provide directions on how to act and what to do, such as use a mask and clean your hands, but don’t explain why.

“That ‘why’ was missing for him,” she said.

Now when she talks to him, he puts a mask on.

In mid-November, Jacobson visited with members of the Rochester partnership via Zoom, part of the group’s initial effort to disseminate vaccine information.

Approving a vaccine under emergency use authorization is no less stringent than the normal procedure, he explained. The process has been dramatically sped up and condensed, he said, by the amount of money poured in and newer technology — and by increased FDA resources.

It’s not all about disseminating facts, however. Focusing on shared values is key to building trust. So when Adeline Abbenyi, the Mayo Clinic program manager for the Center for Healthy Equity and Community Engagement Research, said her mother, who had never feared vaccines, was hesitant to get a COVID-19 vaccine, Jacobson understood.

“A lot of us are feeling the same way,” Jacobson said in that Zoom meeting. “I go into this optimistic that we will have a vaccine that’s safe and effective, but I won’t use it until I see that evidence” of safety and efficacy the FDA is reviewing.

It’s normal for people to hesitate, he said, but that is far different from — and more widespread than — the anti-vaccine movement. Doctors and nurses getting the first doses will likely help many people overcome that hesitancy, he said.

Indeed, one thing that would persuade Torres-Herbeck to be inoculated? Seeing Jacobson get the vaccine, she said.

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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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

The demand for skilled nurses during the pandemic is through the roof! Travel nurses command a hefty salary and they are worth every penny… #COVID19 #pandemic #RN https://t.co/gYQpkHqaoX

— Talmage Egan, MD (@UofU_Anes_Chair) November 26, 2020

— Dr. Talmage Egan, Salt Lake City

Nurses Deserve to Be Paid Handsomely

I read your article “Need a COVID-19 Nurse? That’ll Be $8,000 a Week” (Nov. 24) in the Springfield Journal-Register. It was an interesting article as I have a daughter who is a nurse. Nurses have been underpaid and unappreciated for years. It made me angry that the article characterized the wages some hospitals are willing to pay for nurses as exorbitant. Hogwash if you think someone should risk their life every hour of the day to care for COVID patients without proper compensation. How many doctors make over a million a year? You don’t cite that as unusual. I feel that nurses should go for the gold as they have been taken advantage of for years and, too bad, but good for them. Choose your words more carefully in the future. Nurses ROCK!!!!

— Mike Booher, Lincoln, Illinois

Hospitals go out of their way to avoid competing for nursing labor by raising wages. Now hospital executives and public health advocates act like it’s a travesty that COVID nurses are finally getting paid market rates to take on risky jobs. https://t.co/6z0idToVn6

— Devon M. Herrick (@DevonHerrick) November 24, 2020

— Devon M. Herrick, Dallas

Missing in the Mix of Vaccine Coverage

I must note two important omissions in the article “Time to Discuss Potentially Unpleasant Side Effects of COVID Shots? Scientists Say Yes” (Nov. 12). First, although these were interim trial results, the placebo arm should also have been reported out. What was the placebo infection rate? Reporting 90% effectiveness is irrelevant without reporting the placebo rate simultaneously. And one needs to align the infection rate in trial subjects with the incidence of disease in the U.S. population. They should be similar, but if not, any discrepancy must be explained (such as, no elderly people or children participating in the trial). Secondly, and perhaps more important: What other mitigating measures were volunteers in this trial required/advised to take? For example, physical distancing, masks, etc. I could find no mention of this, positively or negatively, when reading the protocol on clinicaltrials.gov. Any vaccine alone could not provide 94.5% efficacy. To determine the relative contributions of other measures, you’d need, say, a four-arm study — placebo with mask, placebo without mask, vaccine with mask, vaccine without mask. Statistically and clinically, one must account for other variables that may confound an apparent result.

This is a crucial point as the lay public is thinking that, by getting the vaccine, masks might no longer be necessary and they’ll have a 95% chance of not being infected. This is rubbish. The media and the public “experts” need to address this as they are setting themselves up for an immense PR failure and still greater skepticism. People may need to wear masks for many more months, maybe years, even with an effective vaccine.

— Stephen Zaruby, Truckee, California

I’m already confused 😕 https://t.co/UlJPh2EEvK

— hameen tariq (@hameentariq) November 23, 2020

— Hameen Tariq, Wilmington, Delaware

Exploring Cancer Drug’s Effects on COVID

Your story “Clots, Strokes and Rashes: Is COVID a Disease of the Blood Vessels?” (Nov. 13) was reprinted in my local newspaper. My brother, James L. Kinsella Ph.D., led the original work at the National Institutes of Health researching how the chemotherapy drug Taxol could reduce inflammation in coronary articles following the placement of coronary stents. This led to the very effective use of drug-eluting coronary stents. My unprofessional musing causes me to wonder if this anti-inflammatory response to Taxol might have some application as an early therapeutic intervention to reduce the inflammatory response of COVID-19 being studied by Dr. William Li. I can’t ask my brother; he passed away.

— Rick Kinsella, Oneida, New York

He wouldn’t be dead without covid. We’ve learned that things that aren’t life threatening are made life threatening by this disease. It attacks your blood vessels so it can exacerbate anything anywhere in your body that uses blood vessels. Stay safe indeed https://t.co/BFsqrKSFmH

— James McPicnic (@WhiteRatbit) December 3, 2020

— James “J.P.” McPicnic, Los Angeles

Women’s Health Should Not Be Up for Debate

Birth control medication is so much more than a pawn in politics (“Coming Abortion Fight Could Threaten Birth Control, Too,” Nov. 5). It changes the lives of so many women for the better. Birth control access has been proven to lead to higher rates of education for women, lower levels of child poverty, lower Medicaid costs for women’s health and higher productivity of society as a whole. It also treats a large number of medical conditions associated with women’s health. It effectively treats severe menstrual migraines, hormonal acne, endometriosis, severe menstrual pain, uterine abnormalities, anemia and heavy menstrual bleeding, among other health conditions. This medication is involved in treating so many women’s health concerns, improves infant and child health outcomes, and reduces child poverty, and yet almost 20 million women in the U.S. currently have no access to birth control medication. American politicians need to consider, if nothing else, the spillover costs to society when birth control access is reduced.

Women’s reproductive health should not be up for debate and yet it is at the center of so many political agendas. As a 24-year-old woman pursuing dual master’s degrees in public health and physician assistant studies, my focus should be on learning to become an exceptional health care provider, not whether my health will be up for debate in court. If politicians truly have the best interests of Americans at heart, they should be looking to expand birth control access, not restrict it.  Evidence needs to be incorporated into political agendas, and the evidence shows that when women succeed, society succeeds. Women’s education, health and reproductive rights should be at the forefront of every discussion on what constitutes a thriving population — the evidence has proven that women’s autonomy holds the answer and access to birth control is a vital piece of that.

— Gabby Henshue, Madison, Wisconsin

Scary times for women’s bodies.

“States could effectively ban contraception by arguing that some contraceptives act as abortifacients.” Threat is real. I’ve worked in states where this argument has been made.https://t.co/LmdWFRUNOZ

— Elizabeth M. Baskett (@EMBaskett) November 11, 2020

— Elizabeth M. Baskett, Denver

Injustice in High Gear

I was appalled at the charges on the medical bill from the Carson City emergency department for that child who fell off his bike (“Bill of the Month: After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion,” Nov. 25) — $18,000 for an exam and stitches? What would it take to sort out such problems in our health system? Lower prices from providers could only result in lower insurance premiums.

— Karen Johnson, San Rafael, California

Attempted subrogation, man, I tell yah https://t.co/spxcMlSiCk

— Annie M. Davidson (@attyannie) November 25, 2020

— Annie M. Davidson, St. Paul, Minnesota

KHN Morning Briefing: A Wealth of Information in One Spot!

I just wanted to say it is awesome to have portions of articles from many major news outlets because never does one tell the whole story. Case in point: I was trying to research what exactly President Donald Trump had done that “allowed doctors to discriminate against LGBT people,” and it was very helpful having a wide array of media sources on a single page to help get the bigger picture and try and weed through the bias of all of them (“Trump Administration’s Expanded Conscience Rule Will Allow Medical Professionals To Refuse To Provide Health Care Services,” May 3). Just sending my compliments. Keep up the great work.

— Nolan Steeley, Greensburg, Pennsylvania

💥Racism in #healthcare undermines #quality of care and patient safety. There’s hard work to be done to weed it out of all parts of society, especially clinical care. https://t.co/TbK0yIuraB

— Natalie S. Burke (@natalie4health) November 28, 2020

— Natalie S. Burke, Washington, D.C.

Education and Coverage Gaps Lead to Avoidable Amputations 

Coming to terms with systemic racism in health care is long overdue (“What Doctors Aren’t Always Taught: How to Spot Racism in Health Care,” Nov. 16). The way medicine is taught and the payment policies that shape the system have created persistent disparities in patient outcomes across racial and ethnic groups.

