This story was originally published by Grist and is reproduced here as part of the Climate Desk collaboration.

Two weeks after the United States began its first coronavirus lockdown in March 2020, then-President Donald Trump instructed the Federal Emergency Management Agency, or FEMA, to reimburse cities, counties, and tribes for 75 percent of costs related to housing homeless people in unoccupied hotels, as well as administering COVID-19 tests to those without housing. When Joe Biden assumed the presidency in January, he increased coverage to include fees related to vaccinating homeless populations and also guaranteed that reimbursements would now retroactively cover 100 percent of related expenses. 

In theory, the program would both curb the spread of the novel coronavirus and also protect the more than 580,000 people experiencing homelessness at any given time from the variety of threats that come without steady access to housing. For the 225,000 homeless people living without formal shelter of any kind on a given night, encounters with extreme weather events, pollution, and policing can be uniquely deadly. 

But as Winter Storm Uri descended upon the South in mid-February, leaving millions of people without water and electricity across at least seven states, more than half of Texas’ 500,000 hotel rooms were unoccupied and not a single municipality in the state had requested funds to house people living on the streets. As temperatures in the Lone Star State dropped to 20 degrees F, dozens of unhoused people were left frostbitten and hospitalized and at least six were found dead.  

Texas wasn’t the only place where localities neglected the program. According to reimbursement request records released to Grist after a Freedom of Information Act request, one year into the program only 23 local governments, including one federal tribe, had submitted funding requests. Roughly 80 percent of the requests, which altogether total just over $600 million, came from just four major urban counties: Los Angeles County, California; Denver County, Colorado; Cook County, Illinois; and King County, Washington. (The data is current as of April 7; a comprehensive list of the requesters is available here.)

Of the top 10 major metropolitan areas with the highest levels of homelessness per capita, according to data from the Department of Housing and Urban Development, only three submitted reimbursement requests.

Officials from New York City, where nearly 15 percent of all unhoused people in the U.S. shuffle through the city’s vast shelter system, did not respond to Grist’s requests for comment about why the city did not participate in the program to relieve the threats posed by congregate living during the pandemic. But leaked reports show that dysfunction within city leadership led to the city passing on funds while COVID-19 spread through at least 94 percent of the city’s shelters, and 60 people living in the facilities died.

In San Francisco, where there are more than 8,000 people experiencing homelessness on a given night, county leaders hinted at the possibility of taking advantage of the funding following Biden’s increased coverage, but no requests had been submitted as of April 7. San Francisco officials did not respond to Grist’s requests for comment.

The program and its funding were made available through the 1988 Stafford Act, a federal law designed to help facilitate a uniform federal approach to state and local disaster relief. Unlike other coronavirus funding, the program is not earmarked for a certain dollar amount, so FEMA resources can be scaled to meet all eligible needs. But like other coronavirus relief programs, this particular deployment of the Stafford Act is a temporary fix, set to end on September 30.

Interviews with policy experts and municipal leaders suggest that poor governing relationships between federal and local governments, a difficult reimbursement process, and decentralized planning left the program to be largely ignored—and the country’s unsheltered population unprotected from the spread of COVID-19 and a slew of recent severe weather events. 

John Beard, a former city council member in Port Arthur, Texas, learned the inner workings of FEMA’s reimbursement process while helping to lead his city out of the destruction caused by Hurricane Harvey in 2017. He said the processes to obtain federal funding favor large cities and undermines the reason the money was made available in the first place: to help people no matter where they live. Larger cities that have regular communication with the federal government are more likely to know of the many different funding options available, he told Grist.

“It’s a failure at the federal level to not get [the money] out to the cities, because they know which cities need it the most,” Beard said. “And it’s a failure by cities for not amplifying their needs and making the requests.”

“A lot of cities simply don’t have the wherewithal or resources,” he added. “Bigger cities can afford consultants who spend every day searching for funding opportunities, but smaller cities don’t have anybody watching the clock, so everyday paperwork expires and funds dry up.”

