Necessary or not, Covid booster shots are probably on the horizon

The drugmaker Pfizer recently announced that vaccinated people are likely to need a booster shot to be effectively protected against new variants of covid-19 and that the company would apply for Food and Drug Administration emergency use authorization for the shot. Top government health officials immediately and emphatically announced that the booster isn’t needed right now — and held firm to that position even after Pfizer’s top scientist made his case and shared preliminary data with them last week. This has led to confusion. Should the nearly 60% of adult Americans who have been fully vacci...

The Delta Variant thrives in a state of political and public health discord

ST. LOUIS — The day after Missouri Gov. Mike Parson finished his bicentennial bus tour to drum up tourism to the state in mid-July, Chicago issued a travel advisory warning about visiting Missouri. Earlier this summer, as covid-19 case counts began to tick up when the highly transmissible delta variant took hold in the state, the Republican-majority legislature successfully enacted laws limiting public health powers and absolving businesses from covid legal exposure. The state health officer post has sat vacant since Dr. Randall Williams resigned suddenly in late April — leaving Missouri witho...

Why we may never know whether the $56,000-a-year Alzheimer’s drug actually works

The Food and Drug Administration’s approval in June of a drug purporting to slow the progression of Alzheimer’s disease was widely celebrated, but it also touched off alarms. There were worries in the scientific community about the drug’s mixed results in studies — the FDA’s own expert advisory panel was nearly unanimous in opposing its approval. And the annual $56,000 price tag of the infusion drug, Aduhelm, was decried for potentially adding costs in the tens of billions of dollars to Medicare and Medicaid. But lost in this discussion is the underlying problem with using the FDA’s “accelerat...

Trump country sees rising share of California's new Covid infections

Most of us are familiar with the good news: In recent weeks, rates of covid-19 infection and death have plummeted in California, falling to levels not seen since the early days of the pandemic. The average number of new covid infections reported each day dropped by an astounding 98% from December to June, according to figures from the California Department of Public Health.

And bolstering that trend, nearly 70% of Californians 12 and older are partially or fully vaccinated.

But state health officials are still reporting nearly 1,000 new covid cases and more than two dozen covid-related deaths per day. So, where does covid continue to simmer in California? And why?

An analysis of state data shows some clear patterns at this stage of the pandemic: As vaccination rates rose across the state, the overall numbers of cases and deaths plunged. But within that broader trend are pronounced regional discrepancies. Counties with relatively low rates of vaccination reported much higher rates of covid infections and deaths in May and June than counties with high vaccination rates.

There were about 182 new covid infections per 100,000 residents from May 1 to June 18 in California counties where fewer than half of residents age 12 and older had received at least one vaccine dose, CDPH data shows. By comparison, there were about 102 covid infections per 100,000 residents in counties where more than two-thirds of residents 12 and up had gotten at least one dose.

“If you live in an area that has low vaccination rates and you have a few people who start to develop a disease, it's going to spread quickly among those who aren't vaccinated," said Rita Burke, assistant professor of clinical preventive medicine at the University of Southern California's Keck School of Medicine. Burke noted that the highly contagious delta variant of the coronavirus now circulating in California amplifies the threat of serious outbreaks in areas with low vaccination rates.

The regional discrepancies in covid-related deaths are also striking. There were about 3.2 covid-related deaths per 100,000 residents from May 1 to June 18 in counties where first-dose vaccination rates were below 50%. That is almost twice as high as the death rate in counties where more than two-thirds of residents had at least one dose.

While the pattern is clear, there are exceptions. A couple of sparsely populated mountain counties with low vaccination rates — Trinity and Mariposa — also had relatively low rates of new infections in May and June. Likewise, a few suburban counties with high vaccination rates — among them Sonoma and Contra Costa — had relatively high rates of new infections.

“There are three things that are going on," said Dr. George Rutherford, a professor of epidemiology and biostatistics at the University of California-San Francisco. “One is the vaccine — very important, but not the whole story. One is naturally acquired immunity, which is huge in some places." A third, he said, is people still managing to evade infection, whether by taking precautions or simply by living in areas with few infections.

As of June 18, about 67% of Californians age 12 and older had received at least one dose of covid vaccine, according to the state health department. But that masks a wide variance among the state's 58 counties. In 14 counties, for example, fewer than half of residents 12 and older had received a shot. In 19 counties, more than two-thirds had.

The counties with low vaccination rates are largely rugged and rural. Nearly all are politically conservative. In January, about 6% of the state's covid infections were in the 23 counties where a majority of voters cast ballots for President Donald Trump in November. By May and June, that figure had risen to 11%.

While surveys indicate politics plays a role in vaccine hesitancy in many communities, access also remains an issue in many of California's rural outposts. It can be hard, or at least inconvenient, for people who live far from the nearest medical facility to get two shots a month apart.

“If you have to drive 30 minutes out to the nearest vaccination site, you may not be as inclined to do that versus if it's five minutes from your house," Burke said. “And so we, the public health community, recognize that and have really made a concerted effort in order to eliminate or alleviate that access issue."

Many of the counties with low vaccination rates had relatively low infection rates in the early months of the pandemic, largely thanks to their remoteness. But, as covid reaches those communities, that lack of prior exposure and acquired immunity magnifies their vulnerability, Rutherford said. “We're going to see cases where people are unvaccinated or where there's not been a big background level of immunity already," Rutherford said.

As it becomes clearer that new infections will be disproportionately concentrated in areas with low vaccination rates, state officials are working to persuade hesitant Californians to get a vaccine, even introducing a vaccine lottery.

But most persuasive are friends and family members who can help counter the disinformation rampant in some communities, said Lorena Garcia, an associate professor of epidemiology at the University of California-Davis. Belittling people for their hesitancy or getting into a political argument likely won't work.

When talking to her own skeptical relatives, Garcia avoided politics: “I just explained any questions that they had."

“Vaccines are a good part of our life," she said. “It's something that we've done since we were babies. So, it's just something we're going to do again."

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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.

USE OUR CONTENT

This story can be republished for free (details).

Subscribe to KHN's free Morning Briefing.

Most inmates have had their Covid shots — but their guards likely haven't

When the number of covid-19 cases among inmates in Pennsylvania state prisons last fall topped 1,000 and staff cases hovered in the hundreds, the union representing 11,000 corrections officers began lobbying to get prison staffers to the front of the line for vaccinations.

John Eckenrode, president of the Pennsylvania State Corrections Officers Association, pressed state officials for months to give prison workers the same status as hospital staff members, first responders and teachers.

“This is a health and public safety crisis," Eckenrode said in a January statement. “It's time to prioritize vaccinating staff, so they can do their jobs and also not worry about bringing the virus home to their loved ones."

Yet, after the lifesaving shots became widely available, Pennsylvania prison guards have not rushed out to get them — even though the corrections department has had more than 4,700 staff members test positive over the course of the pandemic and eight die.

By mid-June, 22% of Department of Corrections employees were inoculated, according to voluntary reports collected by the department. At one prison, just 7% of staffers had received shots.

Meanwhile, more than 75% of the 39,000 men and women incarcerated in Pennsylvania's 24 state prisons have had the shots, according to the department.

That disparity is evident across the country. While a majority of inmates in most states are fully vaccinated, prison staffers are not, according to data on 36 states and the federal Bureau of Prisons compiled by the Prison Policy Initiative using information from several prison advocacy and journalism groups.

That report — released in April, when the vaccine was becoming more easily accessible — found 48% of prison staff members nationwide had received at least one dose, although in some states rates were in the teens or lower.

Eckenrode declined to comment to KHN. But he recently told WHYY, the NPR member station in Philadelphia, that he believes many more officers are vaccinated and not reporting their status to prison officials.

He acknowledged reluctance among his members. “I think that no matter what kind of demographic you look at, there's vaccine hesitancy," he said. The vaccines were “approved under experimental conditions, and I believe that it should be an individual choice."

One officer with the New York Department of Corrections and Community Supervision, which reported last month that it had vaccinated 43% of inmates, compared with 30% of staffers, said he waited until late June because he and his wife had survived a bout of covid and felt they had natural protection from the virus.

Some colleagues have been spooked by internet videos from anti-vaccination groups showing doctors talking about vaccine-related deaths or stoking concerns that the Food and Drug Administration's emergency use authorization for the vaccines — rather than formal approval — means they are less dependable, said the officer, who asked to remain anonymous because corrections staffers are not authorized to speak to reporters. He added that a sense of “I don't want people to think I'm weak" machismo and right-wing politics play into the decision-making.

“There are a lot of conspiracy theorists," the New York guard said.

Covid has taken a high toll inside prisons. Two news organizations, the Marshall Project and The Associated Press, have found nearly 400,000 covid cases in U.S. prisons and more than 2,700 inmate deaths. Among staff members, more than 114,000 cases and more than 200 deaths have been reported nationwide.

Staff vaccination statistics often do not give the full picture, since states generally don't require corrections staffers to report their status.

In California, which has the nation's second-largest prison system, a reform group is suing over low staff vaccination rates, arguing that unprotected prison workers put vulnerable inmates at risk.

State tallies show that in late June 52% of prison staffers had been fully vaccinated versus 71% of inmates. In its court filing, the Prison Law Office said that, despite efforts by California officials encouraging vaccinations, “infected and unvaccinated staff members continue to pose a significant threat to incarcerated communities."

Health experts say prison staff members also endanger surrounding communities.

Unvaccinated officers are a common cause of infection, because they go back and forth between the prison and the community, said Dr. Anne Spaulding, an associate professor in epidemiology at Emory University and former medical director at the Rhode Island Department of Corrections.

Spaulding also pointed to the “downstream effects" of unvaccinated staffers — especially corrections officers (known as COs), who are in daily close contact with inmates — on the inmates' mental health.

“If it passes from CO to CO, what does that mean with staff shortages? More lockdowns, less programming," she said. “It's going to affect the mental health of those incarcerated, who already have restricted lives."

Kirstin Cornnell, social services director with the Pennsylvania Prison Society, which advocates for reforms, said lockdowns resulting from sick staff members could lead to suspension of family visitation, disrupting connections critical to inmates' mental health.

“We have really serious concerns about how low the rate of staff vaccination is," said Cornnell. “This increases tension in an already stressful situation."

Pennsylvania Corrections Secretary John Wetzel and officials in other states say that, while they are not considering making the shots mandatory, they are pressing employees to get vaccinated.

“We continue to educate our staff and encourage them to get vaccinated for their own protection, but also for those around them," said Wetzel. “Everyone knows that prisons are breeding grounds for infectious diseases like covid-19, largely because inmates live so close together."

While union officials in several states did not respond to queries, prison officials said their employees have the same concerns as the general public: religious or other objections, false conspiracy theories about the vaccines, worries about a new shot that was developed quickly.

“They want to see how it plays out with others who are vaccinated," said John Bull, a spokesperson for the Department of Public Safety in North Carolina — where 6,607 department employees, or roughly half the staff at 55 facilities, have been vaccinated through prison clinics. “They didn't want to be guinea pigs."

