Arthur Allen: Why patients who could most benefit from Paxlovid aren't getting it

From Kaiser Family Foundation Health News

“Proactive and health-literate people get the drug. Those who are receiving information more passively have no idea whether it’s important or harmful.’’

— Michael Barnett, M.D., a primary-care physician at Brigham and Women’s Hospital, in Boston, and an associate professor at Harvard Medical School

Evangelical minister Eddie Hyatt believes in the healing power of prayer but “also the medical approach.” So on a February evening a week before scheduled prostate surgery, he had his sore throat checked out at an emergency room near his home in Grapevine, Texas.

A doctor confirmed that Hyatt had COVID-19 and sent him to CVS with a prescription for the antiviral drug Paxlovid, the generally recommended medicine to fight COVID. Hyatt handed the pharmacist the script, but then, he said, “She kept avoiding me.”

She finally looked up from her computer and said, “It’s $1,600.”

The generally healthy 76-year-old went out to the car to consult his wife about their credit-card limits. “I don’t think I’ve ever spent more than $20 on a prescription,” the astonished Hyatt recalled.

That kind of sticker shock has stunned thousands of sick Americans since late December, as Pfizer shifted to commercial sales of Paxlovid. Before then, the federal government covered the cost of the drug.

The price is one reason that Paxlovid is not reaching those who need it most. And patients who qualify for free doses, which Pfizer offers under an agreement with the federal government, often don’t realize it or know how to get them.

“If you want to create a barrier to people getting a treatment, making it cost a lot is the way to do it,” said William Schaffner, M.D., a professor at Vanderbilt University School of Medicine and spokesperson for the National Foundation for Infectious Diseases.

Public and medical awareness of Paxlovid’s benefits is low, and putting people through an application process to get the drug when they’re sick is a non-starter, Schaffner said. Pfizer says it takes only five minutes online.

It’s not an easy drug to use. Doctors are wary about prescribing it because of dangerous interactions with common drugs that treat cholesterol, blood clots and other conditions. It must be taken within five days of the first symptoms. It leaves a foul taste in the mouth. In one study, 1 in 5 patients reported “rebound” COVID symptoms a few days after finishing the medicine — though rebound can also occur without Paxlovid.

A recent JAMA Network study found that sick people 85 and older were less likely than younger Medicare patients to get COVID therapies such as Paxlovid. The drug might have prevented up to 27,000 deaths in 2022 if it had been allocated based on which patients were at highest risk from COVID. Nursing-home patients, who account for around 1 in 6 U.S. COVID deaths, were about two-thirds as likely as other older adults to get the drug.

Shrunken confidence in government health programs is one reason the drug isn’t reaching those who need it. In senior living facilities, “a lack of clear information and misinformation” are “causing residents and their families to be reluctant to take the necessary steps to reduce covid risks,” said David Gifford, chief medical officer for an association representing 14,000 health-care providers, many in senior care.

The anti-vaxxers spreading falsehoods about vaccines have targeted Paxlovid as well. Some call themselves anti-paxxers.

“Proactive and health-literate people get the drug. Those who are receiving information more passively have no idea whether it’s important or harmful,” said Michael Barnett, a primary-care physician at Brigham and Women’s Hospital and an associate professor at Harvard, who led the JAMA Network study.

In fact, the drug is still free for those who are uninsured or enrolled in Medicare, Medicaid, or other federal health programs, including those for veterans.

That’s what rescued Hyatt, whose Department of Veterans Affairs health plan doesn’t normally cover outpatient drugs. While he searched on his phone for a solution, the pharmacist’s assistant suddenly appeared from the store. “It won’t cost you anything!” she said.

As Hyatt’s case suggests, it helps to know to ask for free Paxlovid, although federal officials say they’ve educated clinicians and pharmacists — like the one who helped Hyatt — about the program.

“There is still a heaven!” Hyatt replied. After he had been on Paxlovid for a few days his symptoms were gone and his surgery was rescheduled.

About That $1,390 List Price

Pfizer sold the U.S. government 23.7 million five-day courses of Paxlovid, produced under an FDA emergency authorization, in 2021 and 2022, at a price of around $530 each.

Under the new agreement, Pfizer commits to provide the drug for the beneficiaries of the government insurance programs. Meanwhile, Pfizer bills insurers for some portion of the $1,390 list price. Some patients say pharmacies have quoted them prices of $1,600 or more.

How exactly Pfizer arrived at that price isn’t clear. Pfizer won’t say. A Harvard study last year estimated that the cost of producing generic Paxlovid at about $15 per treatment course, including manufacturing expenses, a 10 percent profit markup, and 27 percent in taxes.

Pfizer reported $12.5 billion in Paxlovid and COVID-vaccine sales in 2023, after a $57 billion peak in 2022. The company’s 2024 Super Bowl ad, which cost an estimated $14 million to place, focused on Pfizer’s cancer drug pipeline, newly reinforced with its $43 billion purchase of biotech company Seagen. Unlike some other recent oft-aired Pfizer ads (“If it’s covid, Paxlovid”), it didn’t mention COVID products.

Connecting With Patients

The other problem is getting the drug where it is needed. “We negotiated really hard with Pfizer to make sure that Paxlovid would be available to Americans the way they were accustomed to,” Department of Health and Human Services Secretary Xavier Becerra told reporters in February. “If you have private insurance, it should not cost you much money, certainly not more than $100.”

Yet in nursing homes, getting Paxlovid is particularly cumbersome, said Chad Worz, CEO of the American Society of Consultant Pharmacists, specialists who provide medicines to care homes.

If someone in long-term care tests positive for COVID, the nurse tells the physician, who orders the drug from a pharmacist, who may report back that the patient is on several drugs that interact with Paxlovid, Worz said. Figuring out which drugs to stop temporarily requires further consultations while the time for efficacious use of Paxlovid dwindles, he said.

His group tried to get the FDA to approve a shortcut similar to the standing orders that enable pharmacists to deliver anti-influenza medications when there are flu outbreaks in nursing homes, Worz said. “We were close,” he said, but “it just never came to fruition.” “The FDA is unable to comment,” spokesperson Chanapa Tantibanchachai said.

Los Angeles County requires nursing homes to offer any covid-positive patient an antiviral, but the Centers for Medicare & Medicaid Services, which oversees nursing homes nationwide, has not issued similar guidance. “And this is a mistake,” said Karl Steinberg, chief medical officer for two nursing home chains with facilities in San Diego County, which also has no such mandate. A requirement would ensure the patient “isn’t going to fall through the cracks,” he said.

While it hasn’t ordered doctors to prescribe Paxlovid, CMS on Jan. 4 issued detailed instructions to health insurers urging swift approval of Paxlovid prescriptions, given the five-day window for the drug’s efficacy. It also “encourages” plans to make sure pharmacists know about the free Paxlovid arrangement.

Current COVID strains appear less virulent than those that circulated earlier in the pandemic, and years of vaccination and covid infection have left fewer people at risk of grave outcomes. But risk remains, particularly among older seniors, who account for most COVID deaths, which number more than 13,500 so far this year in the U.S.

Steinberg, who sees patients in 15 residences, said he orders Paxlovid even for COVID-positive patients without symptoms. None of the 30 to 40 patients whom he prescribed the drug in the past year needed hospitalization, he said; two stopped taking it because of nausea or the foul taste, a pertinent concern in older people whose appetites already have ebbed.

Steinberg said he knew of two patients who died of COVID in his companies’ facilities this year. Neither was on Paxlovid. He can’t be sure the drug would have made a difference, but he’s not taking any chances. The benefits, he said, outweigh the risks.

Arthur Allen is a Kaiser Family Foundation Health News reporter. Reporter Colleen DeGuzman contributed to this report.

Amy Maxmen: Right wingers' battle against science and facts imperils public health

The American Institute for Economic Research, in the wealthy Berkshires town of Great Barrington, Mass. The right-wing think tank has been a center of anti-science activism, at least when the science is defended by Democrats.

— Photby Dariusz Jemielniak ("pundit")

From Kaiser Family Foundation Health News

Rates of routine childhood vaccination in America hit a 10-year low in 2023. That, according to the Centers for Disease Control and Prevention, puts about 250,000 kindergartners at risk for measles, which often leads to hospitalization and can cause death. In recent weeks, an infant and two young children have been hospitalized amid an ongoing measles outbreak in Philadelphia that spread to a day care center.

It’s a dangerous shift driven by a critical mass of people who now reject decades of science backing the safety and effectiveness of childhood vaccines. State by state, they’ve persuaded legislators and courts to more easily allow children to enter kindergarten without vaccines, citing religious, spiritual, or philosophical beliefs.