As a result, Black Americans are 80% more likely than whites to be diagnosed with diabetes and are twice as likely to die from the disease. Furthermore, Black American patients are up to four times more likely to experience an amputation than their white counterparts due to advanced peripheral artery disease (PAD), a common complication for people with diabetes and other chronic conditions. Similarly, Latinos are up to 75% more likely to experience an amputation than whites, while Native Americans are twice as likely to lose a limb.

As many as 85% of the nation’s 200,000 non-traumatic amputations could be prevented with access to screening and early detection. By screening for PAD through non-invasive arterial testing, the likelihood of an individual needing a PAD-related amputation can be reduced by up to 90%. Unfortunately, too few Americans — particularly racial and ethnic minorities — are even offered routine screening for PAD due to a widespread lack of understanding about the disease, as well as structural coverage barriers to simple, painless tests. As a result, many do not even know they have the disease until it is too late to save their limbs.

Communities of color deserve better. Members of the Congressional PAD Caucus — led by Rep. Donald Payne Jr. (D-N.J.) — recently introduced the Amputation Reduction and Compassion (ARC) Act to establish an education program about the disease — particularly for high-risk populations — and update reimbursement policy to disallow payment for non-emergent amputations unless arterial testing has been done in the three months before amputation. These simple solutions have the power to prevent thousands of avoidable amputations, and begin to correct health disparities in minority communities.

While we still have a long way to go as our country continues to grapple with systemic racism in health care, the ARC Act represents an important step toward ending disparities in PAD care.

— Dr. Foluso Fakorede, CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi

Racism in Health Care? Another example of injecting Politics. Inarguably, racism exists everywhere, but to make this a big issue is a disservice. Diff DX requires inclusion of Race/Ethnicity, to wit: Sickle Cell in Blacks,Alpha & Beta Thalassemia in Asians https://t.co/xyP54dPjH8

— Alexander R. Lim, MD (@AlexanderLim13) November 25, 2020

— Dr. Alexander R. Lim, Corpus Christi, Texas

‘Obamacare’ Unfairly Politicizes Health Law

I found this article interesting (“Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” Nov. 11) but was surprised that the Affordable Care Act was referred to as “Obamacare.” Please don’t politicize the ACA — we really need it to continue allowing people to access health care. Many people do not have health care through their workplace and are unable to afford private insurance premiums. I was once one of those people before I was hired at our local library. It was really tough. Thank you for your reporting.

— Pamela Elicker, Port Townsend, Washington

Putting People First on the Podcast

When you were talking about drug policy and the ballot in a recent podcast (“KHN’s ‘What the Health?’: Change Is in the Air,” Nov. 6), you used terms that are considered incorrect or stigmatizing. For example, saying “opioid epidemic” when it’s really a crisis and referring to substance use as “abuse.” The Associated Press and NPR, among others, have pledged to use people-first language, as also supported by the American Psychological Association.

— Deirdre Dingman, Philadelphia

 

Not Tickling My Funny Bone

You ought to find some cartoonists who are not so flagrantly left-leaning — continuing to provide left-sided commentary is not right. It’s like all of the news stations pushing for socialism.

— Harry Gousha, Upland, California

Editor’s note: It is the tradition and mission among editorial cartoonists to satirize those in power. As with the nation’s leadership, the targets of political cartoons toggle from right to left. Balance is not these artists’ goal, but over time their commentary balances out. Stick with us, and we hope to amuse you in the future.

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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Troy Muenzer has seen the damage that COVID can do. A flight attendant who was diagnosed with a “suspected” case of the deadly virus, Muenzer, 32, endured months of lingering breathing problems; hefty, unexpected medical bills; lost wages, then furlough; and, earlier this month, the loss of his health insurance.

Last week, his bank account was hacked, causing him to lie awake one night worrying he wouldn’t be able to get back all that 2020 has taken. “From everything that’s happened this year, it just seems like it’s never-ending,” he said.

At the beginning of the pandemic, Congress passed several relief bills to help the country’s companies and its workforce: business grants and loans, paycheck protection for furloughed workers, one-time stimulus checks for taxpayers, expanded unemployment benefits. Much of the aid is set to expire by year’s end, if it hasn’t already.

This week, Muenzer’s furlough checks will stop coming. His monthly unemployment check is not enough to cover food and rent. He gave up his health insurance earlier this month because he could no longer afford the premium.

A little over two months ago, just before cutting his hours from few to none, his employer — a major airline — told him Congress could save his job. But lawmakers have shown they can’t, or won’t, put partisan politics aside to help the millions of Americans like Muenzer suffering the devastating impacts of the pandemic.

The chances for another round of pandemic relief before the end of the year look grim. Senate Majority Leader Mitch McConnell has signaled that Republicans could not accept a $908 billion bipartisan compromise written by moderates. Last spring, House Democrats introduced a proposal more than three times larger that they said was necessary to tackle the pandemic. Congress approved its last substantial relief bill nearly eight months ago.

Muenzer first got blindsided by COVID-19 in March. He was on a business trip, and as he got ready for bed in his hotel room, he began having trouble breathing. A former college football player who normally ran near his home by Lake Michigan, he lay awake, short of breath and terrified he would die in his sleep.

When the pandemic first gripped the nation, he had taken what precautions he could but was not permitted to wear a mask while working crowded flights. The Centers for Disease Control and Prevention did not recommend that Americans wear masks in public until April 3, but Muenzer was already sick.

Muenzer notified his employer that he had COVID symptoms and isolated himself at home. A telehealth doctor told him he needed in-person medical attention, but he was afraid he couldn’t afford it. He was already burning through his sick days.

Meanwhile, on April 14, with COVID cases exploding in cities like New York and San Francisco and among close-quartered groups like nursing homes and prisons, McConnell announced the Senate would extend its already weeks-long recess on the advice of public health officials. The day before, Democratic leaders said the House would do the same.

Congress had just passed a record $2 trillion stimulus package, its third relief measure. With House Democrats calling for more, including worker protections and medical leave, Rep. Kevin McCarthy of California, the House Republican minority leader, said it was too soon to talk about more aid. “I wouldn’t be so quick to say you have to write something else,” he said, according to NPR. “Let’s let this bill work.”

Muenzer did benefit from those early interventions. He received the one-time $1,200 stimulus check. But it barely made a dent in the wages he had lost being out sick, let alone once passenger demand cratered and the airline reduced his hours.

His employer was one of many companies that accepted help from the government on the condition they would temporarily hold off on furloughing employees. Muenzer was furloughed Oct. 1.

Muenzer has been receiving unemployment since then. But the extra $600 Congress gave the unemployed early in the pandemic expired long before that, and his monthly $1,200 unemployment check is not enough to cover his rent in Chicago, let alone food or medical care.

The relief legislation also required Muenzer’s private insurance plan to cover testing to detect or diagnose COVID-19 without Muenzer being required to pay anything. But that didn’t work.

The day the Senate extended its recess, Muenzer was so short of breath that he went to Northwestern Memorial Hospital’s emergency room. There, health care workers in full protective suits examined him and administered a chest X-ray. Diagnosed as “suspected COVID” and sent home to quarantine for 14 days, he did not get a COVID test.

With those critical diagnostic tests in short supply across the country at that time, they were reserved for seniors or patients with serious health conditions.

Muenzer received a bill for $108.59 for that emergency room visit, which he paid. Then another arrived, this one for $806.85 for the chest X-ray and other emergency room charges. Such billing problems were not unusual in the early days of the pandemic. Because COVID tests were not administered widely, patients like Muenzer lacked the official COVID diagnosis that required the medical system to zero out patient charges.

“I went to the COVID testing sign,” Muenzer said. “Then I didn’t even get tested and still got billed all that money.”

Muenzer was fortunate: A local television reporter heard about his problems and called the billing department herself. Though he had been fighting the bills for weeks, that day, the hospital returned Muenzer’s calls, blaming the problem on a coding error and assuring him his bills would be covered. But the hospital never returned his first payment.

When the payroll protection program’s conditions expired on Oct. 1, thousands of pilots, flight attendants like Muenzer and other airline employees — whose hours had already been trimmed — were furloughed. Muenzer said they were told the airline may be able to hold onto them a little longer, if Congress could pass another relief bill.

Indeed, Congress had considered legislation that would specifically bail out the airline industry. Muenzer watched as lawmakers debated bills that could have saved his job. But he did not overtly root for the legislation to pass. “It felt almost selfish,” he said. “Everybody’s hurting.”

Muenzer’s employer will stop sending him furlough pay on Dec. 15. Because it was calculated by averaging his pay for the past year, and his pay is based on flight hours, it wasn’t much. And given he has barely worked since he began feeling sick in March, his average work hours dropped significantly. He has tried to find a new job, but no luck yet.

But he feels lucky because he received furlough pay at all. He feels lucky because the hospital reduced his COVID testing bill to just $109. He feels lucky because he has family who can help him.