Incentives, such as gift cards, cash lotteries and paid time off, have boosted staff rates in some states, officials said. But Chris Gautz, a spokesperson for the Michigan corrections department, said his state will not provide incentives, despite having only about 15% of staffers vaccinated. He said his agency decided disease prevention was a better motivator.

“The benefit of not dying is not dying," he said. “A $5 gift card to Frosty Boy is not going to put someone over the edge."

The Prison Law Office and other groups are advocating for mandatory prison staff vaccinations, but the potential face-off with powerful prison worker unions has thwarted that idea in some states.

California Gov. Gavin Newsom said at a May news conference that he had no plans to make vaccinations mandatory and would instead urge the corrections officers union to persuade its members to get the shots.

Health experts point to other public institutions, such as schools and colleges, that require vaccination.

“States have the ability to mandate vaccination when it puts someone at risk," said Joseph Amon, an epidemiologist and director of the Office of Global Health at Drexel University in Philadelphia. “This is a case that makes sense. There could be limited exemption, but there should be an expectation that all staff be vaccinated."

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.

USE OUR CONTENT

This story can be republished for free (details).

Subscribe to KHN's free Morning Briefing.

Delta variant surges in Colorado as the bands play on

GRAND JUNCTION, Colo. — Dr. Rachel LaCount grasped a metal hoop at a playground and spun in circles with her 7-year-old son, turning the distant mesas of the Colorado National Monument into a red-tinged blur.

LaCount has lived in this western Colorado city of 64,000 nearly her whole life. As a hospital pathologist, she knows better than most that her hometown has become one of the nation's top breeding grounds for the delta variant of covid-19.

“The delta variant's super scary," LaCount said.

That highly transmissible variant, first detected in India, is now the dominant covid strain in the United States. Colorado is among the states with the highest proportion of the delta variant, according to the Centers for Disease Control and Prevention.

Mesa County has the most delta variant cases of any county in Colorado, state health officials report, making the area a hot spot within a hot spot. A CDC team and the state's epidemiologist traveled to Grand Junction to investigate how and why cases of the variant were moving so quickly in Mesa County.

At her hospital, LaCount has put in orders for more rapid covid tests as the caseload has grown. She's seen the intensive care unit start filling up with covid patients, so that hospital officials are placing two in a room against normal practices.

Despite these alarming signs, many in Mesa County have let down their guard. The rate of eligible residents fully vaccinated has stalled at about 42%. LaCount has noticed that few people wear masks anymore at the grocery store. Thousands of people recently flocked to Mack, 20 miles from Grand Junction, to attend the Country Jam music festival, which could accelerate the variant's spread to the concertgoers' hometowns.

“We're making national news for our covid variant and the CDC is here investigating, but we have a huge festival where people aren't masking," said LaCount. “Are we going to get herd immunity over here just because everyone's going to get it? I mean, that's probably going to happen at some point, but at what cost?"

LaCount's worries aren't necessarily for herself or her spouse — they are both vaccinated — but for their son, who can't be vaccinated because he is under 12. She is uneasy about sending him to school in the fall for fear of exposure to the variant. She is reluctant to take him to birthday parties this summer knowing there's a good likelihood he'll be teased for wearing a mask.

A few yards away from LaCount and her son on the playground, a man fished in a still pond with his 10-month-old daughter in a backpack. Garrett Whiting, who works in construction, said he believes covid is still being “blown out of proportion," especially by the news media.

“They got everybody scared really, really fast," said Whiting, slowly reeling in a sparkly blue lure from the water. “There's no reason to stop living your life just because you're scared of something."

Whiting tested positive for covid about three months earlier. He said he doesn't plan to get vaccinated, nor does his wife. As for the baby on his back, he said he's not sure whether they'll have her vaccinated when regulators approve the shot for young children.

The delta variant is one of six “variants of concern" circulating in the U.S., according to the CDC, because the delta strain spreads more easily, might be more resistant to treatment and might be better at infecting vaccinated people than other variants.

The delta variant has raised alarms around the world. Parts of Australia have locked down again after the variant leapfrogged its way from an American aircrew to a birthday party where it infected all unvaccinated guests, health officials said, and after it also jumped between shoppers in a “scarily fleeting" moment in which two people walked past each other in a mall. Israel reissued an indoor mask requirement after a spate of new cases linked to schoolchildren. A leading health official there said about a third of the 125 people who were infected were vaccinated, and most of the new infections were delta variant.

A rise in delta variant cases delayed the United Kingdom's planned reopening in June. But public health officials have concluded after studying about 14,000 cases of the delta variant in that country that full vaccination with the Pfizer-BioNTech vaccine is 96% effective against hospitalization. Studies around the world have made similar findings. There is also evidence the Moderna and Johnson & Johnson vaccines are effective against the variant.

Los Angeles County recently recommended that residents resume wearing masks indoors regardless of vaccination status, over concern about the delta variant. The World Health Organization is also urging vaccinated people to wear masks, though the CDC hasn't changed its guidelines allowing vaccinated people to gather indoors without masks.

The variant arrived in Mesa County this spring, when it accounted for just 1% of all cases nationwide, said Jeff Kuhr, executive director of Mesa County Public Health.

“We were winding down just like everyone else. We were down to less than five cases a day. I think we had about two people hospitalized at one point," Kuhr said. “We felt as if we were out of the woods."

He even signed off on Country Jam, which bills itself as the state's “biggest country music party."

But in early May, the delta variant appeared in a burst, with five cases among adults working for the school district.

“It started to hit the children, those that were not of the age to be vaccinated," Kuhr said. “That was telling me that, you know, wearing masks in school was not providing the protection with this new variant that it had previously."

The county then started to see breakthrough cases in fully vaccinated elderly residents in long-term care facilities. The hospitals began to fill once more. Nine vaccinated people died, seven of them since the delta variant's arrival, though it's still unclear whether the variant is to blame. All were at least 75 years old, and seven lived in long-term care facilities. Now, Kuhr estimates, “above 90%" of cases in the county are delta variant.

The county is seeing the same trend as the state: The vast majority of people testing positive for covid, and people being hospitalized with it, are unvaccinated. “It's a superspreader strain if there ever was one," Eric Topol with the Scripps Research Institution told Scientific American. But he said people fully vaccinated with Pfizer or Moderna shots “should not worry at all." There is less information about the protection offered by Johnson & Johnson's vaccine.

Mesa County health officials considered canceling the music festival, but “it was really too late," Kuhr said. After the announcement that the festival was on, about 23,000 people bought tickets.

Officials weighed banning alcohol or trying to get attendees a Johnson & Johnson single-dose vaccine in the weeks leading up to the festival. In the end, they settled on messaging: signs warning people online and at the venue that the area was a covid hot spot.

According to CDC guidance, outdoor events were low risk. A sporting event at the end of May in Grand Junction that filled a baseball stadium had resulted in only one known case, which made Kuhr optimistic.

“We put messaging on Country Jam's website, and then in their social media pages, saying, you know, 'Mesa County's a hot spot. Be prepared,'" Kuhr said.

A stormy Friday dampened concert attendance at Country Jam. But on the last day of the festival, the sun was out and throngs of cowboy boot-clad concertgoers stepped around prairie dog burrows and kicked up gray-yellow dust on the path to the venue entrance.

Many reveled in being able to attend a summertime event like an outdoor festival, taking it as another sign that the pandemic was waning.

“Covid is over in Colorado," said Ryan Barkley, a college student from Durango who was playing beer pong in an inflatable pool at his campsite outside the gates.

That day, 39 people in the county were hospitalized with covid, and a CDC investigative team had arrived just four days earlier.

Inside the gates, an open field was filled with stages, concession stands, and vendors selling cowboy hats, coffee mugs and hunting clothes — and crowds of people. Chelsea Sondgeroth and her 5-year-old daughter took in the scene.

“It's just nice to see people's faces again," said Sondgeroth, who lives in Grand Junction and previously had covid. She described it as one of the mildest illnesses she's ever had, though her senses of taste and smell have not returned to normal. Watermelon tastes rotten to her, beer tasted like Windex for a while, and her daughter said Sondgeroth can't smell certain flowers anymore.

Sondgeroth said she's holding off on getting vaccinated until more research comes out.

Waiting in line at the daiquiri stand, Alicia Nix was one of the few people in sight wearing a mask. “I've gotten people that say, you know, 'That stuff is over. Get over yourself and take that off,'" said Nix, who is vaccinated. “It isn't over."

Amid the music, beer and dancing, a bus turned into a mobile vaccine clinic was empty. A nurse on duty played Jenga with an Army National Guard soldier. Just six people of the thousands attending were vaccinated on the bus.

“You can lead a horse to water, but you can't make them drink," Nix said from behind her blue surgical mask.

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.

USE OUR CONTENT

This story can be republished for free (details).

Subscribe to KHN's free Morning Briefing.

Is Rand Paul mixing up the vaccine message for Covid survivors?

Last week, Sen. Rand Paul (R-Ky.) posted a Twitter thread asserting that people who have survived a covid-19 infection were unlikely to be reinfected and have better immunity against variants than those who have been vaccinated against — but not infected by — SARS-CoV-2, the virus that causes covid.

The social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination.

While the science on the subject is still evolving, a look at the evidence behind Paul's series of tweets seemed in order. After all, though almost 65% of Americans have received at least one dose of a covid vaccine, some people who have recovered from covid may not feel a need to get shot. Paul, who was the first senator to be diagnosed with the virus, is among them. Here's a deeper look at what Paul said on Twitter, the studies he cited and how researchers characterized his comments.

Breaking Down the Twitter Thread

In his first tweet, Paul referenced a recent Cleveland Clinic study finding that among subjects who were unvaccinated but had already had covid-19, there were no re-infections in a five-month observation period: “Great news! Cleveland clinic study of 52,238 employees shows unvaccinated people who have had COVID 19 have no difference in re-infection rate than people who had COVID 19 and who took the vaccine."

In subsequent tweets, the senator said: “The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only." All three vaccines authorized for emergency use in the U.S. (Pfizer-BioNTech, Moderna and Johnson & Johnson) contain genetic instructions that tell our cells how to make a spike protein associated with the coronavirus. The presence of that spike protein then causes our bodies to make antibodies to protect against covid.

At the end of his final tweet, Rand then linked to a second study led by scientists at the Fred Hutchinson Cancer Research Center in Seattle to support his assertions.

Digesting the Scientific Papers

Paul referenced two scientific papers in his tweet thread — both of which are preprints, meaning they have not yet been published in scientific journals or been peer-reviewed.

One was a study from the Cleveland Clinic following four categories of health care workers: unvaccinated but previously infected; unvaccinated but not previously infected; vaccinated and previously infected; and vaccinated but not previously infected. The workers were followed for five months.

The researchers found that no one who was unvaccinated but had previously been infected with covid became infected again during the five-month study period. Infections were almost zero among those who were vaccinated, while there was a steady increase in infections among those who were unvaccinated and previously uninfected.

When asked whether he believed Paul's tweet had interpreted his study results correctly, the study's lead author, Dr. Nabin Shrestha, an infectious diseases specialist at Cleveland Clinic, said “it was an accurate interpretation of the study's findings."

