CareOne Nursing Homes Said They Could Safely Take More COVID-19 Patients. But Death Rates Soared.

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On Friday, March 20, the New Jersey Department of Health got an urgent call from a Catholic nursing home. COVID-19 was tearing through St. Joseph’s Senior Home in Woodbridge Township. At least a dozen of the nuns who worked at the facility had fallen ill, and they feared they didn’t have enough staff on hand to care for the residents.

Instead of sending in state inspectors to assess the situation, health officials reached out to private care providers for help, and CareOne, one of the largest nursing home chains in New Jersey, said it would assist. When nurses from the company arrived at St. Joseph’s on Sunday afternoon, they found just three nuns trying to manage almost 90 residents. The company sent a report to the state on Monday, and the following day, state officials took the extraordinary step of ordering St. Joseph’s to evacuate.

The state determined that CareOne, with its network of homes across the state, had the resources to accommodate the influx of transfers. The company quickly began to make space in its 94-bed Hanover facility, CareOne at Hanover. In a span of hours, about 70 residents at Hanover were hustled out, their belongings moved in trash bags, and taken to three other CareOne facilities in the area.

By Wednesday morning, residents from St. Joseph’s were arriving in a caravan of ambulance buses. They were frail and, in some cases, gravely ill.

It was a frantic effort, undertaken as infections in New Jersey were starting to surge. The first that local officials in Hanover heard of the evacuation was from township residents calling the police about the line of ambulances outside the facility.

In the weeks that followed, CareOne would go on to have the highest rate of COVID-19-related deaths among large long-term care companies in New Jersey. At least 518 residents of the company’s New Jersey facilities have died from the novel coronavirus.

Of the 363 nursing homes in New Jersey, two of the three CareOne facilities that received transfers from Hanover — facilities in Morristown and Parsippany — have had among the highest death rates. At the Morristown facility, where 45 residents died, there has been one death for every four beds in the facility. At the Parsippany home, there were 36 deaths, nearly one for every three beds. Infections at CareOne’s Morristown facility went on to raise alarms with the local Health Department, and the Parsippany home was cited for infection-control issues.

Melissa O’Connor, an expert in nursing care for the elderly, said that with testing as scarce as it was early in the pandemic, the moves between CareOne facilities may have helped spread the virus.

“They exposed all of those people they moved unnecessarily,” said O’Connor, an associate professor at Villanova University’s M. Louise Fitzpatrick College of Nursing in Pennsylvania. “They probably made an assumption that they had no positive cases in those other two places, but that was a really huge, and wrong, assumption.”

New Jersey has reported more deaths from the coronavirus linked to long-term care facilities than any other state.
Andrew Seng, special to ProPublica

By then, CareOne had become a key player in the state’s response to COVID-19. Not only had it been enlisted to deal with the crisis at St. Joseph’s, but soon after, it was given a license agreement to provide more than 700 hundred beds at five of its facilities to care for COVID-19 patients being discharged from hospitals.

As the pandemic continued to ravage the state in early April, cases exploded in nursing homes, which had been given less attention and fewer resources than hospitals in the early weeks of the outbreak. New Jersey would record nearly 6,800 deaths linked to long-term care facilities, more than any other state has reported, including 81 residents at a veteran’s home in the town of Paramus and 63 at a nursing facility in rural Andover.

The toll on CareOne and its 21 nursing homes in New Jersey is particularly striking given the crucial role the state gave the company in helping manage the crisis. The death rate at the company’s New Jersey homes is more than 60% higher than the rate for all homes statewide, a ProPublica analysis found.

Eric Bloom, a spokesman for the company, said in an email that the high death rates at CareOne facilities found in ProPublica’s analysis are misleading because the company took in and treated a large number of COVID-19 patients. But according to the New Jersey Department of Health, the data does not count patients who are already COVID-19-positive when admitted to a facility toward that facility’s case and death totals; thus, those patients would not have inflated death rates for facilities in the analysis.

In an emailed response to questions, New Jersey Department of Health spokeswoman Donna Leusner said that CareOne received the license agreement because “it had facilities statewide” and the staff, protective equipment and capacity to separate infected residents from uninfected ones that was “necessary to provide beds for COVID-positive patients in this pandemic crisis.”

Once the original residents of Hanover were moved to other facilities, 78 residents from St. Joseph’s were moved in. Their arrival prompted worried calls to the local Health Department, which struggled to allay concerns with what limited information it had.

Carlos Perez Jr., the health officer for Morris County, where Hanover is located, heard from CareOne staff that the new residents were “filthy, unkempt, completely unwell.” He said a CareOne nurse broke down crying, describing the situation over the phone.

“They just moved them and that was it,” Perez said. “I was offered no assistance at all.”

Several families of residents transferred from St. Joseph’s and CareOne at Hanover said they were kept in the dark while the evacuation was taking place. Marilyn Minsk said she only received a call from CareOne after her 98-year-old mother had been moved from Hanover to another of the company’s homes.

“I said: ‘No, I didn’t want her moved. What are you talking about?’ And then the phone was hung up. I didn’t know where she was,” Minsk said. “I was in shock. We’re all locked down. We can’t even move. How can you take her out of a place when I can’t even see her?”

Minsk would learn that her mother, Sylvia Sternhell, had been moved to the facility at Parsippany and her belongings had been thrown into trash bags and stored in the basement at CareOne at Hanover. Within 10 days of the move, Sternhell developed a respiratory illness and was later diagnosed with COVID-19. Over the next month, she was moved back and forth between the hospital and the nursing home. She died on May 13.

Left: Sylvia Sternhell with her daughter, Marilyn Minsk, and granddaughter. Right: Sternhell on a FaceTime call with Minsk after she was transported. Minsk said her mother was wearing clothing she didn’t recognize because Sternhell’s belongings had been thrown in trash bags and put in storage.
Courtesy of Minsk

CareOne did not address questions from ProPublica about Minsk’s dealings with the company. “The actions taken by CareOne staff saved lives and were applauded by state officials, including Governor Murphy,” Bloom wrote. “We are proud of our people and any attempt to by [sic] the media to attack them is misguided.”

Minsk remains heartsick not only because she couldn’t see her mother in person during her last months, but also because she’s convinced CareOne took on more residents than it could safely handle.

“They were not heroes,” Minsk said. “Very far from being heroes at all.”

To understand which nursing homes bore the brunt of COVID-19’s spread through New Jersey, ProPublica used state long-term care outbreak reports and data from the Centers for Medicare and Medicaid Services on the number of licensed beds per facility to calculate death and infection rates for each home. Read more about our analysis here.

CareOne homes stood out, with a death rate equal to 17% of its certified beds, compared with the 10% death rate statewide. The chain’s homes also had an infection rate of 56% compared with 38% statewide.

COVID-19 Deaths at CareOne Homes Outpace Other New Jersey Chains

Coronavirus deaths in CareOne facilities, as a share of certified beds, have been consistently higher than in other nursing homes in the state.

Note: Reporting before May 20 includes staff deaths.

The pandemic hit some counties harder than others, but in seven of the nine counties where CareOne operates, its homes had higher death rates. In Morris County, where the Hanover, Morristown and Parsippany homes are located, the chain’s death rate was 21% compared with 10% for the rest of the county. In Bergen County, which recorded the most deaths of any county in the state, the company’s death rate was 16% compared with 14% countywide; in Burlington County, the chain’s rate was 19% compared with 8% for the rest of the county.

ProPublica’s analysis excludes assisted living facilities, which are not regulated by CMS. Rates are as of July 10, after which the state changed its reporting practices, making tracking cumulative deaths by facility impossible.

Bloom, the CareOne spokesman, said the state data used in the analysis is “imperfect” because it flows from local health departments that interpret the reporting guidelines differently. CareOne also contends that ProPublica’s method for calculating infection and death rates is inaccurate because it uses facilities’ licensed bed capacity rather than actual numbers of patients treated. Bloom said the analysis didn’t reflect CareOne’s higher patient turnover.

“CareOne operates post-acute care centers that focus on medically complex short-stay cases — not traditional long-term care nursing homes,” he said.

It’s true that CareOne homes, like many nursing facilities, offer short-term care, but 20 of its 21 homes in New Jersey are rated by CMS for providing long-term care as well. The most recent publicly available data for admissions across all nursing facilities is from 2017, and the three largest chains in New Jersey, including CareOne, declined to share current admission numbers with ProPublica.

Using the number of licensed beds to control for population size is common in analyses of nursing homes, including in a report commissioned by New Jersey and produced by expert consulting group Manatt Health on the impacts of COVID-19 in long-term care facilities.

The number of short-term patients flowing into nursing homes during the pandemic almost certainly declined from previous years: elective surgeries, a major source of short-term stays in nursing homes, were suspended in New Jersey for most of April and May, when the pandemic was at its peak. During the spring, the main source of short-term stays was likely patients recovering from COVID-19 who were discharged from hospitals to nursing homes, including many operated by CareOne.

Founded in 1999 by entrepreneur Daniel Straus, CareOne operates some 55 facilities in six states. The largest share of its business is in New Jersey, where it runs 31 nursing homes and assisted living facilities. It also operates facilities in Massachusetts, Virginia, Pennsylvania, Maryland and Connecticut.

Before starting CareOne, Straus, 63, and his brother built a national chain of long-term care facilities that they sold for $1 billion. Straus lives in Englewood, a few miles from CareOne’s headquarters in Fort Lee.

Over the past 20 years, CareOne has cultivated an image as a family business that puts its residents first. Court records show it is also one that’s hard-nosed in responding to criticism of its care and business practices.

Despite a family-friendly image, CareOne has faced lawsuits from residents and families over its care standards.
Andrew Seng, special to ProPublica

Amid ongoing legal battles in 2016, CareOne sought the help of Michael Cohen, the New York lawyer who worked for many years as a fixer for President Donald Trump.

Cohen, who went to prison in connection with some of his work for Trump, hired an IT company, RedFinch Solutions, to set up websites filled with positive stories about Straus to help offset unflattering Google search results, according to RedFinch’s CEO, John Gauger. (Without naming Straus or the company, court documents say that Cohen was paid $200,000 in 2016 for “consulting.”)

After the company was faulted by the National Labor Relations Board for its dealings with workers and the Service Employees International Union in New Jersey and Connecticut, the company went after the union with a law often used against the Mafia. In 2012, it filed a Racketeer Influenced and Corrupt Organizations, or RICO, lawsuit against the union’s affiliates in New Jersey and Connecticut.

The suit accused organizers of “criminal sabotage, intimidation and other acts of extortion.” A federal judge in New Jersey ruled in favor of SEIU in October 2019, saying its organizing efforts constituted “lawful, albeit aggressive, bargaining.” CareOne has appealed.

Late last year, a jury found the company at fault to the tune of over $6 million in a racial discrimination lawsuit brought by a Black woman who had been promoted to vice president. Soon after she was given the new position, she claimed in court documents, she was told by a superior: “I don’t want a black person walking around here in a suit as a VP. I want you in scrubs, flats, and a lab coat.” The woman was fired the next day.

The company says the woman was terminated for poor performance and filed a motion to dismiss the damages, which a judge denied in January. “This verdict was unfounded and represents a run-away jury,” Bloom said. CareOne says it is appealing.

CareOne has faced a number of lawsuits in recent years in which residents or their families have claimed CareOne facilities aren’t meeting care standards for nursing homes. It’s not uncommon for homes to face such suits, but in several, CareOne has taken an unusual position in response: It has argued that, when it comes to short-term residents, it isn’t obligated to meet standards for nursing facilities.

“Safe and decent living environment?” Katelyn Cutinello, CareOne’s attorney, asked during a hearing last month in one such lawsuit. “He never intended to live at CareOne. He was admitted for subacute rehab to be discharged home.” (The judge denied the company’s motion to dismiss the plaintiff’s claim three weeks later.)

Deborah Gough, the resident’s lawyer, said she’d seen CareOne use this defense before and called it particularly troubling right now since most of the COVID-19 patients the chain has admitted from hospitals would be considered short-term residents.

CareOne did not respond to questions about its use of this legal argument.

One case taken to trial last year by a law firm in Cherry Hill, New Jersey, dealt with a 57-year-old recovering cancer patient who suffered a bedsore that went to the bone and severe catheter injury to his penis under CareOne’s watch. In that case, CareOne claimed that its facility in Evesham Township wasn’t required to meet standards for nursing homes in caring for the man. (The Evesham facility is one of the five that took COVID-19 patients from hospitals under CareOne’s agreement with the state.)

“They try to say that the rehab resident, since they are just there for the short-term rehabilitation, is not subject to the nursing home laws,” said Richard Talbot, the lead lawyer on the case. “It’s beyond disingenuous to even make that argument.”

The jury agreed, and last year the executor of the man’s estate, his brother, was awarded over $400,000 including attorney’s fees and other costs.

New Jersey’s COVID-19 crisis gave CareOne an opportunity to work closely with state officials and burnish its reputation.

When it was called upon to help with the emergency at St. Joseph’s, the governor singled out the company and Executive Vice President Elizabeth Straus, daughter of Daniel, for public praise. At a March 24 press conference, Gov. Phil Murphy gave a “shoutout in particular to CareOne,” he said. “I spoke to Lizzy Straus yesterday, who’s terrific, and CareOne in particular with this challenge.”

The state also looked to CareOne and other large long-term care providers when it appeared a surge in COVID-19 patients might cause a bed shortage at New Jersey hospitals. It made agreements with three large chains to provide dedicated COVID-19 care at their facilities. The New Jersey chain Alaris Health had three homes licensed, providing around 300 beds. National nursing home operator Genesis HealthCare agreed to provide more than 100 beds at two facilities. The first, and biggest, deal went to CareOne, for 707 “COVID-capable” beds at five facilities, on March 30.

State-Licensed COVID-19 Facilities

The state made license agreements with three long-term care companies in 10 locations to ease the pandemic’s burden on hospitals.

Then, on March 31, New Jersey issued an order compelling all long-term care facilities to accept stable COVID-19 patients discharged from hospitals. Homes could not turn away patients because they tested positive for the virus and could not require a person to be tested before being admitted.

While the wisdom of moving COVID-19 patients into communities full of vulnerable elderly people spurred instant debate, the financial incentives for homes were substantial: Facilities could fill beds left empty by the pause on elective surgeries and, in some cases, have their bills covered by Medicare, which pays more, instead of Medicaid. Beyond per-patient payments, the homes with licenses from the state could also be eligible for reimbursement of all reasonable costs through the Federal Emergency Management Agency or through emergency compensation boards appointed by Murphy.