His company has assured its furloughed employees that they hope to bring them back in waves next year, if a vaccine is successful, if customer demand goes up again and if Congress can pass a relief bill.

That’s a lot of ifs at the moment — especially that last one, with Congress at a partisan logjam over a new COVID stimulus bill as it also tries to close out business for the year. Republicans are pushing for broader protections for businesses that could be sued if workers or customers become infected with the coronavirus. Democrats are pushing for funding for state and local governments battling the pandemic. Some lawmakers are also pushing for another round of one-time, $1,200 stimulus checks.

Even the bipartisan compromise would boost unemployment by only $300 a week through April. But it also includes support for the transportation sector, including airlines.

When he isn’t drowning out his anxieties watching Netflix, he keeps a close eye on Congress, “praying for something to happen.” It has been “very stressful, to say the least,” he said, “to feel like your life depends on the decisions of people in political power.”

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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This story can be republished for free (details).

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A Florida taxi driver and his wife had seen enough conspiracy theories online to believe the virus was overblown, maybe even a hoax. So no masks for them. Then they got sick. She died. A college lecturer had trouble refilling her lupus drug after the president promoted it as a treatment for the new disease. A hospital nurse broke down when an ICU patient insisted his illness was nothing worse than the flu, oblivious to the silence in beds next door.   

Lies infected America in 2020. The very worst were not just damaging, but deadly. 

President Donald Trump fueled confusion and conspiracies from the earliest days of the coronavirus pandemic. He embraced theories that COVID-19 accounted for only a small fraction of the thousands upon thousands of deaths. He undermined public health guidance for wearing masks and cast Dr. Anthony Fauci as an unreliable flip-flopper. 

But the infodemic was not the work of a single person. 

Anonymous bad actors offered up junk science. Online skeptics made bogus accusations that hospitals padded their coronavirus case numbers to generate bonus payments. Influential TV and radio opinion hosts told millions of viewers that physical distancing was a joke and that states had all of the personal protective equipment they needed (when they didn’t).

It was a symphony of counter-narrative, and Trump was the conductor, if not the composer. The message: The threat to your health was overhyped to hurt the political fortunes of the president. 

Every year, PolitiFact editors review the year’s most inaccurate statements to elevate one as the Lie of the Year. The “award” goes to a statement, or a collection of claims, that prove to be of substantive consequence in undermining reality. 

It has become harder and harder to choose when cynical pundits and politicians don’t pay much of a price for saying things that aren’t true. For the past month, unproven claims of massive election fraud have tested democratic institutions and certainly qualify as historic and dangerously baldfaced. Fortunately, the constitutional foundations that undergird American democracy are holding. 

Meanwhile, the coronavirus has killed more than 300,000 in the United States, a crisis exacerbated by the reckless spread of falsehoods.

PolitiFact’s 2020 Lie of the Year: claims that deny, downplay or disinform about COVID-19. 

‘I Wanted to Always Play It Down’

On Feb. 7, Trump leveled with book author Bob Woodward about the dangers of the new virus that was spreading across the world, originating in central China. He told the legendary reporter that the virus was airborne, tricky and “more deadly than even your strenuous flus.”

Trump told the public something else. On Feb. 26, the president appeared with his coronavirus task force in the crowded White House briefing room. A reporter asked if he was telling healthy Americans not to change their behavior.

“Wash your hands, stay clean. You don’t have to necessarily grab every handrail unless you have to,” he said, the room chuckling. “I mean, view this the same as the flu.”

Three weeks later, March 19, he acknowledged to Woodward: “To be honest with you, I wanted to always play it down. I still like playing it down. Because I don’t want to create a panic.”

His acolytes in politics and the media were on the same page. Rush Limbaugh told his audience of about 15 million on Feb. 24 that the coronavirus was being weaponized against Trump when it was just “the common cold, folks.” That’s wrong — even in the early weeks, it was clear the virus had a higher fatality rate than the common cold, with worse potential side effects, too.

As the virus was spreading, so was the message to downplay it. 

“There are lots of sources of misinformation, and there are lots of elected officials besides Trump that have not taken the virus seriously or promoted misinformation,” said Brendan Nyhan, a government professor at Dartmouth College. “It’s not solely a Trump story — and it’s important to not take everyone else’s role out of the narrative.” 

Hijacking the Numbers 

In August, there was a growing movement on Twitter to question the disproportionately high U.S. COVID-19 death toll.  

The skeptics cited Centers for Disease Control and Prevention data to claim that only 6% of COVID-19 deaths could actually be attributed to the virus. On Aug. 24, BlazeTV host Steve Deace amplified it on Facebook.

“Here’s the percentage of people who died OF or FROM Covid with no underlying comorbidity,” he said to his 120,000 followers. “According to CDC, that is just 6% of the deaths WITH Covid so far.”

That misrepresented the reality of coronavirus deaths. The CDC had always said people with underlying health problems — comorbidities — were most vulnerable if they caught COVID-19. The report was noting that 6% died even without being at obvious risk. 

But for those skeptical of COVID-19, the narrative confirmed their beliefs. Facebook users copied and pasted language from influencers like Amiri King, who had 2.2 million Facebook followers before he was banned. The Gateway Pundit called it a “SHOCK REPORT.”

“I saw a statistic come out the other day, talking about only 6% of the people actually died from COVID, which is very interesting — that they died from other reasons,” Trump told Fox News host Laura Ingraham on Sept. 1.

Fauci, director of the National Institute of Allergy and Infectious Diseases, addressed the claim on “Good Morning America” the same day. 

“The point that the CDC was trying to make was that a certain percentage of them had nothing else but just COVID,” he said. “That does not mean that someone who has hypertension or diabetes who dies of COVID didn’t die of COVID-19 — they did.”

Trump retweeted the message from an account that sported the slogans and symbols of QAnon, a conspiracy movement that claims Democrats and Hollywood elites are members of an underground pedophilia ring. 

False information moved between social media, Trump and TV, creating its own feedback loop.

“It’s an echo effect of sorts, where Donald Trump is certainly looking for information that resonates with his audiences and that supports his political objectives. And his audiences are looking to be amplified, so they’re incentivized to get him their information,” said Kate Starbird, an associate professor and misinformation expert at the University of Washington.

Weakening the Armor: Misleading on Masks

At the start of the pandemic, the CDC told healthy people not to wear masks, saying they were needed for health care providers on the front lines. But on April 3 the agency changed its guidelines, saying every American should wear non-medical cloth masks in public.

Trump announced the CDC’s guidance, then gutted it.

“So it’s voluntary. You don’t have to do it. They suggested for a period of time, but this is voluntary,” Trump said at a press briefing. “I don’t think I’m going to be doing it.”

Rather than an advance in best practices on coronavirus prevention, face masks turned into a dividing line between Trump’s political calculations and his decision-making as president. Americans didn’t see Trump wearing a mask until a July visit to Walter Reed National Military Medical Center.

Meanwhile, disinformers flooded the internet with wild claims: Masks reduced oxygen. Masks trapped fungus. Masks trapped coronavirus. Masks just didn’t work.

In September, the CDC reported a correlation between people who went to bars and restaurants, where masks can’t consistently be worn, and positive COVID-19 test results. Bloggers and skeptical news outlets countered with a misleading report about masks.

On Oct. 13, the story landed on Fox News’ flagship show, “Tucker Carlson Tonight.” During the show, Carlson claimed “almost everyone — 85% — who got the coronavirus in July was wearing a mask.”

“So clearly [wearing a mask] doesn’t work the way they tell us it works,” Carlson said.

That’s wrong, and it misrepresented a small sample of people who tested positive. Public health officials and infectious disease experts have been consistent since April in saying that face masks are among the best ways to prevent the spread of COVID-19.

But two days later, Trump repeated the 85% stat during a rally and at a town hall with NBC’s Savannah Guthrie. 

“I tell people, wear masks,” he said at the town hall. “But just the other day, they came out with a statement that 85% of the people that wear masks catch it.”

The Assault on Hospitals 

On March 24, registered nurse Melissa Steiner worked her first shift in the new COVID-19 ICU of her southeastern Michigan hospital. After her 13-hour workday caring for two critically ill patients on ventilators, she posted a tearful video.

“Honestly, guys, it felt like I was working in a war zone,” Steiner said. “[I was] completely isolated from my team members, limited resources, limited supplies, limited responses from physicians because they’re just as overwhelmed.” 

“I’m already breaking, so for f—’s sake, people, please take this seriously. This is so bad.”

Steiner’s post was one of many emotional pleas offered by overwhelmed hospital workers last spring urging people to take the threat seriously. The denialists mounted a counteroffensive.

On March 28, Todd Starnes, a conservative radio host and commentator, tweeted a video from outside Brooklyn Hospital Center. There were few people or cars in sight.

“This is the ‘war zone’ outside the hospital in my Brooklyn neighborhood,” Starnes said sarcastically. The video racked up more than 1.5 million views.