Steve Sanders, a former director of the sustainable communities program at the nonprofit Institute for Local Government, said that, with too many issues and not enough resources, many localities prioritize areas where there is a widely understood economic benefit or a powerful constituency to satisfy—neither of which is obviously the case when it comes to providing housing to those without.

“The reality is development decisions are based on return on investment—and these aren’t flashy investments,” Sanders said. “When there is scarce political power for the key actors who care about the underlying issues of environmental justice and housing justice, don’t bet on seeing positive outcomes.”

Three jurisdictions with some of the country’s highest rates of homelessness—Honolulu, Hawaii, and California’s San Diego and Santa Cruz Counties—told Grist that they were either unaware of the FEMA program’s existence or declining to use it. All three jurisdictions had locally funded homeless projects in place during the pandemic. In Santa Cruz County, people qualifying for California’s public assistance program were offered subsidized hotel rates if they were experiencing homelessness.

In Honolulu and San Diego County, leaders used the federal Coronavirus Aid, Relief, and Economic Security Act, or CARES Act—which appropriated $12 billion to be used for homelessness and rent support—to extend their shelter services and make COVID-19 testing and vaccination more accessible to unhoused residents. However, the $12 billion was spread over a wide range of activities, including everything from mortgage assistance and home rehabilitation to the maintenance of traditional shelters, meaning it’s unclear how much actually went toward providing safe, private housing for those without shelter. After Grist’s correspondence with San Diego County, reports surfaced that the county plans to utilize the FEMA program to “free up” CARES money to be used for other social services.

Even in cities that took advantage of FEMA funding during the program’s first year, success was fleeting. In Los Angeles at the program’s peak, only around 4,300 individuals—less than 7 percent of people experiencing homelessness in the county—were housed before county leaders withdrew their support for the program altogether. In Washington state’s King County, where Seattle is located, critics have argued that the government continues to leave federal funds on the table, and suburban opposition has slowed program implementation.

For other cities, a complex reimbursement process has made it extremely difficult to receive funds, according to Rajan Bal, a campaign manager at the National Homelessness Law Center.

“It’s a complicated application process that hasn’t necessarily been conveyed as best and easy as it should be, especially under Trump,” Bal told Grist. Bal said that initially there was confusion around which populations of people qualified for housing; it was unclear if those temporarily displaced by disasters or people experiencing temporary, transitional homelessness qualified for support. (Current guidelines say they do.) FEMA and White House officials did not respond to Grist’s requests for comment. 

While Bal believes the FEMA program has had some effectiveness as a temporary solution, he said that municipalities should be “using the opportunity to inject local communities with cash to provide more housing solutions for people right now, as a springboard to combat the long term homelessness crisis and protect this vulnerable population from freezing or melting on the streets.”

This way, he said, jurisdictions can follow San Diego County’s lead and free up other funding streams, such as CARES funding, to pay for other social services and move toward funding more permanent housing solutions such as supportive housing, which allows people experiencing chronic homelessness the opportunity to have their own space while still receiving social support services.

Instead, Bal continued, many municipalities are pursuing policies such as encampment sweeps that are exposing unhoused people to coronavirus and potentially even landing them in jail.

“There are elected officials actively pursuing the criminalization of homelessness and are actively choosing not to use available funding sources like FEMA reimbursement for shelters,” he said. “They’re spending taxpayer dollars to criminalize people instead of relying on these options that address homelessness.” 

Unhoused people are disproportionately threatened by air pollution, toxic waste, and severe weather, so solutions have to be direct and targeted, said Beard, the former city council member whose Southeast Texas region has experienced an uptick in homelessness since Hurricane Harvey.

“At the end of the day, there is money to help people and it’s going unclaimed,” the former politician said. “Elected officials are chosen to look out for people, but there is help readily available and they let it slip past.

For the first time in my life, I understand why so many people who make their livings in front of the camera—reality show personalities, news anchors, movie stars—get plastic surgery. I empathize with them. I get it. I, too, have had the experience of spending an inordinate amount of time looking at myself—not with millions of others on Bravo, but with a select group of colleagues on Zoom.

