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Apr 03, 2020

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

The country’s top employers of emergency room doctors are cutting their hours — leaving clinicians with lower earnings and hospitals with less staff in the middle of a pandemic.

TeamHealth, a major medical staffing company owned by the private-equity giant Blackstone, is reducing hours for ER staff in some places and asking for voluntary furloughs from anesthesiologists, the company confirmed to ProPublica. Multiple ER providers working for a main competitor, KKR-owned Envision Healthcare, said their hours also are being cut.

Even as some hospitals risk running out of room to care for COVID-19 patients, demand for other kinds of health care is collapsing. This irony is straining the business models of hospitals and the companies that staff them with doctors and other medical professionals.

Most ER doctors aren’t direct employees of the hospitals where they work. Historically, the doctors belonged to practice groups that contracted with the hospitals. In recent years, private-equity investors started buying up and consolidating those practice groups into massive staffing companies.

Reduced hours are also hitting doctors employed by SCP Health, another medical staffing company backed by the investment firm Onex Corporation, according to internal memos obtained by ProPublica. US Acute Care Solutions, backed by the private-equity firm Welsh, Carson, Anderson & Stowe, said it’s cutting hours in some places while increasing staffing elsewhere.

The staffing companies said they’re responding to dropping revenue as non-coronavirus patients avoid the ER and hospitals cancel elective procedures. The companies also emphasize that they’re not cutting physicians’ hourly rates.

But by assigning fewer hours to doctors and other providers such as physician’s assistants and nurse practitioners, the companies are effectively paying them less. It also means that some hospitals have fewer clinicians working in the ER at a time.

“These actions are unacceptable and unnecessary,” Scott Hickey, president of the Virginia College of Emergency Physicians, said in a statement. “This is very likely the ‘calm before the storm’ of critically ill patients entering hospitals with COVID-19 symptoms. Who will be there waiting to save those lives?”

The steepest cuts so far have occurred at Alteon Health, whose private-equity backers are New Mountain Capital and Frazier Healthcare Partners. The company says ER visits are down as much as 40% nationwide. In addition to the benefits cuts that ProPublica first reported on Tuesday, Alteon is furloughing some clinicians for 30 days to six months and won’t guarantee any hours for part-time employees, according to company memos obtained by ProPublica.

“Anyone not willing or unable to share the burden will need to be terminated to preserve employment for those who really feel part of our team and care about their coworkers,” one manager wrote.

Alteon said its ER doctors and clinicians in places that are inundated with COVID-19 patients are working longer hours and being paid more. “We are doing all we can to provide the support to the people who are on the front lines of this fight right now and ensure we have resources for those who may be called on to do even more when surges come to their areas in the future,” the company said in a statement to ProPublica.

In an earlier statement posted on Alteon’s website, CEO Steve Holtzclaw said ProPublica’s earlier article “mischaracterized” Alteon’s actions, saying, “We have not cut clinical rates for providers in the field.” In fact, ProPublica reported that Alteon wasn’t cutting rates but was cutting hours, and fewer hours at the same rate amounts to lower earnings.

“It was worded in a way to make it sound like we weren’t affected by this, but by cutting our hours we are,” said an ER clinician who works for Alteon and has had hours reduced in a hospital with coronavirus patients. (The clinician, like others interviewed by ProPublica, spoke on the condition of anonymity because company policy prohibits their speaking publicly.) “When they’re saying clinician pay is not affected, it certainly is. That was a straight lie.”

The clinician added: “Health care workers are being applauded in the streets, and we are being stepped on by them.”

TeamHealth initially told ProPublica that it was “not instituting any reduction in pay or benefits.” However, the company is in fact paying some clinicians less in the form of reducing their hours. The company provided a new statement saying “we are not instituting any reduction in rate of pay or benefits as our emergency physicians face current challenges.”

An ER clinician who works for TeamHealth said, “I probably wouldn’t have complained as this situation is unprecedented, but to see TeamHealth blatantly lying is infuriating.”

TeamHealth said it has reduced hours in some markets but is maintaining staffing above current demand in anticipation of a future surge of COVID-19 patients. While the company is asking anesthesiologists to take furloughs that may be mandatory if there aren’t enough volunteers, TeamHealth said it’s also looking for ways for anesthesiologists to use their skills to help out in emergency rooms or intensive care units. Blackstone declined to comment.

While some ERs in New York are overflowing with coronavirus patients, in many places people are staying home instead of going to the hospital. Studies have repeatedly shown that much of the care provided in the emergency room is for non-life-threatening issues.

“We always try to match our clinician coverage to our patient flow and we have done our best to do the same in this unpredictable time,” Amer Aldeen, US Acute Care Solutions’ chief medical officer, said in a statement. The company has not laid off, furloughed, reduced pay rates or cut benefits for any employees, Aldeen said.

Two clinicians working for Envision Healthcare said they were experiencing reduced hours. The company and its owner KKR did not respond to repeated requests for comment.

At SCP, salaries for nurse practitioners and physician’s assistants will decrease in line with reduced hours, the company said in a memo on Thursday. Employees who don’t accept the change will be terminated, the memo said.

“We know that this time is also difficult and uncertain for each of you, and we want all employees to be able to focus on getting through this time with as little worry as possible about their pay and benefits while avoiding unnecessary exposure to COVID-19,” SCP executives said in the memo. “SCP Health is using its reasonable best efforts to retain all team members at this time in light of this unforeseeable pandemic.”

SCP spokeswoman Maura Nelson said the company is dealing with a 30% drop in patients nationwide while the patients its providers are treating are more seriously ill. “We are calibrating our clinical coverage accordingly, so that we can address more flexibly the needs of our client hospitals,” Nelson said. “This was a necessary adjustment as we weather this crisis, together.”

Hickey of the Virginia physicians group called on staffing companies to take advantage of relief in the recent stimulus packages such as the Paycheck Protection Program and Medicare Accelerated and Advance Payment Program. But Alteon said it had already taken into account those relief measures before cutting compensation and benefits. “We have factored these actions into our plan,” Holtzclaw said in his message to employees on Monday.

The pandemic’s strain on the economics of the health care industry is not limited to private-equity-backed staffing companies. Hospital operators are also announcing layoffs and pay cuts. Dallas-based Tenet Healthcare said it would furlough 500 staff members and borrow money.

“We have this crisis going on where hospitals need as many people as possible, and at the same time hospitals have to cut their budgets,” said Brandon Jones, a nurse anesthetist and part-owner of a practice group called Greater Anesthesia Solutions in the Phoenix area. “Doctors are being sidelined or they’re being let go completely.”

While Jones’ colleagues are out of work for elective surgeries, he said they’re redeploying their skills to help treat COVID-19 patients — in particular by intubating them for breathing machines, which puts providers at a high risk to catch the virus. They’re wearing hazmat suits donated by a nearby nuclear power plant, Jones said, and they’re helping out even when they can’t bill for it or stand to make much less than normal.

“We’re going to do it because it’s right,” he said.

Maryam Jameel contributed reporting.

Apr 03, 2020

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

This article is co-published with The Texas Tribune, as part of an investigative partnership.

On Monday afternoon, paramedic Theresa Fitzpatrick inched her Dodge Dart through a brand new drive-in testing center for COVID-19 in the small South Texas border city of Edinburg, a dozen miles from the Rio Grande. She had been wracked for a week with a dry, hacking cough ever since picking up a patient who had just crossed the international bridge with similar symptoms.

But she hadn’t been able to get a test since seeing her doctor last week, until a local university opened up drive-thru testing sites in her home county on Monday.

“They haven’t been testing people, that’s the problem,” said Fitzpatrick, a mother of four who earns $16 an hour as a paramedic for a private EMS company. “It just seems like the forgotten man down here.”

Hours earlier, Dr. Martin Garza, a pediatrician and former president of the Hidalgo-Starr County Medical Society, spent his lunch break drafting a plea to border-area lawmakers for help finding more testing kits.

Garza noted that at-risk areas such as South Texas, with lower numbers of confirmed cases, are precisely where enhanced testing is needed to detect and prevent a fatal spread of the virus, as is unfolding in New York City, New Orleans and smaller cities like Athens, Georgia.