Growing vaccine hesitancy is just a small part of a broader rejection of scientific expertise that could have consequences ranging from disease outbreaks to reduced funding for research that leads to new treatments. “The term ‘infodemic’ implies random junk, but that’s wrong,” said Peter Hotez, a vaccine researcher at Baylor College of Medicine in Texas. “This is an organized political movement, and the health and science sectors don’t know what to do.”

Changing views among Republicans have steered the relaxation of childhood vaccine requirements, according to the Pew Research Center. Whereas nearly 80% of Republicans supported the rules in 2019, fewer than 60% do today. Democrats have held steady, with about 85% supporting. Mississippi, which once boasted the nation’s highest rates of childhood vaccination, began allowing religious exemptions last summer. Another leader in vaccination, West Virginia, is moving to do the same.

An anti-science movement picked up pace as Republican and Democratic perspectives on science diverged during the pandemic. Whereas 70% of Republicans said that science has a mostly positive impact on society in 2019, less than half felt that way in a November poll from Pew. With presidential candidates lending airtime to anti-vaccine messages and members of Congress maligning scientists and pandemic-era public health policies, the partisan rift will likely widen in the run-up to November’s elections.

Dorit Reiss, a vaccine policy researcher at the University of California Law San Francisco, draws parallels between today’s backlash against public health and the early days of climate change denial. Both issues progressed from nonpartisan, fringe movements to the mainstream once they appealed to conservatives and libertarians, who traditionally seek to limit government regulation. “Even if people weren’t anti-vaccine to start with,” Reiss said, “they move that way when the argument fits.”

Even certain actors are the same. In the late ’90s and early 2000s, a right-wing think tank, the American Institute for Economic Research, undermined climate scientists with reports that questioned global warming. The same institute issued a statement early in the pandemic, grandly called the “Great Barrington Declaration.” It argued against measures to curb the disease and advised everyone — except the most vulnerable — to go about their lives as usual, regardless of the risk of infection. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, warned that such an approach would overwhelm health systems and put millions more at risk of disability and death from COVID. “Allowing a dangerous virus that we don’t fully understand to run free is simply unethical,” he said.

Another group, the National Federation of Independent Business, has fought regulatory measures to curb climate change for over a decade. It moved on to vaccines in 2022 when it won a Supreme Court case that overturned a government effort to temporarily require employers to mandate that workers either be vaccinated against covid or wear a face mask and test on a regular basis. Around 1,000 to 3,000 COVID deaths would have been averted in 2022 had the court upheld the rule, one study estimates.

Politically charged pushback may become better funded and more organized if public health becomes a political flashpoint in the lead-up to the presidential election. In the first few days of 2024, Florida’s surgeon general, appointed by Ron DeSantis, the former Republican and still Florida governor, called for a halt to use of mRNA covid vaccines as he echoed DeSantis’s incorrect statement that the shots have “not been proven to be safe and effective.” And vaccine skeptic Robert F. Kennedy Jr., who is running for president as an independent, announced that his campaign communications would be led by Del Bigtree, the executive director of one of the most well-heeled anti-vaccine organizations in the nation and host of a conspiratorial talk show. Bigtree posted a letter on the day of the announcement rife with misinformation, such as a baseless rumor that covid vaccines make people more prone to infection. He and Kennedy frequently pair health misinformation with terms that appeal to anti-government ideologies like “medical freedom” and “religious freedom.”

A product of a Democratic dynasty, Kennedy’s appeal appears to be stronger among Republicans, a Politico analysis found. DeSantis said he would consider nominating Kennedy to run the FDA, which approves drugs and vaccines, or the CDC, which advises on vaccines and other public health measures. Another fotmer Republican candidate for president, Vivek Ramaswamy, had vowed to gut the CDC should he win.

Today’s anti-science movement found its footing in the months before the 2020 elections, as primarily Republican politicians rallied support from constituents who resented such pandemic measures as masking and the closure of businesses, churches, and schools. Then-President Donald Trump, for example, mocked Joe Biden for wearing a mask at the presidential debate in September 2020.

Democrats fueled the politicization of public health, too, by blaming Republican leaders for the country’s soaring death rates, rather than decrying systemic issues that rendered the U.S. vulnerable, such as underfunded health departments and severe economic inequality that put some groups at far higher risk than others. Just before Election Day, a Democratic-led congressional subcommittee released a report that called the Trump administration’s pandemic response “among the worst failures of leadership in American history.”

Republicans launched a subcommittee investigation into the pandemic that sharply criticizes scientific institutions and scientists once seen as nonpartisan. On Jan. 8 and 9, the group questioned Anthony Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases in 1984-2022 and a leading infectious-disease researcher. Without evidence, committee member Marjorie Taylor Greene (R.-Ga.) accused Fauci of supporting research that created the coronavirus in order to push vaccines: “He belongs in jail for that,” Greene, a vaccine skeptic, said. “This is like a, more of an evil version of science.”

Taking a cue from environmental advocacy groups that have tried to fight strategic and monied efforts to block energy regulations, Hotez and other researchers say public health needs supporters knowledgeable in legal and political arenas. Such groups might combat policies that limit public health power, advise lawmakers, and provide legal counsel to scientists who are harassed or called before Congress in politically charged hearings.

Other initiatives aim to present the scientific consensus clearly to avoid both-sidesism, in which the media presents opposing viewpoints as equal when, in fact, the majority of researchers and bulk of evidence point in one direction. Oil and tobacco companies used this tactic effectively to seed doubt about the science linking their industries to harm.

Kathleen Hall Jamieson, director of the Annenberg Public Policy Center, at the University of Pennsylvania, said the scientific community must improve its communication. Expertise, alone, is insufficient when people mistrust the experts’ motives. Indeed, nearly 40% of Republicans report little to no confidence in scientists to act in the public’s best interest.

In a study published last year, Jamieson and colleagues identified attributes the public values beyond expertise, including transparency about unknowns and self-correction. Researchers might have better managed expectations around covid vaccines, for example, by emphasizing that the protection conferred by most vaccines is less than 100% and wanes over time, requiring additional shots, Jamieson said. And when the initial covid vaccine trials demonstrated that the shots drastically curbed hospitalization and death but revealed little about infections, public health officials might have been more open about their uncertainty.

As a result, many people felt betrayed when COVID vaccines only moderately reduced the risk of infection. “We were promised that the vaccine would stop transmission, only to find out that wasn’t completely true, and America noticed,” said Rep. Brad Wenstrup (R.-Ohio), chair of the Republican-led coronavirus subcommittee, at a July hearing.

Jamieson also advises repetition. It’s a technique expertly deployed by those who promote misinformation, which perhaps explains why the number of people who believe the anti-parasitic drug ivermectin treats covid more than doubled over the past two years — despite persistent evidence to the contrary. In November, the drug got another shoutout at a hearing where congressional Republicans alleged that the Biden administration and science agencies had censored public health information.

Hotez, author of a new book on the rise of the anti-science movement, fears the worst. “Mistrust in science is going to accelerate,” he said.

And traditional efforts to combat misinformation, such as debunking, may prove ineffective.

“It’s very problematic,” Jamieson said, “when the sources we turn to for corrective knowledge have been discredited.”

Amy Maxmen is a Kaiser Family Health News reporter.

Mixed messaging of vaccine skeptics sows seeds of doubt

An early 19th-Century satire of antivaxxers by Isaac Cruikshank

Headquarters, in Cambridge, Mass., of Moderna, one of the major COVID-19 vaccine makers

From Kaiser Family Foundation Health News

“It seems to me to be implying the government knows the vaccine to be unsafe” and that it’s “covering it up.’’

— Matt Motta, a political scientist at Boston University specializing in public health and vaccine politics

It was a late-spring House of Representatives hearing, where members of Congress and attendees hoped to learn lessons from the pandemic. Witness Marty Makary made a plea.

“I want to thank you for your attempts at civility,” Makary, a Johns Hopkins Medicine researcher and surgeon, said softly. Then his tone changed. His voice started to rise, blasting the “intellectual dishonesty” and “very bizarre” decisions of public health officials. Much later, he criticized the “cult” of his critics, some of whom “clap like seals” when certain studies are published. Some critics are “public health oligarchs,” he said.

Makary was a marquee witness for this meeting of the Select Subcommittee on the Coronavirus Pandemic. His testimony had the rhythm of a two-step — alternating between an extended hand and a harsh rhetorical slap. It’s a characteristic move of this panel, a Republican-led effort to review the response to the pandemic. Both sides of the aisle join in the dance, as members claim to seek cooperation and productive discussions before attacking their preferred coronavirus villains.