When I first installed Zoom, I didn’t think too much about the personal implications. As with much of the rest of the world, the pandemic forced my work life online, so I got the tool that allowed me to have meetings and see co-workers while we stayed physically apart. But I could never have imagined how hours and hours of looking at myself would affect me psychologically. I’m someone whose makeup routine takes five minutes max, who doesn’t wear high heels as a matter of principle, and who avoids taking selfies or looking at photos of myself. For most of my life, this hasn’t been a problem.

But slowly, during my Zoom-focused, quarantined life I’ve felt my occasionally ambivalent but generally self-confident sense of my appearance erode. Day in and day out I was forced to stare at the puffy bags under my eyes, the unfortunate spattering of adult acne on my chin, the way my face looks when I laugh too hard (which I usually do). It became impossible not to critically dissect my appearance, to silence my hectoring inner Anna Wintour. After one particularly Zoom-heavy day, I googled eye-lift procedures and how much they cost. (Around $3,000 with a recovery time of two weeks.) 

Why not merely select the “hide self” function on Zoom, you might reasonably ask. Because now that I have the option to stare at myself in action, I need to know what everyone else sees my face do. During the pre-pandemic days of uncomplicated indoor dining, when I found myself eating at a restaurant with a mirror on the wall opposite my seat, I couldn’t help checking myself out. It’s too tempting to try to plumb the depths of that impossible question: What do other people see when they see me? And how can I fix it so that what they see looks like I want it to?

Turns out, I’m not alone. 

Plastic surgeons are reporting that interest in plastic surgery has markedly increased during the pandemic, especially for the whole menu of facial procedures, from rhinoplasty to face lifts, cheek implants, ear surgery, eye lifts, forehead lifts, neck lifts, botox, and fillers. They’ve even given the phenomenon a name: the “Zoom Boom.”

The market research firm Equation Research surveyed more than 1,000 women across the United States and found that interest in plastic surgery has gone up by 11 percent among women over the last year, though we don’t know the age breakdown. (The absence of men in the survey is glaring—certainly they’re not exempt.) Although almost all cosmetic procedures decreased overall during the pandemic due to office closures, facial procedures decreased by the smallest percentage.

A survey conducted by the American Society of Plastic Surgeons (ASPS) of their nearly 8,000 members revealed that nose reshaping (352,555 procedures), eyelid surgery (352,112 procedures), and face lifts (234,374 procedures) were the top three cosmetic surgical procedures in 2020. When accounting for the fact that most plastic surgeon were closed for an average of eight weeks in the year, the demand for each of these procedures actually rose by 12 percent, 7 percent, and 4 percent respectively. Demand for the most popular body-focused procedures, by contrast, dropped. Breast augmentation surgeries were down by 18 percent, liposuction was down by 5 percent, tummy tucks were down by 2 percent, and breast lifts were down by 6 percent. During these days spent sitting and staring at the screen, why bother fixing anything from the neck down? (Though demand for butt implants has notably soared!)

I decided to talk to some experts about this—just as a reporter of course. So I tracked down Dr. Lynn Jeffers, a plastic surgeon and chief medical officer at the St. John’s Pleasant Valley Hospital in Camarillo, California, to ask what this Zoom Boom is all about. (Jeffers has also been working overtime running the vaccine rollout at her hospital.) She thinks there are three main factors. People had more disposable income during the pandemic because they were saving money on things like travel and dining out. Also, working from home made recovering from surgery easier and more discreet. And the only factor I could personally relate to: “We were suddenly all on Zoom, and our faces were so big in front of us, and most of us didn’t have great lighting or great webcams and so forth,” says Jeffers. “A number of people attributed the increased interest in facial procedures, as well as Botox and fillers, because that’s what everybody was seeing.”