“We have all heard, ‘If (only) we had been able to test sooner,’” he wrote. “Well the ‘sooner’ is still available in our community.”

While many places across the country are struggling to get enough testing, the problems are magnified in the Rio Grande Valley. It has among the highest poverty rates in the state, nearly half of its residents don’t have health insurance and chronic health conditions are rife.

Two weeks ago, Texas Gov. Greg Abbott promised that all those who need a coronavirus test “will get one,” but public health officials, politicians and doctors up and down the Rio Grande say that hasn’t happened and they are scrambling to assemble sufficient testing kits. Hidalgo County, the largest in the Valley, is only able to process 20 government tests a day, officials said this week.

In the border city of Laredo, 80 miles upriver from the Rio Grande Valley, a cluster of residents died on four consecutive days starting Sunday, bringing the city’s COVID-19 death toll to five, just below that of the state’s largest city Houston as of Friday morning. The first four were women in their 60s to 97. The latest was a 43-year-old man. Health authorities say all five suffered from underlying health conditions.

Also troubling to local health leaders is that the highest percentage of the city’s 65 positive cases is the result of some form of community contact.

As Laredo reeled from the deaths, its Mexican sister city, Nuevo Laredo, announced its first two positive cases this week, including a 56-year-old man who had recently traveled to Dallas. Health experts believe cases in Mexico are vastly underreported because of almost nonexistent testing there.

Responding to the threat, some border cities took drastic steps, including setting up roadblocks to catch people violating orders to shelter in place and requiring masks inside public buildings.

In many ways, the situation along the Texas border reflects the chaotic manner that the second-largest state in the country, with the highest percentage of people lacking health insurance, has approached the issue of testing — and the pandemic itself. Unlike some governors, Abbott, a Republican, had declined to impose a mandatory statewide shelter-in-place order, instead urging counties to make their own decisions. On Tuesday, he did issue such an order urging most people to stay home.

Texas as a whole also has lagged when it comes to testing. It’s completed more than 50,600 tests so far, more than double what it had less than a week ago, but it still ranks among the lowest in the nation in per-capita testing, well behind other large states such as New York and California, according to a ProPublica analysis. At least 70 people have died in Texas.

Abbott’s spokesman, John Wittman, referred questions to the state’s Division of Emergency Management.

Seth Christensen, that agency’s spokesman, said in a statement that the state is available to assist “every mayor and county judge” across Texas. He said that swabs are in short supply nationally, but that the state is trying to procure more from the federal government and private companies.

He said private health care providers should also make an effort to obtain testing supplies through the private sector to “ensure we are leveraging every available avenue.”

To ward off the virus spreading across international borders, President Donald Trump has largely closed border crossings to “nonessential” travel, but epidemiologists say that’s not the solution to an epidemic that has likely already taken root on both sides of the Rio Grande.

“The answer is not closing the border,” said epidemiologist Benjamin King of the University of Texas at Austin. “It’s aggressive testing on both sides.”

Population at Risk

The Rio Grande Valley is a world away from the state’s largest regions, Houston and Dallas, which have seen the most cases. It is a sprawling mix of rural farmland and urban spread that is home to more than 1.3 million mostly Hispanic residents and shares river frontage with a bustling Mexican border region of factories, busy land crossings and outbreaks of drug cartel violence.

The Valley’s population is particularly vulnerable to the virus, experts say. About half a million Texas border residents live in so-called colonias across the U.S. side of the border, which often lack basic amenities such as running water. Roughly one in three people in the Rio Grande Valley is diabetic, a major risk factor for complications from COVID-19. And one in 10 of the state’s undocumented population lives in the region, with potential immigration consequences often making them fearful to seek help.

“My concern is not only that it is circulating without our knowledge, but we also have a population at high risk for severe disease,” said Dr. Joseph McCormick, an epidemiologist at the Brownsville campus of the University of Texas Health Science Center at Houston. “I don’t think it will take very long at all to overwhelm the facilities at our hospitals.”

Hidalgo County, the largest in the Rio Grande Valley, has about 2,000 hospital beds, compared with about 14,000 in Houston.

McCormick, who helped investigate the first-recorded Ebola outbreak in 1976, blamed the lack of testing on the state and federal government.

“The state is depending on the federal government to bring tests in and that hasn’t happened. … I don’t know why the state hasn’t done more,” he said. “Our folks are now relying more on private labs.”

“Some Very Sick People”

On Monday, UT Health RGV, which is part of the University of Texas Rio Grande Valley School of Medicine, began drive-thru testing in Brownsville and Edinburg.

In a few days, its hotline received almost a thousand calls and health workers were seeing “some very sick people,” said Dr. Linda Nelson, senior director of clinical operations heading the initiative. “Some of them can’t even talk on the phone without coughing.”

Dr. Rosemary Recavarren, a pathologist who oversees four hospital laboratories in the Rio Grande Valley, has been worried about this for weeks. She and her staff have been reaching out to the state health department and private testing companies since February, but they were told they were not a priority and that testing kits were allocated to areas much harder hit.

“We are not going to get testing for our machines until probably the end of April,” she said.

Eddie Olivarez, chief administrative officer for Hidalgo County’s health department, said only about 20% of COVID-19 testing in the region was being conducted by public labs, compared with 80% done through private institutions, because of capacity and because state criteria is more stringent on who can qualify for testing. Patients must have traveled and had known exposure to a confirmed case to be eligible for state tests, whereas private institutions allow more flexibility from each physician in recommending testing.

Olivarez said the Harlingen public health laboratory through which his county does testing can only process about 40 tests a day.

Chris Van Deusen, a spokesman for the Texas Department of State Health Services, said the agency had shipped more tests to the Rio Grande Valley on Wednesday and was working to start a “high-throughput” testing platform that would allow tests at a faster pace.

Most metropolitan areas in Texas rely on private hospitals for some in-house analysis of testing, but almost no hospitals in the Rio Grande Valley currently have that ability, Recavarren, the pathologist, said. They must either send swabs to public health laboratories, which comply with the state’s stricter criteria, or to private companies.

But as demand has skyrocketed across the country, companies are now overwhelmed and many Texas health workers said it can take days for results back from Quest Diagnostics and up to two weeks for LabCorp.

Quest Diagnostics said in a statement this week that between March 9 and April 1 it performed more than 400,000 COVID-19 tests across the country, “a sharp influx of test orders that continued to outpace our growing capacity.”

But it has since implemented a “higher throughput” diagnostic test at laboratories across the country, reducing the national backlog from 160,000 to 115,000 in a week.

“While we are more confident now in our ability to meet demand and report results for COVID-19 testing than in mid-March, when we were still ramping up capacity, this crisis is fluid and unpredictable, and so is the demand for COVID-19 testing,” the company said.

LabCorp said in a statement that it was also working “tirelessly” to increase capacity.

The lack of testing and delay in labs has even metropolitan areas with far more physicians and hospitals struggling.

Bexar County Judge Nelson Wolff, who oversees the state’s second-largest city of San Antonio, said its public laboratories can get results in a day, but when they send tests to Quest Diagnostics, it takes up to five days. More than 220 cases have been confirmed there with at least nine deaths, including a nursing home outbreak this week that killed one resident and infected at least 66 of the 84 residents.

In Harris County, home to Houston, the fourth-largest city in the nation, officials have struggled to open enough testing centers, receiving only enough supplies from the federal government for two publicly run sites in the county, testing 500 a day — far fewer than the 10 sites sought by Harris County Judge Lina Hidalgo, the region’s chief executive. The city of Houston has another two public testing sites able to jointly run another 500 tests daily.

The metropolitan area is also home to one of the country’s biggest medical centers, with many hospitals running in-house testing and analysis, including Houston Methodist, which can test about 250 patients in-house a day.

By Friday morning, at least 955 people in Houston and Harris County had tested positive — the most in the state — and at least 10 had died. The county is home to about 16% of the state’s 29 million residents.

Dr. Peter Hotez, a vaccine researcher and dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, has predicted Houston could follow New Orleans as a hot spot in the South. He thinks the Rio Grande Valley is also at risk, due to its high percentage of people living in poverty with diabetes and hypertension.

“Testing is crucial in poor neighborhoods, both on the border or in the urban core, that’s the most vulnerable populations,” Hotez said. “Wherever there is crowding and poverty, those are the areas I worry about the most.”