“This is very lucrative for the nursing home,” said David Grabowski, a professor of health policy at Harvard University who specializes in long-term care. “They make double-digit margins for this type of care. It’s exactly the care from a financial perspective that they would like to be doing.”

CareOne was among the most aggressive in opening its doors to COVID-19 transfers and swiftly moved to use its agreement with the state to bolster its corporate branding. On April 1, it filed an application with the United States Patent and Trademark Office to register the COVID-Capable service mark and now uses it prominently in its marketing.

A company article included with CareOne’s application to register the service mark.

Not all the transfers went well, however.

Dorothy and Edward McBride, a married couple in their 80s, were discharged to CareOne at Livingston after testing positive for COVID-19 at their assisted living facility, where they’d been for almost a year, and going to the hospital for a day.

Their daughter, Linda, who requested that her last name not be published, says her parents complained they were neglected at the home, their calls for assistance going unanswered for hours. Aides were sometimes unavailable to help her father with meals, so his elderly wife would try to shift the 6-foot-2, 200-pound man into an upright position so that he could eat.

Edward McBride died six days after he was admitted. The only call Linda received was at 1:10 a.m. on Easter Sunday to let her know he had passed. Linda, who is a nurse, said, “I know I would never ever treat my patients, or my patients’ family, the way my parents were treated.”

CareOne did not address questions about the McBrides’ treatment in CareOne at Livingston.

Less than two weeks after issuing the directive to nursing homes, New Jersey pulled back. On April 13 the state Health Department established strict criteria for a facility to accept COVID-19 patients.

By then, CareOne was preparing to return the residents it had taken in from St. Joseph’s — 78 evacuees plus four additional people who had been in the hospital during the evacuation. Fifty-one were moved back starting on April 16, Dawn Thomas, a spokeswoman for the state Health Department, said in an email responding to ProPublica questions.

It’s unclear what happened to the other 31. The Health Department wouldn’t say how many St. Joseph’s residents died while with CareOne. St. Joseph’s did not respond to several calls and an email seeking comment.

CareOne defended its care of the St. Joseph’s residents. “After CareOne’s heroic measures at St. Joseph’s and a review of the extensive protocols and procedure [sic] derived from that experience, the state designated some of our facilities COVID-capable,” it said in a written response to questions from ProPublica.

The company’s role in the March evacuation of St. Joseph’s, in which it both assessed another nursing home and then took in its residents, remains troubling to some local officials and nursing home experts.

“It’s hard to imagine any circumstance where the entity doing the evaluation should also be the one profiting off of the outcome of that evaluation when peoples’ lives are at stake,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a national nonprofit focused on improving practices at nursing homes and assisted living facilities.

After the transfers from CareOne at Hanover that were spurred by the St. Joseph’s situation, Morristown health officials became increasingly concerned about how CareOne at Madison Avenue, the company’s facility in Morristown, was managing COVID-19.

When a health official in Morristown directed the company in April to suspend admissions, he was rebuffed by the company, emails obtained by ProPublica show.

Local officials were concerned about dozens of deaths at CareOne at Madison Avenue as it continued to accept more patients.
Andrew Seng, special to ProPublica

The facility’s administrator said that the nursing home’s procedures complied with state standards, and that nursing homes were not subject to regulation by local health departments.

Morristown health officials then emailed the state for assistance. Ten days passed without reply. But while they were waiting, the state issued a directive on April 22 to local health officials to take the lead on outbreak investigations in long-term care facilities.

The township officials wrote to the state again about CareOne at Madison Avenue. They said that based on data from the facility, 38 residents had died from COVID-19 as of April 27, and 43 staff members had fallen ill, but the facility was continuing to admit people and was not addressing concerns from local health officials.

The state promised to investigate, but a few days later, Morristown officials were told the state had conducted an inspection of the facility and deemed it in compliance. The Morristown officials were left uncertain about the scope and depth of the state’s review and say the state has refused multiple requests for more details.

In May, spurred by the burgeoning death toll from COVID-19 at New Jersey nursing homes, the state commissioned an independent assessment of the facilities and their regulatory overseers.

The report by experts with the consulting group Manatt Health released in June found that nursing homes were underprepared for the pandemic’s wave of infection, and that the state’s oversight infrastructure, inadequate even before the crisis, couldn’t keep up.

“Under-resourced state agencies did not have sufficient staff to deploy to facilities and conduct meaningful oversight prior to COVID-19,” the report read. “COVID-19 didn’t create the problem–it exacerbated the long-standing, underlying systemic issues affecting nursing home care in New Jersey.”

The state’s order to compel nursing homes to take COVID-19 patients from hospitals, and CareOne’s central role in taking them, has left some families bitter.

Carmela Minor’s father, Joseph Ferrante, 92, was a resident at CareOne’s King James nursing home in a small town on the Jersey Shore when she received a letter from the facility saying it was accepting COVID-19 patients.

“By order of the Commissioner of Health, all facilities, including ours, must accept as new residents those who are being discharged from the hospital who have tested positive for COVID-19,” the April 14 letter read.

Minor says she wishes she had pulled her father out as soon as she learned that.

Joseph Ferrante, a resident of CareOne at King James.
Courtesy of Carmela Minor

By May 1, her father had developed a 103-degree fever. Minor had him admitted to a nearby hospital, but 11 days later, he was dead from the virus.

CareOne at King James first appeared in the state’s COVID-19 outbreak report with eight cases on May 4, three weeks after Minor received the facility’s letter. Two days later, there were 30 confirmed COVID cases. By the time her father died, there were over 100 cases and eight dead residents. By July 13 — just before the state stopped publishing key data on outbreaks at long-term care facilities, making it harder to see their full toll — there were 140 cases, involving staff and residents, and at least 19 residents had died.

CareOne did not respond to ProPublica’s questions about the outbreak in the King James facility.

Minor tries not to blame herself for what happened to her father, but mostly, she wishes CareOne had handled COVID-19 differently.

“To not be careful with this virus, and to accept people into the facility that you know have it, doesn’t make sense.”

Do you have access to information about New Jersey’s public health or response to the COVID-19 pandemic that should be public? Email Sean Campbell at or contact him on Signal at 352-448-5247. Here’s how to send tips and documents to ProPublica securely.

Caroline Chen contributed reporting.

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An Indian Company Is Gearing Up to Make Millions of Doses of a $3 Covid-19 Vaccine

As the Covid-19 pandemic drags on, there’s one thing we’re all counting on to rescue us from the drudgery of socially-distanced life: a vaccine.

How many times have you heard “X won’t happen again until there’s a vaccine”? Concerts, conferences, festivals, sporting events, weddings, and anything else that entails a lot of people being in one place has been put on hold indefinitely—and we miss it. All of it.

But as much as we’re counting on a vaccine to put an end to this nightmare, the reality is that even once a fateful scientist, company, or lab does find a vaccine, the story doesn’t end there; the next steps are manufacturing the vaccine at scale, ensuring equitable distribution both between and within countries, and making sure everyone who needs vaccination—billions of people around the world—can access and afford it. We’ve never been faced with a challenge like this, and the way it plays out will speak to our collective compassion and humanity.

An Indian company is getting a jump-start on manufacturing low-cost vaccines. With funding from the Bill & Melinda Gates Foundation, the Serum Institute of India plans to crank out 100 million doses of Oxford University’s coronavirus vaccine for poor countries at a cost of $3 or less per dose. In a separate deal with multinational pharma giant AstraZeneca, which licensed Oxford’s vaccine in late April, the Serum Institute also agreed to produce a billion doses for low- and middle-income countries.

The Serum Institute

The Serum Institute of India isn’t widely known, but as Bill Gates points out in this video from 2012, the company plays a crucial role in global health. As the world’s biggest manufacturer of vaccines by volume (not by revenue—that title goes to British GlaxoSmithKline), Serum makes vaccines for dozens of diseases, including measles, mumps, diptheria, tetanus, and hepatitis-b, among others. According to the company’s website, 65 percent of children in the world receive at least one of its vaccines, and they’re used in over 170 different countries.

Serum was founded in 1966 and is privately owned, which gives it the freedom to make quick, risky decisions that publicly-traded pharma companies can’t; Bloomberg says the company “may be the world’s best hope for producing enough vaccine to end the pandemic.”

The Oxford Vaccine

As detailed in a paper published in The Lancet on July 20, a vaccine developed by researchers at Oxford University showed highly encouraging results in phase 1 and 2 clinical trials. Of 1,077 people that took part in the trials, 90 percent developed antibodies that neutralized Covid-19 after just one vaccine dose.

Its unwieldy name, “ChAdOx1 nCoV-19,” is a mashup of its various attributes: it’s a chimpanzee (Ch) adenovirus-vectored vaccine (Ad) developed at Oxford (Ox). Unlike American company Moderna’s vaccine, which prompts an immune response using Covid-19 messenger RNA, the Oxford vaccine is made from a virus genetically engineered to resemble coronavirus. Scientists used a virus that causes the common cold in chimpanzees, and added the spike protein that Covid-19 uses to break into human cells. The resulting virus doesn’t actually cause people to get infected, but it prompts the immune system to launch a defense against it and block it from continuing to invade cells.

The vaccine’s only side effects were headaches and a mild fever. More extensive trials are now being launched in the US (this will be the biggest with 30,000 people), UK, South Africa, and Brazil. The vaccine may be used in controversial human challenge trials as well—this is when vaccinated people are infected with the virus to see whether the vaccine can effectively neutralize it.

Risky Business, Onward

The Serum Institute is taking a pretty big risk by forging ahead with these plans, even outside of the fact that the Oxford vaccine hasn’t yet passed Phase 3 clinical trials. If the vaccine falls through for any reason, Serum stands to lose up to $200 million.

Even once a vaccine (this one or any other) is determined safe, cranked out at lightning speed, and distributed, there’s no guarantee it will eradicate Covid-19. The virus could mutate and develop a new strain. The ultra-accelerated timeline under which vaccines are being developed could leave us with one that’s not truly safe and time-tested. Production constraints and supply hoarding could complicate manufacturing. And according to one study, 50 percent of Americans and more than a quarter of people in France say they don’t even want to be vaccinated.

As Carolyn Johnson wrote in the Washington Post, “The declaration that a vaccine has been shown safe and effective will be a beginning, not the end. Deploying the vaccine to people in the United States and around the world will test and strain distribution networks, the supply chain, public trust and global cooperation. It will take months or, more likely, years to reach enough people to make the world safe.”

Despite these caveats, though, a vaccine is still a finish line we must race towards, and the only logical next step short of letting the virus rage in an attempt to achieve herd immunity. So, fraught as it may be when (or if) it arrives, we’ll keep waiting, hoping, and looking forward to all the things we’re going to do again once there’s a vaccine.

Image Credit: Bao_5 from Pixabay

Local Officials Say a Nursing Home Dumped Residents to Die at Hospitals

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The nurse with the Columbia County Health Department recorded the COVID-19 deaths at nearby hospitals — two at Albany Medical Center on May 4, another at the same hospital two days later; one at Columbia Memorial Hospital on May 17, and another there two days later — and, along with her boss, concluded there was a pattern.

The people dying at the hospitals had been residents of a local nursing home, the Grand Rehabilitation and Nursing at Barnwell in the tiny town of Valatie, New York. In all, the nurse counted 18 deaths of residents over five weeks. She didn’t have detailed medical records for the patients, but she noted that all had arrived at the hospital with orders saying no extraordinary measures were to be taken to keep them alive. As a result, she and the Columbia County health director developed a theory: “For me,” said Jack Mabb, the health director, “it appeared they were sending people to the hospital so they wouldn’t die in the facility.”

A change in the way New York tabulated nursing home deaths could have incentivized such behavior, he said, making homes’ records on COVID-19 containment appear better than they were.

In the early weeks of the pandemic, the state had counted these deaths by attributing them to the nursing home regardless of where they physically occurred. But in April — as the death toll related to nursing homes mushroomed, hitting as many as 250 deaths a day — that changed: The administration of Gov. Andrew Cuomo decided not to count residents who died of COVID-19 in hospitals as nursing home deaths, saying it feared that their deaths would be double-counted if they were recorded that way.

The administration insisted the move wasn’t meant to suppress the numbers at nursing homes, facilities Cuomo had reassured the public were his top priority for protecting from the pandemic. In public testimony this month, Howard Zucker, the state’s health commissioner, defended the decision and argued that New York had been as transparent about nursing home casualties as any state in the nation.

Today, more than 6,500 nursing home residents are known to have perished in New York facilities, some 6% of the state’s nursing home population. The state declined to say how many additional residents died in hospitals after being sickened in nursing homes.

Mabb said that his department’s nurse had sent reports about the deaths of Barnwell residents at local hospitals to state authorities, and that he had asked for an investigation. Some of the residents died soon after arriving at the hospitals, Mabb said, while others took longer to pass away. But the fact that all 18 had do-not-resuscitate orders or similar directives suggested to him that they had been sent to the hospitals with little hope of ever returning to the home. The department, Mabb said, shared its documenting of the deaths with the state.

“There are very few legitimate reasons for a nursing home to send seriously ill residents with do-not-resuscitate orders to a hospital unless there is a real chance that their conditions could be improved,” Mabb said. “We flagged it for the state. We told the Department of Health we thought something big was going on.”

Mabb said the state Health Department, which regulates nursing homes, has yet to tell him if it’s investigating what happened to the Barnwell residents.

Bruce Gendron, a vice president of the company that operates the Barnwell nursing home and 15 others, rejected Mabb’s claims that the home had sought to dump dying residents at local hospitals. He said that residents only would have been sent if they needed care beyond what the home could provide, and that those residents deserved every chance to survive.

Gendron said any scheme to inappropriately send residents to die elsewhere would have involved the home’s medical director and several of its nurses, all of whom are licensed by the state and would have been putting their careers at risk.

Twice in May, state Health Department investigators conducted “complaint surveys” at the Barnwell home after scores of staff members and residents at the home tested positive for COVID-19.

The Department of Health website shows that inspectors found problems with the facility’s ability to contain the virus: Uninfected residents were living alongside infected residents; residents suspected of having COVID-19 also were not separated. Some Barnwell staffers told the Health Department that they were confused about when they were supposed to wear masks and gloves or change out of old equipment and under what circumstances. The inspectors cited the facility and ordered a halt to additional admissions. Dozens of residents were eventually relocated.