While Zoom fatigue has been a struggle for many of us, the effects have been especially distressing for the roughly 2 to 3 percent of Americans who struggle with body dysmorphic disorder (BDD). “Skin, nose, lots of different facial features tend to be the focus of concern in BDD,” says Dr. Hilary Weingarden, a practicing psychologist and clinical researcher at Massachusetts General Hospital who specializes in OCD and related disorders, such as BDD. She explained to me that any concerns I might have about my facial appearance can take on a heightened, or even distorted, presence in my self-perception when I see myself on Zoom for long periods of time. 

“When you sit on Zoom, you’re staring at them all day long, and so we can tend to over-focus on that body part of concern,” she says. “When we look at ourselves in that way, we can start to actually distort our perception. And it starts to look more blown out of proportion.”

Weingarden points out that when people focus on small flaws about themselves, they are seeing a very different picture from what other people see, which is more holistic. Also, Zoom is a particularly strange and unforgiving vehicle in that it literally lines our faces up next to other faces, which creates a situation that’s ripe for unflattering comparisons—a dangerous rabbit hole, as anyone with a propensity for late-night Instagram scrolling will tell you.

Of course, there are lots of reasons to want to tweak or alter appearance, but my own obsessive dissection of my face just made me feel bad. Self-conscious about laughing or smiling. Deflated by a bad hair day. But more than anything, I’ve felt disappointed in myself that I can be troubled by an issue that is so damn superficial when, yes, I have much to be grateful for. I don’t value other people based on their appearance. Why can’t I extend that same courtesy to myself? 

But I think it goes deeper than that. OCD disorders like body dysmorphia have strong ties to anxiety and depression. The obsessive checking and rituals around perceived issues are a channel for anxieties around much bigger things: like the fear of social exclusion, or illness, or dying, or other catastrophic, irreparable calamities—that the pandemic brought to all of our lives to a certain extent. It should be noted that BDD is a severe disorder with high rates of co-morbid depression, high rates of suicidal thoughts and suicidal attempts, and, in severe cases, a paralyzing fear of leaving the house. I do not have OCD or BDD, but I think the ties to anxiety are interesting.

“Most of us have aspects of our physical appearance that we don’t like, that we worry about. And that’s normal to being human,” says Weingarden. “So that experience of worrying about physical appearance, and even engaging in some of these ritual behaviors—we all do some of that to some extent. It can vary anywhere from very mild to full-blown BDD, and everything in between.”

If someone had offered to install a mirror in my computer so that I can stare at myself all day, I never would have agreed to it. Yet somehow that’s what I got. That’s what we’ve all got. Among the innumerable aspects of the pandemic that have been unnatural, add functioning under the constant surveillance of a virtual mirror.

Flow theory posits that people achieve peak performance when they are engrossed in an activity to the point that they lose their sense of self. It’s like being in the zone, or in a groove. For me the best feeling is when my self-awareness fades into the background and I am fully immersed in editing, or reading a good book, or listening to a friend’s story. 

When I confided to a friend about my Zoom Appearance Crisis (ZAC!), she pointed out that Narcissus stared at himself all day every day and it didn’t work out so well for him. Sitting at the edge of a lake and engrossed in his own reflection, he ultimately lost all interest in his worldly surroundings and turned into a flower. Clearly, this is not an ideal picture of engagement with the world—much less baseline productivity.

But maybe we got the message from the myth all wrong. Maybe Narcissus didn’t expire because he loved looking at himself. Maybe he just couldn’t look away.

The Paycheck Protection Program was supposed to help small businesses struggling from the crippling financial effects of the coronavirus pandemic. But the benefits, as with other government responses to the crisis, flowed disproportionately to white communities.

A new investigation from Reveal, which analyzed the distribution of more than five million PPP loans, found that the program was plagued with widespread racial disparities. The findings show a persistence of the type of structural racism—exemplified by the racial covenants and redlining policies of 20th century—that has long prevented communities of color from thriving. Reveal found, for example, that in the “vast majority” of major metropolitan regions, businesses in majority-white neighborhoods were approved for loans at much higher rates than those in majority Latino, Black, or Asian ones. According to the investigation, published in partnership with the Los Angeles Times:

Los Angeles had some of the worst [disparities] in the nation. Although communities of color were hit far harder by COVID-19, businesses in majority-White areas received loans at twice the rate that majority-Latinx tracts received, one and a half times the rate of businesses in majority-Black areas and 1.2 times the rate in Asian areas. 