“A Tsunami Coming”

Starr County, an isolated, mostly rural county with one of the highest poverty rates in the state, bucked the border trend and was the first south of San Antonio to establish a drive-thru testing site in early March, thanks to a partnership between the county, university and a local businessman.

“Our testing here has not been short of anything,” Starr County Judge Eloy Vera said. “Anyone who needs to be tested is getting tested.”

The effort has paid off, local officials believe. The businessman is footing the first month’s bill, and the site has done about 300 tests, with just five people testing positive.

This week, Webb County, slammed with five deaths in four days, finalized a deal to bring 5,000 rapid tests to the Laredo area through a partnership with a local ER provider, Clear Choice ER.

City officials hoped to have the tests up and running by the end of this week, but on Friday announced they had determined the tests were not reliable and that Laredo police would investigate the validity of the kits’ FDA certification. Officials said they would continue “scouring the world for testing kits.”

Officials are feeling the pressure to slow the virus.

“We only have one shot at this,” Laredo City Manager Robert Eads said. “We have to get this right now.”

As testing increases and cases rise by the day, border officials brace for what lies ahead.

On Thursday, as 17 more people tested positive in Hidalgo County, including four children under the age of 5, county officials said there was now “clear evidence” of community spread. More than 630 in the county have now been tested, with at least 79 confirmed cases.

Fitzpatrick, the paramedic in Edinburg who struggled to get tested, learned Thursday she was not among them. She plans to return to her ambulance this weekend and hopes her department will receive more of the personal protective gear it needs.

“If we don’t do it, who’s going to do it?” she said. “There’s a lot more down here who will get sick.”

A University of Texas at Austin model of potential new COVID-19 hospitalizations released this week showed that depending on the measures taken by local officials, overall cases could reach between roughly 95,000 and 335,000 combined in the metro areas of Laredo, Brownsville and McAllen.

Hidalgo County Judge Richard Cortez, in his strongest words yet, warned “there is a tsunami coming. It hasn’t hit us yet.”

Apr 03, 2020

ProPublica announced Friday that Lisa Larson-Walker will be joining its staff as art director. She will lead ProPublica’s story presentation team, overseeing the use of photography, illustrations and other visuals to elevate the newsroom’s journalism and maximize its impact.

Larson-Walker comes to ProPublica from Slate Magazine, where she has helped shape visuals since 2013, most recently as art director. During her seven years at Slate, she led branding and content strategy for the site’s redesign, spearheaded a yearly summer illustration internship program, and launched and edited its Instagram feed, among other initiatives. She previously worked as photo editor at Newsweek and The Daily Beast and as a freelance photo editor for Matter. As a freelance illustrator, she has worked for ACLU Magazine, Barron’s, Foreign Policy, The New Republic and The New York Times, among other media outlets and institutions. She’s a graduate of the Cooper Union School of Art.

“Lisa’s innovative vision, paired with her keen understanding of how visuals can help readers fully understand and care about complex stories, make her the perfect creative force for ProPublica,” Scott Klein, deputy managing editor, said. “We’re thrilled to bring her immense talents to our visual storytelling.”

“I am profoundly humbled and honored to be joining the team at ProPublica,” Larson-Walker said. “Everyone I've had the chance to meet so far throughout the hiring process radiates a kindness, rigor and intelligence that shines through the work published, and I'm so excited to be inspired by everyone else I have the good fortune to be working with soon.”

Apr 03, 2020

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

The coronavirus entered Milwaukee from a white, affluent suburb. Then it took root in the city’s black community and erupted.

As public health officials watched cases rise in March, too many in the community shrugged off warnings. Rumors and conspiracy theories proliferated on social media, pushing the bogus idea that black people are somehow immune to the disease. And much of the initial focus was on international travel, so those who knew no one returning from Asia or Europe were quick to dismiss the risk.

Then, when the shelter-in-place order came, there was a natural pushback among those who recalled other painful government restrictions — including segregation and mass incarceration — on where black people could walk and gather.

“We’re like, ‘We have to wake people up,’” said Milwaukee Health Commissioner Jeanette Kowalik.

As the disease spread at a higher rate in the black community, it made an even deeper cut. Environmental, economic and political factors have compounded for generations, putting black people at higher risk of chronic conditions that leave lungs weak and immune systems vulnerable: asthma, heart disease, hypertension and diabetes. In Milwaukee, simply being black means your life expectancy is 14 years shorter, on average, than someone white.

As of Friday morning, African Americans made up almost half of Milwaukee County’s 945 cases and 81% of its 27 deaths in a county whose population is 26% black. Milwaukee is one of the few places in the United States that is tracking the racial breakdown of people who have been infected by the novel coronavirus, offering a glimpse at the disproportionate destruction it is inflicting on black communities nationwide.

In Michigan, where the state’s population is 14% black, African Americans made up 35% of cases and 40% of deaths as of Friday morning. Detroit, where a majority of residents are black, has emerged as a hot spot with a high death toll. As has New Orleans. Louisiana has not published case breakdowns by race, but 40% of the state’s deaths have happened in Orleans Parish, where the majority of residents are black.

Illinois and North Carolina are two of the few areas publishing statistics on COVID-19 cases by race, and their data shows a disproportionate number of African Americans were infected.

“It will be unimaginable pretty soon,” said Dr. Celia J. Maxwell, an infectious disease physician and associate dean at Howard University College of Medicine, a school and hospital in Washington dedicated to the education and care of the black community. “And anything that comes around is going to be worse in our patients. Period. Many of our patients have so many problems, but this is kind of like the nail in the coffin.”

The U.S. Centers for Disease Control and Prevention tracks virulent outbreaks and typically releases detailed data that includes information about the age, race and location of the people affected. For the coronavirus pandemic, the CDC has released location and age data, but it has been silent on race. The CDC did not respond to ProPublica’s request for race data related to the coronavirus or answer questions about whether they were collecting it at all.

Experts say that the nation’s unwillingness to publicly track the virus by race could obscure a crucial underlying reality: It’s quite likely that a disproportionate number of those who die of coronavirus will be black.

The reasons for this are the same reasons that African Americans have disproportionately high rates of maternal death, low levels of access to medical care and higher rates of asthma, said Dr. Camara Jones, a family physician, epidemiologist and visiting fellow at Harvard University.

“COVID is just unmasking the deep disinvestment in our communities, the historical injustices and the impact of residential segregation,” said Jones, who spent 13 years at the CDC, focused on identifying, measuring and addressing racial bias within the medical system. “This is the time to name racism as the cause of all of those things. The overrepresentation of people of color in poverty and white people in wealth is not just a happenstance. … It’s because we’re not valued.”

Five congressional Democrats wrote to Health and Human Services Secretary Alex Azar, whose department encompasses the CDC, last week demanding the federal government collect and release the breakdown of coronavirus cases by race and ethnicity.

Without demographic data, the members of Congress wrote, health officials and lawmakers won’t be able to address inequities in health outcomes and testing that may emerge: “We urge you not to delay collecting this vital information, and to take any additional necessary steps to ensure that all Americans have the access they need to COVID-19 testing and treatment.”

The city’s health officials have tried to take a purposeful approach to communicate information. (Darren Hauck for ProPublica)

Milwaukee, one of the few places already tracking coronavirus cases and deaths by race, provides an early indication of what would surface nationally if the federal government actually did this, or locally if other cities and states took its lead.

Milwaukee, both the city and county, passed resolutions last summer that were seen as important steps in addressing decades of race-based inequality.

“We declared racism as a public health issue,” said Kowalik, the city’s health commissioner. “It frames not only how we do our work but how transparent we are about how things are going. It impacts how we manage an outbreak.”

Milwaukee is trying to be purposeful in how it communicates information about the best way to slow the pandemic. It is addressing economic and logistical roadblocks that stand in the way of safety. And it’s being transparent about who is infected, who is dying and how the virus spread in the first place.

Kowalik described watching the virus spread into the city, without enough information, because of limited testing, to be able to take early action to contain it.

At the beginning of March, Wisconsin had one case. State public health officials still considered the risk from the coronavirus “low.” Testing criteria was extremely strict, as it was in many places across the country: You had to have symptoms and have traveled to China, Iran, South Korea or Italy within 14 days or have had contact with someone who had a confirmed case of COVID-19.

