'Are you going to keep me safe?' Hospital workers sound the alarm on rising violence

By Bram Sable-Smith and Andy Miller

The San Leandro Hospital emergency department, where nurse Mawata Kamara works, went into lockdown recently when a visitor, agitated about being barred from seeing a patient due to covid-19 restrictions, threatened to bring a gun to the California facility.

It wasn't the first time the department faced a gun threat during the pandemic. Earlier in the year, a psychiatric patient well known at the department became increasingly violent, spewing racial slurs, spitting toward staffers and lobbing punches before eventually threatening to shoot Kamara in the face.

“Violence has always been a problem," Kamara said. “This pandemic really just added a magnifying glass."

In the earliest days of the pandemic, nightly celebrations lauded the bravery of front-line health care workers. Eighteen months later, those same workers say they are experiencing an alarming rise in violence in their workplaces.

A nurse testified before a Georgia Senate study committee in September that she was attacked by a patient so severely last spring she landed in the ER of her own hospital.

At Research Medical Center in Kansas City, Missouri, security was called to the covid unit, said nurse Jenn Caldwell, when a visitor aggressively yelled at the nursing staff about the condition of his wife, who was a patient.

In Missouri, a tripling of physical assaults against nurses prompted Cox Medical Center Branson to issue panic buttons that can be worn on employees' identification badges.

Hospital executives were already attuned to workplace violence before the pandemic struck. But stresses from covid have exacerbated the problem, they say, prompting increased security, de-escalation training and pleas for civility. And while many hospitals work to address the issue on their own, nurses and other workers are pushing federal legislation to create enforceable standards nationwide.

Paul Sarnese, an executive at Virtua Health in New Jersey and president of the International Association for Healthcare Security and Safety, said many studies show health care workers are much more likely to be victims of aggravated assault than workers in any other industry.

Federal data shows health care workers faced 73% of all nonfatal injuries from workplace violence in the U.S. in 2018. It's too early to have comprehensive stats from the pandemic.

Even so, Michelle Wallace, chief nursing officer at Grady Health System in Georgia, said the violence is likely even higher because many victims of patient assaults don't report them.

“We say, 'This is part of our job,'" said Wallace, who advocates for more reporting.

Caldwell said she had been a nurse for less than three months the first time she was assaulted at work — a patient spit at her. In the four years since, she estimated, she hasn't gone more than three months without being verbally or physically assaulted.

“I wouldn't say that it's expected, but it is accepted," Caldwell said. “We have a lot of people with mental health issues that come through our doors."

Jackie Gatz, vice president of safety and preparedness for the Missouri Hospital Association, said a lack of behavioral health resources can spur violence as patients seek treatment for mental health issues and substance use disorders in ERs. Life can also spill inside to the hospital, with violent episodes that began outside continuing inside or the presence of law enforcement officers escalating tensions.

A February 2021 report from National Nurses United — a union in which both Kamara and Caldwell are representatives — offers another possible factor: staffing levels that don't allow workers sufficient time to recognize and de-escalate possibly volatile situations.

Covid unit nurses also have shouldered extra responsibilities during the pandemic. Duties such as feeding patients, drawing blood and cleaning rooms would typically be conducted by other hospital staffers, but nurses have pitched in on those jobs to minimize the number of workers visiting the negative-pressure rooms where covid patients are treated. While the workload has increased, the number of patients each nurse oversees is unchanged, leaving little time to hear the concerns of visitors scared for the well-being of their loved ones — like the man who aggressively yelled at the nurses in Caldwell's unit.

In September, 31% of hospital nurses surveyed by that union said they had faced workplace violence, up from 22% in March.

Dr. Bryce Gartland, hospital group president of Atlanta-based Emory Healthcare, said violence has escalated as the pandemic has worn on, particularly during the latest wave of infections, hospitalization and deaths.

“Front-line health care workers and first responders have been on the battlefield for 18 months," Garland said. “They're exhausted."

Like the increase in violence on airplanes, at sports arenas and school board meetings, the rising tensions inside hospitals could be a reflection of the mounting tensions outside them.

William Mahoney, president of Cox Medical Center Branson, said national political anger is acted out locally, especially when staffers ask people who come into the hospital to put on a mask.

Caldwell, the nurse in Kansas City, said the physical nature of covid infections can contribute to an increase in violence. Patients in the covid unit often have dangerously low oxygen levels.

“People have different political views — they're either CNN or Fox News — and they start yelling at you, screaming at you," Mahoney said.

“When that happens, they become confused and also extremely combative," Caldwell said.

Sarnese said the pandemic has given hospitals an opportunity to revisit their safety protocols. Limiting entry points to enable covid screening, for example, allows hospitals to funnel visitors past security cameras.

Research Medical Center recently hired additional security officers and provided de-escalation training to supplement its video surveillance, spokesperson Christine Hamele said.

In Branson, Mahoney's hospital has bolstered its security staff, mounted cameras around the facility, brought in dogs (“people don't really want to swing at you when there's a German shepherd sitting there") and conducted de-escalation training — in addition to the panic buttons.

Some of those efforts pre-date the pandemic but the covid crisis has added urgency in an industry already struggling to recruit employees and maintain adequate staffing levels. “The No. 1 question we started getting asked is, 'Are you going to keep me safe?'" Mahoney said.