One target of the subcommittee’s Republican members has drawn concern from public health experts: COVID-19 vaccines. Because the attacks range from subtle to overt, there’s a fear all vaccines could end up as collateral damage.

During that May 11 hearing, Republican members repeatedly raised questions about coronavirus vaccines. Right-wing star Rep. Marjorie Taylor Greene (R.-Ga.) emphasized the vaccines were “experimental” and fellow Georgia Republican Rep. Rich McCormick, an emergency room physician, argued the government was “pushing” Federal Drug Administration-approved boosters “with no evidence and possible real harm.”

Some Republican members, who have been investigating for months various pandemic-related matters, are keen to say they’re supportive of vaccines — just not many of the policies surrounding COVID vaccines. Rep. Brad Wenstrup (R.-Ohio), who chairs the subcommittee, has said he supports vaccines and claimed he’s worried about declining vaccination rates.

During the May hearing, he also two-stepped, arguing the COVID shots were “safe as we know it, to a certain point.” He questioned the government’s safety apparatus, including VAERS, the Vaccine Adverse Event Reporting System, a database that receives reports potentially connected to vaccines. He said the committee would be “looking” at it “to make sure it’s honest and to be trusted.”

It’s this two-step — at once proclaiming oneself in favor of vaccines, while validating concerns of vaccine-skeptical audiences — that has sparked worries of deeper vaccine hesitancy taking root.

“It seems to me to be implying the government knows the vaccine to be unsafe” and that it’s “covering it up,” said Matt Motta, a political scientist at Boston University specializing in public health and vaccine politics. The implication validates some long-held fringe theories about vaccinations, without completely embracing “conspiracism,” he said.

Vaccine skeptics run the gamut from individuals with scientific credentials who nevertheless oppose public health policies from a libertarian perspective to individuals endorsing theories about widespread adverse events, or arguing against the need for multiple shots. VAERS is a favorite topic among the latter group. When one witness testifying during the May 11 hearing attempted to defend covid vaccination policies, Taylor Greene cited the number of reports to VAERS as evidence of the vaccines’ lack of safety.

That muddles the purpose of the database, Motta said, which gathers unverified and verified reports alike. It’s a signal, not a diagnosis. “It’s more like a smoke alarm,” he said. “It goes off when there’s a fire. But it also goes off when you’ve left an omelet on the stove too long.”

In a March hearing focusing on school reopening policies, Democratic members of the panel and a witness from a school nurses association frequently touted the important role covid vaccines played in enabling schools to reopen. Wenstrup offered generalized skepticism. “I heard we were able to get more vaccines for the children,” he said. “We didn’t know fully if they needed it. A lot of data would show they don’t need to vaccinate.”

Witnesses can eagerly play into vaccine-skeptical narratives. After a question from Taylor Greene premised on the idea that the covid vaccines “are not vaccines at all,” and alleging the government is spreading misinformation about their effectiveness, Makary suggested that while he was not anti-vaccine, it was understandable others were. “I understand why they are angry,” he said, in response. “They’ve been lied to,” he said, before criticizing evidence standards for the newest covid boosters, tailored to combat emerging variants.

The signals aren’t lost on audiences. The subcommittee has, like most congressional panels, posted important moments from its hearings to Twitter. Anti-vaccine activists and other public health skeptics reply frequently.

“It’s hard for me to think of a historical analogue for this — it’s not often that we have a Congressional committee producing content that has its fingers on the pulse of the anti-vaccine community,” Motta wrote in an e-mail, after reviewing many of the subcommittee’s tweets. “The committee isn’t expressly endorsing anti-vaccine positions, beyond opposition to vaccine mandates; but I think it’s quite possible that anti-vaccine activists take this information and run with it.”

Motta’s concern is echoed by the panel’s Democratic members. “I pray this hearing does not add to vaccine hesitancy,” said Rep. Kweisi Mfume (D.-Md.), who represents Baltimore.

One witness reiterated that point. Many members “have a lot of skepticism about vaccines and were not afraid to express that,” Tina Tan, a specialist in pediatric infectious diseases at Northwestern University, told KFF Health News. She testified at the hearing on behalf of the minority.

Polling is showing a substantial — and politically driven — level of vaccine skepticism that reaches beyond covid. A slim minority of the country is up to date on vaccinations against the coronavirus, including the bivalent booster. And the share of kindergartners receiving the usual round of required vaccines — the measles, mumps, and rubella, or MMR, inoculation; tetanus; and chickenpox among them — dropped in the 2021-22 school year, according to the Centers for Disease Control and Prevention. Support for leaving vaccination choices to parents, not as school requirements, has risen by 12 percentage points since just before the pandemic, mostly due to a drop among Republicans, according to a recent poll by the Pew Research Center.

And vaccine skepticism is resonating beyond the halls of Congress. Some state governments are considering measures to roll back vaccine mandates for children. As part of a May 18 procedural opinion, Supreme Court Justice Neil Gorsuch cited two vaccination mandates — one in the workplace, and one for service members — and wrote that Americans “may have experienced the greatest intrusions on civil liberties in the peacetime history of this country.” He made this assertion even though American military personnel have routinely been required to get shots for a host of diseases.

“We can’t get to a spot where we’re implicitly or explicitly sowing distrust of vaccines,” cautioned California Rep. Raul Ruiz, the Democratic ranking member of the coronavirus subcommittee.

Darius Tahir is a Kaiser Family Foundation Health News reporter.
DariusT@kff.org, @dariustahir

Judith Graham: What elderly people should know about taking Paxlovid for COVID

Paxlovid blister pack

— Photo by Kches16414

From Kaiser Health News

“There’s lots of evidence that Paxlovid can reduce the risk of catastrophic events that can follow infection with COVID in older individuals.’’

— Dr. Harlan Krumholz, a professor of medicine at Yale University

A new coronavirus variant is circulating, the most transmissible one yet. Hospitalizations of infected patients are rising. And older adults represent nearly 90% of U.S. deaths from COVID-19 in recent months, the largest portion since the start of the pandemic.

What does that mean for people 65 and older catching COVID for the first time or those experiencing a repeat infection?

The message from infectious-disease experts and geriatricians is clear: Seek treatment with antiviral therapy, which remains effective against new COVID variants.

The therapy of first choice, experts said, is Paxlovid, an antiviral treatment for people with mild to moderate COVID at high risk of becoming seriously ill from the virus. All adults 65 and up fall in that category. If people can’t tolerate the medication — potential complications with other drugs need to be carefully evaluated by a medical provider — two alternatives are available.

“There’s lots of evidence that Paxlovid can reduce the risk of catastrophic events that can follow infection with COVID in older individuals,” said Dr. Harlan Krumholz, a professor of medicine at Yale University.

Meanwhile, develop a plan for what you’ll do if you get the disease. Where will you seek care? What if you can’t get in quickly to see your doctor, a common problem? You need to act fast since Paxlovid must be started no later than five days after the onset of symptoms. Will you need to adjust your medication regimen to guard against potentially dangerous drug interactions?

“The time to be figuring all this out is before you get COVID,” said Dr. Allison Weinmann, an infectious-disease expert at Henry Ford Hospital, in Detroit.

Being prepared proved essential when I caught COVID in mid-December and went to urgent care for a prescription. Because I’m 67, with blood cancer and autoimmune illness, I’m at elevated risk of getting severely ill from the virus. But I take a blood thinner that can have life-threatening interactions with Paxlovid.

Fortunately, the urgent-care center could see my electronic medical record, and a physician’s note there said it was safe for me to stop the blood thinner and get the treatment. (I’d consulted with my oncologist in advance.) So, I walked away with a Paxlovid prescription, and within a day my headaches and chills had disappeared.

Just before getting COVID, I’d read an important study of nearly 45,000 patients 50 and older treated for the disease between January and July 2022 at Mass General Brigham, the large Massachusetts health system. Twenty-eight percent of the patients were prescribed Paxlovid, which had received an emergency use authorization for mild to moderate covid from the FDA in December 2021; 72% were not. All were outpatients.

Unlike in other studies, most of the patients in this one had been vaccinated. Still, Paxlovid conferred a notable advantage: Those who took it were 44% less likely to be hospitalized with severe COVID-related illnesses or die. Among those who’d gotten fewer than three vaccine doses, those risks were reduced by 81%.

A few months earlier, a study out of Israel had confirmed the efficacy of Paxlovid — the brand name for a combination of nirmatrelvir and ritonavir — in seniors infected with COVID’s omicron strain, which arose in late 2021. (The original study establishing Paxlovid’s effectiveness had been conducted while the delta strain was prevalent and included only unvaccinated patients.) In patients 65 and older, most of whom had been vaccinated or previously had covid, hospitalizations were reduced by 73% and deaths by 79%.