The New York metro area, which includes Newark and Jersey City in New Jersey, saw equally striking disparities, with White areas receiving loans at twice the rate of Latinx areas, 1.8 times the rate for Black areas and 1.2 times the rate in Asian areas.

In other metro areas, including Dallas, San Francisco, San Diego, Las Vegas and Phoenix, businesses in majority-White areas also received loans at about twice the rate as those in majority-Latinx areas. 

The first batch of loans, totaling $349 billion, went out last spring, days after Congress passed the CARES Act. But amid the hasty rollout, a lack of federal guidance meant that, as Reveal put it, “any obstacle, such as missing paperwork or a lack of an existing relationship with a bank, risked leaving a business last in line.”  

In early April, Malik Muhammad, the owner of a Los Angeles bookstore specializing in African American literature, reached out to Wells Fargo—a bank that “effectively starved communities of color of PPP money,” Reveal reports. Muhammad heard nothing about his loan request for weeks. In early June, he received a form letter: “We cannot confirm that all applications will be submitted and processed by the SBA before the funds are depleted, and we anticipate that demand will exceed available funding.” He never received any follow-up communication from Wells Fargo, though he later managed to get a small loan from Square. “I know we’re not big business, but we deserve a call,” he said. 

The CARES Act had instructed the federal Small Business Administration to prioritize “socially and economically disadvantaged individuals,”  according to an October 2020 congressional subcommittee report cited by Reveal. But the SBA, the Treasury Department, and the big banks administering the PPP loans ignored that guidance. In fact, the subcommittee found, Treasury had privately encouraged the banks to limit their initial loans to existing customers, excluding many minority and women-owned businesses.

None of the lenders the subcommittee interviewed recalled any guidance from the Trump administration on how to prioritize underserved communities, and several set up lending programs in which large commercial clients enjoyed a “separate, faster process.” In some cases, PPP loans for wealthier clients were processed at twice the speed of loans for truly needy small businesses.

Reveal had reported back in April 2020 that the owners of small businesses in Republican states without stay-at-home orders were more likely to have gotten PPP loans than those in Democratic states where COVID hit hard first. In December, the New York Times and Washington Post both reported that the majority of PPP money had flowed to big businesses, including dozens of national chains, many publicly traded. The same month, when Congress passed its second COVID relief package, the legislation included a bipartisan provision that helped all PPP recipients, but was most beneficial for the companies with the biggest loans, resulting in an estimated $120 billion tax break for America’s richest business owners.  

The botched rollout of a program supposedly intended to help small businesses and their employees has proved devastating for many—particularly Black owners, who are far more likely to be sole proprietors. Reveal cites a study by the Federal Reserve Bank of New York, which found that from February through April 2020, the number of active businesses plummeted by 22 percent, but the number of Black and Latino businesses dropped by 41 percent and 32 percent, respectively.

The Centers for Disease Control and Prevention on Tuesday released new guidelines on outdoor mask-wearing, greenlighting fully vaccinated people to engage in outdoor activities, including running, hiking, and walking—without a mask—if they are alone or with members of their household. Attending small outdoor gatherings and dining outdoors without a mask are also considered safe, federal officials said. 

But in situations where crowds are likely and social distancing presents a challenge, masking, even if fully vaccinated, is still recommended.

“Today is another day we can take another step to the normalcy of before,” CDC Director Rochelle Walensky said in a White House news conference.

“The examples today show that when you are fully vaccinated, you can return to many activities safely,” Walensky added. “And most of them, outdoors and unmasked, can begin to get back to normal. The more people who are vaccinated, the more steps we can take toward spending time with people we love, doing the things we love to enjoy.”

The updated guidance comes as nearly half of the country reports being vaccinated with at least the first dose. But public health experts remain cautious, with vaccination rates slowing recently following months of rapid growth, while some areas of the country continue to see alarming surges of the virus and its new variants.  