So, she said, she waited, wondering: “When are we going to be able to test for this to see if it is in our community?”

About two weeks later, Milwaukee had its first case.

The city’s patient zero had been in contact with a person from a neighboring, predominately white and affluent suburb who had tested positive. Given how much commuting occurs in and out of Milwaukee, with some making a 180-mile round trip to Chicago, Kowalik said she knew it would only be a matter of time before the virus spread into the city.

A day later came the city’s second case, someone who contracted the virus while in Atlanta. Kowalik said she started questioning the rigidness of the testing guidelines. Why didn’t they include domestic travel?

By the fourth case, she said, “we determined community spread. … It happened so quickly.”

Within the span of a week, Milwaukee went from having one case to nearly 40. Most of the sick people were middle-aged, African American men. By week two, the city had over 350 cases. And now, there are more than 945 cases countywide, with the bulk in the city of Milwaukee, where the population is 39% black. People of all ages have contracted the virus and about half are African American.

Milwaukee offers a glimpse into the disproportionate destruction the virus is inflicting on black communities nationwide. (Darren Hauck for ProPublica)

The county’s online dashboard of coronavirus cases keeps up-to-date information on the racial breakdown of those who have tested positive. As of Thursday morning, 19 people had died of illness related to COVID-19 in Milwaukee County. All but four were black, according to the county medical examiner’s office. Records show that at least 11 of the deceased had diabetes, eight had hypertension and 15 had a mixture of chronic health conditions that included heart and lung disease.

Because of discrimination and generational income inequality, black households in the county earned only 50% as much as white ones in 2018, according to census statistics. Black people are far less likely to own homes than white people in Milwaukee and far more likely to rent, putting black renters at the mercy of landlords who can kick them out if they can’t pay during an economic crisis, at the same time as people are being told to stay home. And when it comes to health insurance, black people are more likely to be uninsured than their white counterparts.

African Americans have gravitated to jobs in sectors viewed as reliable paths to the middle class — health care, transportation, government, food supply — which are now deemed “essential,” rendering them unable to stay home. In places like New York City, the virus’ epicenter, black people are among the only ones still riding the subway.

“And let’s be clear, this is not because people want to live in those conditions,” said Gordon Francis Goodwin, who works for Government Alliance on Race and Equity, a national racial equity organization that worked with Milwaukee on its health and equity framework. “This is a matter of taking a look at how our history kept people from actually being fully included.”

Fred Royal, head of the Milwaukee branch of the NAACP, knows three people who have died from the virus, including 69-year-old Lenard Wells, a former Milwaukee police lieutenant and a mentor to others in the black community. Royal’s 38-year-old cousin died from the virus last week in Atlanta. His body was returned home Tuesday.

Royal is hearing that people aren’t necessarily being hospitalized but are being sent home instead and “told to self-medicate.”

“What is alarming about that,” he said, “is that a number of those individuals were sent home with symptoms and died before the confirmation of their test came back.”

Royal has spent the past days coordinating with front-line community groups trying to make sure residents have what they need in order to stay inside. (Darren Hauck for ProPublica)

Health Commissioner Kowalik said that there have been delays of up to two weeks in getting results back from some private labs, but nearly all of those who died have done so at hospitals or while in hospice. Still, Kowalik said she understood why some members in the black community distrusted the care they might receive in a hospital.

In January, a 25-year-old day care teacher named Tashonna Ward died after staff at Froedtert Hospital failed to check her vital signs. Federal officials examined 20 patient records and found seven patients, including Ward, didn’t receive proper care. The report didn’t reveal the race of those whose records it examined at the hospital, which predominantly serves black patients. Froedtert Hospital declined to speak to issues raised in the report, according to a February article from the Milwaukee Journal Sentinel, and it had not submitted any corrective actions to federal officials.

“What black folks are accustomed to in Milwaukee and anywhere in the country, really, is pain not being acknowledged and constant inequities that happen in health care delivery,” Kowalik said.

The health commissioner herself, a black woman who grew up in Milwaukee, said she’s all too familiar with the city’s enduring struggles with segregation and racism. Her mother is black and her father Polish, and she remembers the stories they shared about trying to buy a house as a young interracial couple in Sherman Park, a neighborhood once off-limits to blacks.

“My father couldn’t get a mortgage for the house. He had to go to the bank without my mom,” Kowalik said.

It is the same neighborhood where fury and frustration sparked protests that, at times, roiled into riots in 2016 when a Milwaukee police officer fatally shot Sylville Smith, a 23-year-old black man.

And it is the same neighborhood that has a concentration of poor health outcomes when you overlay a heat map of conditions, be it lead poisoning, infant mortality — and now, she said, COVID-19.

Knowing which communities are most impacted allows public health officials to tailor their messaging to overcome the distrust of black residents.

“We’ve been told so much misinformation over the years about the condition of our community,” Royal, of the NAACP, said. “I believe a lot of people don’t trust what the government says.”

Kowalik has met — virtually — with trusted and influential community leaders to discuss outreach efforts to ensure everyone is on the same page about the importance of staying home and keeping 6 feet away from others if they must go out.

Police and inspectors are responding to complaints received about “noncompliant” businesses forcing staff to come to work or not practicing social distancing in the workplace. Violators could face fines.

“Who are we getting these complaints from?” she asked. “Many people of color.”

Residents have been urged to call 211 if they need help with anything from finding something to eat or a place to stay. And the state has set up two voluntary isolation facilities for people with COVID-19 symptoms whose living situations are untenable, including a Super 8 motel in Milwaukee.

Despite the work being done in Milwaukee, experts like Linda Sprague Martinez, a community health researcher at Boston University’s School of Social Work, worry that the government is not paying close enough attention to race, and as the disease spreads, will do too little to blunt its toll.

“When COVID-19 passes and we see the losses … it will be deeply tied to the story of post-World War II policies that left communities marginalized,” Sprague said. “Its impact is going to be tied to our history and legacy of racial inequities. It’s going to be tied to the fact that we live in two very different worlds.”

Update, April 3, 2020: This story has been updated to reflect that Illinois and North Carolina are breaking coronavirus cases down by race.

Doris Burke and Hannah Fresques contributed reporting.

Apr 03, 2020

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Dire shortages of vital medical equipment in the Strategic National Stockpile that are now hampering the coronavirus response trace back to the budget wars of the Obama years, when congressional Republicans elected on the Tea Party wave forced the White House to accept sweeping cuts to federal spending.

Among the victims of those partisan fights was the effort to keep adequate supplies of masks, ventilators, pharmaceuticals and other medical equipment on hand to respond to a public health crisis. Lawmakers in both parties raised the specter of shortchanging future disaster response even as they voted to approve the cuts.

“There are always more needs for financial support from our hardworking taxpayers than we have the ability to pay,” said Denny Rehberg, a retired Republican congressman from Montana who chaired the appropriations subcommittee responsible for overseeing the stockpile in 2011. Rehberg said it would have been impossible to predict a public health crisis requiring a more robust stockpile, just as it would have been to predict the Sept. 11, 2001, terrorist attacks.

“It’s really easy to second-guess and suggest we didn’t do as much,” he said. “Why didn’t we have a protocol to protect the Twin Towers? Whoever thought that was going to happen? Whoever thought Hurricane Katrina was going to occur? You tell me what’s going to happen in 2030, and I will communicate that to congressmen and senators.”

There were, in fact, warnings at the time: A 2010 Centers for Disease Control and Prevention-funded report by the Association of State and Territorial Health Officials urged the federal government to treat public health preparedness “on par with federal and state funding for other national security response capabilities,” and said that its store of N95 masks should be “replenished for future events.”

But efforts to bulk up the stockpile fell apart in tense standoffs between the Obama White House and congressional Republicans, according to administration and congressional officials involved in the negotiations. Had Congress kept funding at the 2010 level through the end of the Obama administration, the stockpile would have benefited from $321 million more than it ended up getting, according to budget documents reviewed by ProPublica. During the Trump administration, Congress started giving the stockpile more than the White House requested.

By late February, the stockpile held just 12 million N95 respirator masks, a small fraction of what government officials say is needed for a severe pandemic. Now the emergency stash is running out of critical supplies and governors are struggling to understand the unclear procedures for how the administration is distributing the equipment.