Gendron first told ProPublica that the allegations of dumping dying residents at hospitals had been investigated by the state Health Department and found to be unsubstantiated. Asked to produce such a finding, Gendron referred to the inspections done in May, saying the absence of any findings related to hospital transfers proved the home had been cleared. Barnwell’s quality of care related to COVID-19 had become a public controversy in May, prompting coverage in the local media, and Gendron said he assumed the state would have been alert to any other problems at the home, including signs of dumping residents.

The state’s inspection reports make no mention of investigating hospital transfers. The Health Department did not respond to questions from ProPublica about whether it had investigated Mabb’s allegations. ProPublica shared Gendron’s version of events with the state, but again, the Health Department did not respond. Jill Montag, a department spokeswoman, appeared to be unaware of the allegations involving the home’s dying residents, asking ProPublica to send along a record of them.

There is little doubt that Barnwell, a 236-bed facility in the Hudson Valley, was overwhelmed by the virus this spring. From March 30 through the first week of June, according to county statistics, scores of staff members and residents tested positive for the virus.

A tally of COVID-19 cases as of early June shared by the Columbia County Health Department shows the scale of the outbreak at Barnwell.
Columbia County Health Department

But trying to unpack what exactly unfolded at Barnwell lays bare the confusing and often conflicting available information about COVID-19’s deadly path through the state’s elderly population.

The county Health Department is responsible for identifying cases of COVID-19, and nursing homes are obligated to report such cases to it. But nursing homes are regulated by the state, and the county has a limited ability to make sure such facilities are responsibly reporting and managing outbreaks.

Mabb said he had only received notifications from the Barnwell home on two deaths inside the facility. The state Health Department says online that the death toll from the home is 12. Mabb said he thought the first infection at Barnwell had involved a staff member; the state has said the first case of COVID-19 at the facility involved a resident, but it can’t say with certainty what role if any the resident played in the eventual outbreak.

Mabb said he has ultimately come to mistrust any information coming from either the state or officials with Barnwell. He said he counts the 18 deaths of Barnwell residents at the hospitals as nursing home deaths.

ProPublica contacted the three hospitals where Barnwell residents died, but none would talk about the deaths or the county’s allegation that residents had been sent to them to avoid being recorded as nursing home fatalities.

As Gendron pointed out, decisions to send nursing home residents to the hospital for additional care are supposed to be approved by a home’s medical director. He would not provide copies of such approvals involving the 18 residents who later died at hospitals, however, saying he didn’t have the staff to do such work, and noted that some of the residents had been taken to the hospital after 911 calls, when a medical director’s approval would not have been required.

Sorting out the events at Barnwell, it turns out, also involves another disputed state policy: the order from the Health Department that nursing homes accept medically stable COVID-19 patients being discharged from hospitals. The policy also barred patients from being tested to see if they were still positive for the virus.

The policy, enacted March 25, alarmed and angered many — nursing home operators, families of residents, elected officials worried about an already vulnerable population being subjected to additional possible harm. The state, after a blizzard of criticism, abandoned the order some seven weeks after implementing it.

Last month, the Health Department issued a report asserting that the policy had not significantly contributed to deaths of nursing home residents.

The report was met with open skepticism among nursing home personnel, epidemiologists, and Republican and Democratic officials in New York and Washington. Those lawmakers repeated their calls for a truly independent investigation of the state’s handling of the COVID-19 crisis at its more than 600 nursing homes.

In the Health Department’s report, which said more than 6,400 COVID-19 patients had been sent from hospitals to nursing homes under the policy, the state said the vast majority of the roughly 310 homes that accepted those patients had already had a case of COVID-19 among their staff members or residents. The report said the spread of the virus in the homes had been driven by infected staff members.

But the report made clear that dozens of homes had experienced no cases of COVID-19 before receiving a coronavirus patient from a nearby hospital. ProPublica asked the state to produce the data involving 58 homes that had not been affected prior to taking in a COVID-19 patient.

Days later, the state Health Department said the data in its report had been inaccurate. And several days after that, the department said updated information indicated that just six homes, not 58, had been free of COVID-19 prior to the arrival of a patient from a hospital.

The department would not answer an array of questions about how and why it had changed the data in its report, one it had used to defend its controversial policy. It would not say how what it had called a peer-reviewed study had relied on erroneous or incomplete data; it would not say how the new information had come to light.

It did say, though, that the Barnwell home was one of the facilities that did not have a case of COVID-19 among its staff or residents prior to the first arrival of a COVID-19 patient from a hospital. The state, however, would not say when that transfer occurred or if it had studied what role, if any, it had played in the eventual outbreak that overran the facility. The county recorded Barnwell’s first COVID-19 case on March 30, two weeks before the surge in cases among both staff and residents.

Ron Kim, a Democratic state legislator from Queens, said he has no faith that the state has been honest about what happened as a result of its policy.

Kim, a member of the State Assembly’s Health Committee, said he had taken an intense interest in the state’s efforts to protect nursing home residents. One ZIP code in his Queens district had more nursing home deaths than any other in the state, he said. One of those deaths was a member of his family. Kim said he had filed Freedom of Information requests seeking all administration communications about nursing homes during the pandemic.

“The theme of the report was to shift the blame and scapegoat the workers and the families over the decision that the executive office had made,” Kim said of the Health Department report made public last month. “It’s clear that the executive office is directing and ordering up the report and data collection in a way that will give them what they want out of the report.

“They are trying their best to use government resources and the Department of Health to exonerate the executive office of any wrongdoing,” Kim added.

Kim said given the state’s lack of transparency, it was impossible to say whether what’s alleged to have happened at the Barnwell facility may have been more widespread.

Kim and other lawmakers have said they know of no other state that counts nursing home deaths the way New York currently does.

Informed of Kim’s specific claims, the state Health Department referred ProPublica to public statements made by Zucker, the department’s commissioner.

On Aug. 3, Zucker testified before a joint hearing held by state legislators. He was grilled repeatedly about the state’s seeming inability or unwillingness to answer basic questions about how many nursing home residents might have died to date in the pandemic.

The policy of not counting deaths in hospitals was revisited again and again.

Howard Zucker, the state health commissioner, testifies at a joint hearing held virtually on Aug. 3.
Screenshot via New York State Assembly

Addressing Zucker in one exchange, State Senate Investigations Committee Chair James Skoufis, a Democrat from the Hudson Valley where Barnwell is located, said: “It’s my opinion that your administration’s definition truly misrepresents the scale of this crisis as a result. So let’s try and get the full picture here and now: How many of New York’s nursing home residents died in hospitals?”

Zucker insisted the state couldn’t say because it didn’t yet have a fully accurate count.

“You don’t have a ballpark that you can give? So the total official number is about 6,500. Are we talking with the hospital deaths: 8,000? 10,000? 15,000? What are we looking at?” Skoufis countered.

“I’m not prepared to give you a specific number. We are in the middle of a pandemic obviously, we always forget about that sometimes,” Zucker said. “We are looking at all the numbers, we are looking at the data, when the data comes in and I have an opportunity to piece through that, then I will be happy to provide that data to you and to the other members of the committee.”

State Senate Health Committee Chairman Gustavo Rivera, a Democrat from the Bronx, suggested a final count wasn’t needed to see what the administration was doing.

“It seems, sir, that in this case you are choosing to define it differently so you can look better,” he said. “That is a problem, bro.”

ProPublica asked the state Health Department if it had ever excluded fatalities of residents transferred to hospitals in counting deaths of nursing homes residents during outbreaks of the flu or other infectious diseases.

The state did not directly respond but said in a statement, “This is a global pandemic, the likes of which we have never seen before. There is no precedent.”

Elaine Healy, acting president of the New York Medical Directors Association, said it shouldn’t be hard for the state to have an accurate count of how many nursing home residents died of COVID-19 in hospitals. They’d counted these deaths in the nursing home totals early on, she said, and “the numbers would be quite easy to get from the hospitals.”

The outbreak at Barnwell was one of two involving local nursing homes in Columbia County.

When the outbreak at Barnwell became public in early May, Patsy Leader, the town supervisor in nearby Kinderhook, called for the state to intervene, accusing Barnwell of trying to cover up the dumping of dying residents. Leader repeated the allegation in a brief interview with ProPublica.

Gendron, the Barnwell executive, eventually traveled to Barnwell to personally handle the crisis.

In a series of interviews and exchanges with ProPublica, Gendron said he was not aware of the state’s claim that Barnwell’s first case of COVID-19 involved a hospital transfer. He said the company had been alarmed by the Cuomo administration’s policy requiring nursing homes to accept COVID-19 patients being discharged from hospitals. The chance that such patients could trigger or worsen an outbreak in nursing facilities was real, he said.

“We were very concerned,” Gendron said. “It’s a very contagious virus. And nursing homes provide very hands on care.”

The challenge, he said, was only worsened by the fact that the state’s policy prohibited homes from testing arriving hospital transfers to see if they were still positive and thus possibly contagious. Gendron said he was not even sure if the hospitals were obligated to notify the home that the arriving patient had been treated for COVID-19.

“One would think they should have disclosed that,” Gendron said. “We always believed the best practice was to isolate any COVID residents. But we didn’t even know who was or wasn’t.”


White House Paid Up to $500 Million Too Much for These Ventilators

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Citing “evidence of fraud, waste, and abuse,” a congressional subcommittee investigating the federal government’s purchase of $646.7 million worth of Philips ventilators has asked the U.S. Department of Health and Human Services Office of Inspector General to launch its own investigation of the deal.

The House subcommittee launched its review after ProPublica stories in March and April showed how a U.S. subsidiary of Royal Philips N.V. received millions in federal tax dollars years ago to develop a low-cost ventilator for pandemics but didn’t deliver it. Instead, as the coronavirus began spreading around the globe and U.S. hospitals were desperate for more, Philips was selling commercial versions of the government-funded ventilator overseas from its Pennsylvania factory. Then in April, despite having not fulfilled the initial contract, the Dutch company struck a much more lucrative deal to sell the government 43,000 ventilators for four times the price.

Under this new deal, ventilators that the Obama administration had agreed to buy for $3,280 each suddenly cost $15,000. When the deal was announced in April, neither HHS nor Philips would say how the more expensive ventilators differed from the cheaper ones.

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It turns out that they were “functionally identical,” according to investigators with the House Committee on Oversight and Reform’s Subcommittee on Economic and Consumer Policy, and the “waste of taxpayer funds” may have reached $500 million.

The investigators reviewed thousands of pages of emails and other records obtained from Philips and concluded that “inept contract management and incompetent negotiating by the Trump Administration denied the country the ventilators it needed.” And the subcommittee’s report, which it shared with the inspector general’s office, named names: Peter Navarro, President Donald Trump’s director of trade and manufacturing policy, was the administration’s point man on the deal. In addition, Jared Kushner, the president’s son-in-law and senior adviser, and HHS Secretary Alex Azar participated in calls with Philips’ executives.

In a letter to the inspector general, Rep. Raja Krishnamoorthi, the Illinois Democrat who chairs the subcommittee, wrote: “The Subcommittee requests that you immediately open an investigation into this apparent waste of taxpayer funds, how it was able to happen unchecked, and how to prevent it in the future. Moreover, the Subcommittee requests that your office’s review include an assessment of the reasonableness of the price of the contract and the amount of excess profits received.”

He attached the subcommittee’s 49-page report of its investigative findings.

In a written statement, Philips said that it has been transparent about its ramp-up plans, pricing and allocation policies, and that it cooperated with the subcommittee. “We do not recognize the conclusions in the subcommittee’s report, and we believe that not all the information that we provided has been reflected in the report,” Philips CEO Frans van Houten said. “I would like to make clear that at no occasion has Philips raised prices to benefit from the crisis situation.”

White House Deputy Press Secretary Judd Deere called the House investigators’ report “a stunt that is only meant to politicize the coronavirus.”

“Because of the president’s leadership, the United States leads the world in the production and acquisition of ventilators,” Deere said. “No American who needed a ventilator was denied one, and no American who needs a ventilator in the future will be denied one. Democrats should be ashamed of themselves for this misleading and inaccurate report.”

An HHS spokesperson said the department moved with “deliberate and determined speed” and followed federal contracting rules in reaching the deal. She noted that some of the Philips ventilators are already being used to treat patients with COVID-19.

The federal government’s quest for a cheap, durable ventilator that could be stockpiled for emergencies began a decade ago during the Obama administration. The first deal fell apart after a small California ventilator manufacturer was bought by a much larger competitor, which dropped the project. Philips in 2014 struck a $13.8 million deal with HHS’ Biomedical Advanced Research and Development Authority to develop a low-cost, portable ventilator that would be easy to use by people with limited medical training. (In their report, the congressional investigators wrote that Philips later was granted an additional $547,000 to develop the ventilator.) The original deal included an option to purchase 10,000 of the ventilators for $3,280 each with delivery by June 2019.

HHS under the Obama administration granted one extension, and then the Trump administration allowed several more. When Philips finally won Food and Drug Administration clearance for the stockpile ventilator in July 2019, it also got the green light to sell a commercial version, which the company sold at far higher prices. The government didn’t exercise the option to buy the stockpile ventilators until September 2019. Under the timeline in the original contract, there would have been four waves of deliveries starting in June 2020 and ending in June 2021 and the government would have the power to increase its order in times of need, the House investigators wrote in their report.

Among the most surprising findings of the investigation was an email communication between the company and the government on the day the U.S. reported its first coronavirus case. On Jan. 21, a Philips manager sent a news story about that case to an HHS contracting officer and asked “how we could help out or if you may expect a need to accelerate any shipments.” Yet nobody from the federal government responded to Philips for six weeks, the investigators found.

On March 4, the HHS contracting officer told Philips managers in an email that Azar’s office had directed him to “expedite production of the ventilators.” Philips responded the same day suggesting a contract modification “to allow for the earlier shipments.”

Rather than speed up delivery, though, the modification Philips suggested gave the company until September 2022 to deliver any of the stockpile ventilators. Still, HHS signed off on the deal, the investigators found.

“Philips appears to have duped the Administration into thinking that this amendment, which permits a lengthy delay, was necessary for it to expedite production,” the congressional investigators wrote.

That same month, as the administration sought to cut a new deal, a Philips executive shared with Azar the slide deck he planned to present to Navarro. In the presentation, Philips described the government-funded stockpile ventilator design as “the best solution to confront exactly the pandemic we are facing.”