Starnes’ video was one of the first examples of #FilmYourHospital, a conspiratorial social media trend that pushed back on the idea that hospitals had been strained by a rapid influx of coronavirus patients. 

Several internet personalities asked people to go out and shoot their own videos. The result: a series of user-generated clips taken outside hospitals, where the response to the pandemic was not easily seen. Over the course of a week, #FilmYourHospital videos were uploaded to YouTube and posted tens of thousands of times on Twitter and Facebook.

Nearly two weeks and more than 10,000 deaths later, Fox News featured a guest who opened a new misinformation assault on hospitals.

Dr. Scott Jensen, a Minnesota physician and Republican state senator, told Ingraham that, because hospitals were receiving more money for COVID-19 patients on Medicare — a result of a coronavirus stimulus bill — they were overcounting COVID-19 cases. He had no proof of fraud, but the cynical story took off. 

Trump used the false report on the campaign trail to continue to minimize the death toll. 

“Our doctors get more money if somebody dies from COVID,” Trump told supporters at a rally in Waterford, Michigan, on Oct. 30. “You know that, right? I mean, our doctors are very smart people. So what they do is they say, ‘I’m sorry, but, you know, everybody dies of COVID.’”  

The Real Fake News: The Plandemic

The most viral disinformation of the pandemic was styled to look as if it had the blessing of people Americans trust: scientists and doctors.

In a 26-minute video called “Plandemic: The Hidden Agenda Behind COVID-19,” a former scientist at the National Cancer Institute claimed the virus was manipulated in a lab, hydroxychloroquine is effective against coronaviruses, and face masks make people sick. 

Judy Mikovits’ conspiracies received more than 8 million views, partly credited to the online outrage machine — anti-vaccine activists, anti-lockdown groups and QAnon supporters — that push disinformation into the mainstream. The video was circulated in a coordinated effort to promote Mikovits’ book release.

Around the same time, a similar effort propelled another video of fact-averse doctors to millions of people in only a few hours. 

On July 27, Breitbart published a clip of a press conference hosted by a group called America’s Frontline Doctors in front of the U.S. Supreme Court. Looking authoritative in white lab coats, these doctors discouraged mask-wearing and falsely said there was already a cure in hydroxychloroquine, a drug used to treat rheumatoid arthritis and lupus.

Trump, who had been talking up the drug since March and claimed to be taking it himself as a preventive measure in May, retweeted clips of the event before Twitter removed them as misinformation about COVID-19. He defended the “very respected doctors” in a July 28 press conference. 

When Olga Lucia Torres, a lecturer at Columbia University, heard Trump touting the drug in March, she knew it didn’t bode well for her own prescription. Sure enough, the misinformation led to a run on hydroxychloroquine, creating a shortage for Americans like her who needed the drug for chronic conditions. 

A lupus patient, she went to her local pharmacy to request a 90-day supply of the medication. But she was told they were granting only partial refills. It took her three weeks to get her medication through the mail. 

“What about all the people who were silenced and just lost access to their staple medication because people ran to their doctors and begged to take it?” Torres said.

No Sickbed Conversion

On Sept. 26, Trump hosted a Rose Garden ceremony to announce his nominee to replace the late Ruth Bader Ginsburg on the U.S. Supreme Court. More than 150 people attended the event introducing Amy Coney Barrett. Few wore masks, and the chairs weren’t spaced out.

In the weeks afterward, more than two dozen people close to Trump and the White House became infected with COVID-19. Early on Oct. 2, Trump announced his positive test.

Those hoping the experience and Trump’s successful treatment at Walter Reed might inform his view of the coronavirus were disappointed. Trump snapped back into minimizing the threat during his first moments back at the White House. He yanked off his mask and recorded a video.

“Don’t let it dominate you. Don’t be afraid of it,” he said, describing experimental and mostly out-of-reach therapies he received. “You’re going to beat it.” 

In Trump’s telling, his hospitalization was not the product of poor judgment about large gatherings like the Rose Garden event, but the consequence of leading with bravery. Plus, now, he claimed, he had immunity to the virus.

On the morning after he returned from Walter Reed, Trump tweeted a seasonal flu death count of 100,000 lives and added that COVID-19 was “far less lethal” for most populations. More false claims at odds with data — the U.S. average for flu deaths over the past decade is 36,000, and experts said COVID-19 is more deadly for each age group over 30.

When Trump left the hospital, the U.S. death toll from COVID-19 was more than 200,000. Today it is more than 300,000. Meanwhile, this month the president has gone ahead with a series of indoor holiday parties. 

The Vaccine War 

The vaccine disinformation campaign started in the spring but is still underway.

In April, blogs and social media users falsely claimed Democrats and powerful figures like Bill Gates wanted to use microchips to track which Americans had been vaccinated for the coronavirus. Now, false claims are taking aim at vaccines developed by Pfizer and BioNTech and other companies.

• A blogger claimed Pfizer’s head of research said the coronavirus vaccine could cause female infertility. That’s false.
• An alternative health website wrote that the vaccine could cause an array of life-threatening side effects, and that the FDA knew about it. The list included all possible — not confirmed— side effects.
• Social media users speculated that the federal government would force Americans to receive the vaccine. Neither Trump nor President-elect Joe Biden has advocated for that, and the federal government doesn’t have the power to mandate vaccines, anyway.

As is often the case with disinformation, the strategy is to deliver it with a charade of certainty. 

“People are anxious and scared right now,” said Dr. Seema Yasmin, director of research and education programs at the Stanford Health Communication Initiative. “They’re looking for a whole picture.” 

Most polls have shown far from universal acceptance of vaccines, with only 50% to 70% of respondents willing to take the vaccine. Black and Hispanic Americans are even less likely to take it so far.

Meanwhile, the future course of the coronavirus in the U.S. depends on whether Americans take public health guidance to heart. The Institute for Health Metrics and Evaluation projected that, without mask mandates or a rapid vaccine rollout, the death toll could rise to more than 500,000 by April 2021.

“How can we come to terms with all that when people are living in separate informational realities?” Starbird said.

PolitiFact staff researcher Caryn Baird contributed to this report.

Note: Readers can find the detailed source list for this story, as well as PolitiFact’s related coverage, or vote in the Lie of the Year Readers’ Choice Poll at PolitiFact.com.

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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When host Dan Weissmann and his wife set out to pick a health insurance plan for next year, they realized that keeping the plan they have means paying $200 a month more. But would a “cheaper” plan cost them more in the long run?  It depends. And the COVID pandemic makes their choice a lot more complicated.

After trying to puzzle it out, Weissmann debriefs with Karen Pollitz, a health insurance expert at KFF, who knows about the angst of medical bills from personal experience.

Health insurance can be painful, but the alternative ― not having health insurance ― is so much worse. If you want to go deeper on health insurance, you might want to check out these episodes from the first season of the podcast:

• In “Why You (and I) Will Likely Pick the Wrong Health Insurance,” we learn: Smart economists have proved it’s actually super hard — even they aren’t sure they’ll pick correctly.
• In an episode inspired by KHN reporter Jenny Gold, we learn about insurance companies’ price-gouging. And often we end up paying the price.
• In the first-ever episode of this show, Weissmann’s family confronts the big puzzle: Can we even get insurance that’ll work for us?
• In “A ‘Deal’ on Health Insurance Comes With Troubling Strings,” we go on a journey with a kinda-famous “financial therapist” who says she gets rattled when it comes to picking health insurance. And she’s pretty uncomfortable — morally, personally — with some of the choices she’s made. (Also, Weissmann’s family makes another cameo.)

And here are some other helpful big-picture takes:

• Listener Anna Jo Beck made a really great booklet explaining how health insurance works. You can read it online.
• Weissmann borrowed some core insurance-picking advice — consider what a health plan does for you if you get hit by a bus — from this story by Zachary Tracer at Business Insider, spelling out how he picked his insurance.

Want to go a lot deeper? Especially if you’re actually looking at buying health insurance, maybe on the Obamacare exchange?

Weissmann found healthcare.gov to be super usable this year, way better than the last time he checked.

“I punched in the answers to a few questions, and got to quickly tell it which doctors our family sees (and what meds we take) … and it provided a clear list that showed which plans cover our docs, how much they would cost us, etc.,” he said.

• Subsidies are available for Affordable Care Act plans. KFF has this explanation of how they work. It’s a slog, but thorough. Print it out, grab a snack and settle in. This bit of research explains that a lot of people qualify for a plan with no premium. (KHN, which co-produces “An Arm and a Leg,” is an editorially independent program of KFF.)
• KFF has a whole database of frequently asked questions about the ACA. Hundreds of Q’s and A’s, including 180-plus in Spanish.
• Also great, also very thorough: The Georgetown University Center on Health Insurance Reforms has a whole site full of resources for navigating the ACA. (It’s actually for “navigators” — folks who help civilians understand the sign-up process.)