Still, several factors have obstructed Paxlovid’s use among older adults, including doctors’ concerns about drug interactions and patients’ concerns about possible “rebound” infections and side effects.

Dr. Christina Mangurian, vice dean for faculty and academic affairs at the University of California-San Francisco School of Medicine, encountered several of these issues when both her parents caught covid in July, an episode she chronicled in a recent JAMA article.

First, her father, 84, was told in a virtual medical appointment by a doctor he didn’t know that he couldn’t take Paxlovid because he’s on a blood thinner — a decision later reversed by his primary care physician. Then, her mother, 78, was told, in a separate virtual appointment, to take an antibiotic, steroids, and over-the-counter medications instead of Paxlovid. Once again, her primary care doctor intervened and offered a prescription.

In both cases, Mangurian said, the doctors her parents first saw appeared to misunderstand who should get Paxlovid, and under what conditions. “This points to a major deficit in terms of how information about this therapy is being disseminated to front-line medical providers,” she told me in a phone conversation.

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, agrees. “Every day, I hear from people who are misinformed by their physicians or call-in nurse lines. Generally, they’re being told you can’t get Paxlovid until you’re seriously ill — which is just the opposite of what’s recommended. Why are we not doing more to educate the medical community?”

The potential for drug interactions with Paxlovid is a significant concern, especially in older patients with multiple medical conditions. More than 120 medications have been flagged for interactions, and each case needs to be evaluated, taking into account an individual’s conditions, as well as kidney and liver function.

The good news, experts say, is that most potential interactions can be managed, either by temporarily stopping a medication while taking Paxlovid or reducing the dose.

“It takes a little extra work, but there are resources and systems in place that can help practitioners figure out what they should do,” said Brian Isetts, a professor at the University of Minnesota College of Pharmacy.

In nursing homes, patients and families should ask to speak to consultant pharmacists if they’re told antiviral therapy isn’t recommended, Isetts suggested.

About 10% of patients can’t take Paxlovid because of potential drug interactions, according to Dr. Scott Dryden-Peterson, medical director of COVID outpatient therapy for Mass General Brigham. For them, Veklury (remdesivir), an antiviral infusion therapy delivered on three consecutive days, is a good option, although sometimes difficult to arrange. Also, Lagevrio (molnupiravir), another antiviral pill, can help shorten the duration of symptoms.

Many older adults fear that after taking Paxlovid they’ll get a rebound infection — a sudden resurgence of symptoms after the virus seems to have run its course. But in the vast majority of cases “rebound is very mild and symptoms — usually runny nose, nasal congestion, and sore throat — go away in a few days,” said Dr. Rajesh Gandhi, an infectious-disease physician and professor of medicine at Harvard Medical School.

Gandhi and other physicians I spoke with said the risk of not treating COVID in older adults is far greater than the risk of rebound illness.

Side effects from Paxlovid can include a metallic taste in the mouth, diarrhea, nausea and muscle aches, among others, but serious complications are uncommon. “Consistently, people are tolerating the drug really well,” said Dr. Caroline Harada, associate professor of geriatrics at the University of Alabama-Birmingham Heersink School of Medicine, “and feeling better very quickly.”

Judith Graham is a Kaiser Health News reporter.

khn.navigatingaging@gmail.com, @judith_graham

Omicron boosters: Is salesmanship trumping science?

Moderna headquarters in Cambridge, Mass.

From Kaiser Health News

Last month, the Food and Drug Administration authorized Omicron-specific vaccines (with Moderna’s the best known), accompanied by breathless science-by-press release and a media blitz. Just days after the FDA’s move, the Centers for Disease Control and Prevention followed, recommending updated boosters for anyone age 12 and up who had received at least two doses of the original COVID-19 vaccines. The message to a nation still struggling with the COVID pandemic: The cavalry — in the form of a shot — is coming over the hill.

But for those familiar with the business tactics of the pharmaceutical industry, that exuberant messaging — combined with the lack of completed studies — has caused considerable heartburn and raised an array of unanswered concerns.

The updated shots easily clear the “safe and effective” bar for government authorization. But in the real world, are the Omicron-specific vaccines significantly more protective — and in what ways — than the original COVID vaccines so many have already taken? If so, who would benefit most from the new shots? Since the federal government is purchasing these new vaccines — and many of the original, already purchased vaccines may never find their way into taxpayers’ arms — is the $3.2 billion price tag worth the unclear benefit? Especially when these funds had to be pulled from other covid response efforts, like testing and treatment.

Several members of the CDC advisory committee that voted 13-1 for the recommendation voiced similar questions and concerns, one saying she only “reluctantly” voted in the affirmative.

Some said they set aside their desire for more information and better data and voted yes out of fear of a potential winter COVID surge. They expressed hope that the new vaccines — or at least the vaccination campaign that would accompany their rollout — would put a dent in the number of future cases, hospitalizations, and deaths.

That calculus is, perhaps, understandable at a time when an average of more than 300 Americans are dying of COVID each day.

But it leaves front-line health care providers in the impossible position of trying to advise individual patients whether and when to take the hot new vaccines without complete data and in the face of marketing hype.

Don’t get us wrong. We’re grateful and amazed that Pfizer-BioNTech and Moderna (with assists from the National Institutes of Health and Operation Warp Speed) developed an effective vaccine in record time, freeing the nation from the deadliest phase of the covid pandemic, when thousands were dying each day. The pandemic isn’t over, but the vaccines are largely credited for enabling most of America to return to a semblance of normalcy. We’re both up-to-date with our covid vaccinations and don’t understand why anyone would choose not to be, playing Russian roulette with their health.

But as society moves into the next phase of the pandemic, the pharmaceutical industry may be moving into more familiar territory: developing products that may be a smidgen better than what came before, selling — sometimes overselling — their increased effectiveness in the absence of adequate controlled studies or published data, advertising them as desirable for all when only some stand to benefit significantly, and in all likelihood raising the price later.

This last point is concerning because the government no longer has funds to purchase COVID vaccines after this autumn. Funding to cover the provider fees for vaccinations and community outreach to those who would most benefit from vaccination has already run out. So updated boosters now and in the future will likely go to the “worried well” who have good insurance rather than to those at highest risk for infection and progression to severe disease.

The FDA’s mandated task is merely to determine whether a new drug is safe and effective. However, the FDA could have requested more clinical vaccine effectiveness data from Pfizer and Moderna before authorizing their updated omicron BA.5 boosters.

Yet the FDA cannot weigh in on important follow-up questions: How much more effective are the updated boosters than vaccines already on the market? In which populations? And what increase in effectiveness is enough to merit an increase in price (a so-called cost-benefit analysis)? Other countries, such as the United Kingdom, perform such an analysis before allowing new medicines onto the market, to negotiate a fair national price.

The updated booster vaccine formulations are identical to the original covid vaccines except for a tweak in the mRNA code to match the omicron BA.5 virus. Studies by Pfizer showed that its updated Omicron BA.1 booster provides a 1.56 times higher increase in neutralizing antibody titers against the BA.1 virus as compared with a booster using its original vaccine. Moderna’s studies of its updated Omicron BA.1 booster demonstrated very similar results. However, others predict that a 1.5 times higher antibody titer would yield only slight improvement in vaccine effectiveness against symptomatic illness and severe disease, with a bump of about 5 percent and 1 percent, respectively. Pfizer and Moderna are just starting to study their updated Omicron BA.5 boosters in human trials.

Though the studies of the updated Omicron BA.5 boosters were conducted only in mice, the agency’s authorization is in line with precedent: The FDA clears updated flu shots for new strains each year without demanding human testing. But with flu vaccines, scientists have decades of experience and a better understanding of how increases in neutralizing antibody titers correlate with improvements in vaccine effectiveness. That’s not the case with COVID vaccines. And if mouse data were a good predictor of clinical effectiveness, we’d have an HIV vaccine by now.

As population immunity builds up through vaccination and infection, it’s unclear whether additional vaccine boosters, updated or not, would benefit all ages equally. In 2022, the U.S. has seen COVID-hospitalization rates among people 65 and older increase relative to younger age groups. And while COVID vaccine boosters seem to be cost-effective in the elderly, they may not be in younger populations. The CDC’s Advisory Committee on Immunization Practices considered limiting the updated boosters to people 50 and up, but eventually decided that doing so would be too complicated.

Unfortunately, history shows that — as with other pharmaceutical products — once a vaccine arrives and is accompanied by marketing, salesmanship trumps science: Many people with money and insurance will demand it whether data ultimately proves it is necessary for them individually or not.