However, Dr. George Rutherford, an epidemiologist at the University of California-San Francisco, wrote in an email that he would add one caveat to the wording of Paul's tweet: “Note that in his tweet Senator Paul seems to suggest that the denominator of previously infected health care workers at the Cleveland Clinic was 52,238 — that was the total number in the whole study. There were 1,359 that were previously infected and never vaccinated, and there were no reinfections noted over a median follow up of 143 days. So, the tweet itself is accurate if read literally but the denominator is really 1,359."

As for the other study Paul mentioned, researchers analyzed covid-19 immunity in those who had been infected with the covid virus and those who hadn't and found that infection activated a range of immune cells and immunity lasted at least eight months.

In his last two tweets in the thread, Paul quotes directly from the study's “discussion" section: “The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only."

The lead study author, Kristen Cohen, a senior staff scientist in the Vaccine and Infectious Disease Division at the Fred Hutchinson Cancer Research Center in Seattle, acknowledged that Paul's tweet was a direct quote from the study. Still, she said, in her view, the quote was taken out of context and presented to suit Paul's objective — but does not accurately reflect the overall take-home message from the study's findings.

That's because, she said, Paul was quoting from the discussion section of the paper. The discussion is the final section of a scientific paper, and Cohen said its purpose here was to project what the study's findings could imply for a broader scientific significance.

“We wrote that recovering covid patients are “likely" to better defend against variants than those who have just been immunized, but it's not saying they do," said Cohen. “It's not saying they have been known to. It's making a hypothesis or basically saying this could be the case."

In fact, Cohen's study did not include any subjects who had been vaccinated. The researchers were merely reasoning in the sentence Paul quoted that, based on the data showing the immune system's broad natural response, those who recover from covid-19 and then receive a vaccine may be better protected against covid variants than those who had only vaccine-induced immunity.

“We did not intend to argue that infected people do not need to get vaccinated or that their immune responses are superior," Cohen wrote in an email.

However, Cohen recognized the sentence was confusing when taken out of context and said she will eliminate it from the paper when it gets submitted for publication.

Cohen pointed us to another Fred Hutchinson-led study with which she was involved. It did show that people who previously had covid-19 benefited from also getting vaccinated, because there was a significant boost in immune response, especially against variants.

The Conventional Wisdom on Natural Immunity

So, what's known from these two studies is that surviving a covid infection confers a significant amount of immunity against the virus. Other studies also support this assertion.

“Existing literature does show natural immunity provides protection against COVID-19," said Shane Crotty, a professor at the Center for Infectious Disease and Vaccine Research at the La Jolla Institute for Immunology who has published numerous peer-reviewed studies on natural immunity against covid-19. He said such immunity particularly protects against hospitalizations and severe illness.

In Crotty's own recent study, the largest yet to measure the molecules and cells involved in immune protection, his team found that natural immunity against covid lasted at least eight months. Based on projections, it could last up to a couple of years.

While that is good news, Crotty said, there are three points of caution.

First, though natural immunity appears to be very effective against the current dominant U.S. variant (known as alpha), it also appears weaker than vaccine immunity against some of the variants circulating, such as the delta variant, first detected in India. That means if those variants eventually become dominant in the U.S., people relying on natural immunity would be less protected than those who are vaccinated.

Second, there is a lack of data about whether natural immunity prevents asymptomatic transmission and infection. Several other studies, though, show vaccines do.

Third, Crotty said his studies have shown that levels of natural immunity can vary widely in individuals. His team even found a hundredfold difference in the number of immune cells among people.

“If you thought about the immune system as a basketball game and you thought about that as a team scoring 1 point, and another team scoring 100 points, that's a big difference," said Crotty. “We're not so confident that people at the low end of immunity levels would be as protected against covid-19."

But those who receive a vaccine shot have a much more consistent number of immune cells, since everyone receives the same dose amount, said Crotty.

With all that in mind, the Centers for Disease Control and Prevention recommends that those who previously had covid-19 should get vaccinated and receive both doses of a vaccine, whether it's the Pfizer-BioNTech or Moderna vaccine. Fauci, the nation's leading infectious disease expert, reiterated this message during a White House covid-19 briefing last month.

Subscribe to KHN's free Morning Briefing.

Rand Paul says people who've been infected with COVID-19 don't need to get vaccinated – is he right?

Last week, Sen. Rand Paul (R-Ky.) posted a Twitter thread asserting that people who have survived a covid-19 infection were unlikely to be reinfected and have better immunity against variants than those who have been vaccinated against — but not infected by — SARS-CoV-2, the virus that causes covid.

The social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination.

While the science on the subject is still evolving, a look at the evidence behind Paul's series of tweets seemed in order. After all, though almost 65% of Americans have received at least one dose of a covid vaccine, some people who have recovered from covid may not feel a need to get shot. Paul, who was the first senator to be diagnosed with the virus, is among them. Here's a deeper look at what Paul said on Twitter, the studies he cited and how researchers characterized his comments.

Breaking Down the Twitter Thread

In his first tweet, Paul referenced a recent Cleveland Clinic study finding that among subjects who were unvaccinated but had already had covid-19, there were no re-infections in a five-month observation period: “Great news! Cleveland clinic study of 52,238 employees shows unvaccinated people who have had COVID 19 have no difference in re-infection rate than people who had COVID 19 and who took the vaccine."

In subsequent tweets, the senator said: “The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only." All three vaccines authorized for emergency use in the U.S. (Pfizer-BioNTech, Moderna and Johnson & Johnson) contain genetic instructions that tell our cells how to make a spike protein associated with the coronavirus. The presence of that spike protein then causes our bodies to make antibodies to protect against covid.

At the end of his final tweet, Rand then linked to a second study led by scientists at the Fred Hutchinson Cancer Research Center in Seattle to support his assertions.

Digesting the Scientific Papers

Paul referenced two scientific papers in his tweet thread — both of which are preprints, meaning they have not yet been published in scientific journals or been peer-reviewed.

One was a study from the Cleveland Clinic following four categories of health care workers: unvaccinated but previously infected; unvaccinated but not previously infected; vaccinated and previously infected; and vaccinated but not previously infected. The workers were followed for five months.

The researchers found that no one who was unvaccinated but had previously been infected with covid became infected again during the five-month study period. Infections were almost zero among those who were vaccinated, while there was a steady increase in infections among those who were unvaccinated and previously uninfected.

When asked whether he believed Paul's tweet had interpreted his study results correctly, the study's lead author, Dr. Nabin Shrestha, an infectious diseases specialist at Cleveland Clinic, said “it was an accurate interpretation of the study's findings."

However, Dr. George Rutherford, an epidemiologist at the University of California-San Francisco, wrote in an email that he would add one caveat to the wording of Paul's tweet: “Note that in his tweet Senator Paul seems to suggest that the denominator of previously infected health care workers at the Cleveland Clinic was 52,238 — that was the total number in the whole study. There were 1,359 that were previously infected and never vaccinated, and there were no reinfections noted over a median follow up of 143 days. So, the tweet itself is accurate if read literally but the denominator is really 1,359."

As for the other study Paul mentioned, researchers analyzed covid-19 immunity in those who had been infected with the covid virus and those who hadn't and found that infection activated a range of immune cells and immunity lasted at least eight months.

In his last two tweets in the thread, Paul quotes directly from the study's “discussion" section: “The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only."

The lead study author, Kristen Cohen, a senior staff scientist in the Vaccine and Infectious Disease Division at the Fred Hutchinson Cancer Research Center in Seattle, acknowledged that Paul's tweet was a direct quote from the study. Still, she said, in her view, the quote was taken out of context and presented to suit Paul's objective — but does not accurately reflect the overall take-home message from the study's findings.

That's because, she said, Paul was quoting from the discussion section of the paper. The discussion is the final section of a scientific paper, and Cohen said its purpose here was to project what the study's findings could imply for a broader scientific significance.

“We wrote that recovering covid patients are “likely" to better defend against variants than those who have just been immunized, but it's not saying they do," said Cohen. “It's not saying they have been known to. It's making a hypothesis or basically saying this could be the case."

In fact, Cohen's study did not include any subjects who had been vaccinated. The researchers were merely reasoning in the sentence Paul quoted that, based on the data showing the immune system's broad natural response, those who recover from covid-19 and then receive a vaccine may be better protected against covid variants than those who had only vaccine-induced immunity.

“We did not intend to argue that infected people do not need to get vaccinated or that their immune responses are superior," Cohen wrote in an email.

However, Cohen recognized the sentence was confusing when taken out of context and said she will eliminate it from the paper when it gets submitted for publication.

Cohen pointed us to another Fred Hutchinson-led study with which she was involved. It did show that people who previously had covid-19 benefited from also getting vaccinated, because there was a significant boost in immune response, especially against variants.

The Conventional Wisdom on Natural Immunity

So, what's known from these two studies is that surviving a covid infection confers a significant amount of immunity against the virus. Other studies also support this assertion.

“Existing literature does show natural immunity provides protection against COVID-19," said Shane Crotty, a professor at the Center for Infectious Disease and Vaccine Research at the La Jolla Institute for Immunology who has published numerous peer-reviewed studies on natural immunity against covid-19. He said such immunity particularly protects against hospitalizations and severe illness.

In Crotty's own recent study, the largest yet to measure the molecules and cells involved in immune protection, his team found that natural immunity against covid lasted at least eight months. Based on projections, it could last up to a couple of years.

While that is good news, Crotty said, there are three points of caution.

First, though natural immunity appears to be very effective against the current dominant U.S. variant (known as alpha), it also appears weaker than vaccine immunity against some of the variants circulating, such as the delta variant, first detected in India. That means if those variants eventually become dominant in the U.S., people relying on natural immunity would be less protected than those who are vaccinated.

Second, there is a lack of data about whether natural immunity prevents asymptomatic transmission and infection. Several other studies, though, show vaccines do.

Third, Crotty said his studies have shown that levels of natural immunity can vary widely in individuals. His team even found a hundredfold difference in the number of immune cells among people.

“If you thought about the immune system as a basketball game and you thought about that as a team scoring 1 point, and another team scoring 100 points, that's a big difference," said Crotty. “We're not so confident that people at the low end of immunity levels would be as protected against covid-19."

But those who receive a vaccine shot have a much more consistent number of immune cells, since everyone receives the same dose amount, said Crotty.

With all that in mind, the Centers for Disease Control and Prevention recommends that those who previously had covid-19 should get vaccinated and receive both doses of a vaccine, whether it's the Pfizer-BioNTech or Moderna vaccine. Fauci, the nation's leading infectious disease expert, reiterated this message during a White House covid-19 briefing last month.

Subscribe to KHN's free Morning Briefing.

An anti-vaccine film targeted to Black Americans spreads false information

When a filmmaker asked medical historian Naomi Rogers to appear in a documentary, the Yale professor didn't blink. She had done these “talking head" interviews many times before.

She assumed her comments would end up in a straightforward documentary that addressed some of the most pressing concerns of the pandemic, such as the legacy of racism in medicine and how that plays into current mistrust in some communities of color. The subject of vaccines was also mentioned, but the focus wasn't clear to Rogers.