However, Philips soon steered Navarro and his colleagues to a more expensive option, the $15,000 Trilogy EV300, saying in one email to an associate director in Navarro’s office that this hospital ventilator had “more clinician friendly screens.”

Yet, the House investigators found the screens of the pricier model were identical to the less-expensive stockpile version. “The Administration’s willingness to spend hundreds of millions of extra dollars for non-existent ‘more clinician-friendly screens’ constitutes waste,” they wrote.

The White House negotiators were “gullible,” the investigators wrote, “and conceded to Philips on all significant matters, including price.” The contract called for Philips to make monthly deliveries between April and December 2020 with more than half arriving in the final three months.

Philips spokesman Steve Klink on March 28 told ProPublica that the company had only made the stockpile version of the ventilator in small batches and didn’t want to ramp up production on a model it had never mass produced. Rather, he said, the company wanted to “stick with what we have and ramp up and not lose time because we cannot afford to lose time.” HHS echoed that sentiment in a written statement at that time, saying the agency was purchasing “what was immediately available.”

But the congressional investigators wrote that the records Philips turned over showed that was false. Philips did not have a long track record making the $15,000 Trilogy EV300; the company did not start making that version until March, the month the federal negotiators agreed to buy them. And the White House knew this, the investigators wrote.

“In a March 18, 2020 email to the White House, Philips explained that the Trilogy EV300 was a new product being introduced and that it would take time to build up inventory,” they wrote. “By selecting the $15,000 model, the Administration demonstrated that it either failed the most basic duty of reading what Philips sent it or that it was not concerned about overpaying.”

Navarro and his colleagues never tried to lower the $645 million price and agreed to pay an additional $1.7 million for circuits and filters, the investigators found.

In its statement, Philips said the list price of the EV300 ventilator, stand and accessories that HHS selected is “over $21,000,” so the final price does reflect a discount “while taking into account part of the higher costs for the expedited delivery schedule.”

The records Philips turned over to the congressional subcommittee showed that before May 27, Philips sold 5,339 other Trilogy EV300 ventilators in the U.S. No buyer paid more than HHS did. One Missouri purchaser bought a single ventilator for $9,327, records show.

“It would stand to reason that a purchaser of 43,000 units would be able to negotiate a better deal than a purchaser of a single unit,” the House investigators wrote.

The ranking Republicans on the House committee and subcommittee said they disagreed with the findings of the investigation. In a prepared statement, James Comer of Kentucky, who sits on the House committee, and Michael Cloud of Texas, who sits on the subcommittee, accused the congressional investigators of failing to take “the most basic investigative steps to ensure they get the facts right.”

“Democrats read a few documents produced by the cooperating company and made a bundle of assumptions,” they wrote. “They received no briefings, conducted no transcribed interviews or depositions, and did not try to engage with the Administration to understand their side of the story.”

Krishnamoorthi, the subcommittee chairman, sent his letter and the investigators’ report to Christi Grimm, who remains in charge of the HHS Office of Inspector General, though President Donald Trump has sought to replace her after her office in April wrote about shortages of testing supplies and protective equipment at hospitals.

Nobody Tracks Health Care Workers Lost to COVID-19. So She Stays Up At Night Cataloging the Dead.

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When police discovered the woman, she’d been dead at home for at least 12 hours, alone except for her 4-year-old daughter. The early reports said only that she was 42, a mammogram technician at a hospital southwest of Atlanta and almost certainly a victim of COVID-19. Had her identity been withheld to protect her family’s privacy? Her employer’s reputation? Anesthesiologist Claire Rezba, scrolling through the news on her phone, was dismayed. “I felt like her sacrifice was really great and her child’s sacrifice was really great, and she was just this anonymous woman, you know? It seemed very trivializing.” For days, Rezba would click through Google, searching for a name, until in late March, the news stories finally supplied one: Diedre Wilkes. And almost without realizing it, Rezba began to keep count.

The next name on her list was world-famous, at least in medical circles: James Goodrich, a pediatric neurosurgeon in New York City and a pioneer in the separation of twins conjoined at the head. One of his best-known successes happened in 2016, when he led a team of 40 people in a 27-hour procedure to divide the skulls and detach the brains of 13-month-old brothers. Rezba, who’d participated in two conjoined-twins cases during her residency, had been riveted by that saga. Goodrich’s death on March 30 was a gut-punch; “it just felt personal.” Clearly, the coronavirus was coming for health care professionals, from the legends like Goodrich to the ones like Wilkes who toiled out of the spotlight and, Rezba knew, would die there.

Diedre Wilkes, left, and Dr. James Goodrich, right, both died from COVID-19 in March.
via Lakes Dunson Robertson Funeral Homes; Kathy Willens/AP Images

At first, seeking out their obituaries was a way to rein in her own fear. At Rezba’s hospital in Richmond, Virginia, as at health care facilities around the U.S., elective surgeries had been canceled and schedules rearranged, which meant she had long stretches of time to fret. Her husband was also a physician, an orthopedic surgeon at a different hospital. Her sister was a nurse practitioner. Bearing witness to the lives and deaths of people she didn’t know helped distract her from the dangers faced by those she loved. “It’s a way of coping with my feelings,” she acknowledged one recent afternoon. “It helps to put some of those anxieties in order.”

On April 14, the Centers for Disease Control and Prevention published its first count of health care workers lost to COVID-19: 27 deaths. By then, Rezba’s list included many times that number — nurses, drug treatment counselors, medical assistants, orderlies, ER staff, physical therapists, EMTs. “That was upsetting,” Rezba said. “I mean, I’m, like, just one person using Google and I had already counted more than 200 people and they’re saying 27? That’s a big discrepancy.”

Rezba’s exercise in psychological self-protection evolved into a bona fide mission. Soon she was spending a couple of hours a day scouring the internet for the recently dead; it saddened, then enraged her to see how difficult they were to find, how quickly people who gave their lives in service to others seemed to be forgotten. The more she searched, the more convinced she became that this invisibility was not an accident: “I felt like a lot of these hospitals and nursing homes were trying to hide what was happening.”

And instead of acting as watchdogs, public health and government officials were largely silent. As she looked for data and studies, any sign that lessons were being learned from these deaths, what Rezba found instead were men and women who worked two or three jobs but had no insurance; clusters of contagion in families; so many young parents, she wanted to scream. The majority were Black or brown. Many were immigrants. None of them had to die.

The least she could do was force the government, and the public, to see them. “I feel like if they had to look at the faces, and read the stories, if they realized how many there are; if they had to keep scrolling and reading, maybe they would understand.”

It’s been clear since the beginning of the pandemic that health care workers faced unique, sometimes extreme risks from COVID-19. Five months later, the reality is worse than most Americans know. Through the end of July, nearly 120,000 doctors, nurses and other medical personnel had contracted the virus in the U.S., the CDC reported; at least 587 had died.

Even those numbers are almost certainly “a gross underestimate,” said Kent Sepkowitz, an infectious disease specialist at Memorial Sloan Kettering Cancer Center in New York City who has studied medical worker deaths from HIV, tuberculosis, hepatitis and flu. Based on state data and past epidemics, Sepkowitz said he’d expect health care workers to make up 5% to 15% of all coronavirus infections in the U.S. That would put the number of workers who’ve contracted the virus at over 200,000, and maybe much higher. “At the front end of any epidemic or pandemic, no one knows what it is,” Sepkowitz said. “And so proper precautions aren’t taken. That’s what we’ve seen with COVID-19.”

Meanwhile, the Centers for Medicare and Medicaid Services reports at least 767 deaths among nursing home staff, making the work “the most dangerous job in America,” a Washington Post op-ed declared. National Nurses United, a union with more than 150,000 members nationwide, has counted at least 1,289 deaths among all categories of health care professionals, including 169 nurses.

The loss of so many dedicated, deeply experienced professionals in such an urgent crisis is “unfathomable,” said Christopher Friese, a professor at the University of Michigan School of Nursing whose areas of study include health care worker injuries and illnesses. “Every worker we’ve lost this year is one less person we have to take care of our loved ones. In addition to the tragic loss of that individual, we’ve depleted our workforce unnecessarily when we had tools at our disposal” to prevent wide-scale sickness and death.

One of the most potentially powerful tools for battling COVID-19 in the medical workforce has been largely missing, he said: reliable data about infections and deaths. “We don’t really have a good understanding of where health care workers are at greatest risk,” Friese said. “We’ve had to piece it together. And the fact that we’re piecing it together in 2020 is pretty disturbing.”

The CDC and the Department of Health and Human Services did not respond to ProPublica’s questions for this story.

Learning from the sick and dead ought to be a national priority, both to protect the workforce and to improve care in the pandemic and beyond, said Patricia Davidson, dean of the Johns Hopkins School of Nursing. “It’s critically important,” she said. “It should be done in real time.”

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But data collection and transparency have been among the most glaring weaknesses of the U.S. pandemic response, from blind spots in the public health system’s understanding of COVID-19 in pregnancy to the sudden removal of hospital capacity data from the CDC’s website, later restored after a public outcry. The Trump administration’s sudden announcement in mid-July that it was wresting control over hospital coronavirus data from the CDC has only intensified the concerns.

“We’d be the first to agree that the CDC has been deficient” in its data gathering and deployment, said Jean Ross, a president of National Nurses United. “But it’s still the most appropriate federal agency to do this, based on clear subject-matter expertise in infectious diseases response.”

The CDC’s basic mechanism for collecting information about health care worker infections has been the standard two-page coronavirus case report form, mostly filled out by local health departments. The form doesn’t request much detail; for example, it doesn’t ask for employers’ names. Information is coming in delayed or incomplete; the agency doesn’t know the occupational status of almost 80% of people infected.

The data about infections and deaths among nursing home staff is more robust, thanks to a rule that went into effect in April that requires facilities to report directly to the CDC. The agency told Kaiser Health News that it is also “conducting a 14-state hospital study and tapping into other infection surveillance methods” to monitor health care worker deaths.

Another federal agency, the U.S. Occupational Safety and Health Administration, investigates worker infections and deaths on a complaint basis and has prioritized COVID-related cases about the health care industry. But it has suggested that most employers are unlikely to face any penalties and has issued only four citations related to the outbreak, to a Georgia nursing home that delayed reporting the hospitalization of six staffers and three Ohio care centers that violated respiratory protection standards. Of the more than 4,500 complaints OSHA has received about COVID-19-related working conditions in the medical industry, it has closed nearly 3,200, a ProPublica analysis found.

Data problems aren’t just a federal issue; many states have fallen short in collecting and reporting information about health care workers. Arizona, where cases have been surging, told ProPublica, “We do not currently report data by profession.” The same goes for New York state, though a report in early July hinted at just how devastating the numbers there might be: 37,500 nursing home employees, about a quarter of the state’s nursing home workforce, were infected with the coronavirus from March through early June. Other states, including Florida, Michigan and New Jersey, provide data about employees at long-term facilities but not about health care workers more broadly. “We are not collecting data on health care worker infections and/or health care worker deaths from COVID-19,” a spokesperson for the Michigan Health Department said in an email.

This problem is global. Amnesty International, in a July report, pointed to widespread data gaps as part of a broader suppression of information and rights that has left workers in many countries “exposed, silenced [and] attacked.” In Britain, where more than 540 medical workers have died in the pandemic, the advocacy group Doctors’ Association UK has begun legal action to force a government inquiry into shortages of personal protection equipment in the National Health Service and “social care” facilities such as nursing homes. And in May, more than three months after the first known medical worker’s death, the International Council of Nurses called for governments across the world to start keeping accurate data on such cases, and for the records to be centrally held by the World Health Organization. The WHO estimates that about 10% of COVID-19 cases worldwide are among health workers. “We are closely following up (on) these cases through our global networks,” a spokesperson said.

“Governments’ failure to collect this information in a consistent way” has been “scandalous,” said the council’s CEO, Howard Catton, and “means we do not have the data that would add to the science that could improve infection control and prevention measures and save the lives of other healthcare workers. … If they continue to turn a blind eye, it sends a message that [those] lives didn’t count.”

So regular people, like Rezba, have stepped up with their makeshift databases.

Dr. Claire Rezba, an anesthesiologist who tracks the COVID-19 deaths of health care workers.
Carlos Bernate for ProPublica

Rezba, 40, initially wanted a career in public health. While finishing her master’s degree at Emory University in Atlanta and for a few months afterward, she worked as a lab tech at the CDC, analyzing nasal swabs to track cases of MRSA, the flesh-eating bacteria. But she decided she cared more about people than bugs, so she headed to Virginia Commonwealth University medical school in Richmond, graduating in 2009 with plans to specialize in the treatment of chronic pain.

During her residency at VCU, her first rotation was in the neonatal intensive care unit. “There was a little baby I helped take care of for three weeks. And the very last day of that rotation, his parents withdrew care. … He was the first little person I pronounced dead. I went and cried in the stairwell after that.” Her next rotation was in the burn unit, then the emergency department. “It seemed like death was just everywhere,” Rezba said. Witnessing it “is something very separate from the rest of your life experiences. People look different when they’re dying. It’s not like TV. They don’t look like they’re sleeping. CPR is pretty brutal. Codes are pretty brutal.”

She began keeping a list as a way to process the grief. “In residency, you record everything — your case logs, the procedures you do. It was just sort of second nature to record their names.” Whenever a patient died she would make another entry in her notebook, then “I would kind of perseverate” — ruminate — “over their names.” At the end of the year, she took the notebook to church. “I lit candles for them. I prayed. And then I let it go.”

A decade later, Rezba was working full time as an anesthesiologist and raising three small children, her list-compiling days long past her, she thought. Then COVID-19 hit. The onetime infectious disease geek became obsessed with the videos leaking out of China — the teams of health care workers in full protective gear, the makeshift wards in tents, the ERs in chaos: “I knew early on that this was going to be a big problem.” In her job, Rezba was often called upon to do intubations. “The possibility of not having enough PPE caused a lot of anxiety for her,” said her husband, Tejas Patel, whom she met in medical school. “She would be the one, if we did hit that level of New York, who could potentially be at risk and bring it home to the kids.”

As it turned out, Rezba’s hospital wasn’t inundated, nor did it experience the PPE shortages that plagued many health care facilities. But her anxiety didn’t disappear; it just took a new shape. If health care workers were front-line heroes, she decided, her role was to search the trenches for the bodies left behind.