The stockpile received a $17 billion influx in the first and third coronavirus stimulus bills that Congress passed in March. But there had not been a big boost in stockpile funding since 2009, in response to the H1N1 pandemic, commonly called swine flu.

After using up the swine flu emergency funds, the Obama administration tried to replenish the stockpile in 2011 by asking Congress to provide $655 million, up from the previous year’s budget of less than $600 million. Responding to swine flu, which the CDC estimated killed more than 12,000 people in the United States over the course of a year, had required the largest deployment in the stockpile’s history, including nearly 20 million pieces of personal protective equipment and more than 85 million N95 masks, according to a 2016 report published by the National Academies of Sciences, Engineering and Medicine.

“We recognized the need for replenishment of the stockpile and budgeted about a 10% increase,” said Dr. Nicole Lurie, who served as the assistant secretary for preparedness and response at the Department of Health and Human Services during the Obama administration. “That was rejected by the Republican House.”

Republicans took over the House of Representatives in the 2010 midterms on the Tea Party wave of opposition to the landmark 2010 health care reform law, the Affordable Care Act, also known as Obamacare. The new House majority was intent on curbing government spending, especially at HHS, which administered Obamacare.

Congressional Republicans, led by Mitch McConnell in the Senate and House Speaker John Boehner, leveraged the debt ceiling — a limit on the government’s borrowing ability that had to be raised — to insist that the Obama administration accept federal spending curbs. The compromise, codified in the 2011 Budget Control Act, required a bipartisan “super committee” to find additional ways to reduce the deficit, or else it would trigger automatic across-the-board cuts known as “sequestration.”

Even in the aftermath of the swine flu pandemic, the stockpile wasn’t a priority then. Without a full committee markup, Rehberg introduced a bill that provided $522.5 million to the stockpile, about 12% less than the previous year and $132 million less than the administration wanted. “Nobody got everything they wanted,” Rehberg said.

The Senate version of the funding bill offered $561 million for stockpile funding. Senators said they regretted the cuts even as they voted for the bill.

“In this bill we’re now getting into the bone marrow,” Tom Harkin, a Democrat from Iowa who then chaired the Senate appropriations committee, said at the markup. “Some of these cuts will be painful and unpopular.”

In the bill’s final version, Congress allocated a compromise $534 million for the 2012 fiscal year, a 10% budget cut from the prior year and $121 million less than the Obama administration had requested.

The next year, the “super committee” failed to secure additional savings demanded by the Budget Control Act, triggering the automatic, across-the-board cuts. This “sequestration” was an outcome that the leaders of both parties disliked — and blamed one another for.

“Did either party ever indicate sequestration was welcome, positive or desirable?” Dave Schnittger, Boehner’s deputy chief of staff at the time, told ProPublica. “Sequestration was conceived — not by Republicans, but by a Democratic White House — as a crude mechanism to compel the super committee to do its job. Republicans consistently advocated for reductions in mandatory spending programs that would have prevented sequestration from ever happening.” (Mandatory spending refers to entitlement programs such as Social Security and Medicare.)

McConnell’s office did not respond to requests for comment.

Katie Hill, a spokeswoman for Obama, pointed to numerous statements he made in 2013 urging Republicans to compromise, warning that the sequester would weaken economic recovery, military readiness and basic public services.

Gene Sperling, then a top Obama economic adviser, said Republicans focused attacks on the HHS budget, along with the Departments of Labor and Education, which are grouped under the same appropriations subcommittee.

“The Labor/HHS budget is where a significant number of progressive priorities are, from Head Start to (the National Institutes of Health) to the Education Department,” Sperling said. “There’s just so much in there, so it is often the hot spot for where conservative budget hawks who don’t believe in public investment go hardest.”

Under sequestration, the CDC, which managed the stockpile at the time, faced a 5% budget cut. In its 2013 budget submission, HHS decreased its stockpile funding request from the previous year, asking for $486 million, a cut of nearly $48 million. “The SNS is a key resource in maintaining public health preparedness and response,” the administration said. “However, the current fiscal climate necessitates scaling back.”

The decrease caught Rehberg’s attention at a budget hearing to review the request.

“Disaster preparedness is something that has been very important to me,” he said at the hearing. “I just would like to have you explain how such a large reduction can possibly not impact the national preparedness posture.”

Then-HHS Secretary Kathleen Sebelius answered that the CDC would prioritize replacing expiring drugs such as smallpox vaccines and anthrax treatments.

The next year, the administration again proposed cutting the stockpile’s funding from the 2012 funding level, but it warned that reduced funding could result in “fewer people receiving treatment during an influenza pandemic.”

Congress did grant extra funding in response to emergencies, but even then, the stockpile was a small-ticket item. In 2014, the Obama administration asked for and received billions of dollars to respond to the Ebola outbreak, but only $165 million went to the CDC’s public health emergency preparedness programs, including the stockpile. And in 2016, Congress granted emergency funding to respond to the Zika virus, but it gave the CDC less than half of what the Obama administration requested.

“It’s clear that the administration prioritized the SNS in this (Zika) request and in the Ebola supplemental,” said Ned Price, who was a spokesman for the National Security Council in the Obama White House. “In the case of Zika, congressional Republicans sat on the request for the better part of a year.”

The stockpile’s mission has steadily expanded as it confronts new public health emergencies. With limited resources, officials in charge of the stockpile tend to focus on buying lifesaving drugs from small biotechnology firms that would, in the absence of a government buyer, have no other market for their products, experts said. Masks and other protective equipment are in normal times widely available and thus may not have been prioritized for purchase, they said.

“It just was never funded at the level that was needed to purchase new products, to replace expiring products and to invest in what we now know are the really necessary ancillary products,” said Dara Lieberman, director of government relations at the Trust for America’s Health, a nonpartisan public health advocacy and research group.

The sequestration and strict budget caps ended with budget deals in 2018 and 2019 — a bipartisan rebuke to the earlier restraints. “It’s a burden off our shoulders,” Senate Appropriations Chairman Richard Shelby, R-Ala., told reporters at the time. “In a troubled world, I think that was the wrong message.”

Yet non-defense spending still hasn’t fully recovered.

“One of the things that happened to public health preparedness was just the result of the general budget stringency we had,” said David Reich, a consultant working on federal appropriations issues for the Center on Budget and Policy Priorities. “We’re still seeing the results of that.”

During the Trump administration, the White House has consistently proposed cutting the CDC and the HHS Office of the Assistant Secretary for Preparedness and Response, which took over stockpile management from the CDC. Congress approved more stockpile funding than Trump’s budget requested in every year of his administration, for a combined $1.93 billion instead of $1.77 billion, according to budget documents.

The White House budget request for 2021, delivered in February as officials were already warning about the dangerous new coronavirus, proposed holding the stockpile’s funding flat at $705 million and cutting resources for the office that oversees it.

Lydia DePillis contributed reporting.

Apr 03, 2020

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There’s an overlooked reason why hospitals treating COVID-19 patients are so short of protective gear. In January, just before the pandemic hit the United States, a key distributor recalled more than 9 million gowns produced by a Chinese supplier because they had not been properly sterilized.

“At this time, we cannot provide sterility assurances with respect to the gowns or the packs containing the gowns because of the potential for cross-contamination,” Cardinal Health wrote to customers on Jan. 15. It added, “We recognize the criticality of our gowns and procedure packs to performing surgeries, and we apologize for the challenges this supply disruption will cause.”

The recall immediately forced the canceling of some elective surgeries. It also meant that supplies of medical gowns were already low when hospitals and state governments began desperately searching for protective gear to cope with the pandemic. Most gowns are supposed to be worn once and not reused. As some doctors and nurses have resorted to covering themselves with trash bags, raincoats and hazardous materials suits bought online, many health care workers have contracted the virus, further taxing already overwhelmed hospitals.

“Demand has gone up at a time when supply was already constrained,” said Bindiya Vakil, the chief executive of Resilinc, a Milpitas, California, firm that monitors supply chain disruptions worldwide. “Coronavirus made what was already a bad situation a lot worse.”