While several states, including California, have rules to address violence in hospitals, National Nurses United is calling for the U.S. Senate to pass the Workplace Violence Prevention for Health Care and Social Service Workers Act that would require hospitals to adopt plans to prevent violence.

“With any standard, at the end of the day you need that to be enforced," said the union's industrial hygienist, Rocelyn de Leon-Minch.

Nurses in states with laws on the books still face violence, but they have an enforceable standard they can point to when asking for that violence to be addressed. De Leon-Minch said the federal bill, which passed the House in April, aims to extend that protection to health care workers nationwide.

Destiny, the nurse who testified in Georgia using only her first name, is pressing charges against the patient who attacked her. The state Senate committee is now eyeing legislation for next year.

Kamara said the recent violence helped lead her hospital to provide de-escalation training, although she was dissatisfied with it. San Leandro Hospital spokesperson Victoria Balladares said the hospital had not experienced an increase in workplace violence during the pandemic.

For health care workers such as Kamara, all this antagonism toward them is a far cry from the early days of the pandemic when hospital workers were widely hailed as heroes.

“I don't want to be a hero," Kamara said. “I want to be a mom and a nurse. I want to be considered a person who chose a career that they love, and they deserve to go to work and do it in peace. And not feel like they're going to get harmed."

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.



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Mounting Covid deaths fuel school bus drivers’ fears

GRIFFIN, Ga. — Natalia D'Angelo got sick right after school started in August.

She was driving a school bus for special education students in Griffin-Spalding County School System about 40 miles south of Atlanta and contracted covid-19.

One of her three sons, Julian Rodriguez-D'Angelo, said his mother, who was not vaccinated against the covid virus, had a history of health problems, including Graves' disease and cancer.

Rodriguez-D'Angelo said his mother “was pretty certain" she got covid from her work duties. He added that D'Angelo's assistant on the same bus also had the disease, and that his mother said some kids on the bus did not wear masks, even though it is required.

The virus spread through the whole family, including her husband, Americo Rodriguez, who came with her to the U.S. from Uruguay 20 years ago. But D'Angelo's illness grew worse, and she was hospitalized at a Griffin hospital in mid-August. On Aug. 28, she died. She was 43.

D'Angelo is among at least 12 school bus workers in Georgia — including three in the Griffin-Spalding district — who have died of covid since the beginning of the school year. News reports and a Twitter feed called “School Personnel Lost to Covid" show that school bus drivers in at least 10 states have died of the disease since August.

The deaths raise questions about whether school bus drivers are at higher risk of getting covid. But medical experts are split. It's difficult, if not impossible when local infection rates are high, to determine how any particular bus worker became infected — whether it occurred at home, in a community setting or on the job.

The buses should be relatively safe. The Centers for Disease Control and Prevention requires that masks be worn on public transportation, including all school buses, public or private and regardless of whether the schools themselves require masks.

“There's no enforcement of that,'' said Ronna Weber, executive director of the National Association of State Directors of Pupil Transportation Services. “Police are not going to board a school bus" to make sure the students are wearing masks.

As with school employees in general, statistics on the number of covid deaths are sparse, without any central government repository, according to the National Education Association union. The Florida Education Association, though, lists seven bus workers among the more than 70 school staffers in the state who have died since July. The School Personnel Lost to Covid account says more than 185 bus drivers have died of the disease during the pandemic.

An estimated 500,000 school buses nationwide operate on a given day. Many drivers are retirees from previous occupations, so age and health conditions could contribute to the deaths. “Every life is an unfortunate loss," said Weber.

Xiaoyan Song, chief infection control officer at Children's National Hospital in Washington, D.C., said drivers are not at increased risk of getting covid from students because they see children up close for only a second or two, when the kids board and exit the bus.

It typically takes several minutes of exposure to an infected person to transmit the virus, she said, adding that drivers face forward with their backs to students while driving, which also diminishes their risk. She said driving with windows open is another factor that can limit transmission of the virus.

But Ye Shen, an associate professor at the University of Georgia College of Public Health, believes drivers face a greater risk.

Shen, lead author of a JAMA Internal Medicine study on covid transmission on buses in China, noted that the vehicles are enclosed spaces in which ventilation can be poor, creating an environment with a high risk of covid transmission.

The danger of airborne transmission is significantly reduced if the kids and the driver are all wearing masks, Shen said. In the China study, no one was wearing a mask and there was a high rate of virus transmission. “Kids often don't fully comply with the mask rule," Shen added.

Risks may climb within school districts that lack mask mandates, he said.

The Bulloch County school district in southeastern Georgia has no mask mandate in classrooms or buses. In early September, Bulloch district bus driver Norma Jean Carter, 55, died of covid.

Besides mask-wearing, the CDC recommends that, whenever possible, drivers and monitors open bus windows to increase air circulation. Bus surfaces should be cleaned and disinfected after each use of the vehicle, the agency said.

Even when precautions are taken, the fears surrounding covid have worsened a nationwide shortage of school bus drivers.

Michael Cordiello, president of the Amalgamated Transit Union local chapter in New York City, representing more than 8,000 school bus workers, said more drivers have retired in 2021 than in previous years.

Officials in several states are working to find solutions to the shortages, and some are requesting that their governors send National Guard troops to help. A Wilmington, Delaware, school is paying its students' parents to drive buses. Some regular drivers have had to work extra shifts.

“Our drivers are scared to death," said Jamie Michael, president of Support Personnel Association of Lee County, a union in southwestern Florida that represents bus drivers and other school staffers.