Rezba is the first to admit she’s not great at technology; she rarely uses a computer at home. Patel discovered what she was doing because their iPhones and iCloud accounts are linked. “Whenever she saves a picture to the phone, I can see it. And I noticed a bunch of pictures of, you know, these strangers.” He remembered how, in their student days, Rezba had insisted on humanizing the cadaver in their anatomy lab: “It upset her that it was just this anonymous person. Knowing his birthday and little things like that would make her feel better.” Patel figured the photos were part of a similar coping strategy. “It wasn’t until much later that I found out she was putting them up on Twitter.”

Rezba conducts most of her research on her phone.
Carlos Bernate for ProPublica

Much of Rezba’s digging happens in the middle of the night, when she can’t sleep. She usually starts by Googling for local news stories; if she’s still not tired, she turns to the obituary site The hunt for a person’s occupation and cause of death invariably takes her to Facebook, where she follows the trail to relatives and co-workers, to vacation slideshows and videos of old men serenading their grandkids on the guitar. Every few days, she checks GoFundMe, where she’s recently been struck by the number of people who linger for weeks or months before dying. She’s still discovering deaths that occurred in April and May. Anyone under 60 gets special scrutiny. “If the obit says, ‘They died surrounded by family,’ I usually don’t bother trying to find out more, because those people didn’t have COVID. The people with COVID are mostly dying alone.”

Doctors and nurses are the easiest to find. “If someone worked in the laundry service at the nursing home, the family doesn’t put that in,” Rebza said. Yet it’s the nonmedical staff that she feels a special obligation to uncover — the intake coordinators and supply techs, the food service workers and janitors. “I mean, the hospital’s not going to function if there’s nobody to take out the trash.” Every so often, a news story mentions that several staffers from a particular nursing home or rehab center have died, without mentioning their names, and Rezba feels the rage start to bubble. “What it comes down to is, these are people that are making $12 an hour. And they get treated like they’re disposable.”

If she can’t find someone’s identity right away, or if the cause of death isn’t clear, she’ll wait a couple of days or weeks and try again. Because she comes across them anyway, she’s started to keep track of other categories of COVID-19 deaths, like kids and pregnant women, as well as health care workers in their 30s and 40s who don’t appear to have the virus but suddenly perish from heart attacks or strokes or other mysterious reasons. “I have a lot of those,” she said.

Once she’s certain she’s found someone who belongs on her list, she selects a photo or two and writes a few words in their honor. Sometimes, these read like a scrap of poetry; sometimes, like a howl.

He enjoyed crazy-dancing at home to Bruno Mars, with the moves becoming wilder the more his family laughed.

As a child, she would wrap her clothes around Dove soap so they would smell like America.

This poor baby should have his mother in his arms. Instead he has her in an urn.

A preprint study out of Italy last week hinted at the kind of lessons researchers and policy makers might glean if they had more complete data about health care workers in the U.S. The study pooled data from occupational medical centers in six Italian cities, where more than 10,000 doctors, nurses and other providers were tested for coronavirus from March to early May. Along with basic demographic information, the data included job title, the facility and department where the employee worked, the type of PPE used and self-reported COVID-19 symptoms.

The most important findings: Working in a designated COVID-19 ward didn’t put workers at greater risk of infection, while wearing a mask “appeared to be the single most effective approach” to keeping them safe.

In the U.S., many medical facilities are similarly monitoring employee infections and deaths and adjusting policies accordingly. But for the most part, that information isn’t being made public, which makes it impossible to see the bigger picture, or for systems to learn from each other’s experiences, to better protect their workers.

Imagine all of the opportunities it would present if everyone could see the full landscape, said Ivan Oransky, vice president for editorial content at Medscape, where a memorial page to honor global front liners has been one of the site’s best-read features. “You could be doing some real great shoe-leather epidemiology. … You could go: ‘Wait a second. That hospital has 12 fatalities among health care workers. The hospital across town has none. That can’t be pure coincidence. What did this one, frankly, do wrong, and what’s the other one doing right?’”

To Adia Harvey Wingfield, a sociologist at Washington University and author of “Flatlining: Race, Work, and Health Care in the New Economy,” some of the most pressing questions relate to disparities: “Where is this virus hitting our health care workers hardest?” Is the impact falling disproportionately on certain categories of workers — for example, doctors vs. registered nurses vs. nursing aides — on certain types of facilities, or in certain parts of the country? Are providers who serve lower-income communities of color more likely to become ill?

“If we aren’t attuned to these issues, that puts everybody at a disadvantage,” Wingfield said. “It’s hard to identify problems or identify solutions without the data.” The answers are especially important in Black and Latino communities that have suffered the highest rates of sickness and death — and where health care workers are themselves more likely to be people of color. Without good information to guide current and future policy, she said, “we could potentially be facing long-term catastrophic gaps in care and coverage.”

The near-term consequences have also been enormous. The lack of public data about health care workers and deaths may have contributed to a dangerous complacency as infections have surged in the South and West, Friese said — for example, the idea that COVID-19 is no more dangerous than other common respiratory viruses. “I’ve been at this for 23 years. I’ve never seen so many health care workers stricken in my career. This whole idea that it’s just like the flu probably set us back quite a way.”

He sees similar misconceptions about PPE: “If we had a better understanding of the number of health care workers infected, it might help our policymakers recognize the PPE remains inadequate and they need to redouble their efforts. … People are still MacGyvering and wrapping themselves in trash bags. If we’re reusing N95 respirators, we haven’t solved the problem. And until we solve that, we’re going to continue to see the really tragic results that we’re seeing.”

The misconceptions appeared to stretch to the highest reaches of the federal government, even as infections and deaths started surging again. At a White House event in July focused on reopening schools in the fall, HHS secretary Alex Azar told the people gathered, “health care workers … don’t get infected because they take appropriate precautions.”

Even some medical workers have continued to be in denial. A few days before Azar spoke, Twitter was abuzz over an Alabama nurse who worked the COVID-19 floor at a hospital by day and decompressed at crowded bars by night, where she often went maskless. “I work in the health care industry,” she was quoted as saying, “so I feel like I probably won’t get it if I haven’t gotten it by now.”

Piercing that sense of invulnerability — making the enormity of the COVID-19 disaster seem real — isn’t only Rezba’s mission. From The New York Times’ iconic front page marking the first 100,000 American deaths to the Guardian/Kaiser Health News project “Lost on the Frontline,” news organizations and social media activists have grappled with how to convey the scale of the tragedy when people are distracted by multiple world-shattering crises and the normal rituals for processing grief are largely unavailable.

“The point at which accountability usually happens is when our leaders have to reckon with the families of those who’ve been lost, and that has not happened,” said Alex Goldstein, a Boston-area communications strategist behind the wrenching @FacesOfCOVID Twitter account, which has posted almost 2,000 memorials since March. With COVID-19, “no one has had to look in the eye of a crying parent who wants to show you a picture of their child or listen to someone telling you about who their mom or dad was. There has been no consequence. What would our policy decisions have looked like if [the people making them] had to come face to face with that death and loss in a more visceral way?”

It’s a question that weighs especially heavily on health care professionals, who have seen, in the most visceral way possible, the worst that COVID-19 can do. Erica Bial, a pain specialist in the neurosurgery department at a Boston-area hospital, fell dangerously ill from COVID-19 in March, her respiratory symptoms lingering for more than six weeks. She lived alone and opted not to go to the hospital, in part because she worried about infecting other people. “At that point [in the outbreak], they would have intubated me, given me hydroxychloroquine and azithromycin and probably killed me.” As her recovery dragged on, she wondered how other doctors were faring: “I couldn’t believe that I was the only physician I knew who was sick.” But as she searched online, “I could not find any data. I just started getting really frustrated at the lack of information and the disinformation. … And then I started thinking about, well, what happens if I die here? Will anybody know?”

Like Rezba, Bial has a background in public health; the Facebook page she created, COVID-19 Physicians Memorial, was an attempt to build “a network where there’s accountability. I wasn’t necessarily trying to create, you know, reverence or memorialization. I was trying to understand the scope of the problem.”

Rezba soon began posting memorials on the page; as it grew to include more than 4,800 members, Bial asked her to help moderate it. Among the things the two women share is a determination to stick to facts. “I didn’t want any politics and I didn’t want any garbage,” Bial said. “(Rezba) was 100% like-minded and trustable.” She was also someone Bial could talk to, doctor to doctor, as she recovered. “It wasn’t just two people obsessed with something kind of morbid,” Bial said. “She was a source of support.”

Emergency room doctor Cleavon Gilman also gained a following for his posts on Facebook, a diary about what he witnessed as an ER resident in the NewYork-Presbyterian hospital system, battling the virus as it engulfed Washington Heights. “It was just … overwhelming,” he recalled. “We were intubating 20 patients a day. We had hallways filled with COVID patients; there was nowhere to put them.” In the space of a few brutal days in late April, three of Gilman’s colleagues died, including one by suicide. “When it’s a colleague that you’re taking care of and you know them as a person you’ve been on a journey with … man, that’s hard.”

Though much of the media focus was on the risks faced by older patients, Gilman was struck by how many of the critically ill were in their 20s, 30s and 40s. In mid-April, his own 27-year-old cousin, a gym teacher at a New Jersey charter school, suddenly died; he went to the ER twice with chest pain but was diagnosed with anxiety and sent home, according to his relatives, only to collapse in his car on the side of the road.

As the crisis in New York City ebbed, Gilman could see trouble ahead in other parts of the country, including in Yuma, Arizona, where he was about to start a new job. It seemed vitally important to help younger people understand the risks they faced — and that they created for others — by not adhering to physical distancing or wearing masks, not to mention the dangers that health care workers faced from continuing shortages of PPE. So Gilman began gathering the memorials he saw on Twitter and Facebook, many of them found by Rezba or on @FacesOfCOVID, and organizing the dead on his website in the type of gallery that he knew would pack an emotional wallop. Then he went a step further, making the photos and obituaries — more than 1,000 people — sortable by age and profession.

“You begin to see a pattern here,” he said. “When someone says, ‘Oh people aren’t dying, they’re not that [young],’ you can come back with actual names, actual articles, quickly. It’s more powerful. You have your evidence there.”

One of the most overtly political projects is Marked by COVID, formed by Kristin Urquiza in honor of her father, Mark, after her “honest obituary” of him went viral in early July. To Urquiza, who earned her master’s in public affairs from the University of California, Berkeley, and works as an environmental advocate in the San Francisco area, “the parallels between the AIDS crisis and what is happening now with COVID are just mind-boggling [in terms of] the inaction by governments and the failure to prioritize public health.” She and her partner, Christine Keeves, a longtime LGBTQ activist, hope the project will be both “a platform for people to come forward and share their stories” and the COVID-19 version of the anti-AIDS group Act Up.

They’re also raising money on GoFundMe to help other families pay for obituaries; the second honest obit on their site was for a respiratory therapist in Texas named Isabelle Odette Hilton Papadimitriou: “Her undeserving death is due to the carelessness of politicians who undervalue healthcare workers through lack of leadership, refusal to acknowledge the severity of this crisis and unwillingness to give clear and decisive direction to minimize the risks of coronavirus. Isabelle’s death was preventable; her children are channeling their grief and anger into ensuring fewer families endure this nightmare.”

It’s a trend that Rezba supports wholeheartedly. By the end of July, she had posted almost 900 names and faces of U.S. health care workers who had perished from COVID-19. She fantasized about what it would be like to leave the counting behind her. “It would be great if I could stop. It would be great if there was nobody else to find.” But she had a backlog of dozens of stories to post, and the number of deaths kept climbing.

Ryann Grochowski Jones and Hannah Fresques contributed reporting.

Out of View: After Public Outcry, CDC Adds Hospital Data Back to Its Website — for Now

Hospitalizations for COVID-19 have been seen as a key metric of both the coronavirus’s toll and the health care system’s ability to deal with it. Recent federal actions may strike a blow to the public’s ability to track them.

The U.S. Centers for Disease Control and Prevention removed from its website, and then restored, data on hospital capacity across the country to deal with the COVID-19 pandemic. But in a note, the agency indicated that the data may no longer be updated because of a change in federal reporting requirements to hospitals.

On Wednesday, ProPublica noticed that the CDC’s website had stopped displaying hospital capacity information, which was seen as a good barometer of whether hospitals in certain states had enough beds to deal with surges in COVID-19 cases. The data showed that more than 70% of intensive care unit beds in some states, including Texas and Arizona, were filled. That had been viewed by some experts as a benchmark for safely reopening businesses.

This week, federal officials instructed hospitals to stop reporting data to the CDC and instead report it using a portal created by the U.S. Department of Health and Human Services. They said that the CDC’s data system was antiquated, and that HHS wanted to use this information to help make real-time decisions about testing and shipments of personal protective equipment.

On Thursday morning, when ProPublica confirmed that the information had not been restored to the CDC website up to that point, members of Congress and a former CDC director weighed in to call for more transparency.

“The American people need transparency from the nation’s public health agencies,” Rep. Don Beyer, D-Va., wrote on Twitter. “The Trump Administration has politicized the pandemic response at every step, we simply can’t trust them not to. I am drafting legislation to require CDC to share this information with the public.”

Rep. Judy Chu, D-Calif., said on Twitter, “The Trump administration is trying to hide their failures, but that only makes it harder for us to fight this virus.”

Rep. Jimmy Gomez, D-Calif., wrote: “Want to see @CDCgov numbers for yourself? Yeah, so do I. But @realDonaldTrump and @WhiteHouse have other plans for this #coronavirus data…”

And former CDC director Dr. Tom Frieden wrote: “We’re in the middle of the worst pandemic in 100 years. More than 137,000 Americans have died. Covid is exploding in Arizona, Texas, South Carolina, Florida, and other states. And the administration has chosen to sideline the CDC. Where did this data go?”

The CDC did not respond to a request for comment but posted data from Tuesday on its website around noon Eastern time Thursday, after several media organizations wrote about the removal of the data. At the top of its site the CDC wrote, “Dashboards last updated as of July 14, 2020,” and it included a link to the guidance from HHS that tells hospitals to stop reporting the data to CDC. The CDC site also notes, “IMPORTANT: Data displayed on this page was submitted directly to CDC’s National Healthcare Safety Network (NHSN) and does not include data submitted to other entities contracted by or within the federal government.”

In an interview with journalist Greta Van Susteren on Wednesday, Vice President Mike Pence defended the switch and said, “The American people can anticipate full transparency.”