That’s a lot, right? Picking a plan can be overwhelming. But don’t let it get you down.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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When her husband was diagnosed with early-stage Alzheimer’s disease in 2015, Elizabeth Pan was devastated by the lack of options to slow his inevitable decline. But she was encouraged when she discovered the work of a UCLA neurologist, Dr. Dale Bredesen, who offered a comprehensive lifestyle management program to halt or even reverse cognitive decline in patients like her husband.

After decades of research, Bredesen had concluded that more than 36 drivers of Alzheimer’s cumulatively contribute to the loss of mental acuity. They range from chronic conditions like heart disease and diabetes to vitamin and hormonal deficiencies, undiagnosed infections and even long-term exposures to toxic substances. Bredesen’s impressive academic credentials lent legitimacy to his approach.

Pan paid $4,000 to a doctor trained in Bredesen’s program for a consultation and a series of extensive laboratory tests, and then was referred to another doctor, who devised a stringent regimen of dietary changes that entailed cutting out all sugars; eating a high-fat, low-carbohydrate diet; and adhering to a complex regimen of meditation, vigorous daily exercise and about a dozen nutritional supplements each day (at about $200 a month). Pan said she had extensive mold remediation done in her home after the Bredesen doctors told her the substance could be hurting her husband’s brain.

But two years passed, she said, and her husband, Wayne, was steadily declining. To make matters worse, he had lost more than 60 pounds because he didn’t like the food on the diet. In April, he died.

“I imagine it works in some people and doesn’t work in others,” said Pan, who lives in Oakton, Virginia. “But there’s no way to tell ahead of time if it will work for you.”

Bredesen wrote the best-selling 2017 book “The End of Alzheimer’s” and has promoted his ideas in talks to community groups around the country and on radio and TV programs like “The Dr. Oz Show.” He has also started his own company, Apollo Health, to market his program and train and provide referrals for practitioners.

Unlike other self-help regimens, Bredesen said, his program is an intensely personalized and scientific approach to counteract each individual’s specific deficits by “optimizing the physical body and understanding the molecular drivers of the disease,” he told KHN in a November phone interview. “The vast majority of people improve” as long as they adhere to the regimen.

Bredesen’s peers acknowledge him as an expert on aging. A former postdoctoral fellow under Nobel laureate Stanley Prusiner at the University of California-San Francisco, Bredesen presided over a well-funded lab at UCLA for more than five years. He has been on the UCLA faculty since 1989 and also founded the Buck Institute for Research on Aging in Marin County. He has written or co-authored more than 200 papers.

But colleagues are critical of what they see as his commercial promotion of a largely unproven and costly regimen. They say he strays from long-established scientific norms by relying on anecdotal reports from patients, rather than providing evidence with rigorous research.

“He’s an exceptional scientist,” said George Perry, a neuroscientist at the University of Texas-San Antonio. “But monetizing this is a turnoff.”

“I have seen desperate patients and family members clean out their bank accounts and believe this will help them with every ounce of their being,” said Dr. Joanna Hellmuth, a neurologist in the Memory and Aging Center at UCSF. “They are clinging to hope.”

Many of the lifestyle changes Bredesen promotes are known to be helpful. “The protocol itself is based on very low-quality data, and I worry that vulnerable patients and family members may not understand that,” said Hellmuth. “He trained here” — at UCSF — “so he knows better.”

The Bredesen package doesn’t come cheap. He has built a network of practitioner-followers by training them in his protocol — at $1,800 a pop — in seminars sponsored by the Institute for Functional Medicine, which emphasizes alternative approaches to managing disease. Apollo Health also offers two-week training sessions for a $1,500 fee.

Once trained in his ReCODE Program, medical professionals charge patients upward of $300 for a consultation and as much as $10,500 for eight- to 15-month treatment packages. For the ReCODE protocol, aimed at people already suffering from early-stage Alzheimer’s disease or mild cognitive decline, Apollo Health charges an initial $1,399 fee for a referral to a local practitioner that includes an assessment and extensive laboratory tests. Apollo then offers $75-per-month subscriptions that provide cognitive games and online support, and links to another company that offers dietary supplements for an additional $150 to $450 a month. Insurance generally covers little of these costs.

Apollo Health, founded in 1998 and headquartered in Burlingame, California, also offers a protocol geared toward those who have a family history of dementia or want to prevent cognitive decline.

Bredesen estimates that about 5,000 people have done the ReCODE program. The fees are a bargain, Bredesen said, if they slow decline enough to prevent someone from being placed in a nursing home, where yearly costs can climb past $100,000.

Bredesen and his company are tapping into the desperation that has grown out of the failure of a decades-long scientific quest for effective Alzheimer’s treatments. Much of the research money in the field has narrowly focused on amyloid — the barnacle-like gunk that collects outside nerve cells and interferes with the brain’s signaling system — as the main culprits behind cognitive decline. Drugmakers have tried repeatedly, and thus far without much success, to invent a trillion-dollar anti-amyloid drug. There’s been less emphasis in the field on the lifestyle choices that Bredesen stresses.

“Amyloids sucked up all the air in the room,” said Dr. Lon Schneider, an Alzheimer’s researcher and a professor of psychiatry and behavioral sciences at the Keck School of Medicine at USC.

Growing evidence shows lifestyle changes help delay the progress of the mind-robbing disease. An exhaustive Lancet report in August identified a long list of risk factors for dementia, including excessive drinking, exposure to air pollution, obesity, loss of hearing, smoking, depression, lack of exercise and social isolation. Controlling these factors — which can be done on the cheap — could delay or even prevent up to 40% of dementia cases, according to the report.

Bredesen’s program involves all these practices, with personalized bells and whistles like intermittent fasting, meditation and supplements. Bredesen’s scientific peers question whether data supports his micromanaged approach over plain-vanilla healthy living.

Bredesen has published three papers showing positive results in many patients following his approach, but critics say he has fallen short of proving his method’s effectiveness.

The papers lack details on which protocol elements were followed, or the treatment duration, UCSF’s Hellmuth said. Nor do they explain how cognitive tests were conducted or evaluated, so it’s difficult to gauge whether improvements were due to the intervention, chance variations in performance or an assortment of other variables, she said.

Bredesen shrugs off the criticism: “We want things to be in an open-access journal so everybody can read it. These are still peer-reviewed journals. So what’s the problem?”

Another problem raised about Bredesen’s enterprise is the lack of quality control, which he acknowledges. Apollo-trained “certified practitioners” can include everyone from nurses and dietitians to chiropractors and health coaches. Practitioners with varying degrees of training and competence can take his classes and hang out a shingle. That’s a painful fact for some who buy the package.

“I had the impression these practitioners were certified, but I realize they all had just taken a two-week course,” said a Virginia man who requested anonymity to protect his wife’s privacy. He said that he had spent more than $15,000 on tests and treatments for his ailing spouse and that six months into the program, earlier this year, she had failed to improve.

Bredesen said he and his staff were reviewing “who’s getting the best results and who’s getting the worst results,” and intended to cut poor performers out of the network. “We’ll make it so that you can only see the people getting the best results,” he said.

Colleagues say that to test whether Bredesen’s method works it needs to be subjected to a placebo-controlled study, the gold standard of medical research, in which half the participants get the treatment while the other half don’t.

In the absence of rigorous studies, said USC’s Schneider, a co-author of the Lancet report, “saying you can ‘end Alzheimer’s now and this is how you do it’ is overpromising and oversimplifying. And a lot of it is just common sense.”

Bredesen no longer says his method can end Alzheimer’s, despite the title of his book. Apollo Health’s website still makes that claim, however.

The percentage of Americans with natural immunity from getting COVID-19 is “a very powerful vaccine in itself.”

— President Donald Trump on Dec. 8 at a White House Operation Warp Speed vaccine summit

This story was produced in partnership with PolitiFact. It can be republished for free.

During a Dec. 8 press conference about Operation Warp Speed, President Donald Trump likened the spread of the coronavirus throughout the population — which experts agree bestows some immunity on the people who became ill — to having a COVID-19 vaccine.

“You develop immunity over a period of time, and I hear we’re close to 15%. I’m hearing that, and that is terrific. That’s a very powerful vaccine in itself,” said Trump, who was responding to a reporter’s question about what his message to the American people was as the holidays approach and levels of COVID cases in the U.S. continue to rise.

It wasn’t the first time Trump had given credence to the idea that if enough people in a population gain immunity to a disease by being exposed to it, the illness won’t be able to spread through the remainder of the population — a concept known as “herd immunity.”

However, experts have warned that attempting to achieve herd immunity naturally, by allowing people to get sick with COVID-19, could result in more than a million deaths and potentially long-term health problems for many. A better way to achieve protection across the population, experts say, is through widespread vaccination.

So, we thought it was important to check whether 15% is anywhere close to the herd immunity threshold, and whether this level of natural immunity could be considered “as powerful as a vaccine.”