We are all likely to encounter the SARS-CoV-2 virus again and again, and the virus will continue to mutate, giving rise to new variants year after year. In a country where significant portions of at-risk populations remain unvaccinated and unboosted, the fear of a winter surge is legitimate.

But will the widespread adoption of a vaccine — in this case yearly updated COVID boosters — end up enhancing protection for those who really need it or just enhance drugmakers’ profits? And will it be money well spent?

The federal government has been paying a negotiated price of $15 to $19.50 a dose of mRNA vaccine under a purchasing agreement signed during the height of the pandemic. When those government agreements lapse, analysts expect the price to triple or quadruple, and perhaps even more for updated yearly COVID boosters, which Moderna’s CEO said would evolve “like an iPhone.” To deploy these shots and these dollars wisely, a lot less hype and a lot more information might help.

Elisabeth Rosenthal (erosenthal@kff.org, @rosenthalhealth) and Céline Gounder (cgounder@kff.org) are Kaiser Health News journalists.

Liz Szabo: More attention, please, to improving building ventilation to fight COVID

The central tower of the Palace of Westminster, in London. The palace is home of the British Parliament. The octagonal spire was for ventilation purposes, aimed at drawing air out the building, with the design aimed at a highly aesthetic disguise of its function.

From Kaiser Health News

Americans are abandoning their masks. They’re done with physical distancing. And, let’s face it, some people are just never going to get vaccinated.

Yet a lot can still be done to prevent covid infections and curb the pandemic.

A growing coalition of epidemiologists and aerosol scientists say that improved ventilation could be a powerful tool against the coronavirus — if businesses are willing to invest the money.

“The science is airtight,” said Joseph Allen, director of the Healthy Buildings program at Harvard University’s T.H. Chan School of Public Health, in Boston. “The evidence is overwhelming.”

Although scientists have known for years that good ventilation can reduce the spread of respiratory diseases such as influenza and measles, the notion of improved ventilation as a front-line weapon in stemming the spread of covid-19 received little attention until March. That’s when the White House launched a voluntary initiative encouraging schools and work sites to assess and improve their ventilation.

The federal American Rescue Plan Act provides $122 billion for ventilation inspections and upgrades in schools, as well as $350 billion to state and local governments for a range of community-level pandemic recovery efforts, including ventilation and filtration. The White House is also encouraging private employers to voluntarily improve their indoor air quality and has provided guidelines on best practices.

The White House initiative comes as many employees are returning to the office after two years of remote work and while the highly contagious BA.2 omicron subvariant gains ground. If broadly embraced, experts say, the attention to indoor air quality will provide gains against covid and beyond, quelling the spread of other diseases and cutting incidents of asthma and allergy attacks.

The pandemic has revealed the dangerous consequences of poor ventilation, as well as the potential for improvement. Dutch researchers, for example, linked a 2020 COVID outbreak at a nursing home to inadequate ventilation. A choir rehearsal in Skagit Valley, Wash., early in the pandemic became a superspreader event after a sick person infected 52 of the 60 other singers.

Ventilation upgrades have been associated with lower infection rates in Georgia elementary schools, among other sites. A simulation by the Centers for Disease Control and Prevention found that combining mask-wearing and the use of portable air cleaners with high-efficiency particulate air filters, or HEPA filters, could reduce coronavirus transmission by 90 percent.

Scientists stress that ventilation should be viewed as one strategy in a three-pronged assault on covid, along with vaccination, which provides the best protection against infection, and high-quality, well-fitted masks, which can reduce a person’s exposure to viral particles by 95 percent. Improved airflow provides an additional layer of protection — and can be a vital tool for people who have not been fully vaccinated, people with weakened immune systems, and children too young to be immunized.

One of the most effective ways to curb disease transmission indoors is to swap out most of the air in a room — replacing the stale, potentially germy air with fresh air from outside or running it through high-efficiency filters — as often as possible. Without that exchange, “if you have someone in the room who’s sick, the viral particles are going to build up,” said Linsey Marr, a professor of civil and environmental engineering at Virginia Tech.

Exchanging the air five times an hour cuts the risk of coronavirus transmission in half, according to research cited by the White House Office of Science and Technology Policy. Yet most buildings today exchange the air only once or twice an hour.

That’s partly because industry ventilation standards, written by a professional group called the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE, are voluntary. Ventilation standards have generally been written to limit odors and dust, not control viruses, though the society in 2020 released new ventilation guidelines for reducing exposure to the coronavirus.

But that doesn’t mean building managers will adopt them. ASHRAE has no power to enforce its standards. And although many cities and states incorporate them into local building codes for new construction, older structures are usually not held to the same standards.

Federal agencies have little authority over indoor ventilation. The Environmental Protection Agency regulates standards for outdoor air quality, while the Occupational Safety and Health Administration enforces indoor-air-quality requirements only in health care facilities.

David Michaels, an epidemiologist and a professor at the George Washington University Milken Institute School of Public Health, said that he’d like to see a strong federal standard for indoor air quality but that such calls inevitably raise objections from the business community.

Two years into the pandemic, it’s unclear how many office buildings, warehouses, and other places of work have been retooled to meet ASHRAE’s recommended upgrades. No official body has conducted a national survey. But as facilities managers grapple with ways to bring employees back safely, advocates say ventilation is increasingly part of the conversation.

“In the first year of the pandemic, it felt like we were the only ones talking about ventilation, and it was falling on deaf ears,” said Allen, with Harvard’s Healthy Buildings program. “But there are definitely, without a doubt, many companies that have taken airborne spread seriously. It’s no longer just a handful of people.”

A group of Head Start centers in Vancouver, Wash., offers an example of the kinds of upgrades that can have impact. Ventilation systems now pump only outdoor air into buildings, rather than mixing fresh and recirculated air together, said R. Brent Ward, the facilities and maintenance operations manager for 33 of the federally funded early-childhood education programs. Ward said the upgrades cost $30,000, which he funded using the centers’ regular federal Head Start operating grant.

Circulating fresh air helps flush viruses out of vents so they don’t build up indoors. But there’s a downside: higher cost and energy use, which increases the greenhouse gases fueling climate change. “You spend more because your heat is coming on more often in order to warm up the outdoor air,” Ward said.

Ward said his program can afford the higher heating bills, at least for now, because of past savings from reduced energy use. Still, cost is an impediment to a more extensive revamp: Ward would like to install more efficient air filters, but the buildings — some of which are 30 years old — would have to be retrofitted to accommodate them.

Simply hiring a consultant to assess a building’s ventilation needs can cost from hundreds to thousands of dollars. And high-efficiency air filters can cost twice as much as standard ones.

Businesses also must be wary of companies that market pricey but unproven cleaning systems. A 2021 KHN investigation found that more than 2,000 schools across the country had used pandemic relief funds to purchase air-purifying devices that use technology that’s been shown to be ineffective or a potential source of dangerous byproducts.

Meghan McNulty, an Atlanta mechanical engineer focused on indoor air quality, said building managers often can provide cleaner air without expensive renovations. For example, they should ensure they are piping in as much outdoor air as required by local codes and should program their daytime ventilation systems to run continuously, rather than only when heating or cooling the air. She also recommends that building managers leave ventilation systems running into the evening if people are using the building, rather than routinely turning them down.

Some local governments have given businesses and residents a boost. Agencies in Montana and the San Francisco Bay area last year gave away free portable air cleaners to vulnerable residents, including people living in homeless shelters. All the devices use HEPA filters, which have been shown to remove coronavirus particles from the air.

In Washington state, the public health department for Seattle and King County has drawn on $3.9 million in federal pandemic funding to create an indoor air program. The agency hired staff members to provide free ventilation assessments to businesses and community organizations and has distributed nearly 7,800 portable air cleaners. Recipients included homeless shelters, child care centers, churches, restaurants, and other businesses.

Although the department has run out of filters, staff members still provide free technical assistance, and the agency’s website offers extensive guidance on improving indoor air quality, including instructions for turning box fans into low-cost air cleaners.

“We did not have an indoor air program before covid began,” said Shirlee Tan, a toxicologist for Public Health-Seattle & King County. “It’s been a huge gap, but we didn’t have any funding or capacity.”

Allen, who has long championed “healthy buildings,” said he welcomes the new emphasis on indoor air, even as he and others are frustrated it took a pandemic to jolt the conversation. Well before covid brought the issue to the fore, he said, research was clear that improved ventilation correlated with myriad benefits, including higher test scores for kids, fewer missed school days, and better productivity among office workers.

“This is a massive shift that is, quite honestly, 30 years overdue,” Allen said. “It is an incredible moment to hear the White House say that the indoor environment matters for your health.”