The director wanted something more polished than a Zoom call, so a well-outfitted camera crew arrived at Rogers' home in Connecticut last fall. They showed up wearing masks and gloves. Before the interview, crew members cleaned the room thoroughly. Then they spent about an hour interviewing Rogers. She discussed her research and in particular controversial figures such as Dr. James Marion Sims, who was influential in the field of gynecology but who performed experimental surgery on enslaved Black women during the 1800s without anesthesia.

“We were talking about issues of racism and experimentation, and they seemed to be handled appropriately," Rogers recalled. At the time, there were few indications that anything was out of the ordinary — except one. During a short break, she asked who else was being interviewed for the film. The producer's response struck Rogers as curiously vague.

“They said, 'Well, there's 'a guy' in New York, and we talked to 'somebody in New Jersey, and California,'" Rogers told NPR. “I thought it's so odd that they wouldn't tell me who these people were."

It wasn't until March that Rogers would stumble upon the answer.

She received an email from a group called Children's Health Defense — prominent in the anti-vaccine movement — promoting its new film, “Medical Racism: The New Apartheid."

When she clicked on the link and began watching the 57-minute film, she was shocked to discover this was the movie she had sat down for back in October.

“I was naive, certainly, in assuming that this was actually a documentary, which I would say it is not. I think that it is an advocacy piece for anti-vaxxers," Rogers said. “I'm still very angry. I feel that I was used."

The free online film is the latest effort by Robert F. Kennedy Jr., the founder of Children's Health Defense. (He's a son of former U.S. Attorney General Robert “Bobby" Kennedy and nephew of President John F. Kennedy.) With this film, Kennedy and his allies in the anti-vaccine movement resurface and promote disproven claims about the dangers of vaccines, while aiming squarely at a specific demographic: Black Americans.

The film draws a line from the real and disturbing history of racism and atrocities in the medical field — such as the Tuskegee syphilis study — to interviews with anti-vaccine activists who warn communities of color to be suspicious of modern-day vaccines.

At one point in “Medical Racism," viewers are warned that “in Black communities something is very sinister" and “the same thing that happened in the 1930s during the eugenics movement" is happening again.

There is a lengthy discussion of the thoroughly disproven link between autism and vaccines. For example, the film references a study from the Centers for Disease Control and Prevention about the measles, mumps and rubella vaccine and autism rates as evidence that African American children are being particularly harmed, but in reality the study did not conclude that African Americans are at increased risk of autism because of vaccination.

The movie then displays a chart claiming to use that same CDC data — obtained through a Freedom of Information Act request — to make a connection between vaccinating Black children and autism risk. The findings in the chart closely resemble another study sometimes mentioned by anti-vaccine activists, but the medical journal later retracted the study, because of “undeclared competing interests on the part of the author" and “concerns about the validity of the methods and statistical analysis." (That study's author was a paid independent contractor for Kennedy's group as of 2020 and sits on its board of directors.)

The film also brings up a 2014 study from the Mayo Clinic that showed Somali Americans and African Americans have a more robust immune response to the rubella vaccine than Caucasians and Hispanic Americans. One of those interviewed in Kennedy's film then asks, “So if you have that process that could be caused by vaccines, why wouldn't there be a link between vaccines and developmental delays?"

But the study's author, leading vaccine researcher Dr. Gregory Poland, said this conjecture is not accurate.

According to a statement provided to NPR by the Mayo Clinic, the study demonstrated “higher protective immune responses in African-American subjects with no evidence of increased vaccine side effects," and any claim of “'increased vulnerability' among African-Americans who receive the rubella vaccine is simply not supported by either this study or the science."

For her part, Rogers, the Yale professor, appears for only about 14 seconds in the film. Her quotes are accurate. But her remarks are embedded in a wider narrative that she has “enormous problems with" — namely that the anti-vaccine movement is heroically engaged in a new civil rights campaign, one meant to stop experimentation on the Black community.

Rogers said the film uses many ideas she holds “passionately, like health disparities, fighting racism in health, working against discrimination, and it's been twisted for the purposes of this anti-vax movement."

Another credible expert from mainstream medicine also appears in the film: Dr. Oliver Brooks, the immediate past president of the National Medical Association. The group is the largest organization representing African American physicians in the United States.

Brooks said he agreed to be in the film because he wanted to provide balance, but after seeing it he regrets doing the interview.

“The crux of the documentary is generally 'Don't get vaccinated,'" Brooks told NPR in a recent interview. “There is an understandable concern in the African American community regarding vaccines — however, in the end, my position is you look past those, have an understanding of those and still get vaccinated. … That nuance was not felt or presented in the documentary."

Kennedy's group released the film in early March, just as the covid-19 vaccine was becoming widely available to the American public.

“The film basically wants people to recognize this history that leads right into the present, and especially when they're facing decisions about whether they should take any vaccine, including covid," said Curtis Cost, one of the film's co-producers and a longtime anti-vaccine activist.

Cost said the film does not explicitly tell people to refuse the covid vaccine, but it “goes all the way to the present experimentations and bad things have been done by the medical establishment in America and in Africa and other parts of the world."

In an emailed statement, a spokesperson for Children's Health Defense denied that the film is misinformation and said it contains “peer reviewed science and historical data."

But the movie is “a classic example of the anti-vaccine industry with a highly targeted message using sophisticated marketing techniques and building alliances with affiliate organizations," said Imran Ahmed, CEO of the nonprofit Center for Countering Digital Hate, which has extensively researched figures such as Kennedy.

“They've seen the opportunity to target a specifically African American audience," he said, during a particular moment of heightened national attention on racial injustices and health disparities.

Black Americans have twice the risk of dying of covid compared with white Americans. Racial disparities in vaccination uptake persist across the United States.

While there are efforts to improve access to the vaccine, media coverage has also focused heavily on historical reasons for vaccine skepticism — too much, some scholars argue, when the focus should be on how Black Americans experience the impact of systemic racism in health care today — and how to fix those problems and improve trust.

“We're in this moment where we're having some necessary discussions about health equity," said Victor Agbafe, a medical student at the University of Michigan. “It's not a good thing to sort of exploit that as a means to undermine trust in the vaccine today, instead of focusing on how we can make the vaccine more accessible for all communities."

Agbafe, who helps lead his school's Black medical student association, was surprised to get an email from Children's Health Defense asking him to promote the movie among his peers.

When it was released, the film did not seem to gain much traction on major social media platforms such as Twitter, although tracking how often this kind of video is being shared privately can be difficult, said Kolina Koltai, a University of Washington researcher who studies the anti-vaccine movement online.

But Kennedy's anti-vaccine activities during the pandemic involve more than this movie.

In February, he was banned from Instagram for posting misinformation on vaccines, but he still has a home on Facebook and Twitter. Ahmed's organization has labeled Kennedy one of the “disinformation dozen" — a group of people responsible for 65% of the shares of anti-vaccine misinformation on social media platforms.

In a recent webinar about the film, Kennedy said those who agree with the film need to use “the tools of advocacy that Martin Luther King Jr. talked about" and promote it “guerrilla-style" against the “darkening cloud of totalitarianism."

Although more than half of American adults have gotten a covid vaccine, demand is falling fast, and polls show almost one-third of adults still either want to “wait and see" or do not want to get the shot. When asked why, many say the vaccine is unsafe, based on false conspiracy theories.

I see the downstream ripple effects of disinformation every day in practice, every day in the patients' lives I treat," said Dr. Atul Nakhasi with the Los Angeles County Department of Health Services and co-founder of the online campaign #ThisIsOurShot, which aims to encourage trust in the covid vaccines.

“We know people have uncertainties, and we need to acknowledge that and have humble, respectful conversations, but for someone to actively subvert that trust is unconscionable," Nakhasi said.

According to the Center for Countering Digital Hate, the ideal strategy for stopping the spread of online misinformation is to cut it off at the source: meaning “deplatform" the most notorious spreaders of that information so they can't gain a following on social media in the first place. But Ahmed said that all too often tech companies don't take those steps themselves. In that case, the next best tactic is to try to “inoculate" people against false and misleading claims.

“You tell people in advance, 'Hey, something terrible is happening. Be careful — they're targeting you,'" Ahmed said.

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

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.

USE OUR CONTENT

This story can be republished for free (details).

Subscribe to KHN's free Morning Briefing.

Unused Johnson & Johnson Covid doses are piling up as FDA waits to see if shelf life can be extended

The Biden administration is encouraging states to hold on to hundreds of thousands of soon-to-expire covid vaccine doses from Johnson & Johnson, given the possibility that additional data will show the shots are viable beyond their expiration date at month’s end. Dr. Janet Woodcock, acting commissioner of the Food and Drug Administration, told state officials during a White House call Tuesday that they could store expired doses until new data shows whether the vaccines are safe to use, according to multiple state officials. State health officials have strenuously warned vaccine administrators ...

The return of the 'Public Option'

Can’t see the audio player? Click here to listen on SoundCloud. You can also listen on on Spotify,** *Apple Podcasts](https://podcasts.apple.com/us/podcast/what-the-health/id1253607372?mt=2), [Stitcher](http://www.stitcher.com/podcast/kaiser-health-news/what-the-health), [Pocket Casts](https://play.pocketcasts.com/web/podcasts/a379e280-3f57-0135-9028-63f4b61a9224) or wherever you listen to podcasts\.* The “public option” is back — both in Washington, D.C., and the states. President Joe Biden as a candidate supported the idea of a government-run or heavily regulated insurance plan that would co...

Pandemic leads doctors to rethink unnecessary treatment

Covid-19 is opening the door for researchers to address a problem that has vexed the medical community for decades: the overtreatment and unnecessary treatment of patients. On one hand, the pandemic caused major health setbacks for non-covid patients who were forced to, or chose to, avoid tests and treatments for various illnesses. On the other hand, in cases in which no harm was done by delays or cancellations, medical experts can now reevaluate whether those procedures are truly necessary. Numerous studies have shown that overtreatment causes unnecessary suffering and billions of dollars in ...

'Kicking you when you're down': Many cancer patients pay dearly for parking

For cancer patients, the road from diagnosis to survivorship feels like a never-ending parade of medical appointments: surgeries, bloodwork, chemotherapy, radiation treatments, scans. The routine is time-consuming and costly. So, when hospitals charge patients double-digit parking fees, patients often leave the garage demoralized.

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

Iram Leon vividly remembers the first time he went for a follow-up MRI appointment at Dell Seton Medical Center in Austin, Texas, after he had been treated at another hospital for a brain tumor.

The medical news was good: His stage 2 tumor was stable. The financial news was not. When he sat down at the receptionist's desk to check out, Leon was confronted by a bold, red-lettered sign on the back of her computer that read: “WE DO NOT VALIDATE PARKING."

Below that all-caps statement was a list of parking rates, starting with $2 for a 30-minute visit and maxing out at $28 a day. Lose your ticket? Then you could pay $27 for an hour.