One county school bus driver there died of covid in mid-August, she said. It is unknown where the woman was infected. She said five drivers then quit Sept. 7 and the county school district is about 100 drivers short of what it needs.

The district requires drivers to wear masks, and they try to ensure that at least some windows are kept open on the bus no matter the weather.

“It's a scary time for anyone working with students," Michael said.

Drivers in the district get paid between $16 and $23 an hour depending on seniority, amounting to $31,000 to about $45,000 annually.

Michael said drivers like to keep the seat behind them vacant to allow for physical distancing, but that is not always possible due to demand for rides, especially amid driver shortages.

The Griffin-Spalding district temporarily switched to remote learning for students after D'Angelo, another bus driver and a bus monitor died of covid. Several more have been infected since school started Aug. 4, said Adam Pugh, spokesperson for the Griffin-Spalding County School System. The school district added a mask requirement early in the school year.

“No one has an exact answer" as to why the district's bus workers have been hit so hard, he said. Many buses are being driven with windows open, and the vehicles are sanitized between routes, Pugh added.

Julian Rodriguez-D'Angelo said his mother “loved being a bus driver and never missed work. She drove for years."

He said he doesn't blame the students but does feel anger about district policies. The delta variant, the dominant strain of covid, “is spreading like crazy," he said. He added he doesn't think students should have been in school amid the surge.

The vaccination rate in Spalding County for all residents, 37%, is far below the state's 46% rate. Both rates are below the national average.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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A daily pill to treat Covid could be just months away, scientists say

Within a day of testing positive for covid-19 in June, Miranda Kelly was sick enough to be scared. At 44, with diabetes and high blood pressure, Kelly, a certified nursing assistant, was having trouble breathing, symptoms serious enough to send her to the emergency room.

When her husband, Joe, 46, fell ill with the virus, too, she really got worried, especially about their five teenagers at home: “I thought, 'I hope to God we don't wind up on ventilators. We have children. Who's going to raise these kids?"

But the Kellys, who live in Seattle, had agreed just after their diagnoses to join a clinical trial at the nearby Fred Hutch cancer research center that's part of an international effort to test an antiviral treatment that could halt covid early in its course.

By the next day, the couple were taking four pills, twice a day. Though they weren't told whether they had received an active medication or placebo, within a week, they said, their symptoms were better. Within two weeks, they had recovered.

“I don't know if we got the treatment, but I kind of feel like we did," Miranda Kelly said. “To have all these underlying conditions, I felt like the recovery was very quick."

The Kellys have a role in developing what could be the world's next chance to thwart covid: a short-term regimen of daily pills that can fight the virus early after diagnosis and conceivably prevent symptoms from developing after exposure.

“Oral antivirals have the potential to not only curtail the duration of one's covid-19 syndrome, but also have the potential to limit transmission to people in your household if you are sick," said Timothy Sheahan, a virologist at the University of North Carolina-Chapel Hill who has helped pioneer these therapies.

Antivirals are already essential treatments for other viral infections, including hepatitis C and HIV. One of the best known is Tamiflu, the widely prescribed pill that can shorten the duration of influenza and reduce the risk of hospitalization if given quickly.

The medications, developed to treat and prevent viral infections in people and animals, work differently depending on the type. But they can be engineered to boost the immune system to fight infection, block receptors so viruses can't enter healthy cells, or lower the amount of active virus in the body.

At least three promising antivirals for covid are being tested in clinical trials, with results expected as soon as late fall or winter, said Carl Dieffenbach, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases, who is overseeing antiviral development.

“I think that we will have answers as to what these pills are capable of within the next several months," Dieffenbach said.

The top contender is a medication from Merck & Co. and Ridgeback Biotherapeutics called molnupiravir, Dieffenbach said. This is the product being tested in the Kellys' Seattle trial. Two others include a candidate from Pfizer, known as PF-07321332, and AT-527, an antiviral produced by Roche and Atea Pharmaceuticals.

They work by interfering with the virus's ability to replicate in human cells. In the case of molnupiravir, the enzyme that copies the viral genetic material is forced to make so many mistakes that the virus can't reproduce. That, in turn, reduces the patient's viral load, shortening infection time and preventing the kind of dangerous immune response that can cause serious illness or death.

So far, only one antiviral drug, remdesivir, has been approved to treat covid. But it is given intravenously to patients ill enough to be hospitalized, and is not intended for early, widespread use. By contrast, the top contenders under study can be packaged as pills.

Sheahan, who also performed preclinical work on remdesivir, led an early study in mice that showed that molnupiravir could prevent early disease caused by SARS-CoV-2, the virus that causes covid. The formula was discovered at Emory University and later acquired by Ridgeback and Merck.

Clinical trials have followed, including an early trial of 202 participants last spring that showed that molnupiravir rapidly reduced the levels of infectious virus. Merck chief executive Robert Davis said this month that the company expects data from its larger phase 3 trials in the coming weeks, with the potential to seek emergency use authorization from the Food and Drug Administration “before year-end."

Pfizer launched a combined phase 2 and 3 trial of its product Sept. 1, and Atea officials said they expect results from phase 2 and phase 3 trials later this year.

If the results are positive and emergency use is granted for any product, Dieffenbach said, “distribution could begin quickly."

That would mean millions of Americans soon could have access to a daily orally administered medication, ideally a single pill, that could be taken for five to 10 days at the first confirmation of covid infection.