Colin Milligan, a spokesman for the American Hospital Association, said that the group’s members continue to experience shortages of medical gowns and that the Cardinal recall “has had a ripple effect.”

A Cardinal spokeswoman said that “the supply of surgical gowns should not impact the supply of PPE,” or personal protective equipment, for health care workers because they usually wear another type of outer garment, isolation gowns, when tending to coronavirus patients.

Cardinal received approval Tuesday from the federal government to donate the 2.2 million recalled gowns that remain in its inventory to the Strategic National Stockpile for distribution as isolation gowns. Each pallet must be “labeled in with a warning that the articles are for use for non-sterile apparel purposes only,” according to the approval letter.

The company is “working around the clock to meet the needs of healthcare providers so they can safely serve the patients who depend on them,” a Cardinal spokeswoman wrote in an email.

The shortage of gowns even before the coronavirus outbreak highlights the vulnerabilities of a U.S. health care system that depends on protective equipment largely made in other countries, led by China. The quality of gowns and other gear has been a recurring problem, including a dead insect in the packaging of a Cardinal gown, complaint records show. Replacing an overseas supplier can take months, and even if a new one is found quickly, it still has to ramp up production and arrange shipping.

“Unfortunately, like others, we are learning in this crisis that overdependence on other countries as a source of cheap medical products and supplies has created a strategic vulnerability to our economy,” U.S. Trade Representative Robert Lighthizer said at a meeting Monday. “For the United States, we are encouraging diversification of supply chains and seeking to promote more manufacturing at home.”

The recall also exposes flaws in how both companies and government regulators monitor the overseas manufacturers that produce much of the country’s inventory of protective medical gear. Because surgical gowns are considered a medical device, their quality is monitored by the U.S. Food and Drug Administration, which inspects manufacturing plants every two years.

A spokeswoman for Cardinal, which is based in Dublin, Ohio, said that it has a “broad and diverse manufacturing and supplier network” that includes the U.S. and is not dependent on any one locale. Cardinal is also one of the largest prescription drug distributors in the world. It had revenues in 2019 of more than $145 billion, making it the 16th largest company in the U.S., according to Fortune.

Cardinal chief executive Mike Kaufmann told Wall Street analysts in February that the company understood “the gravity” of the recall. He said it had hired outside experts to review Cardinal’s quality assurance procedures.

The company’s board has established a special committee to review management’s actions pertaining to the recall, according to Cardinal’s website. The outside experts continue to scrutinize the company’s practices, a spokeswoman said.

Of the recalled gowns, Cardinal had already distributed almost 8 million to health care facilities; the others had not reached customers. Some had been manufactured as early as the fall of 2018, the company has said. Cardinal does not have information on how many of the gowns were used but believes a majority of them were, a spokeswoman told ProPublica. Asked if any health workers or patients were infected as a result, she said that “we continue to track and analyze complaint data.”

The FDA last inspected the problematic Chinese plant in April 2018 and did not identify any violations, an agency spokeswoman said. Manufacturers are responsible for detecting problems and reporting them to the FDA, she said, adding that the Chinese company did not report any such issues during the period covered by the recall.

The January recall was not the first time Cardinal had a problem with the supplier, which it has identified as Siyang HolyMed Products Co. in Jiangsu province on China’s coast. Cardinal disclosed in a January press release that in the spring of 2018, around the same time the FDA was inspecting the Chinese company’s manufacturing facility, the company learned that Siyang outsourced some of its production to an unqualified facility. Cardinal tested products at the time and determined there was no reason to take further action such as a recall, it said.

Then, last Dec. 10, Cardinal received a tip that Siyang was making gowns at two sites that weren’t approved by the U.S. company or registered with the FDA, a Cardinal spokeswoman said. Ten days later, an on-site investigation confirmed the tip, she said.

In a Jan. 21 letter to customers, Cardinal said it couldn’t guarantee that the gowns were sterile because Siyang made some of them at locations that “did not maintain proper environmental conditions as required by law.” They were “commingled with properly manufactured gowns,” Cardinal said.

Phone and email attempts to contact Siyang were unsuccessful. The FDA said in January that it was investigating how the gowns may have been contaminated. An agency spokeswoman did not respond to questions about the status of that investigation.

Health care workers wear gowns to protect themselves from coming in contact with blood and other bodily fluids, microorganisms and particulate material. The gowns offering the highest level of protection are sterilized. A gown that is not properly sterilized increases the risk of infection, which can be transmitted to a patient during a procedure.

Health care workers use two kinds of medical gowns. Surgical gowns, like those sold by Cardinal, provide the highest level of protection and are more heavily regulated by the FDA. Isolation gowns, which are produced in larger amounts, are not sterilized but are appropriate for many interactions with COVID-19 patients. Both are in short supply right now as hospitals are quickly burning through any gowns they have and, in some cases, using already depleted supplies of surgical gowns when isolation gowns are unavailable.

The 9.1 million gowns recalled by Cardinal likely represent about 30% of the company’s global distribution, according to Premier, a Charlotte, North Carolina, company that negotiates prices on supplies bought by more than 4,000 hospitals and health care systems. The recall “absolutely contributed to the challenges that some of our hospitals are having treating their patients,” Chaun Powell, a group vice president at Premier, said. “That put burden on the supply chain prior to COVID outbreaks, and then the COVID outbreaks only exacerbated that issue.”

In the past two years, the FDA has received several complaints about the quality of Cardinal gowns. Adverse event reports filed with the agency include accounts of inadequate and improper protective wrapping on sterile gowns, holes in gowns, and blood soaking through the protective material. The reports disclosed to the public do not name the facilities or individuals reporting the product defects. Complaints have been filed about gowns purchased from distributors other than Cardinal as well.

In 2019, a hospital reported that a sterile gown arrived from Cardinal improperly wrapped, rendering it non-sterile. “This was noticed before it was opened to the surgical field; however, had it been opened it would have contaminated the entire field,” the report said. Ten days later, another report noted another packaging defect that could have caused contamination. “This is not the first time this has happened,” according to the report. “The gowns are coming from the manufacturer this way.”

In February, after the recall, a hospital found a dead insect in the packaging of a Cardinal sterile gown, according to a report filed with the FDA. The hospital said the gown was not part of the recall. The report noted there had been previous, unconfirmed reports of hair, gum and a cigarette butt found in Cardinal products labeled as sterile.

Cardinal did not respond to questions about the adverse event reports.

China is the source of 45% of all the protective medical garments imported to this country, according to an analysis last month by the Peterson Institute for International Economics. Other countries where gowns for U.S. health care workers are manufactured include Mexico, Thailand, Cambodia, Honduras and the Dominican Republic, according to the nonprofit ECRI Institute in Plymouth Meeting, Pennsylvania.

Another major distributor of surgical gowns, Medline Industries Inc., declined to answer questions about where its gowns are made. Attempts to contact another supplier, Halyard, were unsuccessful.

At a health care conference last month, Halyard’s parent company reported making surgical gowns at a plant in San Pedro Sula, Honduras.

For Cardinal, the recall has been a costly blow to its bottom line and reputation. The company’s operating earnings declined 34% in the second quarter ending Dec. 31, in part due to a $96 million charge related to the recall.

“We don’t know how this could affect our business going forward, and we’re hoping that it doesn’t,” Cardinal’s Kaufman said in a conference call with investment analysts in February. “But we know that we have created some pain.”

Apr 03, 2020

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As she sat Wednesday on the covered deck at the 4-Way Saloon in Sidell, overlooking the town grain elevator, Leslie Powell made her way down the list of tasks she had scribbled on her yellow notepad. Asking the utility company for a payment plan was first.

Powell’s husband, Mark, became owner of this busy little bar and grill in east-central Illinois just nine days before Gov. J.B. Pritzker ordered residents across the state to shelter in place in an attempt to halt the spread of the novel coronavirus outbreak.

Now, with the 4-Way closed to dine-in orders, and the couple’s savings spent on buying and fixing it up, the Powells face losing their business if they don’t receive state or federal aid. And that has reinforced a thought Powell has had before: Chicago should be separated from the rest of the state.

The idea of secession has long simmered in Illinois’ more rural and Republican counties, periodically flaring up around issues such as raising the minimum wage, the establishment of sanctuary cities for undocumented immigrants and gun ownership. And though Illinois’ secession movement — or, movements — isn’t exactly united, many who believe in the principle share a general sense of feeling underrepresented in a state dominated by Chicago’s Democratic stronghold.