It’s been long established that outdoor contact poses significantly less risk in the spread of COVID-19 than indoors. But in recent weeks, questions over the necessity of outdoor mask-wearing have sparked some debate, with those on the right expressing special hostility towards the measure. On Monday, before the CDC’s announcement, Fox News’ Tucker Carlson went so far as to instruct viewers to contact child protective services if they see a kid wearing a mask outdoors. He also compared the practice of children wearing masks outside to child abuse.

“What you’re looking at is abuse,” Carlson said, “it’s child abuse and you are morally obligated to attempt to prevent it. If it’s your own child being abused, then act accordingly.” (Just to be clear: unnecessarily calling child protective services, in situations where the child is not in direct danger, can have long-lasting, traumatizing effects on both children and families.)

But Tucker and similarly-minded conservatives who are now professing outrage over outdoor masks appear to deliberately misinterpret the CDC’s previous guidelines, which never mandated strict outdoor mask-wearing. Instead, the CDC has always acknowledged that the outdoors provides greater ventilation—a key component to reducing COVID transmission—and wearing a mask while you are outside by yourself or with others in your household may not be necessary.

Even though roughly half of the United States population has received at least one COVID shot, coronavirus cases have surged in states such as Michigan, prompting concerns among some public health officials that parts of the nation may be reopening too quickly.

Dr. Michael Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy (CIDRP) at the University of Minnesota, used to advocate strongly for the return of in-person learning. But with new outbreaks largely fueled by the B.1.1.7 variant first detected in the United Kingdom, which seems to affect children at a higher rate than other strains do, Osterholm has changed his tune. I caught up with Osterholm to ask about transmission among kids and the path to herd immunity for the rest of us.

How does our current vaccination rate bode for school reopenings this fall?

I think it’s going to be a mixed situation. And what I mean by that is that we’re going to see, hopefully, vaccines available down to as young as age 12, maybe 10. So when we look at transmission, it’s one of those things where how much vaccine is there is going to make a determination of how big the problems are going to be.

Do you think vaccines for children will have to be fully FDA approved, or will they be able to get emergency use authorization?

I think they will get emergency use authorization. Part of the challenge we have right now is the issue of just how much infection is in the community. Because that’s going to drive how well the studies are going to be able to determine how well the vaccine works, and the safety issues. None of us wants to have people get infected, but frankly, that’s how we get vaccines approved: with efficacy and safety data. And so, if we see substantial transmission in kids, then we’re going to have a much faster timeline to understanding what these vaccines could do and can’t do.

Once this is in schools, the challenge is in the community and the schools. Right now, trying to get kids back in with quarantine, we’re seeing many in-person learning experiences abbreviated quickly, because all you need is just to have a few of these [infected] kids in the school and you have large numbers of people quarantined at home. From an intervention standpoint, there just hasn’t been any data yet to support that cloth face coverings on young kids do anything to prevent transmission. That’s never been studied or addressed.

Why would that be different for children than adults?

Even in the rest of the population, we don’t really have any good studies showing face cloth coverings work. [Centers for Medicare and Medicaid Services] actually has an ongoing evaluation of studies looking at cloth face coverings, and they basically say there’s no discernible data yet to show that they reduce transmission.

With N-95 respirators, you get less than 1 percent leakage in or out. If you look at surgical masks, it’s anywhere from 30 to 50 percent leakage in and out. You get to cloth face coverings, it’s in the 60 to 70 percent range. You know, they’re like seatbelts. They can surely reduce your likelihood of having a bad outcome, but it’s all about dose and time. For example, the recent CDC study looking at double masking was criticized for several reasons, but one of them was that they didn’t do anything about dose and time. It’s like an instantaneous hit and that’s it.

Environments such as school kids today, where we’re now using three feet [social distancing]—which we also challenge—means you double the number of people in the schoolroom. What does your HVAC system do to handle that? And cloth face coverings would have no biological reason to filter out or stop the small aerosol particles. So that’s one of the other things that has been kind of accepted as a fait accompli, and it’s not true.