15% Is Nowhere Close

The White House did not respond to our request for more information about the comment or about Trump’s 15% figure.

It may be derived from a Nov. 25 Centers for Disease Control and Prevention report using mathematical models to estimate that 53 million Americans — about 16% of the population — have likely been infected with COVID-19. Those models took into consideration the nation’s number of confirmed cases, and then used existing data to calculate estimates of the number of people who had COVID-19 but didn’t seek medical attention, weren’t able to access a COVID-19 test, received a false-negative test result or were asymptomatic and unaware they had COVID-19.

It’s important to note this estimate is based on data from February through September — and it’s now mid-December, so the share of Americans who have been infected with the coronavirus would likely be much higher. For instance, an independent data scientist, Youyang Gu, estimated that 17.5% of Americans have had COVID-19 as of Nov. 30. His estimate is published on his website, COVID Projections.

Experts have said that a 15% infection rate among Americans is nowhere close to the threshold needed to reach herd immunity against COVID.

“To get to herd immunity, an estimated 60-80% of people need to have immunity (either through natural infection or through the vaccine),” Dr. Leana Wen, an emergency physician and visiting professor at George Washington University, wrote in an email. “We are a very long way off from that.”

Also, Wen said, scientists still don’t know enough about how effective natural immunity is in defending against COVID-19. It appears that once someone has had COVID-19 and recovered, the antibodies their body produced can protect them for at least several months. But, there have also been reports of COVID-19 re-infection.

That’s why medical experts urge everyone to get vaccinated, whether they have had COVID-19 or not.

Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, recently set the saturation level for herd immunity even higher — between 75% and 80% — in an interview with Axios.

At that point, he said, “you create an umbrella of herd immunity — that even though there is virus around, it is really almost inconsequential because it has no place to go, because almost all of the people are protected.”

Both the Pfizer and Moderna COVID-19 vaccines have shown 95% effectiveness at protecting people from developing COVID-19 in clinical trials. The Food and Drug Administration on Friday authorized Pfizer’s vaccine for emergency use. This Thursday, an independent panel will consider whether to recommend that the FDA authorize the emergency use of Moderna’s COVID-19 vaccine.

So, that leads to the next question: Is 15% natural immunity among the American population anywhere close to a “powerful vaccine,” as Trump alleges?

No, said the experts. And there’s nothing “terrific” about that level of infection within the community.

“Fifteen percent ‘natural immunity’ is nowhere close to as powerful as a vaccine,” Dr. Rachel Vreeman, director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai, wrote in an email.

Assuming that natural immunity is effective, reaching a level of 15% of the population would prevent only those individuals who have had COVID from getting sick again, said Stephen Morse, an epidemiology professor at Columbia University.

“But [it] won’t do much to prevent virus spread in the community, because there are still so many susceptible people,” Morse wrote in an email. Plus, 15% of the American population having had COVID-19 “has come at a high cost,” Morse wrote. To achieve 15% natural immunity, more than 300,000 people in the U.S. have been sacrificed.

Our Ruling

Though Trump was in the ballpark when he referenced the share of Americans who have been infected with the coronavirus, his overall point — that the natural immunity these people acquired is a powerful vaccine —does not hold up. Experts repeatedly have warned that not enough is known about the immunity people appear to gain after recovering from a COVID-19 infection to know how effective or lasting it is. And there have been reported cases of COVID re-infections.

Also, experts agree more than 70% of the U.S. population needs to be vaccinated in order to reach herd immunity. Fifteen percent is nowhere close to that threshold and should not be considered as effective as a COVID-19 vaccine. Moreover, that 15% statistic brought with it hundreds of thousands of deaths.

We rate this claim False.

Sources

ABC News, “Trump’s ABC News Town Hall: Full Transcript,” Sept. 15, 2020.

Axios, “The Hurdles We Face Before Reaching Herd Immunity,” Dec. 10, 2020.

Business Insider, “Trump Says It’s ‘Terrific’ So Many Americans Have Caught the Coronavirus Because It ‘Is a Very Powerful Vaccine in Itself’,” Dec. 9, 2020.

Clinical Infectious Disease, “Coronavirus Disease 2019 (COVID-19) Re-infection by a Phylogenetically Distinct Severe Acute Respiratory Syndrome Coronavirus 2 Strain Confirmed by Whole Genome Sequencing,” Aug. 25, 2020.

Clinical Infectious Disease, “Estimated Incidence of COVID-19 Illness and Hospitalization — United States, February-September, 2020,” Nov. 25, 2020.

Email interview with Dr. Leana Wen, visiting professor of health policy and management at George Washington University, Dec. 10, 2020.

Email interview with Dr. Rachel Vreeman, director of the Arnhold Global Health Institute at Mount Sinai, Dec. 10, 2020.

Email interview with Stephen Morse, an epidemiology professor at Columbia University Medical Center, Dec. 10, 2020.

Internet archives, Fox News Tucker Carlson Tonight Interview With Scott Atlas on June 29, 2020, accessed Dec. 12, 2020.

KHN, “Corralling the Facts on Herd Immunity,” Sept. 29, 2020.

KHN, “Morning Briefing — In Letter, Scores of Scientists Strongly Denounce Herd Immunity,” Oct. 15, 2020.

NBC News, “FDA Authorizes Pfizer’s Covid Vaccine for Emergency Use, Major First Step Toward Bringing Pandemic to End,” Dec. 11, 2020.

NPR, “Dr. Scott Atlas, Special Coronavirus Adviser to Trump, Resigns,” Nov. 30, 2020.

PBS, “Pfizer and Moderna Covid Vaccines 95% Effective in Clinical Trials,” Nov. 18, 2020.

Phone interview with Dr. Jon Andrus, adjunct professor of global health at George Washington University, Dec. 11, 2020.

Phone interview with Josh Michaud, associate director of global health policy at KFF, Dec. 10, 2020.

PolitiFact, “Herd immunity Curbed COVID Deaths? No,” April 21, 2020.

The Wall Street Journal, “More Than 15% of Americans Have Had Covid-19, CDC Estimates,” Nov. 27, 2020.

The Washington Post, “Trump Can’t Kick His Coronavirus Herd-Immunity Kick,” Dec. 8, 2020.

The Washington Post, “Trump Has Been Publicly Indicating His Openness to a Herd Immunity Strategy for Months,” Oct. 29, 2020.

The White House, Remarks by President Trump in Press Briefing, Aug. 11, 2020.

The White House, Remarks by President Trump at the Operation Warp Speed Vaccine Summit, Dec. 8, 2020.

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.

USE OUR CONTENT

This story can be republished for free (details).

More than 300,000 people have died from COVID-19 in the United States.

It is the latest sign of a generational tragedy — one still unfolding in every corner of the country — that leaves in its wake an expanse of grief that cannot be captured in a string of statistics.

“The numbers do not reflect that these were people,” said Brian Walter, of New York City, whose 80-year-old father, John, died from COVID-19. “Everyone lost was a father or a mother, they had kids, they had family, they left people behind.”

There is no analogue in recent U.S history to the scale of death brought on by the coronavirus, which now runs unchecked in countless towns, cities and states.

“We’re seeing some of the most deadly days in American history,” said Dr. Craig Spencer, director of Global Health in Emergency Medicine at NewYork-Presbyterian/Columbia University Medical Center.

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During the past two weeks, COVID-19 was the leading cause of death in the U.S., outpacing even heart disease and cancer.

“That should be absolutely stunning,” Spencer said. And yet the most deadly days of the pandemic may be to come, epidemiologists predict.

Even with a rapid rollout of vaccines, the U.S. may reach a total of more than half a million deaths by spring, said Ali Mokdad of the Institute for Health Metrics and Evaluation at the University of Washington.

Some of those deaths could still be averted. If everyone simply began wearing face masks, more than 50,000 lives could be saved, IHME’s model shows. And physical distancing could make a difference too.

No other country has come close to the calamitous death toll in the U.S. And the disease has amplified entrenched inequalities. Blacks and Hispanics/Latinos are nearly three times more likely to die from COVID-19 than whites.

“I’m really amazed at how we have this sense of apathy,” said Dr. Gbenga Ogedegbe, a professor of medicine and population health at New York University Grossman School of Medicine. He said there’s evidence that socioeconomic factors, not underlying health problems, explain the disproportionate share of deaths.

The disease, he said, reveals “the chronic neglect of Black and brown communities” in this country.

Though the numbers are numbing, for bereaved families and for front-line workers who care for people in their dying moments, every life is precious.

Here are reflections from people who’ve witnessed this loss — how they are processing the grief and what they wish the rest of America understood.

‘There Are Things We Can Do to Still Make a Difference’

Darrell Owens, a doctor of nursing practice in Seattle, was startled to learn recently that he had signed more death certificates for COVID-19 than anyone else in Washington.

Owens runs the palliative care program at the University of Washington Medical Center-Northwest, where he has treated COVID patients since the early spring.