“To this day, I remember that sign," Leon, 40, said of the 2017 appointment, which he posted about on Facebook. “These patients were people who were coming in for various types of cancer treatment. These were people who were keenly aware of their own mortality, and yet the sign was screaming at them, 'We do not validate parking.'" (Hospital officials did not respond to requests for comment about their parking policy.)

JulieAnn Villa, who was diagnosed in March with her third bout of cancer, estimates she has spent “thousands of dollars" on parking fees during her years of treatment and follow-up care. She faces a transportation dilemma every time she commutes 6 miles to Chicago's Northwestern Memorial Hospital from her apartment. Should she take public transit? Call a pandemic surge-rate Uber? Ask a friend to drive her? Or pay $12 to $26 (with validation) to park in a garage where each floor is named after singers like Dolly Parton and Frank Sinatra?

She was hospitalized for multiple days in April after spending 23 hours alone in an overburdened ER, because she didn't want friends to pay to wait with her. “I almost drove myself, and I'm so glad I didn't," Villa said. “That would have been expensive."

Long a source of frustration for patients, the costs of parking while in cancer treatment is finally drawing national scrutiny from oncology researchers and even some hospital administrators.

“If you want to rile up patients or caregivers or family members, just bring up parking costs," said Dr. Fumiko Chino, a radiation oncologist at Memorial Sloan Kettering Cancer Center in New York who studies the “financial toxicity" of cancer treatment, including costs not covered by insurance, such as parking fees.

Chino, who enrolled in medical school after her husband died of a rare neuroendocrine cancer in 2007, added, “For people who have to pay $15 to $18 every single time, which is what I remember paying, it really feels like the last straw, frankly — like kicking you when you're down."

Public transit is possible for some cancer patients in larger cities, but not for those too ill or immunocompromised. Others have accessibility issues. Many must travel to get care, making driving the best option.

Parking fees can have implications for more than just the patient. “Some patients say, 'This is the reason I didn't participate in a clinical trial, because I couldn't afford the parking,'" Chino said.

At a time when hospitals and drug companies are under increasing pressure to diversify clinical trial populations, testing only patients who can afford high parking fees is problematic, Chino said.

There are some pilot programs to improve access to drug trials, and some charities, such as the Leukemia & Lymphoma Society, offer travel grants, but accessibility remains a substantial barrier to cancer care, said Elizabeth Franklin, president of the nonprofit Cancer Support Community, which offers financial aid to patients and advocates in Washington, D.C., for “patient-centered" health policies.

“The true definition of a patient-centered health care system," Franklin said, is one that allows patients to choose the best means of transportation. “It's not making them go into debt because they've had to pay a ton of money for parking each time they go to the clinic or the hospital."

Chino and colleagues published a short study in July showing that some cancer patients pay $1,680 over the course of treatment.

According to readership statistics released in late March, the study was the most read and downloaded article in JAMA Oncology last year, and it continues to prompt a lively social media response. A thread on Reddit has logged more than 1,100 comments, including many from patients in other countries voicing surprise at U.S. parking policies.

The researchers calculated the cost to park at 63 National Cancer Institute-designated cancer centers while receiving the standard number of treatments for each of three types of cancers: node-positive breast cancer, head and neck cancers, and acute myeloid leukemia, or AML. They did not calculate costs for follow-up appointments, blood draws, routine scans and immune-boosting injections.

They found that, while 20 of the hospitals provided free parking for all cancer patients, the other 43 had widely varying fees.

“The range was $0 to $800 for breast cancer," Chino said. “That's huge, and it's not like the person who's paying $800 is necessarily getting any better treatment." The maximum charges for a standard course of therapy for head and neck cancer were $665 and for AML, $1,680.

Practices should change, Chino said, “to alleviate this strain for our patients."

Of the 63 hospitals, including those where parking is free for cancer patients, 54% offered free parking for chemotherapy and 68% for radiation treatment.

The top daily parking rate, according to the researchers, is $40 at New York's Mount Sinai Hospital. (A spokesperson for Mount Sinai declined to comment.) Chino's own institution, Memorial Sloan Kettering, is not far behind; parking at one of its main garages begins at $12 an hour and maxes out at $36 a day. A spokesperson for the hospital said some locations do offer free parking, and all patients can apply for aid to cover parking costs.

A few colleagues scoffed when Chino said she was researching parking charges, she said, but a growing number of mostly younger oncologists are concerned about indirect costs that contribute to the financial toxicity of cancer.

“It seems ethically incorrect to nickel-and-dime patients for parking charges," a trio of doctors wrote last year in an editorial published by the American Society of Clinical Oncologists. They acknowledge that most top cancer hospitals are in urban centers, where parking costs are often high and third-party agencies may operate the garages. “Nevertheless, in 2020, with our multibillion-dollar cancer center budgets, we as health care systems should do everything we can to help patients and caregivers," the editorial said.

City of Hope National Medical Center in Los Angeles is one of the 20 NCI-designated hospitals that do not charge patients for parking. Dr. Vijay Trisal, a surgical oncologist who serves as City of Hope's chief medical officer, takes pride in that distinction.

“Charging cancer patients for parking is like a knife in the back," he said. “We can't control copays, but we can control what patients pay for parking."

While Trisal would never want a patient to choose City of Hope for the free parking alone, he acknowledges the policy gives his hospital a competitive advantage.

“You would not believe how many patients have said to me, 'Thank you for not charging for parking,'" he said.

Subscribe to KHN's free Morning Briefing.

Homicides surge in California amid Covid shutdowns of schools and youth programs

Amid a pandemic that left law enforcement agencies stretched thin and forced shutdowns that left young men with little to do, California registered a devastating surge in homicides in 2020 that hit especially hard in Black and Latino communities.

The number of homicide victims in California jumped 27% from 2019 to 2020, to about 2,300, marking the largest year-over-year increase in three decades, according to preliminary death certificate data from the California Department of Public Health.

There were 5.8 homicides per 100,000 residents in 2020, the highest rate in California since 2008.

Similar increases were seen nationwide. The number of homicides in a sampling of large cities grew 32% from 2019 to 2020, according to preliminary FBI data. The data encompasses over 200 cities with more than 100,000 people but does not include some big cities, like New York, Chicago and Philadelphia, that did not report.

The California death certificate data reveals striking disparities in who fell victim to homicide in 2020.

The number of homicides that took the lives of Black Californians rose 36% from 2019 to 2020, while homicides that took Hispanic lives rose 30%. By comparison, the number of white homicide victims rose 15% and the number of Asian victims rose 10%.

Most victims of homicide in 2020 were young, between 15 and 34 years old; the number of homicide victims in this age group rose from about 900 in 2019 to 1,175 in 2020, a 31% rise.

Firearms were the most common instrument of death, and the number of homicides involving guns rose 35% last year, the state data shows. Extending another long-standing trend: Males were five times as likely to be the victims of homicide as females. The number of male victims rose 30% in 2020, compared with a 14% rise in female victims.

The increase in deadly violence played out across large swaths of the state, urban and rural, and was keenly felt in the San Francisco Bay Area. Among California's 10 most populous counties, the sharpest increases were reported in Alameda County, where homicides rose 57%, followed by Fresno (44%), Sacramento (36%) and Los Angeles (32%). Only one of the 10 most populous counties — Contra Costa — saw a decline in homicides last year.

Law enforcement officials and criminologists said an increase in conflict among young adults, particularly those in street gangs, was a significant factor in the violence. They noted that schools and sports programs shut down as covid-19 surged, as did large numbers of community and nonprofit programs that provide support, recreational outlets and intervention services for at-risk youth.

“They were bored," said Reynaldo Reaser, executive director of Reclaiming America's Communities Through Empowerment (R.A.C.E.), which offers sports leagues, gang mediation and youth development in impoverished neighborhoods of South Los Angeles. “And so, having nothing to do — no programs, no sports, no facilities open — the only thing they could focus on is each other."

Reaser runs a dynamic youth softball league that typically would draw more than 600 players and spectators during Sunday play, he said, many of them young gang members. But those games and other programs were curtailed during the covid pandemic.

Terrell Williams, an 18-year-old who lives in the West Athens area of South Los Angeles, said he spent many nights doing “delinquent stuff" before Reaser's program changed his life. He said many of his peers felt cooped up and restless during the pandemic lockdowns, which contributed to an increase in violence.

“Covid tended to, I guess, make people not want to stay inside the house, and drove them outside more towards each other," he said.

Jorja Leap, a UCLA anthropologist and expert in gangs, violence and trauma, echoed that theme, saying the restrictions on youth intervention programs and other healthy activities played “a huge role" in the rise in violence.

“The sports after school — football, basketball, whatever it might be — all that is stopped," said Leap, a faculty member at UCLA's Luskin School of Public Affairs. “So, frankly, you got a lot of adolescent and young adult energies out there."

Leap said young adults were particularly vulnerable to the mental toll of the pandemic. “They finally get programs; they have people interested in them. And then, it's all of a sudden withdrawn," she said.

Pandemic-fueled anxiety and isolation corresponded with a huge increase in gun sales, which Leap said may also explain some of the increase in homicides. “I am worried about how easy it has been to get a gun during such a crisis time in America," she said.

“It's not 'Pick one factor,'" she added. “All of these factors reinforce each other."

David Robinson is the sheriff in Kings County, a largely rural county in Southern California that registered 15 homicides in 2020, up from four in 2019. He is also president of the California State Sheriffs' Association, giving him a wide lens on a difficult year.

Robinson agreed that an increase in gang activity and the “mental impact" of telling young adults they had to stay indoors likely contributed to the violence. But separately, he cited the toll the pandemic took on police agencies. Many officers fell ill with covid, forcing their agencies to reduce patrols and other crime prevention efforts.

The mass protests that followed George Floyd's murder by a Minneapolis police officer last May also diverted resources, said Robinson. And the anger directed at police made it tougher for some officers to do their jobs.

“When there's this call to defund police, it has an impact on the mentality of the men and women doing the job," he said, adding that constant criticism can cause officers to “become more reactive than proactive."

Robinson echoed other law enforcement officers in noting that thousands of inmates were released early from state prisons and county jails during the pandemic to stem covid outbreaks. He said he thinks research eventually will show a correlation with the surge in homicides.

Leap disagreed. “If you get two shoplifting charges, it's a felony," she said. “That's who they're releasing. They're not releasing people from death row."

With mass vaccinations taking place across the state and nation, more places are reopening and young adults have more options to engage in something positive. But Leap said it will take a broad effort to bolster jobs and education, along with short-term intervention aimed at those still hurting from the pandemic, to improve the social conditions that contributed to the increase in homicides.

“As much as we've never dealt with a global pandemic in modern times, we've never dealt with the aftermath of a global pandemic," she said.

Reaser, in Los Angeles, is nonetheless optimistic. After a year of shutdowns, his youth softball league is starting up again. Finally, instead of trying to work out conflicts over the phone or online, Reaser can get young adult rivals to talk, face to face, and bond in a positive way.

“I really think that a lot of programs will open up," he said. “A lot of violence will slow down."