“When we get there, that's the idea," said Dr. Daniel Griffin, an infectious diseases and immunology expert at Columbia University. “To have this all around the country, so that people get it the same day they get diagnosed."

Once sidelined for lack of interest, oral antivirals to treat coronavirus infections are now a subject of fierce competition and funding. In June, the Biden administration announced it had agreed to obtain about 1.7 million treatment courses of Merck's molnupiravir, at a cost of $1.2 billion, if the product receives emergency authorization or full approval. The same month, the administration said it would invest $3.2 billion in the Antiviral Program for Pandemics, which aims to develop antivirals for the covid crisis and beyond, Dieffenbach said.

The pandemic kick-started a long-neglected effort to develop potent antiviral treatments for coronaviruses, said Sheahan. Though the original SARS virus in 2003 gave scientists a scare — followed by Middle East respiratory syndrome, or MERS, in 2012 — research efforts slowed when those outbreaks did not persist.

“The commercial drive to develop any products just went down the tubes," said Sheahan.

Widely available antiviral drugs would join the monoclonal antibody therapies already used to treat and prevent serious illness and hospitalizations caused by covid. The lab-produced monoclonal antibodies, which mimic the body's natural response to infection, were easier to develop but must be given primarily through intravenous infusions.

The federal government is covering the cost of most monoclonal products at $2,000 a dose. It's still too early to know how the price of antivirals might compare.

Like the monoclonal antibodies, antiviral pills would be no substitute for vaccination, said Griffin. They would be another tool to fight covid. “It's nice to have another option," he said.

One challenge in developing antiviral drugs quickly has been recruiting enough participants for the clinical trials, each of which needs to enroll many hundreds of people, said Dr. Elizabeth Duke, a Fred Hutch research associate overseeing its molnupiravir trial.

Participants must be unvaccinated and enrolled in the trial within five days of a positive covid test. Any given day, interns make 100 calls to newly covid-positive people in the Seattle area — and most say no.

“Just generally speaking, there's a lot of mistrust about the scientific process," Duke said. “And some of the people are saying kind of nasty things to the interns."

If the antiviral pills prove effective, the next challenge will be ramping up a distribution system that can rush them to people as soon as they test positive. Griffin said it will take something akin to the program set up last year by UnitedHealthcare, which sped Tamiflu kits to 200,000 at-risk patients enrolled in the insurer's Medicare Advantage plans.

Merck officials predicted the company could produce more than 10 million courses of therapy by the end of the year. Atea and Pfizer have not released similar estimates.

Even more promising? Studies evaluating whether antivirals can prevent infection after exposure.

“Think about that," said Duke, who is also overseeing a prophylactic trial. “You could give it to everyone in a household, or everyone in a school. Then we're talking about a return to, maybe, normal life."

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Health care unions defending Newsom from recall will want single-payer payback

SACRAMENTO, Calif. — Should Gavin Newsom survive the Republican-driven attempt to oust him from office, the Democratic governor will face the prospect of paying back supporters who coalesced behind him.


And the leaders of California's single-payer movement will want their due.

Publicly, union leaders say they're standing beside Newsom because he has displayed political courage during the covid-19 pandemic by taking actions such as imposing the nation's first statewide stay-at-home order. But behind the scenes, they are aggressively pressuring him to follow through on his 2018 campaign pledge to establish a government-run, single-payer health care system.

“I expect him to lead on California accomplishing single-payer and being an example for the rest of the country," said Sal Rosselli, president of the National Union of Healthcare Workers, which is urging Newsom to get federal permission to fund such a system.

Another union, the California Nurses Association, is pushing Newsom to back state legislation early next year to do away with private health insurance and create a single-payer system. But “first, everyone needs to get out and vote no on this recall," said Stephanie Roberson, the union's lead lobbyist.

“This is about life or death for us. It's not only about single-payer. It's about infection control. It's about Democratic and working-class values," she said. “We lose if Republicans take over."

Together, the unions have made hundreds of thousands of dollars in political contributions, funded anti-recall ads and phone-banked to defend Newsom. The latest polling indicates Newsom will survive Tuesday's recall election, which has become a battle between Democratic ideals and Republican angst over government coronavirus mandates. The Democratic Party closed ranks around the governor early and kept well-known Democratic contenders off the ballot, leaving liberal voters with little choice other than Newsom.

“This is a crucial moment for Newsom, and for his supporters who are lining up behind him," said Mark Peterson, a professor of public policy, political science and law at UCLA who specializes in the politics of health care. “They're helping him stay in office, but that comes with an expectation for some action."

But it's not clear that Newsom — who will face competing demands to pay back other supporters pushing for stronger action on homelessness, climate change and public safety — could deliver such a massive shift.

Reorganizing the health system under a single-payer financing model would be tremendously expensive — around $400 billion a year — and difficult to achieve politically, largely because it would require tax increases.

The concept already faces fierce opposition from some of Newsom's strongest supporters, including insurer Blue Shield of California and the California Medical Association, which represents doctors.

No state has a single-payer system. Vermont tried to implement one, but its former governor, a Democrat, abandoned his plan in 2014 partly because of opposition to tax increases. California would not only need to raise taxes, but would also likely have to seek voter approval to change the state constitution, and get permission from the federal government to use money allocated for Medicare and Medicaid to help fund the new system.