The coronavirus outbreak, which has yet to touch some areas of the state, has become the most recent flashpoint, inspiring both serious promises to reintroduce secession on the ballot and Facebook memes that call for building a wall around Chicago.

Political experts say there is virtually no chance that the state will ever split, especially since it will require an act of Congress and lead to the likely election of two Republican senators to represent that new state. Still, the secession conversation is a dramatic expression of the much more widespread — and potentially dangerous — frustration with a sweeping governmental response to the pandemic that many question in areas where some homes sit acres apart and people predominantly travel by car, not public transportation.

“There’s nobody around here that’s got it,” Powell said. “We’re a farming community. We know how to wash our hands. We’re with pigs and cows and chickens. In this community, it’s really hard to comprehend.”

Leslie Powell wipes off the bar at the 4-Way Saloon in Sidell, Illinois, in July 2019. (Rick Danzl/The News-Gazette)

As of Thursday, 41 of Illinois’ 102 counties had yet to see a single case of COVID-19, according to the Illinois Department of Public Health. Experts caution that likely will change soon. Vermilion County, where Powell lives, reported its first two cases this week, officials there said.

On Tuesday, Pritzker announced he was extending the stay-at-home order through April. Many people said they are following it, even if their businesses and livelihoods are suffering.

At the same time, the response to the pandemic has exacerbated the feelings of some residents that the rest of the state is being forced to deal with Chicago’s problem. State Rep. Blaine Wilhour, a Republican from Effingham, said that he would like to see some regional accommodations considered to the shutdown measures, including the possibility of opening up some restaurants at half-capacity and allowing mom-and-pop stores to set up appointments.

“There’s obviously a big difference in how these broad policies affect Chicago, which is a very densely populated area, and how they affect my district,” Wilhour said.

Wilhour, along with six other Republican lawmakers, sent a letter to Pritzker last week asking for measures to help small businesses during the pandemic, including freezing the minimum wage for 18 months and implementing a sales tax holiday for the duration of the stay-at-home order.

While Wilhour said he understands the severity of COVID-19, he said the stay-at-home order has taken an enormous economic toll on his district. Residents are taking the safeguards seriously for now, he said, but they also see that the disease is not nearly as prevalent in their area as it is in Chicago.

“They see the trajectory of Illinois as not good, especially not good for people in our part of the state,” he said. “There’s a lot of pent-up anxiety about adversarial policies that are pushed down to benefit Chicago and they disproportionately don’t benefit us.”

The state’s map of positive COVID-19 cases, as of Thursday. Darker blue shading indicates more positive cases; orange dots represent locations where there have been confirmed deaths. (Illinois Department of Public Health)

One risk of that frustration is that people may feel less inclined to follow what they see as Chicago’s rules. Steve McNeil, who manages Rent One furniture and appliance store in West Frankfort, about 300 miles south of Chicago, said he’s concerned that some people are neither following Pritzker’s stay-at-home order nor social distancing guidelines. Though his store, part of a regional chain, remains open, he said he makes sure his staff sanitizes the store “on the hour, every hour.”

He can’t say all of his customers are taking similar steps, though.

“It’s very lackadaisical,” McNeil said. “A lot of people I don’t see taking the precautions seriously.”

McNeil said his store has seen unprecedented sales of washers, dryers, deep freezers and refrigerators — which he considers “essential items” and the reason he believes he’s allowed to stay open — and has felt heartened by the new role he sees his business providing during the crisis.

On Wednesday, McNeil’s Rent One store posted a photo on its Facebook page advertising its stock of lawn mowers: “Yard season has started and Rent One is here to help you get started. This bad boy is parked out front of the store so feel free to take a look at it TODAY!”

Rick Henson, who owns a barber shop in West Frankfort, closed Tuesday after business slowed because of the coronavirus. He now hopes to reopen next week, after he began getting calls from customers, many of whom are older people, city officials and local police officers, saying he’s a “needed commodity.”

Jared Gravatt, co-owner of Crown Brew Coffee Company in Marion, said he understands the need for the stay-at-home order but thinks the differences between Chicago and the rest of the state are “night and day.”

Gravatt said the county’s businesses are reeling from the shutdown. He and his business partner are organizing a virtual fundraising event on Friday to raise money and awareness for struggling businesses while encouraging people to abide by the stay-at-home order.

Even Gravatt, who said he recognizes the importance of protecting against the coronavirus outbreak, acknowledges the appeal of secession.

COVID-19 has “killed more businesses than it has people in this region,” he said.

Last year, State Rep. Brad Halbrook, a Republican from Shelbyville, filed legislation that urged Congress to declare Chicago the nation’s 51st state. The legislation stalled in the rules committee, where it found little support, but organizing around the issue continues. Once Pritzker’s stay-at-home order is lifted and people are able to gather again, “the interest will be as high as it’s ever been,” Halbrook said. “There’s no question about it.”

Illinois State Rep. Brad Halbrook (Handout photo)

“They want to manage the entire state to suit Chicago,” Halbrook said. “They’re different lifestyles and different cultures. To do this one-size-fits-all management doesn’t work.”

John S. Jackson, a visiting professor at the Paul Simon Public Policy Institute at Southern Illinois University in Carbondale, points to similar secession movements in New York and California, where rural areas have animosity toward those states’ urban centers.

He called the perception of unequal resource distribution between Chicago and the rest of the state “a myth” that has existed for decades, and he said the stakes of that ideological divide are high during the coronavirus crisis.

“It’s a corrosive part of our culture,” Jackson said. “It has no chance at all of becoming law.”

Unlike other supporters, Collin Cliburn, a contractor and carpenter who lives outside Springfield, has led much of the state’s grassroots secession efforts. Cliburn describes his political views as “borderline old-school libertarian” and differentiates his effort from the “New Illinois” secession movement led by Halbrook as more populist and rogue than that of elected political leaders.

Cliburn hopes to collect enough local signatures to force the secession question onto statewide ballots as a referendum, county by county. So far, the strategy has paid off in Jefferson, Fayette and Effingham counties, which during the state’s March primaries voted more than 70% in a nonbinding referendum in favor of secession. While he believes, based on one-on-one conversations as well as the popularity of events he’s organized, that many in southern Illinois favor secession in practice, Cliburn said most are hesitant to vote for it.

To try to build support, Cliburn has turned to social media. He makes memes, shares local news stories and writes posts across a network of Facebook groups and pages he runs to amplify differences he sees between Chicago and the rest of the state.

“What I’m doing is creating a spider web,” Cliburn said.

That spider web, which he’s crafted to function as a sort of social media ecosystem of secession sentiment, includes “Illinois Separation,” a page Cliburn runs that has garnered nearly 27,000 Facebook likes; “Illinoyed,” a page for more general venting about the state, which has about 11,700 likes; and also dozens of county-level pages for local organizers. Lately, Cliburn said, he’s been using coronavirus news to bring attention to the effort to kick Chicago out of the state.

“Everything is about Chicago,” reads a March 24 post on the “Illinois Separation” page, above a news story about Chicago preparing for a “surge in bodies” because of COVID-19 deaths. “When the Governor speaks only Chicago people stand beside him, including their Mayor Lightfoot …” he wrote. “I’m sick and tired of everything being about Chicago.”

Another post, shared on the “Illinois Separation” page on March 25, shows an image of the state of Illinois with the Chicago-area blocked off with a line. “Make Illinois Great Again … build a wall !!” the graphic reads. Comments included individuals blaming Chicago for positive COVID-19 cases in their own counties and criticizing the shelter-in-place order in areas with few if any positive cases.

The post has nearly 800 likes and 400 shares.

Screenshot via “Illinois Separation” Facebook page.

Pritzker spokeswoman Jordan Abudayyeh called it “appalling” that people would focus on division instead of unity during a national crisis. The governor’s duty is to every single resident in Illinois, she said.

“When COVID-19 was first reported in Illinois, it was in one county and quickly spread to more than 50 in the days since,” Abudayyeh said. “Almost every day there is a new county reporting positive cases.”

The frustration that some rural residents feel about the shutdown, or at least their expectation that COVID-19 won’t reach them, may be short-lived.