Methodology

This story draws on data from three sources. The data from these sources matches closely, but not precisely. Cause of death and population figures for 1979 through 2018 come from the federal Centers for Disease Control and Prevention. Cause of death figures for 2019 and 2020 come primarily from the California Department of Public Health and are based on death certificates. The exception is 2019 data for eight largely rural counties with few homicides. CDPH did not publish specific 2019 homicide figures for those counties due to data privacy rules. For those counties, 2019 homicide data comes from the California Department of Justice.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

Subscribe to KHN's free Morning Briefing.

The making of reluctant activists: A police shooting in a hospital forces one family to rethink American justice

The beer bottle that cracked over Christian Pean's head unleashed rivulets of blood that ran down his face and seeped into the soil in which Harold and Paloma Pean were growing their three boys. At the time, Christian was a confident high school student, a football player in the suburbs of McAllen, Texas, a border city at the state's southern tip where teenage boys — Hispanic, Black, white — sung along to rap songs, blaring out the N-word in careless refrain. “If you keep it up, we're going to fight," Christian warned a white boy who sang the racial epithet at a party one evening in the waning years of George W. Bush's presidency. And they did.


Use Our Content

It can be republished for free.

On that fall evening in 2005, Christian pushed and punched, his youthful ego stung to action by the warm blood on his face. A friend ushered Christian into a car and drove through the bedroom community of Mission, passing manicured golf greens, gable roofs and swimming pools, to the well-appointed home of Dr. Harold and Paloma Pean, who received their son with care and grace. At the time, even as he stitched closed the severed black skin on his son's forehead, Dr. Pean, a Haitian exile and internal medicine physician, believed his family's success in America was surely inevitable, not a choice to be made and remade by his adopted country's racist legacy.

Christian's younger brother, Alan, a popular sophomore linebacker who shunned rap music and dressed in well-heeled, preppy clothes, agitated to find the boy and fight him. “Everybody shut up and sit down," Paloma ordered. Inside her head, where thoughts roiled in her native Spanish, Paloma recalled her brother's advice when they were kids growing up in Mexico: No temas nada. Eres una chica valiente. Never be scared. You are a brave girl. She counseled restraint, empathy even. “Christian, we need to forgive. We don't know how the life of this guy is that he took that reaction." This is a country that recognizes wisdom, Paloma thought.

The Pean family's tentative truce with America's darker forces would not last long. In August 2015, when Alan was 26 and under care at a Houston hospital where he had sought treatment for bipolar delusions, off-duty police officers working as security guards would shoot him through the chest in his hospital room, then handcuff him as he lay bleeding on the floor. Alan would survive, only to be criminally charged by the Houston police.

The shot fired into Alan's chest would extinguish the Pean family's belief that diligent high achievers could outwit the racism that shadows the American promise. Equality would not be a choice left up to a trio of ambitious boys.

Nearly six years later, the Peans remain haunted by the ordeal, each of them grappling with what it means to be Black in America and their role in transforming American medicine. Christian and Dominique, the youngest Pean brother, both aspiring doctors, like their father, have joined forces with the legions of families working to expose and eradicate police brutality, even as they navigate more delicate territory cultivating careers in a largely white medical establishment.

Alan has seen his studies derailed. He remains embroiled in a lawsuit with the hospital and wavers over his responsibility to the fraternity of Black men who did not survive their own racist encounters with police.

And Paloma and Harold, torn from their Mexican and Haitian roots, look to buoy and reassure their sons, propel them to the future they have earned — even as they wonder whether the America they once revered doesn't exist.

“People don't want to admit we have racism," Paloma told me. “But Pean and me, we know the pain."

Harold Pean doesn't recall being raised Black or white. His native Haiti was fractured by schisms beyond skin color.

Harold was 13 when he, his sister and five brothers woke on a May morning in 1968 to find that their father, a prominent judge, had fled Port-au-Prince on one of the last planes to leave the island before another anti-Duvalier revolt pitched the republic into a season of executions. His father had received papers from President François Duvalier demanding he sign off on amendments to Haiti's Constitution to allow Duvalier to become president for life. Harold's father refused. Soldiers arrived at the Pean house days after his father escaped.

The Republic of Haiti was marked by Duvalier's capricious cruelty during Harold's youth, but as the son of a judge and grandnephew of a physician, he enjoyed a comfortable life in which the Pean children were expected to excel in school and pursue professional careers: engineering, medicine, science or politics. In school, the children learned of their ancestors' brave heroics, African slaves who revolted against French colonialists and established a free republic, and they saw Black men and women running fruit stands, banks, schools and the government. “I didn't experience racism as a kid," Harold remembers. “When you find racism as a kid, that makes you doubt yourself. But I never doubted myself."

Two years after Harold's father fled Haiti, his mother joined her husband in New York, leaving the Pean children in the care of relatives. In 1975, Harold and his siblings left Haiti and immigrated to New York City. New York was cold, like being inside a refrigerator, and the streets were much wider than in Haiti. His father had found a job as an elevator operator at Rockefeller Center.

At the time, Harold's older brother, Leslie, was attending medical school in Veracruz, Mexico, where tuition was cheaper than in the States, and his father urged Harold to join him. A native French speaker who knew no Spanish, Harold learned anatomy, pathology and biochemistry in a foreign tongue. And he was fluent in Spanish by the time he met María de Lourdes Ramos González, known as Paloma, on Valentine's Day 1979 at a party in Veracruz. Harold remembers the moment vividly: a vivacious young woman spilling out of a car in the parking lot, shouting her disapproval at the low-energy partygoers. “'Everybody is sitting here!'"

“They were so quiet," Paloma remembers. She pointed to the man she would eventually marry, “You! Dance with me!"

Growing up as the only girl in her parents' modest ranch in Tampico, a port city on the Gulf of Mexico, Paloma was expected to stay inside sewing, cleaning and reading while her three brothers ventured out freely. She felt loved and protected but fumed at her circumscribed life, pleading for a car for her quinceañera and pushing her father, the boss at a petroleum plant, to allow her to become a lawyer. Her father thought she should instead become a secretary, teacher or nurse. “I said, 'Why are you telling me that?' He said, 'Because you are going to get married, you are going to end up in your house. But I want you to have a career in case you don't have a good husband, you can leave.'" That good husband, Paloma understood, could be Mexican or white. She remembers her father saying, “I don't want Black or Chinese people in my family."

After earning a degree to teach elementary school, Paloma moved to Veracruz. When she was 21, her father installed her in a boarding house for women. Watched over by a prying house matron, Paloma and Harold's courtship unfolded under the guise of Harold teaching Paloma English. The couple dated for several years before Paloma told her father she wanted to get married to the handsome, young medical student. Harold had returned to New York, and Paloma was eager to join him.

Her father was skeptical. He had spent a few months in Chicago and seen America's racial unrest. “He told me, 'My daughter, I don't have any objections. He's a good man, but I'm scared for you. I'm scared for my grandkids because, let me tell you, your kids are going to be Black. And I don't know if you are ready to raise Black kids in the U.S.,'" Paloma remembers. “At that moment I didn't understand what he meant."

In the early 1980s, as Harold and Paloma started their lives together, the news from America spoke to racial divisions. The country was seized by a presidential campaign, in which the actor and former California Gov. Ronald Reagan courted segregationist Southern voters at a Mississippi fairground a few miles from where civil rights workers had been murdered in 1964. In Miami, Black residents protested after an all-white, all-male jury acquitted four white police officers who had beaten an unarmed Black motorcyclist, Arthur McDuffie, to death with their fists and nightclubs. Beaten him “like a dog" McDuffie's mother, Eula McDuffie, told reporters. Over three days of violent street protests, 18 people died, hundreds were injured, buildings burned and President Jimmy Carter called in the National Guard.

The couple lived in Queens, where Christian was born in 1987, and Harold found work while pursuing medicine. He inspected day care schools for sanitary violations. As he traveled around the city's streets, he never felt imperiled by the color of his skin. “People said there was racism, but I didn't see it." On the few occasions he noticed a police officer or shop security trailing him, he put it out of his mind, trying not to pursue the logic of what had happened. “We never talked about it in the house," he said. “We were concentrating on achieving whatever goals we had to do."

Moving with common purpose, Harold and Paloma went wherever the young doctor could find work. Caguas, Puerto Rico, where Alan was born in 1989; back to New York for Harold's residency in internal medicine at the Brooklyn Hospital Center; then Fort Pierce, Florida, where Dominique was born in 1991; and eventually to McAllen, Texas. Harold's brother, Leslie, had established his practice in Harlingen, 20 miles north of the Mexican border. Harold was comforted to have family nearby and Paloma wanted to reach her family in Mexico more easily. Still, the first hospital that recruited Harold offered an uncharitable contract; he had to cover half the costs of running the medical practice while seeing only a few patients.

Harold remembers few, if any, other Black doctors in the area. Paloma was more certain about the dearth of diversity in the medical ranks: “We were among the only Blacks in the [Rio Grande] Valley and the only [primary care] doctor." Three months into the contract, Paloma, who managed the office's finances, could see they were losing money. She pressed her husband to renegotiate. When he refused, she went to the hospital herself. “I love the Valley," she told the administrator, her optimism unimpeachable. “But I came here to work. My husband is a very good doctor and you are not paying what he deserves. If you don't pay him, we are going to move." Stunned, the administrator, who was white, agreed to her demands, and Paloma returned triumphant.

Daily life was a blur. The couple worked assiduously at the medical practice, finding allies at the hospital who applauded their diligence and, by Harold's account, rooted for their success. But race was never far from the surface. When a medical assistant at the office told Paloma that another doctor had asked her repeatedly if she was still working with “the Black doctor," Paloma fumed. At the medical center's Christmas party that year, Paloma approached the doctor. “'Are you so and so, the doctor?' I said. 'Well, I'm Paloma Pean, and I'm here just to let you know the name of my husband. My husband is Harold Pean. P-E-A-N. His last name is not Black.' And I said, 'Thank you, and nice to meet you.' He opened his eyes big, and then I left."

At home, Paloma insisted on a Catholic upbringing, and the family prayed every evening after dinner in three languages (Paloma in Spanish, Harold in French, the boys in English). Harold pushed his three boys in the ways his own parents had. “I was expecting them to be either a doctor or a professional, like my parents expected us to be professionals."

That was the period in which the three Pean boys — Christian, Alan and Dominique — tried to sort out their Blackness in a place that was almost entirely Hispanic and white. Accustomed to being surrounded by Latinos in Florida and later in McAllen, Paloma recalled her father's warnings. When the boys started nursery school, they were the only Black babies. “That's when I thought, I need to start to make them very proud of what they are."

The questions about skin color came early for Dominique, the youngest brother. His fellow kindergartners watched Paloma, a Latina, drop off her son for school in the mornings, and a cousin, who was Chinese, pick him up after the last bell. (Paloma's brother had married a Chinese woman.) “They asked me if I was adopted," Dominique remembers clearly. He told his mother, “I don't look like you." Would his father, pretty-please, pick him up at school to show the kids, once and for all that, no, he was not adopted? It was a conclusive victory. “The kids stopped bringing it up. 'OK, you're Black!'"