The last big push for single-payer in California ended in 2017 because it did not adequately address financing and other challenges. Leading up to the 2018 gubernatorial election, Newsom campaigned on single-payer health care, telling supporters “you have my firm and absolute commitment as your next governor that I will lead the effort to get it done," and “single-payer is the way to go."

In office, though, Newsom has distanced himself from that promise as he has expanded the existing health system, which relies on a mix of public and private insurance company payers. For instance, he and Democratic lawmakers imposed a health insurance mandate on Californians and expanded public coverage for low-income people, both of which enrich health insurers.

Newsom has, however, convened a commission to study single-payer and in late May wrote to President Joe Biden, asking him to work with Congress to pass legislation giving states freedom and financing to establish single-payer systems. “California's spirit of innovation is stifled by federal limits," Newsom wrote.

Newsom's recall campaign, asked about his stance on single-payer, referred questions to his administration. The governor's office said in prepared comments that Newsom remains committed to the idea.

“Governor Newsom has consistently said that single-payer health care is where we need to be," spokesperson Alex Stack wrote. “It's just a question of how we get there."

Stack also highlighted a new initiative that will build up the state's public health insurance program, Medi-Cal, saying it “paves a path toward a single-payer principled system."

Activists say Newsom has let them down on single-payer but are standing behind him because he represents their best shot at obtaining it. However, some say they're not willing to wait long. If Newsom doesn't embrace single-payer soon, liberal activists say, they will look for a Democratic alternative when he comes up for reelection next year.

“Newsom is an establishment candidate, and we as Democrats aren't shy about ripping the endorsement out from under someone who doesn't share our values," said Brandon Harami, Bay Area vice chair of the state Democratic Party's Progressive Caucus, who opposes the recall. “Newsom has been completely silent on single-payer. A lot of us are really gunning to see some action on his part."

State Assembly member Ash Kalra (D-San Jose), who also opposes the recall, will reintroduce his single-payer bill, AB 1400, in January after he paused it earlier this year to work on a financing plan. Its chief sponsor is the California Nurses Association.

Using lessons learned from the failed 2017 attempt to pass single-payer legislation, the nurses union is deploying activists to pressure state and local lawmakers into supporting the bill. Resolutions have been approved or are pending in multiple cities.

“This is an opportunity for California to lead the way on health care," Los Angeles City Council member Mike Bonin said before an 11-0 vote backing Kalra's single-payer bill in late August.

Kalra argued that support from Los Angeles shows his bill is gaining momentum. He is also preparing a new strategy to take on doctors, hospitals, health insurers and other health industry players that oppose single-payer: highlighting their profits.

“They are the No. 1 obstacle to this passing," Kalra said. “They're going to do whatever they can to discredit me and this movement, but I'm going to turn the mirror around on them and ask why we should continue to pay for wild profits."

An industry coalition called Californians Against the Costly Disruption of Our Health Care was instrumental in killing the 2017 single-payer bill and is already lobbying against Kalra's measure. The group again argues that single-payer would push people off Medicare and private employer plans and result in less choice in health insurance.

Single-payer would “force these millions of Californians who like their health care into a single new, untested government program with no guarantee they could keep their doctor," coalition spokesperson Ned Wigglesworth said in a statement.

Bob Ross, president and CEO of the California Endowment, a nonprofit that works to expand health care access, is on Newsom's single-payer commission. He said it will work through “tension" in the coming months before issuing a recommendation to the governor on the feasibility of single-payer.

“We have a camp of single-payer zealots who want the bold stroke of getting to single-payer tomorrow, and the other approach that I call bold incrementalism," Ross said. “I'm not ruling out any bold stroke on single-payer; I would just want to know how we get it done."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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COVID-19 data is disappearing from state-run dashboards as delta variant surges

Two state government websites in Georgia recently stopped posting updates on covid-19 cases in prisons and long-term care facilities, just as the dangerous delta variant was taking hold.

Data has been disappearing recently in other states as well.

Florida, for example, now reports covid cases, deaths and hospitalizations once a week, instead of daily, as before.

Both states, along with the rest of the South, are battling high infection rates.

Public health experts are voicing concern about the pullback of covid information. Dr. Georges Benjamin, executive director of the American Public Health Association, called the trend “not good for government and the public" because it gives the appearance of governments “hiding stuff."

A month ago, the Georgia agency that runs state prisons stopped giving public updates on the number of new covid cases among inmates and staff members. The Department of Corrections, in explaining this decision, cited its successful vaccination rates and “a declining number of covid-19 cases among staff and inmates."

Now, a month later, Georgia has among the highest covid infection rates in the U.S. — along with one of the lowest vaccination rates. But the corrections department hasn't resumed posting case data on its website.

When asked by KHN about the covid situation in prisons, department spokesperson Joan Heath said Monday that it currently has 308 active cases among inmates.

“We will make a determination whether to begin reposting the daily covid dashboard over the next few weeks, if the current statewide surge is sustained," Heath said.

Another state website, run by the Department of Public Health, no longer links to a listing of the number of covid cases among residents and staffers of nursing homes and other long-term care residences by facility. The data grid, launched early in the pandemic, gave a running total of long-term care cases and deaths from the virus.

Asked about the lack of online information, public health officials directed a reporter to another agency, the Department of Community Health, which explained that covid information on nursing homes could be found on a federal health website. But locating and navigating that link can be difficult.

“Residents and families cannot easily find this information," said Melanie McNeil, the state's long-term care ombudsman. “It used to be easily accessible."