Liz Szabo is a Kaiser Health News reporter.

lszabo@kff.org, @LizSzabo

The courtyard entrance to the Harvard School of Public Health from the Harvard Medical School, in Boston. It doesn’t look well ventilated.

— Photo by MaynardClark 

Judith Graham: New COVID rules for visitors distress relatives of elderly people in nursing homes

From Kaiser Health News

As COVID-19 cases rise again in nursing homes, at least for now, a few states have begun requiring visitors to present proof that they’re not infected before entering facilities, stoking frustration and dismay among family members.

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health-care system.

Officials in California, New York, and Rhode Island say new COVID testing requirements are necessary to protect residents — an enormously vulnerable population — from exposure to the highly contagious omicron variant. But many family members say they can’t secure tests amid enormous demand and scarce supplies, leaving them unable to see loved ones. And being shut out of facilities feels unbearable, like a nightmare recurring without end.

Severe staff shortages are complicating the effort to ensure safety while keeping facilities open; these shortages also jeopardize care at long-term care facilities — a concern of many family members.

Andrea DuBrow’s 75-year-old mother, who has severe Alzheimer’s disease, has lived for almost four years in a nursing home in Danville, Calif. When DuBrow wasn’t able to see her for months earlier in the pandemic, she said, her mother forgot who she was.

“This latest restriction is essentially another lockdown,” DuBrow said at a meeting last week about California’s new regulations. “The time that my mom has left when she can recognize in some small locked-away part of her that it is me, her daughter, cleaning her, feeding her, holding her hand, singing her favorite songs — that time is being stolen from us.”

“This is a huge inconvenience, but what’s most upsetting is that no one seems to have any kind of long-term plan for families and residents,” said Ozzie Rohm, whose 94-year-old father lives in a San Francisco nursing home.

Why are family members subject to testing requirements that aren’t applied to staffers, Rohm wondered. If family members are vaccinated and boosted, wear good masks, stay in a resident’s room, and practice rigorous hand hygiene, do they pose more of a risk than staffers who follow these procedures?

California was the first state to announce new policies for visitors to nursing homes and other long-term care facilities on Dec. 31. Those took effect on Jan. 7 and remain in place for at least 30 days. To see a resident, a person must show evidence of a negative covid rapid test taken within 24 hours or a PCR test taken within 48 hours. Also, covid vaccinations are required.

In a statement announcing the new policy, the California Department of Public Health cited “the greater transmissibility” of the omicron variant and the need to “protect the particularly vulnerable populations in long-term care settings.” Throughout the pandemic, nursing home residents have suffered disproportionately high rates of illness and death.

New York followed California with a Jan. 7 announcement that nursing home visitors would need to show proof of a negative rapid test taken no more than a day before. And on Jan. 10, Rhode Island announced a new rule requiring proof of vaccination or a negative covid test.

Patient advocates are worried other states might adopt similar measures. “We are concerned that omicron will be used as an excuse to shut down visitation again,” said Sam Brooks, program and policy manager for the National Consumer Voice for Quality Long-Term Care, an advocacy group for people living in these facilities.

“We do not want to go back to the past two years of lockdowns in nursing homes and resident isolation and neglect,” he continued.

That’s also a priority for the federal Centers for Medicare & Medicaid Services, which has emphasized since Nov. 12 residents’ right to receive visitors without restriction as long as safety protocols are followed. Nursing homes could encourage but not require visitors to take tests in advance or provide proof of covid vaccination, guidance from CMS explained. Safety protocols included wearing masks, rigorous hand hygiene, and maintaining adequate physical distance from other residents.

With the rise of omicron, however, facilities pushed back. On Dec. 17, an organization representing nursing home medical directors and two national long-term care associations sent a letter to CMS’ administrator asking for more flexibility to “protect resident safety” and “place temporary visitation restrictions in nursing homes.” On Jan. 6, CMS affirmed residents’ right to visitation but said states could “take additional measures to make visitation safer.”

Asked for comment about the states’ recent actions, the federal agency said in a statement to KHN that “a state may require nursing homes to test visitors as long as the facility provides the rapid antigen tests, and there are enough testing supplies. … However, if there are not enough rapid testing supplies, the visits must be allowed to occur without a test (while still adhering to other practices, such as masking and physical distancing).”

Some relief from test shortages may be at hand under the Biden administration’s new plan to distribute four free tests per household. But for family members who visit nursing home residents several times a week, that supply won’t go very far.

Since the start of the year, tension over the balance between safety and residents’ rights to visitation has intensified. In the week ended Jan. 9, 57,243 nursing home staffers reported covid infections, almost 10 times as many as three weeks before. During the same period, resident infections rose to 32,061, almost eight times as many as three weeks earlier.

But outbreaks are occurring against a different backdrop today. More than 87 percent of nursing-home residents have been fully vaccinated, according to CMS, and 63 percent have also received boosters, reducing the risk that covid poses. Also, nursing homes have gained experience handling outbreaks. And the toll of nursing home lockdowns — loneliness, despair, neglect, and physical deterioration — is now far better understood.

“We have all seen the negative effects of restricting visitation on residents’ health and well-being,” said Joseph Gaugler, a professor who studies long-term care at the University of Minnesota’s School of Public Health. “For nursing homes to go back into a bunker mentality and shut everything down, that’s not a solution.”

Amid egregious staffing shortages, “we need people in these buildings who can take care of residents, and often those are visitors who are basically functioning as unpaid certified nursing assistants: grooming and toileting residents, turning and repositioning them, feeding them, stretching, and exercising them,” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform.

Nearly 420,000 staffers have left nursing homes since February 2020, according to the U.S. Bureau of Labor Statistics, worsening existing shortages.

When DuBrow learned of California’s new testing requirement for visitors, she arranged to get a PCR test at a testing site on Jan. 6, expecting results within 48 hours. Instead, she waited 104 hours before getting a response. (Her test was negative.) Eager to visit her mother, DuBrow called every CVS, Walgreens, and Target in a 25-mile radius of her home asking for a test but came up empty.

In a statement, the California Department of Public Health said the state had established 6,288 covid testing sites and sent millions of at-home tests to counties and local jurisdictions.

In New York, Democratic Gov. Kathy Hochul has pledged to deliver nearly 1 million COVID tests to nursing homes, where visitors can take them on the spot, but that presents its own problems. “We don’t want to test visitors who are lining up at the door. We don’t have the clinical staff to do that, and we need to focus all our staff on the care of residents,” said Stephen Hanse, president and CEO of the New York State Health Facilities Association, an industry organization.

With current staff shortages, trying to ensure that visitors are wearing masks, physical distancing, and adhering to infection control practices is “taxing on the staff,” said Janine Finck-Boyle, vice president of regulatory affairs at Leading Age, which represents not-for-profit long-term care providers.

“Really, the challenges are enormous,” said Gaugler, of the University of Minnesota, “and I wish there were easy answers.”

Judith Graham is a Kaiser Health News reporter.

\ khn.navigatingaging@gmail.com, @judith_graham

John O. Harney: N.E.’s changing ethnic demographics; shrinking police forces; honorary degrees and culture wars

1. Northwest Vermont 2. Northeast Kingdom 3. Central Vermont 4. Southern Vermont 5. Great North Woods Region 6. White Mountains 7. Lakes Region 8. Dartmouth/Lake Sunapee Region 9. Seacoast Region 10. Merrimack River Valley 11. Monadnock Region 12. North Woods 13. Maine Highlands 14. Acadia/Down East 15. Mid-Coast/Penobscot Bay 16. South Coast 17. Mountain and Lakes Region 18. Kennebec Valley 19. North Shore 20. Metro Boston 21. South Shore 22. Cape Cod and Islands 23. South Coast 24. Southeastern Massachusetts 25. Blackstone River Valley 26. Metrowest/Greater Boston 27. Central Massachusetts 28. Pioneer Valley 29. The Berkshires 30. South Country 31. East Bay and Newport 32. Quiet Corner 33. Greater Hartford 34. Central Naugatuck Valley 35. Northwest Hills 36. Southeastern Connecticut/Greater New London 37. Western Connecticut 38. Connecticut Shoreline

BOSTON

From The New England Journal of Higher Education (NEJHE), a service of The New England Board of Higher Education (nebhe.org)

Population studies. The U.S. Census Bureau released new population counts to use in “redistricting” congressional and state legisla­tive districts. Delayed by the pandemic, the counts came close to the legal deadlines for redistricting in some states, raising concerns about whether there would be enough time for public input.

The U.S. population grew 7.4% in 2010-2020, the slowest growth since the 1930s, according to the bureau. The national growth of about 23 million people occurred entirely of people who identified as Hispanic, Asian, Black or more than one race.