The boys steered in different directions, employing sports, fashion and culture to signal their preferences to the perplexed children of McAllen. “I really identified with my Hispanic side, but when people see me, they see a Black kid," remembers Dominique. He ventured to look “more Black," braiding his hair into cornrows and wearing FUBU, a line of clothing that telegraphed Black street pride. Meanwhile, Alan forged a collegiate look. He listened to “corny, white boy music" (Christian's words) and dressed in Abercrombie & Fitch.

The boys were left to their own to make sense of the off-handed remarks at school and on the football field. You're Black, you're supposed to jump farther. Do Black kids have extra muscles in their legs? You sound smart for a Black kid. You sound white. Does anyone know if the Pean brothers have big dicks?

“There was open ignorance back then," Christian remembers. The boys absorbed and repelled the remarks, protesting vigorously only when the N-word exploded in front of them. One of Alan's friends on the football team asked him, “What's up, d…igger?" replacing the N and smirking knowingly. Alan responded, “Why would you even do that?"

It never occurred to Dr. Pean to give his teenage boys “the talk," the dreaded conversation Black parents initiate to prepare their sons for police encounters. The day Christian came home, blood running down his forehead, Harold argued against pressing charges. “The chief of police was my friend, and I had a lot of police patients," Harold said. “I would meet white people or Black or Hispanic, and I never thought they would see me differently."

Where Harold was silent, Paloma was explicit. The history of African Americans amazed her. Dominique remembers his mother saying, “Being Black is beautiful. They came to the United States as slaves, and now they are doctors. That blood runs in you, and you are strong."

Of all the sons, the oldest boy, Christian, seemed the most curious about exactly what his heritage and his skin color had to do with who he was. Why hadn't his mother married a Mexican man? Why did other kids want to know if his dark skin rubbed off? Could they touch his hair? At age 6, Christian told his mother a Hispanic girl at school had called him the N-word and his mother a “wetback" as he sat in the cafeteria sipping a Capri Sun.

The racist lexicon of American youth befuddled Paloma. She asked Christian, “What does that mean?" “That word is bad," he responded.

Christian's doubts about his father's faith in American meritocracy emerged early. After he endured racist slurs and other offensive remarks at school, Christian told Harold that he felt he was treated differently “because I'm Black."

“No, Chief," his father responded, “hard work gets rewarded. It's not going to help anybody to get down on your race."

As mixed-race children, the legitimacy of the Pean brothers' Blackness trailed them into adulthood. At Georgetown University, Christian found an abundance of Black students for the first time — African Americans and immigrants from Nigeria, Ghana and the Caribbean — and unfamiliar fault lines began to emerge.

“When I was in high school, there was never Black immigrants vs. Black Americans," Christian said. But in college and later in medical school at Mount Sinai in East Harlem, Christian fielded questions from other Black students about whether scholarships for people of color should be set aside for African Americans descended from slaves, not children of Black immigrants like him.

At the Catholic University of America in Washington, D.C., Dominique was facing similar questions about his racial camp. When he joined the board of the Student Organization of Latinos, he was asked, “Are you Latino enough?"

“When I'm on the street, people see a Black man. But when I'm with my Black friends, they're like, Dom, you're not really Black," he said. The questions followed them into their personal lives: African American women berating Christian and Dominique for dating women who were not Black.

If the Pean brothers' Haitian and Mexican roots called into question their rightful membership among African Americans, the police discerned no difference. After graduating from high school in the McAllen suburbs, Alan matriculated to the University of Texas-Austin, a sprawling campus filled almost entirely with white, Hispanic and Asian students. Alan, laid-back and affable, made friends easily. It surprised him then when a security officer trailed him at a store in the mall while he shopped for jeans. “That was the moment when I was like, 'Oh, I'm Black," he said.

In August 2015, Alan Pean started the fall semester at the University of Houston where he had transferred to finish his degree in biological sciences. Within days, he began to feel agitated, and his mind slipped into a cinematic delusion in which he believed he was a stunt double for President Barack Obama. At other times, armed assassins chased him.

Alarmed by Alan's irrational Facebook posts and unable to reach him by phone, Christian called his parents, who were sitting in a darkened McAllen movie theater. He urged them to get to Houston. This was not a drill. In 2009, Alan had spent a week at a hospital for what doctors believed was bipolar disorder.

In the lucid moments between the delusions traversing his psyche, Alan knew he needed medical help. Around midnight, on Aug. 26, 2015, he drove to St. Joseph Medical Center in Houston, swerving erratically and crashing his white Lexus into other cars in the hospital parking lot. As he was hustled into the emergency room on a stretcher, Alan screamed, “I'm manic! I'm manic!"

The following morning, Paloma and Harold flew to Houston and arrived at St. Joseph Medical Center expecting to find sympathetic nurses and doctors eager to aid their troubled son. Both Harold and Christian had placed calls to the emergency department, alerting them to Alan's mental health history. Instead of finding their son being cared for as a man in the midst of a delusion, Harold and Paloma discovered doctors had not ordered a psychiatric evaluation or prescribed psychiatric medication.

Barred from seeing their son and galled by the hospital's refusal to provide psychiatric care, Harold and Paloma went to their hotel to try to rent a car so they could take Alan for treatment elsewhere. They were gone for half an hour.

In his hospital room, Alan became more agitated. He believed the oxygen tanks next to his bed controlled a spaceship and that he urgently needed to deactivate a nuclear device using the buttons on his bed. He stripped off his hospital gown and wandered into the hallway naked. A nurse called a “crisis code" and two off-duty Houston police officers, one white and one Latino, charged into Alan's room. They were unaccompanied by any nurses or doctors, and they closed the door behind them.

The officers would say later that Alan hit one of them and caused a laceration. The first officer fired a stun gun. When the electroshock failed to subdue Alan, according to officers' statements, the second officer said he feared for his safety and fired a bullet into Alan's chest, narrowly missing his heart.

Paloma and Harold arrived back at the hospital to find themselves plucked from their ordered lives and hurled into a world in which goodwill and compassion had vanished. Alan was in intensive care with a gunshot wound, and police officers were asking questions about his criminal record. (He had none.) Alan would be detained for attacking the security officers, they were told, and it was now a criminal matter.

Christian flew in from New York, Dominique from Fort Worth, and Uncle Leslie from McAllen. Inconclusive conversations with a hospital administrator strained their patience. “That's when I was told that we had to have a lawyer to see him," Leslie said, trembling even as he recounted it nearly six years later.

Paloma was bewildered that her appeals for fairness went unanswered. “I was expecting they would allow me to see my son immediately. I said, 'My son is a good boy. Let me go and see my kid, please! Please!'" She felt like a ghost, wandering the hospital unstuck in time. Suddenly, the complexions and accents of everyone around her mattered: One police officer was surely white, she thought, the other Hispanic, but maybe born in the U.S.? The nurses were Asian, perhaps Filipino?

Days later, the hospital relented, and nurses led her to a glass window. Alan lay sedated, a tube down his throat, handcuffed to the hospital bed. Paloma's chest tightened and she felt faint. “I pinched myself, and I said, 'This cannot be true.' I screamed to my Lord, 'Please hold me in your hands.'"

“That's when I really understood what my father was talking about," Paloma told me. This, she thought, is how America treats Black men.

Over the next few weeks, it became impossible to unravel what exactly had happened to Alan. Sgt. Steve Murdock, a Houston police investigator, told Christian that Alan had been out of control, picking up chairs, acting like a “Tasmanian devil." When the hospital eventually allowed the Pean family into Alan's room, Alan was groggy, his wrists and hands swollen. Standing by his bedside, Uncle Leslie asked Paloma, Harold, Dominique and Christian to hold hands and pray. A week later, Alan was transferred to a psychiatric unit, and his delusions began to lift. A few days later, he was released from the hospital.

It was pouring rain the day the Pean family left Houston. Alan insisted on driving — he always drove on family trips — and his parents and brothers, desperate for a return to normalcy, agreed. Paloma prayed on her rosary in the backseat, nestled next to Christian. Alan drove for 20 minutes until someone suggested they stop and eat. At that moment, Alan turned to his father, “Did I really just drive out of Houston with a bullet wound still in my chest? Pop, I probably shouldn't be driving." Dominique drove the last five hours home.

Back in McAllen, neighbors passed on their sympathies, dumbfounded that the Pean's “well-behaved" middle child, the son of a “respected doctor," had been shot. Just as Harold years before had sewn up the gash in Christian's head left by a racially charged fistfight, he and Christian now tended to the piercing pain in Alan's ribs and changed the dressings of his wound.

That Alan survived a gunshot to the chest meant he faced a messy legal thicket. The police charged him with two counts of aggravated assault of a police officer and, three months after the shooting, added a third charge of reckless driving. The criminal charges shocked his family.

“At the time, I thought the police and the hospital would apologize, or go to jail," said Dominique. “If a doctor amputated the wrong leg, there would be instant changes." A lawyer for the family readied a lawsuit against the hospital and demanded the federal government investigate the hospital's practice of allowing armed security officers into patients' rooms.

The seed of injustice planted in Alan's chest took root in the Pean family.

In October 2015, two months after the shooting, Christian summoned the family from Texas to New York City to march in a #RiseUpOctober protest against police brutality. On a brisk fall day, the five Peans held hands in Washington Square Park wearing custom-made T-shirts that read, “Medicine, Not Bullets." Quentin Tarantino, the film director, had flown in from California for the event, and activist Cornel West addressed the combustive crowd. Families shouted stories of loved ones killed by police.

Harold had never protested before and stood quietly, taking in the crowds and megaphone chants. Paloma embraced the spirit of the march, kissing her sons with hurricane force as the crowd made its way through Lower Manhattan. She found common cause with mothers whose Black sons had not survived their encounters with police. “We were very lucky that my son was alive," Paloma said.

The Peans' attorney had advised Alan not to speak publicly, fearing it would torpedo the lawsuit against the Houston hospital. Christian had his own reservations; he was applying for orthopedic residency programs, a notably conservative field in which only 1.5% of orthopedic surgeons are Black. “Everything is Google-able," he told me. “I wasn't sure what people would think about me being involved in Black Lives Matter or being outspoken."

When protesters began to chant “F— the police!" Christian moved into the crowd to change its tenor. He argued briefly with a white family whose daughter had been shot in the head and killed. This isn't how we move forward, he told them. Christian wanted to summon empathy and unity. Instead, he saw around him boiling vitriol. The protest turned unruly; 11 people were arrested.

Afterward, Alan expressed shock at the crowds, so consumed with anger. Christian wondered, How many of us are out there?

Six months passed, eight months. Expectations of quick justice left the Pean family like a breath. The Houston Police Department declined to discipline the two officers who tased and shot Alan. Mark Bernard, then chief executive officer of St. Joseph hospital, told federal investigators that given the same circumstances, the officers “would not have done anything different."

A brief reprieve arrived in March 2016, when a Harris County grand jury declined to indict Alan on criminal assault charges, and the district attorney's office dropped the reckless driving charge. The family's civil lawsuit against the hospital; its corporate owner, IASIS Healthcare Corp.; Criterion Healthcare Security; the city of Houston; and the police officers dragged on, one lawyer replaced by another, draining the family checkbook.