“This is about making the system better,” Pence said. “CDC will be a part of that, part of the reporting of that, and the American people will have that information. And just as importantly, policymakers that are making decisions about where those critical resources go will have better real time information.”

In a statement to CNBC Thursday, HHS spokesman Michael Caputo said that the CDC was told to post the data again. He said “more powerful insights” will be provided by HHS in the future.

“Yes, HHS is committed to being transparent with the American public about the information it is collecting on the coronavirus,” he told the network. “Therefore, HHS has directed CDC to re-establish the coronavirus dashboards it withdrew from the public on Wednesday.”

The number of people who test positive for COVID-19 has been seen as an imperfect measure of the coronavirus’s toll because of testing shortages and because many infected people do not have symptoms. Hospitalizations, by comparison, are signs of serious cases, and when enough of them happen in one place, they can place the health care system under stress, in terms of beds, staffing and equipment.

In New York City in March and April, the surge was so great that many hospitals had to add beds and transform conference rooms and auditoriums into ICU units.

In Houston, many of the busiest hospitals have asked that ambulances take patients elsewhere because they are so full, and patients have been kept in emergency rooms for hours or days because inpatient beds were not available.

Data from The COVID Tracking Project, which gathers data on COVID-19 from each state, shows that the number of patients hospitalized with COVID-19 has increased in recent weeks, along with the rise in cases. As of Wednesday, more than 56,000 patients were hospitalized nationwide with COVID-19, compared with more than 59,000 in April, which corresponded to the peak in New York and New Jersey. (Some states, such as Florida, are currently reporting their hospitalization numbers but were not doing so earlier in the spring.)

But the data, which is released by states and is unaffected by the federal changes, does not report on hospital capacity consistently, only the number of people in the hospital with COVID-19.

Hospitalizations in the U.S. for COVID-19

The COVID Tracking Project

Some states have seen their ICU capacity strapped in recent weeks. In Arizona, for instance, 89% of ICU beds were in use on Wednesday, according to the state.

Number of ICU Beds Available and in Use at Arizona Hospitals

Arizona Department of Health Services

In some Florida counties, fewer than 10% of ICU beds are available. Tennessee, overall, had 16% of its ICU beds available on Wednesday.

And in Texas, the hospital region that includes the cities of Beaumont and Galveston had no open ICU beds as of Wednesday.

Hospitals often operate with most of their beds full and indeed, their business models rely on that. But doctors and health experts say the deteriorating situation related to COVID-19 has caused some to postpone elective surgeries, which are essential for their financial well-being, and poses stresses on their staffs.

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If you develop emergency warning signs for COVID-19, such as difficulty breathing or bluish lips, get medical attention immediately. The CDC has more information on what to do if you are sick.

Hospitals Are Suddenly Short of Young Doctors — Because of Trump’s Visa Ban

As hospitals across the United States brace for a difficult six months — with the first wave of the coronavirus pandemic still raging and concerns about a second wave in the fall — some are acutely short-staffed because of an ill-timed change to immigration policy and its inconsistent implementation.

A proclamation issued by President Donald Trump on June 22, barring the entry of most immigrants on work visas, came right as hospitals were expecting a new class of medical residents. Hundreds of young doctors were unable to start their residencies on time.

Trump’s order included the H1-B visa for highly skilled workers, which is used by some practicing doctors abroad who get U.S. residency slots. The proclamation stated that doctors “involved with the provision of medical care to individuals who have contracted COVID-19 and are currently hospitalized” should be exempt from the ban, but it delegated the issuing of guidance to the departments of State and Homeland Security. That guidance has been slow and inconsistent.

Many consulates started approving doctors’ visas on Thursday, after ProPublica asked the State Department about the delay. Others say they’re still awaiting guidance.

At hospitals where many incoming residents are visa holders, even a delay of a few weeks in arriving in the U.S. creates a staffing crisis. Doctors and administrators are afraid that the repercussions will last for the rest of the year — leaving them overworked and ill-prepared even before a second wave of the virus hits.

ProPublica has heard from 10 would-be medical residents stuck abroad because of H1-B visa issues. Six of them had gotten emergency consulate appointments for visa approval, but when they arrived for meetings they were told their visas could not be approved. Three were still waiting on DHS approval for their visas, a necessary step before a visa gets a consulate stamp. One resident had application approval but was denied an emergency consulate interview appointment because of the ban. All were destined for hospital positions treating COVID-19 patients.

The State Department told ProPublica on Tuesday that it, “in conjunction with the Department of Homeland Security and interagency partners, is establishing and implementing procedures” for the visa ban, and that it “has communicated and will continue to communicate implementation procedures” to consulates abroad.

On Thursday, the State Department’s website posted guidance, spelling out that doctors treating COVID-19 patients were exempt from the ban. On that day, many of the residents ProPublica spoke to said they had suddenly received visa approvals. “A quite remarkable turnaround, given that I received a rejection email three days ago,” one said. In at least five countries, however, consulates were still not processing doctors’ visas.

The Committee of Interns and Residents, an affiliate of the Service Employees International Union, has heard from over 250 interns stuck abroad. Over 150 of them are on H-1B visas.. (The others are on visas that weren’t covered in Trump’s ban, but can’t get approval because their consulates are still closed due to the pandemic.) Union president Jessica Edwards pointed out to ProPublica that while that number may sound small, each intern is responsible for the care of thousands of patients.

As of 2017, there were 2,532 medical residents on H1-B visas, according to the Journal of the American Medical Association — though the Trump administration’s continued restrictions to legal immigration may have made it less appealing for hospitals to sponsor visas in the last few years. But the impact on hospitals is highly concentrated in the less-prestigious hospitals that tend to rely on residents from overseas.

At one New York City hospital serving low-income residents, nearly half the incoming class is still stuck abroad, multiple sources confirmed to ProPublica. One hospital in a large Midwestern city told ProPublica that “roughly half” of its first-year doctors started on time. In the Deep South, a region now overwhelmed by COVID-19 cases, a doctor who was set to start told ProPublica he was among 10 residents still awaiting visa approval as of early July. All hospitals and doctors spoke to ProPublica on the condition of anonymity because they worried about jeopardizing their visa applications.

ProPublica has also spoken to more-experienced doctors facing the same issue — including an infectious-disease specialist blocked from starting a job in an area of the Western U.S. where COVID-19 cases are rising.

When there aren’t enough incoming residents to replace departing third-year residents, staffing crunches result.

At the New York City hospital, a doctor told ProPublica that after only 10 days of short-staffing, one resident had called in sick from exhaustion. The doctor recounted a recent shift in which there had only been two junior residents on call, compared with the typical six. Even by having residents work individually instead of in teams of two, they couldn’t keep up with new patient admissions.

“The patients had to just stay there waiting in the (emergency department) for the residents to finish their first admission, in order to see them,” the doctor said. “When the shift was over, I logged into the computer and I would see notes written at 10 p.m., 11 p.m. And these residents are expected to go home and then come back again at 6:30 a.m.”

Even at hospitals with decreasing COVID-19 caseloads, short-staffing is a bigger problem than it was in pre-pandemic times. Some hospitals are seeing a “surge of non-COVID patients” who were unable to get care for chronic conditions like heart disease during lockdown and are now deteriorating, a doctor at a short-staffed hospital told ProPublica. And because protocols prevent doctors from switching back and forth between COVID-19 and non-COVID-19 patients, the hospital needs to keep more doctors on-call to maintain staffing levels in both wards.

“If someone is getting acutely ill, who will see them?” a hospital administrator told ProPublica. “I’ve got my poor residents running around trying to make sure everyone is seen in a timely manner. And residents are great, but they can only be in one place at one time.”

Some of these problems will be fixed as residents receive delayed visa approvals and are able to come. But it will take weeks, if not months, to successfully onboard them. The Midwestern hospital anticipates that arriving residents may not be able to start until mid-August. In the meantime, they’re understaffing services and using fourth-year medical students in place of residents.

Hospitals are used to a summertime efficiency gap, as new interns learn the ropes. This year, it could persist into fall — when a second wave of coronavirus infections is expected.

“I’m really worried that in three months,” said the medical administrator, “we’re going to have a bunch of residents who are just exhausted and just getting into the worst part of the fall, flu and COVID season.”

These doctors already had to push themselves through the first wave of COVID-19 this spring. Furthermore, at hospitals hardest hit by the visa ban, the residents picking up the slack are often themselves H1-B visa holders whose futures are now uncertain. Trump’s ban didn’t revoke visas for anyone currently in the U.S., but if they leave the country — which they will have to do if they change jobs — their ability to return is unclear. Some of the doctors interviewed by ProPublica were living in the U.S. before the pandemic and returned home partly to get visa approval for their new jobs. One doctor ended up stuck in India while her husband was unable to travel there from the U.S.

Another doctor from India, now working in the U.S., told ProPublica: “My parents, they’re (in India) by themselves, and both of them are about 70. At some point, probably, they will catch the infection.” If that happens, the doctor plans to leave the U.S. to care for them — “and if I don’t come back, I don’t come back. At this point, I really don’t care.”

The feeling that the U.S. doesn’t value them is compounded among residents who’ve already lived through the first wave of COVID-19 and who are now facing overwork and visa uncertainty. Some said other countries are making it easier for doctors to immigrate, while the U.S. leaves them in limbo.

“We feel underappreciated for what we’re doing,” the New York City resident said. “And what else can you do, more than sacrificing your life?”

Tightly regimented residency schedules can be tricky for H1-B visa holders even in the best cases. Doctors find out in mid-March if they are “matched” with a U.S. hospital, where they’ll be expected to start at the beginning of July. DHS often takes longer than that to approve H1-B applications. Employers can pay for expedited processing to guarantee a decision within five days — but DHS shut down its expedited processing on March 22 because of COVID-19 and didn’t reopen it until June 8.

Shortly afterward, Trump issued his proclamation banning entries on many visa types, including the H1-B.

Most people coming to the U.S. for residencies arrive on a different kind of visa, the J-1, and aren’t covered by Trump’s ban, though some have had issues getting consulate appointments because of the COVID-19 pandemic. But doctors do identical work regardless of their visa types. If anything, doctors with H1-Bs are more qualified than those with J-1s, since they’re required to have completed all three phases of the taxing U.S. Medical Licensing Exam before starting residencies. Residents with H1-B visas were practicing doctors in their home countries, working alongside new medical-school grads from the U.S.

An earlier immigration ban targeting permanent immigrants, which passed in March, contained a broad medical worker exemption. When rumors of a work-visa ban started swirling in late spring, immigration lawyers and hospitals expected it would include the same language. Instead, the June proclamation mentioned only doctors working with hospitalized COVID-19 patients.

Every resident who spoke with ProPublica had provided evidence to the U.S. government that they met that description. Some were told by consular officers that they were probably exempt. But until they received State Department guidance, they had to place their visas in “administrative processing” — an indefinite holding pattern.

ProPublica saw an image of a form given to one visa applicant informing them of a hold. The form is typically used to request more information from the applicant. In this case, though, a consular officer had modified the form to say that processing would not begin until “implementation procedures” for the visa-ban exemption had been provided.

Doctors in limbo have formed WhatsApp groups to share information and support, but the dialogue has shown inconsistencies in the ban’s implementation. Some consulates, such as those in Serbia, Russia and the United Arab Emirates, have approved doctors’ H1-B visas as exempt. Asked about the discrepancy, the State Department told ProPublica: “Applicants who believe they qualify for an exemption from Presidential Proclamation 10052 should check the website of the closest U.S. Embassy or Consulate regarding the current status of services. How appointment systems are managed can vary depending on the consular section.”

One applicant who reached out to the State Department for assistance received an email reply from an employee on July 10. The employee said that as far as they knew, the Office for Consular Affairs had given guidance to consulates and embassies to process visas that were exempt from the ban. (The agency declined to comment on that email.)

On Thursday, that applicant received a second email from the same employee. Guidance had been slow in coming, the employee admitted, but it had finally come through.

But some countries still haven’t changed their practices. One doctor stuck abroad told ProPublica they’d sent a follow-up email to the consulate on Thursday morning. “He gave me the same reply,” the doctor said, “that they are still waiting for guidance from Department of State.”

Emails Reveal Chaos as Meatpacking Companies Fought Health Agencies Over COVID-19 Outbreaks in Their Plants

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For weeks, Rachel Willard, the county health director in Wilkesboro, North Carolina, had watched with alarm as COVID-19 cases rolled in from the Tyson Foods chicken plant in the center of town. Then Tyson hired a private company to take over testing, and the information suddenly slowed to a trickle.

Blinded to the burgeoning health crisis, Willard and her small staff grew increasingly agitated. The outbreak had already spread across 100 miles of the North Carolina piedmont, and two workers had died. But nearly a week after Tyson’s testing ended in May, the county health agency had received less than 20% of the results. The little information it did receive was missing phone numbers and other data, hindering critical efforts to follow up with infected workers, to tell them to isolate and to trace their contacts.

“Our fear and alarm is the fact that close contacts and positive cases are walking around, potentially shedding the virus and infecting others,” Willard, who was coordinating the response while on maternity leave, wrote to state officials on May 14.

Only after the state public health director warned Tyson that failure to turn over information could result in “injunctive relief or prosecution” did the testing company release the information. As of Wednesday, 599 workers had tested positive, more than a fifth of the plant’s workforce.

The dangerous delay by the nation’s largest food company is one of a series of breakdowns revealed in tens of thousands of pages of emails, text messages, meeting notes and reports that ProPublica obtained from dozens of public health agencies across the country.

As the coronavirus swept through the nation’s meatpacking plants this spring, chaotic scenes like those in Wilkesboro have played out in small towns that have become some of the country’s biggest hot spots. The candid, often emotional messages provide a real-time reckoning of how the companies responsible for a critical part of the food supply chain were hazardously unprepared and how a system that relied on tiny local public health agencies was quickly overwhelmed by the consequences.

In Tama, Iowa, where more than 250 workers at a National Beef plant tested positive for the virus, one local health official emailed her colleagues a meme of the chef Gordon Ramsay shouting, “SHUT IT DOWN!”

Obtained by ProPublica via a public records request
Obtained by ProPublica via a public records request

“They just don’t get it!” Mindy Benson, the county emergency management coordinator, later wrote to the group. “They will keep going until all of their employees have this virus. They would rather risk their employees’ health and keep their production going.” (National Beef did not return calls and emails seeking comment.)