The Associated Press reported:

• The population under age 18 dropped from 74.2 million in 2010 to 73.1 million in 2020.

• The Asian population increased by one-third over the decade, to stand at 24 million, while the Hispanic population grew by almost a quarter, to top 62 million.

• White people made up their smallest-ever share of the U.S. population, dropping from 63.7% in 2010 to 57.8% in 2020. The number of non-Hispanic white people dropped to 191 million in 2020.

• The number of people identifying as “two or more races” soared from 9 million in 2010 to 33.8 million in 2020, accounting for about 10% of the U.S. population.

A few New England snippets

Maine remains the nation’s oldest and whitest state, even though it saw a 64% increase in the number of Blacks from 2010 to 2020, as well as large increases in the number of Asians and Pacific Islanders.

Connecticut’s population crawled up 0.9% over the decade from 2010 to 2020 to 3,605,944 residents. The number of residents who are Black, Indigenous and People of Color (BIPOC) increased from 29% of the population in 2010 to 37% in 2020. Connecticut’s number of congressional seats won’t change, but district borders will.

The total population of the only city on Boston’s South Shore, Quincy, Mass., topped 100,000 (at 101,636), as its Asian population grew to represent nearly 31% of all residents. Further south, the city of Brockton’s population increased by nearly 13% as the white population dropped by 29%, and the Black population increased by 26%.

Amazon jungle. Amazon last week announced it will pay full college tuition for its 750,000 U.S. hourly employees, as well as the cost of earning high school diplomas, GEDs, English as a Second Language (ESL) and other certifications. While collecting praise for its educational goodwill, stories of dire conditions in the e-commerce giant’s workplace also triggered a new California law that would ban all warehouses from imposing penalties for “time off-task” (which reportedly discouraged workers from using the bathroom) and prohibit retaliation against workers who complain.

Police shrink. Police forces in New England have recently felt new recruitment and retention pressures. In August 2021, The Providence Journal ran a piece headlined “Promises made, promises delivered? A look at reforms to New England police departments.” GoLocal reported that month that Providence policing staff levels stood at 403, down from 500 or so in the 1980s under then-Mayor David Cicilline. The number of officers employed by Maine’s city and town police departments and county sheriffs’ offices shrank by nearly 6% between 2015 and 2020, according to the Maine Criminal Justice Academy. Reporter Lia Russell of the Bangor Daily News noted, “It’s also a challenge that police in Maine are far from alone in facing, especially following a year during which police practices across the nation were called into question following the murder of George Floyd by Minneapolis police Officer Derek Chauvin.” The Burlington, Vt., City Council in August defeated efforts to reverse a steep cut in city police ranks. The police department currently has 75 sworn officers, down from 90 in June 2020. A survey by the police officers’ union found that roughly half of Burlington cops were actively seeking employment elsewhere.

Honor roll. Honorary degrees are becoming something of a frontline in the culture wars. Springfield College alum­nus Donald Brown, who recently coauthored a piece for NEJHE, tells of his alma mater revoking the honorary master of physical education degree it had bestowed on U.S. Olympic Committee Chair Avery Brundage in 1940. In 1968, Brundage pressured the U.S. to take action against two Olympic athletes who gave the Black Power salute after finishing first and second in the 200 meters. That event was only the tip of the iceberg. Brundage had a history of anti-semitism, sexism and racism. Springfield President Mary-Beth Cooper met with the trustees and others and decided to take back the honor. Meanwhile, the University of Rhode Island has been tying itself in knots over the honorary degree it bestowed on Michael Flynn in 2014, before he was appointed Trump’s national security adviser and accused of sedition.

Refugees. After the U.S. ended its longest war (so far) in Afghanistan and the capital of Kabul fell, the question arose of where Afghan refugees would resettle. New England cities, including Worcester, Providence and New Haven, are among those that have readied plans to welcome Afghan refugees. In higher education, Goddard College President Dan Hocoy said it was a “no-brainer” to offer to house Afghan refugees at its Plainfield, Vt., campus for at least two months this upcoming fall. Back in 2004, NEJHE (then Connection) featured an interview with Roger Williams University President Roy J. Nirschel, who died in 2018, and his former wife Paula Nirschel on the university’s role in its community as well as their pioneering initiative to educate Afghan women.

Sunshine state. Before Florida Gov. Ron DeSantis took his most recent stand against fighting COVID, he displayed a narrow-mindedness that seems to always be in fashion. As Inside Higher Ed reported, after expressing concerns about faculty members “indoctrinating” students, DeSantis signed a law requiring that public institutions survey students­, faculty and staff members about their viewpoint diversity and sense of intellectual freedom. The Miami Herald reported that DeSantis and state Sen. Ray Rodrigues, the original bill’s Republican sponsor, suggested that the results could inform budget cuts at some institutions. Faculty members have opposed the bill, which also allows stude­­­­­­nts to record their professors teaching in order to file free speech complaints against them.

New colleges in a time of contraction. The nonprofit Norwalk (Conn.) Conservatory of the Arts announced plans to open a new performing-arts college and welcome its first class in August 2022. It’s unusual news amid the stream of college mergers and closures only widened by the pandemic. Among the challenges, many of the faculty members don’t have master of fine arts degrees that accrediting agencies require and, without accreditation, the college’s students won’t be eligible for federal financial aid or Pell Grants.

The Conservatory says the college will consolidate a traditional four-year undergraduate program into two years of intense training and a two-year graduate program into one year. Meanwhile, up the coast, the (Fall River, Mass.) Herald News reports that Denmark-based Maersk Training and Bristol Community College will work together to turn an old seafood packaging plant in New Bedford, Mass., into a National Offshore Wind Institute training facility to train offshore wind workers, complete with classrooms and a deepwater pool to train and recertify workers. (NEJHE has reported on the need to train talent for the burgeoning industry and the coastal economy’s special role in New England.)

Other higher-ed institutions are shapeshifting. After months of discussions and lawsuits, Northeastern University and Mills College reached agreement to establish Mills College at Northeastern University. Founded in 1852, Mills is renowned for its pre-eminence in women’s leadership, access, equity and social justice. Also, billionaire investor Gerald Chan and his family’s Morningside Foundation gave $175 million to the University of Massachusetts Medical School, which will be renamed the University of Massachusetts Chan Medical School. That’s the largest-ever gift to the UMass system.

Land deals. I was recently struck by a report titled We Need to Focus on the Damn Land: Land Grant Universities and Indigenous Nations in the Northeast. The report was born of a partnership between Smith College students and the nonprofit Farm to Institution New England (FINE) to look at how land grant universities view their historic relationships with local Indigenous tribes and how food can play a role in repairing those relationships. It grabbed my attention, partly because NEJHE has published some interesting stories about Native Americans and New England higher education. (See Native Tribal Scholars: Building an Academic Community and A Different Path Forward, both by J. Cedric Woods and The Dark Ages of Education and a New Hope, by Donna Loring.) And partly because two NEBHE Faculty Diversity Fellows, professors Tatiana M.F. Cruz of Simmons University and Kamille Gentles-Peart of Roger Williams University, are spearheading a fascinating Reparative Justice initiative. Among other things, Cruz and Gentles-Peart have had the courage to remind us that land grant universities in New England occupy the land of Indigenous communities. The Smith-FINE work offered sensible recommendations: Financially support Native and Indigenous faculty, activists, programs on campuses and beyond; offer free tuition for Native American students; hire Indigenous people, and fund their research.

John O. Harney is executive editor of The New England Journal of Higher Education.

Llewellyn King: Has COVID launched a new age for workers?

Most workers would like to slash the time they spend commuting.

WEST WARWICK, R.I.

Millions of Americans appear to be echoing the words of the Johnny Paycheck song “Take This Job and Shove It.” This   is a sentiment that is changing the work scene, the way we work, and the future of work.

The workers of America are shuffling the deck in a way that has never happened before. It is accentuating an acute labor shortage.

I receive lists of job openings every day and the common denominator seems to be that you must show up at a place of business. Among the big and seemingly frantic employers are FedEx, Walmart and Amazon. Warehouse workers and delivery drivers are the most sought-after employees.

To overcome the labor shortage, wages are rising and adding to the rising inflation -- although what part of that rise is labor cost isn’t clear. Other factors are pandemic-induced supply chain disruptions, a tightening of food flows from California and other Western states, and the acute housing shortage. The economy is rebalancing; and so are workers, reassessing their lives and making changes.

There has been a severe shortage of skilled workers for a long time. It has been felt almost everywhere from construction to electric line workers. It is just worse now, exacerbated by immigration restrictions and workers who have joined the reshuffle. 