The Peans, meanwhile, registered each new death of a Black person killed by police as if Alan were shot once more. “It was all I could think about, I had dreams about it," Dominique said. “I felt powerless." Memories stored away resurfaced, eliciting doubts about a trail of misunderstood clues and neon warnings. Dominique had been close in age to Trayvon Martin when the Florida teenager was killed in 2012. Dominique remembers thinking, “It's terrible, it's wrong, but it would never happen with me. I have nice clothes on. I'm going to get my master's and become a doctor."

Even Uncle Leslie, who each year donated generously to the Fraternal Order of Police and had brushed off the numerous times police had stopped his car, caved under the overwhelming evidence. “I never related to the police killings until it happened to us," he confessed. “Now I doubt about whether they are protecting society as a whole." He has stopped giving money to the police association.

By 2017, Christian, Alan and Dominique had reunited in New York City. For a time, they shared an apartment in East Harlem. Their industrious lives resumed in haste; young men with advanced degrees to earn, careers to forge, loves to be found, just as their parents had done at that dud of a party in Veracruz.

Primed by his own experiences, the nick on his forehead a reminder of earlier battles, Christian pressed the family to speak out. Appointed the family spokesperson, he expanded the problems that would need fixing to guarantee the safety of Black men on the streets and in hospitals: racial profiling, health care inequities, the dearth of Black medical students. Working at a feverish pace, he aced crushing med school exams and pressed more than 1,000 medical professionals across the country to sign a petition protesting Alan's shooting and the use of armed security guards in hospitals.

“My perspective was, we should be public about this," Christian said. “We don't have anything to hide."

He embraced activism as part of his career, even if it meant navigating orthopedic residency interviews with white surgeons who eyed his résumé with skepticism. Would he be too distracted to be a good surgeon? He delivered a speech at his medical school graduation, and wrote a textbook chapter and spoke at the Mayo Clinic on health care inequities. Medical school deans asked Christian to help shape their response to the deaths of Breonna Taylor and George Floyd, and friends sought out his opinion. “For many people, I'm their only Black friend," he said. Christian has told the story of Alan's shooting over and over, at physician conferences and medical schools to shine a bright light on structural racism.

Over the months we spoke, Christian, now 33, juggled long days and nights as chief resident of orthopedic trauma at Jamaica Hospital in Queens with his commitments to Physicians for Criminal Justice Reform, Orthopedic Relief Services International and academic diversity panels. He is the über-polymath, coolly cerebral in the operating room and magnetic and winning in his burgeoning career as a thought leader.

Christian's family imagines he will run for office someday, a congressman, maybe. “He's charismatic, he has good ideas," said Dominique. “He's got big plans."

Dominique, too, has tried to spread the gospel, pushing for action where he could. He led an event in 2016 at the University of North Texas in Fort Worth using Alan's story as a case study in the catastrophic collision of racism, mental health and guns in hospitals.

When he moved to New York for medical school, joining his brothers, Dominique was anxious when he spotted police officers on the street. “I would try to be more peppy or upbeat, like whistling Vivaldi." But with each death — Stephon Clark, Atatiana Jefferson, Breonna Taylor, Daniel Prude, George Floyd, Rayshard Brooks, Daunte Wright — he has come to view these offerings as pointless. “After Alan, it doesn't matter how big I smile," Dominique decided.

Now 29 and a third-year medical student at Touro College of Osteopathic Medicine in Harlem, he said, “You can have all these resources and it doesn't mean anything because of the color of your skin, because there is a system in place that works against you. It's been so many years, and we didn't get justice."

Dominique has devised a routine for each new shooting: watch the videos of Black men and women killed by police or white vigilantes and read about their cases. Then set them aside and pivot back to his studies and school where there are few other Black doctors in training.

“I can escape by doing that," he told me. “I still need to do well for myself."

For Alan, as the years passed, time took on a bendable quality. It snapped straight with purpose — a talk show appearance on “The Dr. Oz Show," presentations with his brothers at medical schools in Texas, Massachusetts and Connecticut — and then lost its shape to resignation. Survival had bought him an uneasy liberty: He feared squandering the emotional potency of his own story but remained squeamish at the prostrations demanded by daytime TV shows, the tedium of repeating his story in front of strangers, doubting whether his life's misfortune was fueling social progress or exploiting a private tragedy.

In 2017, Alan enrolled at the City University of New York to study health care management, digging into a blizzard of statistics about police shootings and patients in crisis, and transferred the following year to a similar program at Mount Sinai. But by last fall, Alan had settled into a personal malaise. He dropped out of Mount Sinai's program, and spent hours in his room, restless and uncertain.

“I'm still working with coming to terms with who I am, my position in the family," said Alan, 32. “Christian is an orthopedic surgeon. Dominique is in medical school." After years of pursuing various degrees (biology, health care management, physician assistant, public health), that might not be who he is after all.

“Inside I didn't want to do it," he said. “It translates as a failure."

“Alan goes back and forth about whether he wants to write about it or go back to his regular life," Christian said. “I see him all the time, every day, being disappointed in himself for not being more outspoken, not feeling the free will to choose what to do with this thing."

Isn't it enough that he survived?

Alan sees a therapist and takes medication for bipolar disorder. He practices yoga. When he breathes deeply, his chest tingles, most likely nerve damage from where the bullet pierced. After a great deal of thinking, he has turned to writing science fiction and posting it online. The writing comes easily, mostly stories of his delusions told with exquisite detail — people, good and bad, with him in a place “that looks like Hell."

Outside of his apartment in New York, there are few places he can find sanctuary. Even as the coronavirus emptied the streets, he walked around the city, his eyes scanning for police cars, police uniforms, each venture to the store a tactical challenge. He selects his clothes carefully. “Never before 2015 had police officers stood out to me. Now, if they are a block away, I see them. That's how real the threat is. I have to think, 'What am I wearing? Do I have my ID? Which direction am I going?'

“If I were a white person, do they ever think those things?"

Reports of new shootings stir up his own trauma, and Alan trembles at the betrayal. “Why is it so hard to register that an unarmed person should not be shot?"

Covid presented new trauma for the Pean family, and underscored the nation's racial divide. The three brothers largely were confined to their apartment. Dominique attended medical school classes online while Christian volunteered to work at Bellevue, a public hospital struggling to treat a torrent of covid patients who were dying at a terrifying pace. Many patients spoke only Spanish, and Christian served as both physician and interpreter.

The patients coming to Bellevue were nearly all Black or Latino and poor, and Christian grew angrier each day as he saw wealthier private hospitals, including NYU Langone just a few blocks away, showered with resources. The gaping death rates between the two hospitals would prove startling: About 11% of covid patients died at NYU Langone; at Bellevue, about 22% died. “This wasn't the kind of death I was used to," Christian said.

At the peak of the epidemic in New York, Christian video-called his dad at home in Mission, Texas, and cried, exhausted and overwhelmed. Harold and Paloma had largely shuttered their clinic after several staff members became infected, but Harold continued to see urgent cases. Knowing the dangers to front-line health care workers, Christian was scared for his parents. “I was worried my dad wasn't going to protect himself," he said. “And that I was going to lose one of my parents and I wasn't going to be able to say goodbye."

All that was stirring inside Christian when Minneapolis police officer Derek Chauvin callously murdered George Floyd in May 2020, sparking protests across the globe. Black Lives Matter demonstrators filled New York City's streets, and Christian and Dominique joined them. Alan did not; the lockdown and blaring ambulance sirens had left him anxious and hypervigilant, and after months indoors, he feared open spaces.

“I'm going to wait this one out," he told Christian.

On the streets, surrounded by the fury and calls for change, Christian wore his white doctor's coat, a potent symbol of solidarity. “I wanted to show that people who were on the front lines of the pandemic realized who the pandemic was affecting was reflective of the racism that led to George Floyd's death." When they returned home, Christian told Alan that the multiethnic makeup of the protesters surprised him. “I think maybe people's minds are changing," Christian said. “It was beautiful to see."

Nearly a year later, on April 20, 2021, a jury found Chauvin guilty of murder, and Christian felt a wash of relief. But in the days that followed, news coverage erupted about the fatal police shooting of a 13-year-old Latino boy in Chicago, and the death of a 16-year-old Black girl in Columbus, Ohio, also at the hands of police. The Pean family was unusually muted. “We only exchanged a few texts about it as a family," Christian said. “We said maybe things are changing, maybe not."

The Pean sons will scatter soon: Christian to Harvard University for a trauma surgery fellowship; Dominique to medical rotations at Nassau University Medical Center; and Alan to McAllen, where he will oversee the financial operations of his parents' business. It will be Alan's first time living alone. “The one semester I was almost going to live by myself I was in Houston, and I got shot. I need to do this by myself to know I can."

Watching violence unravel one of his son's lives has haunted Dr. Harold Pean — the threats to Black lives in American cities not escaped as easily as a Haitian dictator.

But Harold, 66, is reluctant to allow Alan's shooting to rewrite his American gospel; the shooting was a personal tragedy, not a transmutation of his identity. He pushes the memories from his mind when they appear and summons generosity. “Whatever the bad stuff, I keep it inside. I try to psych myself to think positively all the time," he said. “I want to see everyone like a human."

He has convinced himself that no more violence will befall his sons or, someday, his grandchildren. Still, he can no longer reconcile the tragedy of Alan's shooting with his Catholic beliefs. “If God was powerful, a lot of bad things would not have happened," he said.

“It's difficult for him to acknowledge that he's struggling," Christian said of his father. “He's a resilient person. He's never talked about the added burden of being a Black man in America."

“I think Paloma is the one keeping my brother together," Uncle Leslie told me.

But who is keeping Paloma together? To her sons, her husband, her fellow parishioners, Paloma, 63, brims with purpose. She's a fighter, an idealist. But at night, she sleeps with the phone beside her bed. When it rings, she jumps. Are you OK? In her dreams, she is often in danger. Many nights, she lies awake and talks aloud to God. “Why? For what? Tell me, Lord." (She speaks to the Lord in Spanish. “In English, I think he will not understand me!")

Paloma's activism is quietly public: her presence in the community of mostly white doctors; her motherly boasts about Christian and Dominique becoming physicians and Alan's return to McAllen; her insistence that racism is real in a part of the country where “White Lives Matter" signs abound. “I'm on a mission," she said. “I want to disarm hate."

But deep within her, that sense of purpose lives beside a fury she can't quell and a disappointment so profound it can make it hard to breathe. She wonders if God is punishing her for abandoning Mexico, and whether the U.S. soil in which she chose to grow her own family is poisoned. “Sometimes I feel like I want to leave everything," she told me. “I feel like I don't understand how people can be so selfish here in America."

They are dark thoughts that go largely unspoken, secrets kept even from her mother, age 90, who now lives with them in McAllen. Six years have passed since Alan was shot, and Paloma still has not told her mother what happened in that Houston hospital room. Nor will she ever.

“The pain I went through," Paloma said, “I don't want to give that pain to my mom."

Subscribe to KHN's free Morning Briefing.

Don't Sit on the Sidelines of History. Join Raw Story Investigates and Go Ad-Free. Support Honest Journalism.