“I’m feeling much more anger and frustration than I did before because much of what we’re dealing with now was preventable,” Owens said.

“We’re all in this great big storm, but some people are in a yacht and some people are on a cruise ship and some people are on a raft,” he added. “We’re not all in this together.”

Owens still finds moments of grace and meaning as he cares for the dying.

“The other day, there was a lady I was taking care of who’d come from a local nursing home and it was very clear that she was nearing the end,” Owens said. “I just picked up her hand. I sat there. I held her hand for about 25 minutes until she took her last breath.”

He stepped out of the room and called the patient’s daughter.

“It made such a difference for her that her mom was not alone,” he said. “What an incredible gift that she gave me and that I was able to give her daughter. So there are things that we can do to still make a difference.”

‘It’s Not a Joke. It’s Not a Hoax.’

Since his father died of COVID-19 in the spring, Brian Walter of Queens, New York, has helped run a support group on Facebook for people who’ve lost family and friends to COVID-19.

It’s helped him grieve his father John, whom he describes as a very loving man dedicated to his autistic grandson and to running a youth program for teenagers.

“It’s been lifesaving in a lot of ways,” Walter said. “Together, we face a lot of issues since we are grieving in isolation. But at the same time, we’re also dealing with people that openly tell us that this is not a real condition, that this is not a real issue.”

Some in their group admit they denied the severity of the virus and shunned precautions until it was too late.

“It’s not a joke. It’s not a hoax, and you will not understand how horrible this is until it enters your family and takes away someone,” he said.

All of this complicates the grief, but it has also led Walter and others in his group to speak out and share their stories, so that numbers don’t obscure the actual people who were leading full lives before dying from COVID-19.

“I know what it’s like to have to say goodbye to somebody over a Zoom call and to not have a funeral,” Walter said.

‘300,000 Stories That Got Shut Down Too Quickly’

Martha Phillips, an ER nurse who took assignments in New York and Texas in the spring and summer, said there is one patient who has become almost a stand-in for the grief of the many whose deaths she witnessed.

It was the very last COVID patient she cared for in Houston.

“I reached down to just adjust her oxygen tubing just a little bit,” Phillips recalled. “And she looks up at me and she sees me through my goggles and my mask and my shield and meets my eyes and she goes, ‘Do you think I’m going to get better?’”

“What do you say to someone who’s not ready to die? Who has so much to live for, but got this and now they’re trapped?”

Two months later, Phillips discovered the woman’s obituary online.

“That one was the hardest,” she said. “But there’s 300,000 people who had time left that was stolen from them; 300,000 stories that got shut down too quickly.”

‘This Is Worse Than Being in War’

ER physician Dr. Cleavon Gilman, a veteran of the Iraq War, said it’s still hard to communicate the brutality of a disease that kills people in the privacy of a hospital wing.

When Gilman was in New York City during the spring surge, he never imagined the U.S. would be losing thousands of people each day to COVID-19 so many months later.

“That 300,000 Americans would be dead and life would go on and people would not have empathy for their fellow Americans,” he said. “I can tell you this is worse than being in war.”

The enemy is invisible, he said, the war zone is everywhere, and many refuse to take the most simple actions to combat the virus, even as morgues fill up in their own community.

Throughout the pandemic, Gilman, who is now working in Yuma, Arizona, has shared photos and stories of people who’ve died from COVID-19 each day on social media.  “It’s really important to honor them,” he said.

This story is from a reporting partnership with NPR and KHN. 

This story also ran on The Associated Press. It can be republished for free.

Tisha Coleman has lived in close-knit Linn County, Kansas, for 42 years and never felt so alone.

As the public health administrator, she’s struggled every day of the coronavirus pandemic to keep her rural county along the Missouri border safe. In this community with no hospital, she’s failed to persuade her neighbors to wear masks and take precautions against COVID-19, even as cases rise. In return, she’s been harassed, sued, vilified — and called a Democrat, an insult in her circles.

Even her husband hasn’t listened to her, refusing to require customers to wear masks at the family’s hardware store in Mound City.

“People have shown their true colors,” Coleman said. “I’m sure that I’ve lost some friends over this situation.”

By November, the months of fighting over masks and quarantines were already wearing her down. Then she got COVID-19, likely from her husband, who she thinks picked it up at the hardware store. Her mother got it, too, and died on Sunday, 11 days after she was put on a ventilator.

Across the U.S., state and local public health officials such as Coleman have found themselves at the center of a political storm as they combat the worst pandemic in a century. Amid a fractured federal response, the usually invisible army of workers charged with preventing the spread of infectious diseases has become a public punching bag. Their expertise on how to fight the coronavirus is often disregarded.

Some have become the target of far-right activists, conservative groups and anti-vaccination extremists, who have coalesced around common goals — fighting mask orders, quarantines and contact tracing with protests, threats and personal attacks.

The backlash has moved beyond the angry fringe. In the courts, public health powers are being undermined. Lawmakers in at least 24 states have crafted legislation to weaken public health powers, which could make it more difficult for communities to respond to other health emergencies in the future.

“What we’ve taken for granted for 100 years in public health is now very much in doubt,” said Lawrence Gostin, an expert in public health law at Georgetown University in Washington, D.C.

It is a further erosion of the nation’s already fragile public health infrastructure. At least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1, according to an ongoing investigation by The Associated Press and KHN. According to experts, this is the largest exodus of public health leaders in American history. An untold number of lower-level staffers has also left.

“I’ve never seen or studied a pandemic that has been as politicized, as vitriolic and as challenged as this one, and I’ve studied a lot of epidemics,” said Dr. Howard Markel, a medical historian at the University of Michigan. “All of that has been very demoralizing for the men and women who don’t make a great deal of money, don’t get a lot of fame, but work 24/7.”

One in 8 Americans — 40 million people — lives in a community that has lost its local public health department leader during the pandemic. Top public health officials in 20 states have left state-level departments, including in North Dakota, which has lost three state health officers since May, one after another.

Many of the state and local officials left due to political blowback or pandemic pressure. Some departed to take higher-profile positions or due to health concerns. Others were fired for poor performance. Dozens retired.

KHN and AP reached out to public health workers and experts in every state and the National Association of County and City Health Officials; examined public records and news reports; and interviewed hundreds to gather the list.

Collectively, the loss of expertise and experience has created a leadership vacuum in the profession, public health experts say. Many health departments are in flux as the nation rolls out the largest vaccination campaign in its history and faces what are expected to be the worst months of the pandemic.

“We don’t have a long line of people outside of the door who want those jobs,” said Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas, who is retiring from his job earlier than planned because, he said, he’s burned out. “It’s a huge loss that will be felt probably for generations to come.”

Existing Problems

The departures accelerate problems that had already weakened the nation’s public health system. AP and KHN reported that per capita spending for state public health departments had dropped by 16%, and for local health departments by 18%, since 2010. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.

Those diminishing resources were already prompting high turnover. Before the pandemic, nearly half of public health workers said in a survey they planned to retire or leave in the next five years. The top reason given was low pay.

Such reduced staffing in departments that have the power and responsibility to manage everything from water inspections to childhood immunizations left public health workforces ill-equipped when COVID-19 arrived. Then, when pandemic shutdowns cut tax revenues, some state and local governments cut their public health workforces further.

“Now we’re at this moment where we need this knowledge and leadership the most, everything has come together to cause that brain drain,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Politics as Public Health Poison

Public health experts broadly agree that masks are a simple and cost-effective way to reduce the spread of COVID-19 and save lives and livelihoods. Scientists say that physical distancing and curtailing indoor activities can also help.

But with the pandemic coinciding with a divisive presidential election, simple acts such as wearing a mask morphed into political statements, with right-wing conservatives saying such requirements stomped on individual freedom.

On the campaign trail, President Donald Trump ridiculed President-elect Joe Biden for wearing a mask and egged on armed people who stormed Michigan’s Capitol to protest coronavirus restrictions by tweeting “LIBERATE MICHIGAN!”

Coleman, a Christian and a Republican, said that’s just what happened in Linn County. “A lot of people are shamed into not wearing a mask … because you’re considered a Democrat,” she said. “I’ve been called a ‘sheep.’”

The politicization has put some local governments at odds with their own health officials. In California, near Lake Tahoe, the Placer County Board of Supervisors voted to end a local health emergency and declared support for a widely discredited “herd immunity” strategy, which would let the virus spread. The idea is endorsed by many conservatives, including former Trump adviser Dr. Scott Atlas, as a way to keep the economy running, but it has been denounced by public health experts who say millions more people will unnecessarily suffer and die. The supervisors also endorsed a false conspiracy theory claiming many COVID-19 deaths are not actually from COVID-19.

The meeting occurred just days after county Public Health Officer Dr. Aimee Sisson explained to the board the rigorous standards used for counting COVID-19 deaths. Sisson quit the next day.

In Idaho, protests against public health measures are intensifying. Hundreds of protesters, some armed, swarmed health district offices and health board members’ homes in Boise on Dec. 8, screaming and blaring air horns. They included members of the anti-vaccination group Health Freedom Idaho.

Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, has tracked the anti-vaccine movement and said it has linked up with political extremists on the right, and taken on a larger anti-science role, pushing back against other public health measures such as contact tracing and physical distancing.

Members of a group called the Freedom Angels in California, which sprung up in 2019 around a state law to tighten vaccine requirements, have been organizing protests at health departments, posing with guns and calling themselves a militia on the group’s Facebook page.

The latest Idaho protests came after a July skirmish in which Ammon Bundy shoved a public health employee who tried to stop him and his maskless supporters from entering a health meeting.

Bundy, whose family led armed standoffs against federal agents in 2014 and 2016, has become an icon for paramilitary groups and right-wing extremists, most recently forming a multistate network called People’s Rights that has organized protests against public health measures.

“We don’t believe they have a right to tell us that we have to put a manmade filter over our face to go outside,” Bundy said. “It’s not about, you know, the mandates or the mask. It’s about them not having that right to do it.”

Kelly Aberasturi, vice chair for the Southwest District Health, which covers six counties, said the worker Bundy shoved was “just trying to do his job.”

Aberasturi, a self-described “extremist” right-wing Republican, said he, too, has been subjected to the backlash. Aberasturi doesn’t support mask mandates, but he did back the board’s recommendation that people in the community wear masks. He said people who believe even a recommendation goes too far have threatened to protest at his house.

The Mask Fight in Kansas

The public health workforce in Kansas has been hit hard — 17 of the state’s 100 health departments have lost their leaders since the end of March. 

Democratic Gov. Laura Kelly issued a mask mandate in July, but the state legislature allowed counties to opt out. A recent Centers for Disease Control and Prevention report showed the 24 Kansas counties that had upheld the mandate saw a 6% decrease in COVID-19, while the 81 counties that opted out entirely saw a 100% increase.

Coleman, who pushed unsuccessfully for Linn County to uphold the rule, was sued for putting a community member into quarantine, a lawsuit she won. In late November, she spoke at a county commissioner’s meeting to discuss a new mask mandate — it was her first day back in the office after her own bout with COVID-19.

She pleaded for a plan to help stem the surge in cases. One resident referenced Thomas Jefferson, saying, “I prefer a dangerous freedom over a peaceful slavery.” Another falsely argued that masks caused elevated carbon dioxide. Few, besides Coleman, wore a mask at the meeting.

Commissioner Mike Page supported the mask order, noting that a close friend was fighting COVID-19 in the hospital and saying he was “ashamed” that members of the community had sued their public health workers while other communities supported theirs.

In the end, the commissioners encouraged community members to wear masks but opted out of a county-wide rule, writing they had determined that they are “not necessary to protect the public health and safety of the county.”

Coleman was disappointed but not surprised. “At least I know I’ve done everything I can to attempt to protect the people,” she said.

The next day, Coleman discussed Christmas decorations with her mother as she drove her to the hospital.

Stripping of Powers

The state bill that let Linn County opt out of the governor’s mask mandate is one of dozens of efforts to erode public health powers in state legislatures across the country.

For decades, government authorities have had the legal power to stop foodborne illnesses and infectious diseases by closing businesses and quarantining individuals, among other measures.

When people contract tuberculosis, for example, the local health department might isolate them, require them to wear a mask when they leave their homes, require family members to get tested, relocate them so they can isolate and make sure they take their medicine. Such measures are meant to protect everyone and avoid the shutdown of businesses and schools.

Now, opponents of those measures are turning to state legislatures and even the Supreme Court to strip public officials of those powers, defund local health departments or even dissolve them. The American Legislative Exchange Council, a corporate-backed group of conservative lawmakers, has published model legislation for states to follow.

Lawmakers in Missouri, Louisiana, Ohio, Virginia and at least 20 other states have crafted bills to limit public health powers. In some states, the efforts have failed; in others, legislative leaders have embraced them enthusiastically.

Tennessee’s Republican House leadership is backing a bill to constrain the state’s six local health departments, granting their powers to mayors instead. The bill stems from clashes between the mayor of Knox County and the local health board over mask mandates and business closures.

In Idaho, lawmakers resolved to review the authority of local health districts in the next session. The move doesn’t sit right with Aberasturi, who said it’s hypocritical coming from state lawmakers who profess to believe in local control.

Meanwhile, governors in Wisconsin, Kansas and Michigan, among others, have been sued by their own legislators, state think tanks or others for using their executive powers to restrict business operations and require masks. In Ohio, a group of lawmakers is seeking to impeach Republican Gov. Mike DeWine over his pandemic rules.

The U.S. Supreme Court in 1905 found it was constitutional for officials to issue orders to protect the public health, in a case upholding a Cambridge, Massachusetts, requirement to get a smallpox vaccine. But a 5-4 ruling last month indicated the majority of justices are willing to put new constraints on those powers.

“It is time — past time — to make plain that, while the pandemic poses many grave challenges, there is no world in which the Constitution tolerates color-coded executive edicts that reopen liquor stores and bike shops but shutter churches, synagogues, and mosques,” Justice Neil Gorsuch wrote.

Gostin, the health law professor, said the decision could embolden state legislators and governors to weaken public health authority, creating “a snowballing effect on the erosion of public health powers and, ultimately, public’s trust in public health and science.”

Who’s Left?

Many health officials who have stayed in their jobs have faced not only political backlash but also threats of personal violence. Armed paramilitary groups have put public health in their sights.

In California, a man with ties to the right-wing, anti-government Boogaloo movement was accused of stalking and threatening Santa Clara’s health officer. The suspect was arrested and has pleaded not guilty. The Boogaloo movement is associated with multiple murders, including of a Bay Area sheriff deputy and federal security officer.

Linda Vail, health officer for Michigan’s Ingham County, has received emails and letters at her home saying she’d be “taken down like the governor,” which Vail took to be a reference to the thwarted attempt to kidnap Democratic Gov. Gretchen Whitmer. Even as other health officials are leaving, Vail is choosing to stay despite the threats.

“I can completely understand why some people, they’re just done,” she said. “There are other places to go work.”

In mid-November, Danielle Swanson, public health administrator in Republic County, Kansas, said she was planning to resign as soon as she and enough of her COVID-19-positive staff emerged from isolation. Someone threatened to go to her department with a gun because of a quarantine, and she’s received hand-delivered hate mail and calls from screaming residents.

“It’s very stressful. It’s hard on me; it’s hard on my family that I do not see,” she said. “For the longest time, I held through it thinking there’s got to be an end in sight.”

Swanson said some of her employees have told her once she goes, they probably will not stay.

As public health officials depart across the country, the question of who takes their places has plagued Dr. Oxiris Barbot, who left her job as commissioner of New York City’s health department in August amid a clash with Democratic Mayor Bill de Blasio. During the height of the pandemic, the mayor empowered the city’s hospital system to lead the fight against COVID-19, passing over her highly regarded department.

“I’m concerned about the degree to which they will have the fortitude to tell elected officials what they need to hear instead of what they want to hear,” Barbot said.

In Kentucky, 189 employees, about 1 in 10, left local health departments from March through Nov. 21, according to Sara Jo Best, public health director of the Lincoln Trail District Health Department. That comes after a decade of decline: Staff numbers fell 49% from 2009 to 2019. She said workers are exhausted and can’t catch up on the overwhelming number of contact tracing investigations, much less run COVID-19 testing, combat flu season and prepare for COVID-19 vaccinations.

And the remaining workforce is aging. According to the de Beaumont Foundation, which advocates for local public health, 42% of governmental public health workers are over age 50.

Back in Linn County, cases are rising. As of Dec. 14, 1 out of every 24 residents has tested positive.

The day after her mother was put on a ventilator, Coleman fought to hold back tears as she described the 71-year-old former health care worker with a strong work ethic.

“Of course, I could give up and throw in the towel, but I’m not there yet,” she said, adding that she will “continue to fight to prevent this happening to someone else.”

Coleman, whose mother died Sunday, has noticed more people are wearing masks these days.

But at the family hardware store, they are still not required.

This story is a collaboration between The Associated Press and KHN.

Methodology

KHN and AP counted how many state and local public health leaders have left their jobs since April 1, or who plan to leave by Dec. 31.

The analysis includes the exits of top department officials regardless of the reason. Some departments have more than one top position and some had multiple top officials leave from the same position over the course of the pandemic.

To compile the list, reporters reached out to public health associations and experts in every state and interviewed hundreds of public health employees. They also received information from the National Association of County and City Health Officials, and combed news reports and public records, such as meeting minutes and news releases.

The population served by each local health department is calculated using the Census Bureau 2019 Population Estimates based on each department’s jurisdiction.

The count of legislation came from reviewing bills in every state, prefiled bills for 2021 sessions, where available, and news reports. The bills include limits on quarantines, contact tracing, vaccine requirements and emergency executive powers.

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