During the COVID-19 lockdown, millions of individuals have assessed what they do and, apparently, found it wanting.

America’s workforce isn’t returning to the jobs that they held before the lockdown. Some are trying new things; others are demanding changes in the workplace. There is a demand for more remote working. The rat race is running short of willing rats.

Commuting seems to be the one big no-no. People in the major work hubs such as New York, Washington, Chicago, Boston and San Francisco have sampled the joys and the failings of working from home, and commuting has lost.

I know people who used to spend four or five hours every day getting to work and back home in all these cities. Sitting in a traffic jam is neither creative nor the best use of human life, these people are now saying.

In the movie Network, Peter Finch bellows, “I’m as mad as hell, and I’m not going to take this anymore!” That is the new sentiment towards rigid travel and rigid work schedules. Working from home has taken people up the hill and shown them the valley, and they have liked the valley.

Other workers, particularly at the lower end of the work scale, have wondered whether they wouldn’t be happier doing something else now that they have had time to ponder. A friend of mine’s daughter who was a professional waiter in Florida now works for a printer. She has found she gets a more dependable income, better hours and that incalculable: a happier work environment.

I love small business, and I believe it to be the essential force for innovation and job creation. But it is also where petty boss-tyrants flourish. Lousy, egomaniacal employers aren't hard to find, especially in the restaurant business.

When I worked as a waiter in New York, between journalism jobs, I knew waiters who dreamed of the great restaurant where the tips are generous and, above all, the “patron is nice.” Unseen, there is a lot of cussing and pressure in any restaurant, and job security is unknown. 

Enforced downtime has caused many to wonder whether they are even in the right line of work; whether the money, prestige or social recognition that may have gone with their old job was worth it.

For others, the gig economy has beckoned, where the employer has been cut out. Particularly, this is true of young people in communications and related work. Geeks are a hot item and can contract directly. But others, from landscape gardeners to plumbers, are going gig. The downside is there are no benefits, from Social Security deductions to pensions and health care. Society is lagging in recognizing this new arena of work.

Peculiarly, we aren’t at full employment. Unemployment is hovering around 5.9 percent and has gone up slightly as the summer has progressed. This raises the question of how many of the formerly employed are now in the gig economy, skewing the figures.

We are in what is, in effect, a post-war recovery. Traditionally, that is a time for social readjustment, for old bonds to be loosed, and for new energy to be released. Is it time to sack the boss?

Llewellyn King is executive producer and host of White House Chronicle, on PBS. His email is llewellynking1@gmail.com and he’s based in Rhode Island and Washington, D.C.

Web site: whchronicle.com

Rae Ellen Bichell: Live free and die in your county if you wish, but not in my hospital

Adam Baker, chief operating officer of The Old Mine, a cidery and restaurant that has a taproom called the Handlebar Factory, stands at the empty taproom on a December afternoon. The taproom is in Boulder County, where indoor dining is not allowed. The restaurant, just a short walk away, is in Weld County, where officials have said they “will not enforce a rule demanding restaurants close their indoor dining areas.” The company decided to follow the more restrictive guidelines of Boulder County, regardless of the restaurant’s location.

— Photo by Rae Ellen Bichell, Kaiser Health News

From Kaiser Health News

ERIE, Colo.

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

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

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

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

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

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

The town of Erie, Colorado, straddles two counties with opposite views on how to approach COVID-19. (Rae Ellen Bichell/KHN)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

County Line Road is not just a street cutting through Erie, Colorado. It represents a fault line between local governments with very different views on the pandemic. (Rae Ellen Bichell/KHN)

Josh Kelderman works with his father, Larry, at the family’s auto repair business, Integrity Products, on the Boulder County side of Erie, Colorado. Weld County is just across the street. (Rae Ellen Bichell/KHN)

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

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

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

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

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

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

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

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

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

Rae Ellen Bichell is a Kaiser Health News reporter.

Rae Ellen Bichell: rbichell@kff.org, @raelnb

Needing office esprit de corps

 From Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

The office you leave your home to go to work in will not die, and indeed will stage a comeback when the COVID crisis fades. Many kinds of work are much more productive when people can collaborate in the same physical space. Sharing space encourages idea-sharing and esprit de corps. The experience of the past few months has vividly shown the strengths and weaknesses of Zooming and Skyping job work.

The urgent need for in-person instruction at N.E. colleges

St. Michael’s College, in mostly bucolic Colchester, Vt.

BOSTON

This essay is from The New England Journal of Higher Education, a service of The New England Board of Higher Education (nebhe.org). It was written by NEBHE President and CEO Michael K. Thomas in conjunction with leaders and representatives of public and private institutions in all six New England states, including: Mark E. Ojakian, president of the Connecticut State Colleges and Universities; Jennifer Widness, president of the Connecticut Conference of Independent Colleges; Dannel P. Malloy, chancellor of the University of Maine System; Daniel Walker of the Maine Independent Colleges Association; Richard Doherty, president of the Association of Independent Colleges and Universities in Massachusetts; Debby Scire, president of the New Hampshire College and University Council; Daniel P. Egan, president of the Association of Independent Colleges and Universities of Rhode Island; Suresh Garimella, president of the University of Vermont, and Susan Stitely, president of the Association of Vermont Independent Colleges. This essay first appeared in The Boston Globe.

New England colleges and universities are admired for their ability to marshal smart minds to tackle complex problems. This capacity has been evident throughout the pandemic, as their research, teaching and commitment to public service have demonstrated what they do best—chart new paths in the face of uncertainty.

Analysis by the New England Board of Higher Education, an organization supporting students and institutions in the region, indicates that 65 of New England’s colleges and universities plan to provide on-campus and in-person instruction this fall. Ninety-eight will provide a hybrid of in-person and virtual learning, while 35 will support students all virtually. Each institution’s decision was made in response to the risk factors it faces as leaders do their best to respond to the unprecedented health emergency.

We recognize the importance of colleges and universities, both public and private, in the region that will reopen campuses in the coming weeks. These institutions have thoughtfully crafted plans for reopening that, while subject to some risks, will allow them to provide significant benefits to students, institutions, communities and economies. Are there COVID-related risks to reopening? Yes. While such risks cannot be completely eliminated, they can be intelligently managed in a science-supported way.

Leaders of New England colleges and universities have done their COVID homework. They are well prepared to advance their missions of educating students and conducting research and to lead in demonstrating how institutions can begin to carefully move forward in a new environment.

Since March, higher education leaders in all six states have put the full weight of their institutions behind planning, preparation and investment in reopening. This includes plans for robust virus testing, securing adequate personal protective equipment, obligatory mask-wearing, regular health monitoring, contact tracing, quarantine and isolation capacity, regular disinfection, changes to dorms and other campus facilities, limits on group gatherings, training for faculty, students and staff, signed conduct codes, accommodations for those at risk, contingencies for closing campuses or increasing virtual learning—and much more.

These plans have been developed in close collaboration with state government and public health leaders based on science, expert-vetted guidelines and best practices. Many institutions remained open since the start of the pandemic to house and feed students unable to return home or without a safe place to call home. This experience, as well as lessons learned from phased summer re-openings that provided safe access to labs, equipment and clinical experiences will guide the further repopulating of campuses in the coming weeks.

We also support New England institutions that have chosen to offer fully virtual programs this fall. And we support parents and students opting to not return to campus. No single answer is right for all and no option is risk-free. Pursuing a variety of institutional responses in New England can pay important dividends for the region and nation—providing valuable lessons to other institutions and as we reopen other parts of the economy.

The decision to reopen with only remote learning may mitigate some risks, but not all, including possible adverse impacts on individuals, local communities and economies that higher education seeks to serve. We cannot afford a “lost generation” of learners, particularly underrepresented, low-income and minority students—some of whom may not enroll or are at risk of dropping out if on-campus opportunities are reduced. For some such students, the campus provides the only food and housing security they know and staying home may both limit opportunity and increase risk of exposure to the virus.

Delaying or discouraging students’ educations could lead to clogs in the talent pipelines that drive growth for the region’s employers and our innovation-dependent economies. Finally, local communities, already beset by the pandemic’s disruption, will be further deprived of the economic benefits of open institutions and their students. Each of these will have long-term economic and social effects.

We look forward to the time when life on and off campus returns to normal. To do all that is possible to move closer to that goal, we must support colleges and universities in doing what they do best: tackling complex problems with brainpower, innovation and the application of science-based solutions to real-world challenges. Our colleges and universities are engines of innovation because of their ability to explore boundaries. New England institutions are prepared to lead in this time of significant challenge.