Georgia gives updates on overall numbers of covid cases, hospitalizations and deaths in the state five days a week but has recently stopped its weekend covid reporting.

Other states also have cut back their public case reporting, despite the nation being engulfed in a fourth, delta-driven covid surge.

Florida had issued daily reports on cases, deaths and hospitalizations until the rate of positive test results dropped in June. Even when caseloads soared in July and August, the state stuck with weekly reporting.

Florida has been accused of being less than transparent with covid health data. Newspapers have sued or threatened to sue the state several times for medical examiner reports, long-term care data, prison data and weekly covid reports the state received from the White House.

Florida Agriculture Commissioner Nikki Fried, a Democrat running for governor in 2022, has repeatedly questioned Republican Gov. Ron DeSantis' decision to delay the release of public data on covid cases and has called for restoring daily reporting of covid data.

Nebraska discontinued its daily covid dashboard June 30, then recently resumed reporting, but only weekly. Iowa also reports weekly; Michigan, three days a week.

Public health experts said full information is vital for a public dealing with an emergency such as the pandemic — similar to the government reports needed during a hurricane.

“All the public health things we do are dependent on trust and transparency," Benjamin said.

A government, when removing public data, should provide a link redirecting people to where they can get that data, he said. And if a state doesn't have enough staff members to provide regular data, he said, that argues for investment in staff and technology.

People in prisons and long-term care facilities, living in close quarters indoors, are especially vulnerable to infectious diseases such as covid.

“They are usually hotbeds of disease," said Amber Schmidtke, a microbiologist who tracks covid in Georgia. Family members “want to know what's going on in there."

Prison data has been removed or reduced in several states, according to the UCLA School of Law's COVID Behind Bars Data Project, which tracks the spread of covid in prisons, jails and detention facilities.

The group said Alaska provides only monthly updates on covid cases in such facilities, while Florida stopped reporting new data in June.

When Georgia stopped reporting on covid in prisons, the project found, only 24% of employees reported being vaccinated. Prison workers can spread the virus inside the facilities and then in their homes and the community.

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The group reports that at least 93 incarcerated people and four staffers have died of covid in Georgia and that the state has the second-highest case fatality rate, or percentage of those with reported infections who die, among all state and federal prison systems.

“Right now, if there was a massive outbreak in prisons, there would be no way to know it," said Hope Johnson of the COVID Behind Bars Data Project.

Recent Facebook posts point to cases at Smith State Prison in southeastern Georgia.

Heath, when asked about cases there, said Tuesday that the prison has 19 active covid cases and its transitional center has one.

Mayor Bernie Weaver of Glennville, the Tattnall County town where the prison is located, said he hasn't been told about recent covid cases at the prison. But he noted that Tattnall itself has had a spike in cases. The county has a 26% vaccination rate, among the lowest in the state.


By Andy Miller

KHN senior correspondent Phil Galewitz contributed to this report.

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Pandemic unveils growing suicide crisis for communities of color

This story is a collaboration between KHN and “Science Friday.” Listen to the conversation between KHN national correspondent Aneri Pattani and John Dankosky, Science Friday’s director of news and radio projects. Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she’d viewed suicide as a problem most prevalent among middle-aged white men. Until May 27, 2020. That day, Maxie’s 19-year-old son, Jamal Clay — who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for ...

'Tainted blood': Covid skeptics are refusing transfusions from vaccinated donors

The nation's roiling tensions over vaccination against covid-19 have spilled into an unexpected arena: lifesaving blood transfusions.


With nearly 60% of the eligible U.S. population fully vaccinated, most of the nation's blood supply is now coming from donors who have been inoculated, experts said. That's led some patients who are skeptical of the shots to demand transfusions only from the unvaccinated, an option blood centers insist is neither medically sound nor operationally feasible.

“We are definitely aware of patients who have refused blood products from vaccinated donors," said Dr. Julie Katz Karp, who directs the blood bank and transfusion medicine program at Thomas Jefferson University Hospitals in Philadelphia.

Emily Osment, an American Red Cross spokesperson, said her organization has fielded questions from clients worried that vaccinated blood would be “tainted," capable of transmitting components from the covid vaccines. Red Cross officials said they've had to reassure clients that a covid vaccine, which is injected into muscle or the layer of skin below, doesn't circulate in the blood.

“While the antibodies that are produced by the stimulated immune system in response to vaccination are found throughout the bloodstream, the actual vaccine components are not," Jessa Merrill, the Red Cross director of biomedical communications, said in an email.

So far, such demands have been rare, industry officials said. Dr. Louis Katz, chief medical officer for ImpactLife, an Iowa-based blood center, said he's heard from “a small handful" of patients asking for blood from unvaccinated donors. And the resounding answer from centers and hospitals, he added, has been “no."

“I know of no one who has acceded to such a request, which would be an operational can of worms for a medically unjustifiable request," Katz wrote in an email.

In practical terms, blood centers have only limited access to donated blood that has not in some way been affected by covid. Based on samples, Katz estimated that as much as 60% to 70% of the blood currently being donated is coming from vaccinated donors. Overall, more than 90% of current donors have either been infected with covid or vaccinated against it, said Dr. Michael Busch, director of the Vitalant Research Institute, who is monitoring antibody levels in samples from the U.S. blood supply.

“Less than 10% of the blood we collect does not have antibodies," Busch noted.