Experts warn that the low numbers of confirmed COVID-19 cases may simply reflect a lack of testing. In some counties, less than two dozen people have been tested. Because coronavirus spreads first in large urban areas then expands, it’s probably only a matter of time before the rest of the state sees cases, said Dr. Jerry Kruse, Dean and Provost of Southern Illinois University School of Medicine in Springfield

“It’s almost like throwing a pebble into a pool and watching the waves radiate out,” said Kruse, who added that it’s a “virtual inevitability” the coronavirus will reach rural Illinois.

Metro East St. Louis and Sangamon County have already started to see the number of cases rise.

“You should assume that the coronavirus has come to your county,” said Monica Dunn, assistant administrator at Edgar County Public Health Department.

Christian County, about 30 minutes southeast of Springfield, is an example of how quickly the situation can turn.

The county of 32,000 did not see its first case of COVID-19 for more than six weeks after the outbreak hit Chicago. On March 19, the county learned of its first case. For the next week, nothing changed. On March 25, there was one more.

Then overnight, 11 new confirmed cases.

“When we didn’t have any cases, there was a real complacency going on,” said Denise Larson, Christian County public health administrator. Larson said she fears the low number of confirmed cases so far in nearby counties gives a false sense of security.

The outbreak happened at a subsidized apartment complex for seniors in Taylorville after a resident attended church with someone who had contracted the disease. All 22 residents of Rolling Meadows Senior Living Apartments were tested, officials said. Two additional cases have been confirmed, bringing the total number of confirmed cases at the complex to 13 as of Tuesday.

On Wednesday, the county announced two COVID-19 deaths, a man and woman, both in their 80s.

Eighty-five-year-old Peggy Wadkins, who has lived in Christian County for more than 60 years and at the apartment complex for 10, said she spends much of her time now on the phone with her family, including her more than 30 great-grandchildren.

While residents remain in quarantine, city and county officials are checking to see if they need groceries or medicine. This week, Wadkins put her walker in the doorway so a worker could place tissues, tylenol, lunch meat and bananas on the seat without coming into contact with her.

When Wadkins looks out her bedroom window, which overlooks the now vacant parking lot, she imagines a day when all of this has passed.

Until then, she said, “No one is really safe.”

Apr 03, 2020

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This article was produced in partnership with the Anchorage Daily News, which is a member of the ProPublica Local Reporting Network.

Later this spring, Alaska’s Bristol Bay will blossom into one of the largest annual salmon fisheries in the world.

The regional population of about 6,600 will triple in size with the arrival of fishermen, crews and seasonal workers on jets but also private planes and small boats, many traveling from out of state.

And yet the heart of the health care system in southwestern Alaska, in a corner of the state where the Spanish flu once orphaned a generation, is a 16-bed hospital in Dillingham operated by the Bristol Bay Area Health Corp. Only four beds are currently equipped for coronavirus patients. As of Wednesday, the hospital had a few dozen coronavirus tests for the entire Florida-sized region, tribal leaders said.

If those newly arrived workers need to quarantine for two weeks, as mandated by the state, residents said it’s unclear where everyone will hunker down. Local store shelves are already bare of Clorox, Lysol and rubber gloves.

Dillingham, the largest community in the Bristol Bay region with a population of 2,300, is 320 miles from Anchorage by air.

“We’re scared. … People come from all over the world for Bristol Bay fishing,” said Gayla Hoseth, second chief for the Dillingham-based Curyung Tribal Council. “There’s 7,000 of us who live here, and this hospital cannot handle the 7,000 of us if we get sick. Imagine (when) our population triples and quadruples in the summertime.”

Dillingham, Alaska. (Bill Roth/Anchorage Daily News)

Compounding matters, the hospital executive who ran daily operations for the health care system is out of a job after downplaying the coronavirus threat to colleagues.

A March 16 email from the executive — which repeated a conspiratorial meme suggesting the coronavirus is somehow a politically motivated phenomenon — set flame to a deep anxiety among some tribal leaders over the vulnerability of Alaska villages in a pandemic.

“Just a reminder that FLU kills many every year!” wrote Lecia Scotford, who was the chief operating officer. (The coronavirus is not like the flu. It appears to be more contagious and more lethal.)

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The message soon began to circulate in the Bristol Bay region, drawing a blistering response from some tribal and local leaders.

Robert Clark, president and chief executive of Bristol Bay Area Health Corp., said Scotford’s last day was Monday. He would not say if she was fired, citing “personnel stuff,” but said “she was separated.”

Scotford did not respond to emails, phone calls and Facebook messages requesting comment. Her email to lists of “division managers” and “department managers” within the regional health organization also emphasized the need for calm, common sense and good hygiene, and for the hospital to be prepared to serve the public.

“That (email) was very concerning to me because that kind of lets people’s guard down,” Norman Van Vactor, president of the Bristol Bay Economic Development Corp., said in a phone interview.

Bristol Bay is a magnet for people in the summer, with a seasonal migration of about 13,000 workers for the lucrative fishing season. The commercial salmon fishery here is the largest in the state, but as of 2010, about 60% of earnings went to out-of-state permit holders.

Almost all the major Bristol Bay seafood processing companies are based in Seattle, an early hot spot for coronavirus, and two thirds of Bristol Bay processing workers live in West Coast states at other times of the year, according to the Institute of Social and Economic Research at the University of Alaska Anchorage.

The Alaska Department of Fish and Game forecasts some 34.6 million sockeye salmon will be harvested there this year.

“When it comes to wild salmon, we are over half the world’s sockeye and over half of the Alaska salmon value,” said Andy Wink, executive director for the Bristol Bay Regional Seafood Development Association.

The nonprofit industry group on Thursday issued an advisory urging the fleet to delay travel to Bristol Bay until May 1.

“Keep in mind, it is possible to carry this virus without symptoms and unknowingly infect others leading to overtaxed medical capacity and/or death(s),” the advisory said. “You do NOT want to be the outsider photographed or seen around town in public spaces if this situation turns for the worst,” the group warned its fishermen.

Wink said his nonprofit is working with local governments on a plan to avoid overcrowding Bristol Bay Area Health Corp. clinics and the Dillingham hospital with sick fishermen, processors and support workers.

“We are taking the stance that we don’t want to rely on the local clinics or if we do, the need to be bolstered substantially,” Wink said.

As the health care provider for the region, Bristol Bay Area Health Corp. operates the only regional hospital and the clinics in 21 surrounding villages. It employed 470 people and reported revenue of $76.7 million in 2017, according to a tax form that Scotford submitted to the IRS.

Clark, the health corporation chief executive, said the Dillingham hospital is seeking more equipment to meet the potential for coronavirus patients among the local and visiting fishing industry patients.

Chief nursing officer Lee Yale said the hospital had 37 tests on hand as of Wednesday, and that all tests performed had returned negative. The Dillingham facility has no ICU beds, four negative pressure rooms to treat COVID patients without infecting others, plus two ventilators for the region.

“We have staffing but if they get ill we will be in a tight spot,” she wrote in an email. “(The) fishing industry will devastate our surge plan and we can not support and cover our villages if this season opens.”

Meantime, for many in Bristol Bay, the looming COVID-19 threat recalls family histories of death and loss in the face of past epidemics.

The Spanish flu wracked the U.S. in 1918 and 1919, including this Kansas hospital, above. Residents of Bristol Bay are descendants of Spanish flu survivors. (Wikimedia Commons)

“We are the survivors of the survivors of the orphans of the Spanish flu,” said Hoseth, the Dillingham tribe second chief.

Another member of the tribe, tribal administrator Courtenay Carty, said her great-grandmother was orphaned in Dillingham by the 1919 flu and raised by family members, and her grandfather was orphaned by tuberculosis in the 1940s.

“The fact that all of our contemporary families are descendants of those children and few adults that survived 1919 is one of (the) major reasons why we are so passionate about protecting ourselves from this pandemic,” she said. “What is history to others is our tribal and familial identities.”

Her tribe declared a state of emergency because of the coronavirus on March 24, calling for a stop to all but essential travel to the city.

Clarification, April 3, 2020: This story was updated to more accurately describe who raised tribal administrator Courtenay Carty’s great-grandmother.