The nation’s meatpackers along with federal and state officials have for years planned for pandemic flu outbreaks that could wipe out herds and flocks and threaten America’s food supply. But those efforts focused on animals rather than the army of humans — mostly immigrants, refugees and African Americans — hired to slaughter them and cut them up for restaurants and groceries.

The failure to have a coordinated plan for workers left small, often rural communities vulnerable. More than 24,000 coronavirus cases have been tied to meatpacking plants, ProPublica has found. Though many haven’t suffered severe symptoms, at least 87 workers have died. More than 25 of the dead worked for Tyson.

The coronavirus response was complicated by a lack of clarity over which agency had the authority to order meatpacking plants to make changes or shut down. The Centers for Disease Control and Prevention could only offer guidance. The U.S. Department of Agriculture dealt with animals and food. The Labor Department had few rules that applied to a virus. And the power of local and state health officials varied from state to state.

In an emailed response to questions, Tyson acknowledged the delay in releasing the test results in North Carolina. “When we learned that there was a delay with our lab partners, we acknowledged the urgency of the situation and worked to address the situation immediately,” spokesman Gary Mickelson said.

He said Tyson formed a coronavirus task force in January to assess risks and work on mitigation plans and began engaging with the CDC and other health officials shortly thereafter. “At the majority of our facilities across the country, there have been no cases of COVID-19 that we know of,” he said. ProPublica found cases at slightly less than half of Tyson’s major processing plants.

But the scores of emails and other records show that best practices to protect workers, such as slowing the processing line to accommodate social distancing, installing plexiglass barriers and having workers wear masks, weren’t implemented until outbreaks began to occur. Instead, meatpacking companies spent crucial early weeks urging officials to keep their plants open.

Demonstrators outside the Smithfield Foods pork plant in Sioux Falls, South Dakota, on April 17 after it was closed indefinitely because of a rash of coronavirus cases among employees.
(Shannon Stapleton/Reuters)

In mid-March, a few weeks before a massive outbreak at its South Dakota pork plant, Smithfield Foods’ chief executive Kenneth Sullivan sent a letter to Nebraska Gov. Pete Ricketts saying he had “grave concerns” that stay-at-home orders were causing “hysteria.”

“We are increasingly at a very high risk that food production employees and others in critical supply chain roles stop showing up for work,” Sullivan wrote. “This is a direct result of the government continually reiterating the importance of social distancing, with minimal detail surrounding this guidance.”

“Social distancing,” he added, “is a nicety that makes sense only for people with laptops.”

In a statement, Smithfield said, “We have continued to run our facilities for one reason: to sustain our nation’s food supply during the COVID-19 pandemic.”

Once the virus hit meatpacking towns, it quickly overwhelmed rural health departments whose primary role before the crisis involved maintaining vital records and promoting public health initiatives. Before the virus, many health officials, the documents show, didn’t have much contact with the local meatpacking plant, even though it was often the town’s largest employer.

Decisions about what authority health officials had over meatpacking plants, who would test workers and who would notify close contacts were made on the fly. In Dakota County, Nebraska, home of Tyson’s largest beef plant, the health director wrote the state on April 16, “We are at capacity for our monitoring as we only have one nurse.” That was at 22 cases. The plant now has nearly 800.

The companies, which often employ large contingents of employees from Asia, Africa and Latin America, nevertheless didn’t have health guidance translated in the languages of their employees. And as the virus raged, public health officials struggled to communicate with patients in languages as varied as Q’anjob’al (Guatemala), Karen (Burma) and Tigrinya (Ethiopia and Eritrea). Workers’ phones were often disconnected, and they lived across county or even state lines, making coordination difficult.

In some states, laws aimed at protecting individual privacy barred health officials from releasing names of businesses where outbreaks were occurring, preventing them from alerting their communities. In Louisa County, Iowa, where more than 200 Tyson pork workers have tested positive and two have died, the county health director said she felt that she couldn’t even ask her board of health or emergency management coordinator for help “because I couldn’t release the information about the outbreak.”

Obtained by ProPublica via a public records request

When local health officials did try to take action, the documents show that meatpacking companies used their power to go over their heads. In Schuyler, Nebraska, the regional health officer reached out to Cargill regarding a “considerable outbreak” to find out what the company was doing to prevent the spread. But instead of working with local health officials, Cargill appealed to the governor’s office to intervene, which emails suggest it did. Cargill spokesman Daniel Sullivan said the email to the governor’s office was an effort to collaborate with officials at all levels.

In some communities, the fear of tangling with the main economic engine was palpable, especially given the intertwined relationships of a small town. When workers at a Tyson chicken plant in Camilla, Georgia, started complaining about safety issues, the county health director had a problem. “My husband and I are chicken growers for Tyson,” she wrote the state. “I want to recuse myself from any investigation into these allegations based on the fact that they can and will pull my contract if I am involved.”

In Waterloo, Iowa, where more than 1,000 workers tested positive at Tyson’s biggest pork plant, the chair of the county board of health excused herself from discussions about whether to urge it to shut down because she worked as a chaplain for Tyson.

A Tyson spokesman said, “The contract grower should have no fear of her contract being canceled.”

The meatpackers’ push to keep their production lines moving ultimately won over the nation’s highest office when in late April, President Donald Trump issued an executive order to put federal muscle behind ensuring meat processing plants could remain open. In emails, local health officials expressed frustration that it would only embolden the companies to ignore their advice. One Kentucky health director, faced with repeated reports that Perdue Farms was pressuring sick and quarantined workers to return, wrote, “My guess is they will force them to work citing the presidential order to stay open.” Perdue said it has strictly followed CDC guidelines and the safety of its employees is its top concern.

Battles between health officials and the companies were compounded by constantly changing guidance from the CDC about how long essential workers who tested positive needed to quarantine. Initially, the CDC said two weeks but amended that guidance several times, eventually saying that asymptomatic workers could go back to work immediately.

All along, the documents show, some corporate and government officials sought to shift the focus away from meatpacking plants and onto the workers themselves, blaming the crowded living situations, carpooling and lifestyles of immigrants and refugees. In Kentucky, Tyson asserted the outbreak spiked after 30 Burmese refugees gathered for an Easter celebration, even though the first infection at the plant was recorded nine days earlier.

“This is a culture issue,” notes from a conference call local officials had with Tyson about the outbreak read.

For health officials like Willard, the issue was even more basic. It was unclear whether she could do anything about it.

As officials in Wilkesboro discussed how to respond to the growing Tyson cluster, Willard told them the department couldn’t even make a statement about a business having an outbreak. “We have no regulatory authority over Tyson,” she wrote local officials. “We are not legally able to mandate that they put any additional measures in place or shut down.” In an interview, Willard explained how that created a difficult dynamic.

“Meat processing plants sit in this weird limbo where the USDA has some authority, but then the health department doesn’t really regulate them,” she said. “So there’s this weird gap of who really has the power and authority to make any decisions to shut the plant down.”

National planning for pandemic influenza began during the George W. Bush administration, largely in response to the H5N1 bird flu that arose in the late 1990s and wiped out flocks in Asia, Europe and Africa.

“It is impossible to predict whether the H5N1 virus will lead to a pandemic,” the plan issued in 2006 warned, “but history suggests that if it does not, another novel influenza virus will emerge at some point in the future and threaten an unprotected human population.”

Over the next 14 years, meat producers, animal disease researchers and government regulators developed detailed and coordinated systems for planning and responding to animal outbreaks. But protections for workers further along the supply chain at meatpacking plants were not considered in those preparations.

So when a virus that was infecting humans alone began in other parts of the world, the meat industry had no clear model to follow. When the virus hit China hard in January, the country locked down. Throughout China, slaughterhouses and poultry processing plants closed and didn’t reopen for weeks, wreaking havoc on the nation’s meat supply but largely preventing outbreaks.

Those events appeared to do little to mobilize U.S. meatpackers. In the cache of public records, there are no emails discussing the risk of coronavirus in meatpacking plants until March, when some companies began restricting the travel of their executives, increasing sanitation and educating workers about hand-washing and COVID-19 symptoms.

But other measures meatpackers took, such as using attendance bonuses to keep workers on the job, coupled with long-standing policies to discipline workers who called in sick, may have helped fuel the spread, the CDC and other health officials said.

Some of the first emails local health authorities received about the coronavirus and meatpacking plants came not from the companies but from workers and their relatives. On March 16, the mayor of Green Bay, Wisconsin, received one about a JBS beef plant.

“I have family members that work at JBS,” the son of a longtime worker wrote, “and to my understanding there hasn’t been any communication about the virus, what their plan is if someone gets infected or anything of the like.”

Around the same time, 700 miles west, workers at a JBS plant in Grand Island, Nebraska, told the governor they were working shoulder-to-shoulder and sent him photos of workers eating in a crowded cafeteria.

Both plants would eventually have outbreaks infecting more than 300 workers each.

In fact, one of the first communications from JBS to public health officials in Colorado concerned not the workers in its Greeley processing plant, but whether the cafeteria at its corporate headquarters had to abide by the state’s restrictions on restaurants. And it came from its executive chef.

The Greeley plant would shut down weeks later as cases among its workers multiplied. To date, nearly 300 workers there have contracted the virus and seven have died, state data shows.

A worker at the JBS meatpacking plant in Greeley, Colorado, on April 30.
(RJ Sangosti/MediaNews Group/The Denver Post via Getty Images)

JBS spokesman Cameron Bruett said in an email that the company began holding daily COVID-19 planning meetings to track CDC guidance in February. “Before and during this crisis, we have had regular, transparent and proactive communication with all applicable federal and state health organizations,” he said.

Roxanne Smith, the health director in Louisa County, Iowa, was one of the first local health officials to contact a meatpacking company about the coronavirus when she asked for Tyson’s help in getting public health guidance to the area’s Burmese residents in early March. None of the Tyson managers she contacted responded. The situation, Smith said in an interview, was challenging.

Nearly a week later, the plant’s nurse manager sent an email to introduce herself, part of what appeared to be a corporate initiative to establish communication and begin coordinating with local health departments — or as a Tyson safety manager in East Texas put it, to “contain the spread of any of the negative around the virus, and the actual virus itself.”

Several local health directors seem to have developed close working relationships with the nurses at their local plants. But those employees were often limited themselves in how much they could do.

At the Tyson plant in Wilkesboro, health officials learned that the test data had to go from the lab back to the testing company and then through Tyson corporate before it reached the local nurses who could share it with them.

When the test results finally arrived, they were so disorganized that the communicable disease nurse had to spread them out on her kitchen table and enter the data manually. “I am having to work from 3 different spreadsheets because of the methods used to provide us with the data,” she wrote to the state.

The burden the meatpacking plant outbreaks placed on health officials was evident across the country. Epidemiologists and nurses were updating colleagues after 1 a.m. They worked on Easter and Mother’s Day.

In Tama County, Iowa, health and emergency management officials joked about snacking on Reese’s Easter eggs to get through the stress and having Cheetos and Dr Pepper for breakfast. “I’m having one of those nights where it’s just like I want to throw in the towel,” Benson, the emergency management coordinator, wrote to her colleagues one evening.

As the outbreak unfolded at the National Beef plant there, Benson wrote, “That petri dish needs to close.”

The truth, however, was that the local health agencies on the front lines had little power to make the plants do much of anything. And when plants did shut, or local authorities could order them to, the politics were tense, requiring the organized effort of multiple local officials and navigating last-minute appeals by company officials to governors. Health officials carefully worded their letters to the companies, often noting the plants’ economic importance to the community.

After ordering the JBS plant in Greeley to close, local officials discussed whether to use the word “shall” or “should” when talking about the need for workers to quarantine. “Shall is a loaded word,” the county health director replied. “Should is more collaborative.”

In Nebraska, Gina Uhing, the director of the Elkhorn Logan Valley Public Health Department, wrote to the governor’s staff after Tyson refused to give her department the names of workers who’d been exposed to someone infected so the workers could be tested. “We are being met with corporate gridlock,” Uhing wrote, “and it makes containing these outbreaks incredibly difficult at the most inopportune time when time is of critical essence.”

Tyson said that the email chain reflected only a small part of the discussion, and that the company worked collaboratively with the department.

As plants began to reopen, several health directors worried that the companies weren’t doing enough to ensure the virus was under control. “I am very concerned about their handling of this situation,” Smith, the health director in Louisa County, Iowa, wrote state officials. “I am concerned politics are winning over what we know is right for the citizens of our county and state.”

Tensions with the companies were only one of the challenges. In Iowa, which saw some of the country’s biggest outbreaks, the state communicable disease law prohibited local officials from disclosing the identity of a business where an outbreak occurred unless approved by the state medical director. Health officials in Sioux City noted that without being able to mention where the cases were coming from, “we’re dancing all over the place.”

The law stymied the local response and prevented health officials from informing other businesses about how to protect their customers and employees. In Louisa County, Kent Wollenhaupt, the president of the State Bank of Wapello, wrote to Smith to complain that he hadn’t been told of the outbreak. The husbands of two of his three tellers worked at Tyson, he said, and the bank served many of the plant’s employees. “We could have implemented these precautions 2 days earlier, if informed,” he wrote. Privacy issues, he said, “should not come ahead of public interest.”

After weeks of outbreaks across the state, Iowa Gov. Kim Reynolds eventually released staggering numbers in early May. It wasn’t until then that the health director in Dallas County, Iowa, found out that 58% of the employees at the local Tyson plant tested positive, resulting in 730 cases. This was largely because testing was being done by the state, and most employees lived outside the county where the plant is located.

The chaotic nature of the response was underscored further by the lack of coordination among the hard-hit counties and the governor’s office.

In mid-April, Reynolds suddenly announced the state was sending 900 tests to Tyson’s plant in Louisa County — without apparently coordinating with local officials on how the testing and contact tracing would be carried out. “Even with all the other counties helping, I don’t think it can be done,” Smith wrote to a state epidemiologist she had been working with. “What…900?” the epidemiologist replied. “You are joking???”

Reynolds’ office didn’t respond to a request for comment.

Communication issues were even greater for Iowa’s Siouxland District Health Department, which borders Nebraska and South Dakota. A significant number of its cases came from Tyson’s Dakota City, Nebraska, beef plant, where workers cross the Missouri River bridge each day for work.