In addition, outside of research studies, blood centers in the U.S. don't retain data noting whether donors have been infected with or vaccinated against covid, and there's no federal requirement that collected blood products be identified in that manner.

“The Food and Drug Administration has determined there's no safety risk, so there's no reason to label the units," said Dr. Claudia Cohn, chief medical officer for AABB, a nonprofit focused on transfusion medicine and cellular therapies.

Indeed, the FDA does not recommend routine screening of blood donors for covid. Respiratory viruses, in general, aren't known to spread by blood transfusion and, worldwide, there have been no reported cases of SARS-CoV-2, the virus that causes the disease, being transmitted via blood. One study identified the risk as “negligible."

All donors are supposed to be healthy when they give blood and answer basic questions about potential risks. Collected units of blood are tested for transmissible infectious diseases before they're distributed to hospitals.

But that hasn't quelled concerns for some people skeptical of covid vaccines.

In Bedford, Texas, the father of a boy scheduled for surgery recently asked that his son get blood exclusively from unvaccinated donors, said Dr. Geeta Paranjape, medical director at Carter BloodCare. Separately, a young mother fretted about transfusions from vaccinated donors to her newborn.

Many patients expressing concerns have been influenced by rampant misinformation about vaccines and the blood supply, said Paranjape. “A lot of people think there's some kind of microchip or they're going to be cloned," she said.

Other patients have balked at getting blood from people previously infected with covid, even though federal guidance greenlights donations two weeks after a positive test or the last symptom fades.

Last month, a woman facing a cesarean section for a high-risk pregnancy said she didn't want blood from a donor who had had covid, recalled Cohn with AABB. “I said, 'Listen, the alternative is you don't get the blood and that's what will affect you,'" Cohn said.

Some industry experts were hesitant to discuss the vaccine-free blood requests, for fear it would fuel more such demands. But Cohn and others said correcting widely spread misinformation outweighed the risk.

Patients are free to refuse transfusions for any reason, industry officials said. But in dire situations — trauma, emergency surgery — saving lives often requires using the available blood. For patients with chronic conditions requiring transfusion, alternative treatments such as medication or certain equipment may not be as efficient or effective.

People who require transfusions also may donate their own blood in advance or request donations from designated friends and family members. But there's no evidence that the blood is safer when patients select donors than that provided by the volunteer blood system, according to the Red Cross.

Earlier in the pandemic, many blood donations were tested to see whether they contained antibodies to the covid virus. The hope was that blood from previously infected people who had recovered from covid could be used to treat those who were very sick with the disease. Tens of thousands of patients were treated with so-called convalescent plasma under a Mayo Clinic-led program and through authorization from the FDA.

But the much-hyped use of convalescent plasma largely fell flat after studies showed no clear-cut benefits for the broad swath of covid patients. (Research continues into the potential benefits of treating narrowly targeted patient groups with high-potency plasma.) Most hospitals stopped testing blood and labeling units with high levels of antibodies this spring, said Busch. “It's really no longer a germane issue because we're not testing anymore," he said. “There's no way we can inform recipients."

Busch stressed that the studies also have shown no harm associated with infusing antibody-containing blood plasma into covid patients.

Past health crises have raised similar concerns about sources of donor blood. In the mid-1980s, recipients scared by the AIDS epidemic didn't want blood donated from cities such as San Francisco with large gay populations, Busch recalled. Even now, some recipients demand not to receive blood from people of certain races or ethnicities.

Such requests, like those for vaccine-free blood, have no medical or scientific basis and are soundly refused, blood center officials said.

The most pressing issue for blood centers remains the ongoing shortage of willing donors. As of the second week of August, the national blood supply was down to two days' worth or less at a third of sites affiliated with America's Blood Centers. That can limit the blood available for trauma victims, surgery patients and others who rely on transfusions to survive.

“If for some reason we didn't want vaccinated people to donate blood, we'd be in a real problem, wouldn't we?" Karp said. “Please believe us when we tell you it's fine."

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Poop: The newest disease detection tool for Covid and beyond

Since reopening campus at the University of California-San Diego last summer, university officials have relied on the tried-and-true public health strategies of testing and contact tracing. But they have also added a new tool to their arsenal: excrement.

That tool alerted researchers to about 85% of cases in dorms before they were diagnosed, according to a soon-to-be published study, said Rob Knight, a professor of pediatrics and computer science and engineering who helped create the campus's wastewater testing program.

When covid is detected in sewage, students, staffers and faculty members are tested, which has allowed the school to identify and isolate infected individuals who aren't yet showing symptoms — potentially stopping outbreaks in their tracks.

UC-San Diego's testing program is among hundreds of efforts around California and the nation to turn waste into valuable health data. From Fresno, California, to Portland, Maine, universities, communities and businesses are monitoring human excrement for signs of covid.

Researchers have high hopes for this sludgy new data stream, which they say can alert public health officials to trends in infections and doesn't depend on individuals getting tested. And because people excrete virus in feces before they show symptoms, it can serve as an early warning system for outbreaks.

The Centers for Disease Control and Prevention finds the practice so promising that it has created a federal database of wastewater samples, transforming raw data into valuable information for local health departments. The program is essentially creating a public health tool in real time, experts say, one that could have a range of uses beyond the current global pandemic, including tracking other infectious diseases and germs' resistance to antibiotics.

“We think this can really provide valuable data, not just for covid, but for a lot of diseases," said Amy Kirby, a microbiologist leading the CDC effort.