Andom Yosef, 38, who works at Smithfield Foods pork processing plant in South Dakota, tested positive for COVID-19.
(Kerem Yucel/AFP via Getty Images)

Because some testing of Iowa residents was done in Nebraska, Siouxland had to rely in part on the Nebraska Department of Health and Human Services. “To further compound the situation, the DHHS system they set up has a glitch in it and we are not even getting phone numbers for many of the positive cases,” Siouxland’s director Kevin Grieme wrote in one email. “It has created an undue burden upon us and my staff bears the brunt of the frustrated individuals that are already nervous about their results and then can’t get them.”

In an interview, Grieme said the glitch delayed the response four to five days.

Grieme also touched on one of the key frustrations of health officials: In the middle of a fast-moving pandemic, neither the meatpacking plants nor the health departments were prepared to deal with so many patients who didn’t speak English.

Many of the workers they needed to contact, he said, spoke only Spanish, Vietnamese, Oromo, Tigrinya, French or Somali. “My language line bill is at $9,000 with only three weeks of work,” he wrote in one email. It’s usually $600 a month, he said.

In Dallas County, Iowa, health officials ended email after email with the word “Ugh” as they tried unsuccessfully to communicate with Burmese workers or dialed out-of-service numbers. In other areas, public health officials showed up to an address to find a vacant lot. And when they reached out to the companies for help, the human resources offices didn’t even have current contact information for their employees.

In Owensboro, Kentucky, the hospital’s patient access director noted that it often took 30 to 40 minutes to get a language interpreter on the line. But many of the Burmese workers couldn’t understand the directions to the COVID-19 clinic and didn’t know how to use GPS. Some of them couldn’t read.

By the end of April, as dozens of plants closed in response to local pressure to control outbreaks and implement safety measures, meatpackers began witnessing huge drops in beef and pork production. Tyson took out full-page ads in The New York Times, Washington Post and Arkansas Democrat-Gazette and warned, “The food supply chain is breaking.”

Tyson’s message was so effective that the next day, Trump signed his executive order, promising to help keep plants running and try to shield them from liability. The news was a gut-punch to many of the local health departments that were still struggling to rein in multinational corporations that already had far more power than they did.

“This is completely disgusting to me,” Julie Pryde, the administrator of the Champaign-Urbana Public Health District in Illinois, wrote. “This is literally putting human lives at risk. It is also shifting the cost of their lack of response to local communities. >: (”

In Western Kentucky, officials at the Green River District Health Department already suspected the local Perdue plant was not giving them the full picture of what was going on inside.

“We hear proactive steps from corporate representatives about solid preventative practices being put in place,” Green River health director Clay Horton wrote his colleagues a week before Trump’s order. “But at the contact investigation level, we are hearing stories of management pressuring people to work while symptomatic and other anecdotal stories that don’t square with the official corporate line.”

Obtained by ProPublica via a public records request

One worker who tested positive and still had a cough and sore throat told the department that Perdue told him “as long as he didn’t have a fever he needed to return to work.” Another who tested positive said that Perdue had fired her because “they didn’t believe I was sick.” Conference calls between health officials and Perdue’s medical director had become heated at times, and Kentucky officials strongly considered recommending the plant be temporarily closed.

But after Trump’s executive order, Horton said in an interview, “it was more of like: ‘We can’t listen to you because of this executive order. We have to stay open.’”

The situation was frustrating, Horton wrote in one email, because the company wanted public health agencies to provide it with “$65,000 worth of testing” without even committing to bar workers who tested positive from the plant.

“I believe we/they should err on the side of caution,” Horton wrote. “They are erring on the side of you better get back to work.”

So far, nearly 300 workers have tested positive at the plant and at least one has died.

On Tuesday, the Trump administration announced a new milestone: beef, pork and chicken plants were back, operating at more than 95% of their average capacity compared with this time last year. A statement from the USDA credited Trump’s executive order with “the safe reopening” of America’s meatpacking plants.

Local officials, however, have been left thinking about how the virus exposed the fragility of the system designed to protect the nation’s food supply and how few tools they had to respond. The worst part, Benson, the Tama emergency coordinator, remembers, was watching what was happening and feeling helpless.

“We were flying the plane as we were building it because you didn’t have all the pieces that you needed,” she said. “But you were still in the air and still trying to keep things from crashing and burning, and we were doing the best that we could.”

Melissa Sanchez and Benjamin Hardy contributed reporting.

Federal Agencies Have Spent Millions on KN95 Masks, Often Without Knowing Who Made Them

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In scrambling to buy protective equipment for the coronavirus pandemic, federal agencies purchased up to $11 million worth of Chinese-made masks, often with little attention to manufacturing details or rapidly evolving regulatory guidance about safety or quality, a ProPublica review shows.

Some agencies cannot say who made their masks at a time when thousands of foreign-made respirators appeared on the market, some falsely claiming approval or certification by the Food and Drug Administration. Some agencies bought the masks, known as KN95s, from companies that share a U.S. representative with another firm recently accused of fraud by the Justice Department.

The contracts reflect the intense pressure federal agencies were under to procure protective equipment as the pandemic surfaced and rapidly spread in the U.S. Now, some experts worry that the products could remain in circulation long past the crisis and be used by unsuspecting federal employees who believe they have legitimate respirator masks.

Agencies have relaxed procurement standards, including granting many contracts without competitive bidding, and have been tripped up by shifting FDA standards, the flood of foreign companies entering the U.S. market and a limited domestic supply of respirators made for medical use.

“I’m so glad we didn’t get involved in this KN95 market,” said Andy Mitchell, a vice president at Mallory Safety and Supply, which supplies N95 masks. “This isn’t right what’s happening here.”

ProPublica reported last month that the Indian Health Service had purchased $3 million of Chinese-made respirator masks from a company started by a former White House official, and that the masks did not meet FDA standards. A House of Representatives committee plans to hold a hearing on Thursday examining the IHS’ response to the COVID-19 pandemic.

ProPublica reviewed 21 contracts awarded by 11 federal agencies that specifically mentioned procuring KN95 masks, a Chinese version of N95 respirator masks. Five agencies — the Bureau of Prisons, the Department of Veterans Affairs, the U.S. Marshals Service, the U.S. Mint and the U.S. Forest Service — could not say who manufactured their masks or did not respond to questions. The total spent on the 21 contracts was more than $11 million, but some of the deals also involved other items such as ear loop face masks and hand sanitizer.

Foreign-made masks have come under increasing scrutiny from federal regulators. The FDA issued an emergency use authorization for some Chinese-made masks in health care settings in April, but it narrowed the authorization after some masks were found to let through far more particles than advertised.

In many cases, the agencies buying the masks are not directly involved in health care provision, and are thus beyond the scope of the FDA authorization, although the Indian Health Service and the National Institutes of Health were among the purchasers. Some agencies told ProPublica they would use the masks they purchased only in nonmedical settings, a recognition of the lesser protection they may provide.

But experts said the purchase of such products at all still poses a risk to employees. Dr. Meghan Dierks, a Harvard Medical School professor who previously worked at the FDA on medical device shortage issues, said she is concerned about “all of these potentially inferior products remaining in circulation, remaining on shelves” after the current crisis passes, whether used in medical or nonmedical settings.

“If you’re in charge of procuring a product that you expect to confer some level of safety or protection to your workers, there’s responsibility there for knowing what’s the basic performance criteria and what’s the regulatory authority in the United States that monitors this,” Dierks said.

The FDA tightened its April emergency rules rules a month later, after testing by the Centers for Disease Control and Prevention revealed that some Chinese masks let in too many fine particles. Dozens of Chinese manufacturers that had initially appeared on an approved FDA list were removed, tripping up buyers who had purchased masks just weeks earlier.

Dr. Suzanne Schwartz, deputy director of the Office of Strategic Partnerships and Technology Innovation at the FDA’s Center for Devices and Radiological Health, said the agency has “encouraged importers and distributors to do their own due diligence and take the appropriate steps to verify the product’s authenticity prior to importing, particularly those products not authorized by the FDA.”

Typically, the FDA moves slowly when issuing rules and regulations, but it quickened its pace during the pandemic, said Michael Abrams, a co-founder of Numerof & Associates, which advises hospitals, pharmaceutical companies, financial institutions and others on health care issues.

“They’ve been forced to make decisions that they sometimes need to go back on,” he said. “Certainly that makes it more difficult for anyone who’s relying on what these regulatory entities have to say.”

That includes the rest of the federal government. On May 1, the Department of the Interior purchased $114,400 worth of KN95 masks from Red River Resources LLC, a California vendor. The manufacturer was Guangdong ZhiZhen Biological Medicine Co. Ltd., according to the agency.

“At the time of purchase, the respirators were on the list of approved products,” Andrea Antunes, an Interior spokeswoman, wrote in an email. “Subsequently, they were removed from the approved list and will not be purchased again.”

Antunes did not respond to questions about what the agency would do with the purchased masks.

The website of Guangdong ZhiZhen Biological Medicine displays a mask it labeled “FDA approved FFP2 KN95 Mask.” Phone calls and emails sent to CCTC Service Inc., the company’s U.S.-based agent, were not returned. CCTC, based in Delaware, is named as the representative for nearly 1,600 devices listed with the FDA this year, including KN95 masks manufactured by two firms used by Zach Fuentes, a former White House deputy chief of staff, to fulfill the contract with the Indian Health Service.

In a federal court complaint filed June 5 against another Chinese mask manufacturer, King Year Printing and Packaging Co. Ltd., by the Justice Department, an FDA special agent said that there is “probable cause to believe CCTC is a fictitious corporation.” FDA records list a residential address for the company, the complaint said, and the house’s occupant and owners said they had no knowledge of or connection to CCTC. The Wall Street Journal first reported the federal complaint against King Year.

In the complaint, the government alleges that King Year falsely labeled its respirators with the logo of the National Institute for Occupational Safety and Health, which conducts medical device testing, and included “a test report showing compliance with the N95 standard despite the respirators not meeting the minimum standard for N95 respirators.”

Since a national emergency was declared in the U.S. on March 13, more than 3,600 Chinese-made products categorized as “surgical respirators” have been listed with the FDA, a ProPublica analysis of government data shows. In all of 2019, the total number of surgical respirators registered with the FDA was five.

“There are a lot of people producing face masks who are not necessarily reputable suppliers or historic suppliers of this product,” said Phil Farinelli, vice president at Government Scientific Source, a Northern Virginia supplier that sold KN95s to the National Institutes for Health. “I probably get 10 emails a day from people trying to sell me face masks from China.”

The NIH, the agency responsible for public health research, signed a separate contract worth nearly $700,000 for respirator masks in March with Missouri-based Phoenix Textile Corp., federal data shows.

The original contract was for N95 masks, the agency said in a statement to ProPublica. But because those were unavailable, Phoenix Textile proposed KN95s as an alternative.

“When NIH received the order and learned that the masks were not FDA-approved, NIH tested the products using the FDA standards for respirators and the product had failed,” the agency said.

NIH requested a refund for the masks it had already received, will not pay for any more and plans to return the masks to Phoenix Textile. Executives with Phoenix Textile did not respond to an email and voicemail requesting comment.

Tests of some imported respirator masks are finding that they often do not provide the level of protection they advertise. Evan Floyd, a professor at the University of Oklahoma’s Health Sciences Center, has been testing the filtration capability of KN95 masks purchased by the state of Oklahoma and private businesses.

Around one-third of the approximately 70 brands he has tested thus far do not meet the 95% filtration standard, Floyd said.

Dr. John Howard, the director of NIOSH, said in an FDA webinar on Tuesday that the agency recently had tested over 130 international respirator models and found that more than half were “substandard.”

The Indian Health Service purchased 4,000 KN95 masks manufactured by a Chinese firm, ZhangJiaGang ShineYa Sanitary Products Co. Ltd., in an April 9 contract, an IHS spokesman said. The contract is separate from the Fuentes deal. The masks were sent to the IHS office in Bemidji, Minnesota, which serves tribes in Illinois, Indiana, Michigan, Minnesota and Wisconsin.

ZhangJiaGang ShineYa does not appear on the FDA approved list of Chinese manufacturers.

Half of the masks are still in the Bemidji area office and “will not be distributed to health care personnel,” an IHS spokesman said. The other 2,000 masks are being used by IHS environmental health officers “and are being used in non-health care settings,” he said.

The company’s listed U.S. agent, John Flair, did not respond to a request for comment. The U.S. vendor that supplied IHS with the masks, California-based West Coast Business Products Inc., also did not respond.

The U.S. Marshals Service purchased $77,500 worth of KN95 masks in April from Knock-Out Specialties, a Texas firm that recently began selling PPE. The masks were made in China and “the products or vendors have been registered or certified by FDA,” said Drew J. Wade, a Marshals Service spokesman, in an email. They are being used in “non-medical, law enforcement situations.”

But “registration” with the FDA does not mean that the FDA approves the manufacturer or its products, a fact prominently mentioned on the FDA website. FDA’s registration and listing database serves merely to provide a public, central listing of companies that may sell certain medical equipment.

When asked to clarify if the masks were just registered with the FDA or had some further certification, Wade responded: “I’m not sure I can sufficiently answer that question at this time. USMS holds certificates that appeared to denote some sort of FDA approval.”

John Bottone, the owner of Knock-Out Specialties, did not respond to a phone call and email seeking comment.

One agency that kept up with the FDA’s shifting rules was the Department of Energy’s National Nuclear Security Administration. In a contract with a Georgia-based vendor, American Dream Builders, the agency purchased over $400,000 worth of KN95 masks. An NNSA spokeswoman identified the masks’ manufacturer as “Guangzhou Powecom Labor Insurance Supplies Company LTD,” which does appear on the FDA-approved list.

Another manufacturer was originally supposed to fulfill the order, spokeswoman Kate Hewitt said. But when the FDA updated its criteria and the original manufacturer fell off the approved list, the purchase order for the mask contract was modified on May 18 to change to “an FDA-approved manufacturer,” Hewitt said.

The Federal Emergency Management Agency also appears to have purchased KN95 masks from Guangzhou Powecom, although FEMA provided ProPublica with a slightly different manufacturer name when asked about a $4 million contract for KN95 masks it signed in May.

FEMA’s vendor was Osirius Group, an automotive manufacturing firm based in Birmingham, Michigan. Timothy Smith, Osirius Group’s CEO, said in an email that “they are the same company.” Osirius’ first shipment to FEMA was set to arrive this week.

Guangzhou Powecom and other firms with the FDA’s endorsement are being inundated with orders, Smith said.

“The FDA list has become a bible of sorts and any one on that list gets overrun,” he said via email. He said his firm has been doing business in China since 1992.

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