The virus that causes covid infects many types of cells in the body, including those in the respiratory tract and gut. The virus's genetic signature, viral RNA, makes its way into feces, and typically shows up in poop days before symptoms start.

At UC-San Diego and other campuses, researchers take samples flowing from individual buildings, capturing such granular data that they can often deduce the number of infected people living or working there. But in most other settings, because of privacy concerns and resource constraints, testing is done on a much larger scale, with the goal of tracking trends over time.

Samples are drawn from wastewater, which is what comes out of our sewer pipes, or sludge, the solids that have settled out of the wastewater. They are typically extracted mechanically or by a human with a dipper on the end of a rod.

When researchers in Davis, California, saw the viral load rise in several neighborhood sewage streams in July, they sent out text message alerts and hung signs on the doors of 3,000 homes recommending that people get tested.

Before the pandemic, testing sewage to identify and ward off illness in the U.S. was largely limited to academic use. Israel used it to stave off a polio outbreak in 2013, and some communities in the U.S. were sampling sewage before the pandemic to figure out what kinds of opioids people in their communities were using, a service offered by the company Biobot.

But when covid hit the U.S. amid political chaos and a shortage of tests, local governments scrambled for any information they could get on the virus.

In rural Lake County, California, health officials had identified a handful of cases by sending nurses out to look for infected people. They were sure there were more but couldn't get their hands on tests to prove it, so in spring 2020 they signed up for a free sewage testing program run by Biobot, which pivoted to covid testing as the pandemic took off and now is charging to test in K-12 schools, office buildings and nursing homes, in addition to local governments and universities, said Mariana Matus, CEO and co-founder of the company.

The covid virus turned up in samples at four wastewater treatment facilities in Lake County.

“It is a way to just get more information because we can't do testing," Gary Pace, then the county's health officer, told KHN at the time.

As sewage sampling took off around the world, the U.S. Department of Health and Human Services began awarding grants in fall 2020 to wastewater treatment plants. Biobot won a bid to run a second round of that program, currently underway through late August, testing the sewage of up to 30% of the U.S. population.

At least 25 California wastewater treatment plants are participating in the program, and numerous others are getting money from the CDC, working with local universities or paying for their own testing. While such states as Ohio and Missouri have created public dashboards to show their data, California's efforts remain scattershot.

The test data alone doesn't provide much value to health officials — it needs to be translated to be useful. Scientists are still learning how to read the data, a complicated process that involves understanding the relationships between how much virus people excrete, how many people are using a wastewater system and how much rainwater is running into the system, potentially diluting the sewage, among many other factors. Since using wastewater to track diseases was not widespread before the pandemic, there's been a steep and ongoing learning curve.

Beleaguered public health officials have struggled to incorporate the new data into their already overwhelming workloads, but the CDC hopes it can address those issues with its new national system that tracks and translates wastewater data for local governments.

Throughout 2020, Kirby, the CDC microbiologist, and engineer Mia Mattioli were a two-person wastewater team inside the agency's larger 7,000-person covid response. During that time, academic colleagues generously shared what they knew about wastewater epidemiology, Kirby said. By September 2020, the pair had launched the National Wastewater Surveillance System, which interprets sampling data for state and local governments. Today, they lead a team of six and have a permanent place in one of the CDC's departments.

“Every piece of this system had to be built largely from scratch," Kirby said. “When I look at that, it really amazes me where we are now."

In the months since the system debuted, it has been able to detect an uptick in cases anywhere from four to six days before diagnostic testing shows an increase, Kirby said.

She hopes that by the end of next year the federal monitoring program will be used to check for a range of diseases, including E. coli, salmonella, norovirus and a deadly drug-resistant fungus called Candida auris, which has become a global threat and wreaked havoc in hospitals and nursing homes.

The longer these programs are up and running, the more useful they become, said Colleen Naughton, a professor and civil engineer at the University of California-Merced who leads COVIDPoops19, which tracks wastewater monitoring efforts globally. Naughton is working with colleagues at the University of California-Davis to launch monitoring programs near where she works in the Central Valley but is finding that some smaller communities don't have the resources to conduct testing or sufficient health personnel to analyze or use the data.

It's in these smaller communities with limited access to testing and doctors where the practice may hold the most promise, Naughton said. Covid laid bare long-standing inequities among communities that she fears will be perpetuated by the use of this new public health tool.

Privacy concerns also need to be addressed, experts said. Wastewater data hasn't traditionally been considered protected personal health information the way diagnostic tests are. Health officials have managed earlier concerns about wastewater tracking of illicit drug use by sampling from large enough sewage streams to offer anonymity. But testing for certain health problems requires looking at DNA. “I think that's going to be a challenge for public communication," Knight said, “to make sure that's not perceived as essentially spying on every individual's genetic secrets."

Public health and wastewater officials said they are thrilled by the potential of this new tool and are working on ways to address privacy concerns while taking advantage of it. Greg Kester, director of renewable resource programs at the California Association of Sanitation Agencies, wrote to CDC officials in June 2020 asking for a federal surveillance network. He can hardly believe how quickly that call became a reality. And he hopes it is here to stay, both for the ongoing pandemic and for the inevitable next outbreak.

“As vaccination rates increase and we get the variants, it's still going to be important because clinical testing is decreasing," Kester said. “We really want to make this part of the infrastructure."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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A California bill would limit protests at vaccination sites. Does it violate the First Amendment?

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