The other thing is, hygiene theater has to stop. That has been such a big challenge. The CDC, finally, after a year, came out and said that this week. I’ve watched millions and millions of dollars be spent on these deep sanitizings that had nothing to do with reducing COVID-19 transmission. I’ve been saying this since last spring.

How can we overcome the partisan divide on willingness to get vaccinated?

First of all, you have to understand who it is you’re concerned about with vaccine hesitancy or reluctance. I’m part of a group that’s led by Dr. Stephen Thomas, one of the most prominent Black public health professors in the country. He works in Maryland, and he started a program there called the Black Barbers and Beauty Shop program. It’s basically taking barbers and beauticians and really educating them on a number of aspects of health, hypertension, diabetes, etc. And they have served as a major source of information on COVID-19 in their communities. And they are highly trusted; they’re very, very good. And when you actually have a peer like that, or someone that people look up to, explaining to them about this, the number of people willing to take the vaccines goes up dramatically. I think that is an example of the kind of programs we need. That’s not going to work if I’m a pregnant health care worker who is fearful of getting the vaccine. That’s a whole separate issue, and a critical one. And so you need to have the data and the programs to address that group, too.

One of the challenges we have is the billboard that just says “get vaccinated” really has little to no impact. Almost all the time, it’s really about answering specific questions and messages. That’s one where you can surely help them turn around. But I don’t have an answer on this partisan political issue.

The average number of vaccines administered per day is starting to fall. How big of a risk does vaccine hesitancy pose in terms of generating new vaccine-resistant variants?

We have to be very careful. Michigan’s immunization levels are among some of the higher in the country. The Southern Sun Belt states, which have been through this twice now—big waves, one last July, once in January—still have many, many people that are highly vulnerable. The vaccination rate in those states is significantly lower than what we’re seeing in many other states.

Well, if Michigan can have the problem it has, there are a number of states that can have the same problem. People often say, “Well, the vaccine is going to knock it down.” Surely it has an impact, but the amount of vaccination we have right now, as demonstrated in Michigan, is not enough to keep infections from surging. And I think that’s a big challenge for people. They don’t still believe that. And so we can’t get enough people vaccinated quickly enough right now, from my perspective, to try to deal with what is still the potential for other Michigans to occur in the country. It’s a huge issue. We think about this all the time here at CIDRAP.

What sort of public health surveillance systems do we have to detect breakthrough infections in people who have already been vaccinated?

A lot of our surveillance right now is held together by baling wire and twine. I mean, the number of locations still using fax machines to support case reporting! It is really a serious challenge, and if there’s no other lesson from the pandemic, it’s the fact that how critical real-time information is from a public health perspective, and how it has to be made a priority to get systems in place to do that.

Second, you have to have the systems in place to work with private sector and public sector organizations, such that right now we’re seeing a problem where somebody goes and gets tested, they’re positive. Turns out, they’re a breakthrough case but the lab testing them didn’t know that. By the time the health department gets the information and identifies this person as a breakthrough, they contact the lab and the sample has already been thrown away. It’s as simple as that, yet as complicated as that. How do you get that sample for sequencing? Who does the sequencing? When? We’re seeing in many locations two to four weeks before you get sequencing data back. If you’re trying to look at breakthroughs, and you’re trying to understand, is it due to the virus? Or is it just due to the natural experience you’re going to have with a vaccine that is 90, 95 percent effective for most people? What’s happening? We don’t have a good system in place for that.

I know that the administration knows that, but now’s the time where we’ve got to really work with state and local health departments. We’ve got to work with our laboratories, whether they be private or public. And we’ve got to have a much better system in place to identify and capture these samples before they’re lost. And then we got to have quick turnaround on them getting sequenced.

It’s not sequence capacity. We have sequence capacity in this country! It’s the system to get it done. Imagine if every time you tried to use your bank card, you had to run a mile around the bank before you could use it. It’d be a big challenge to get your money out.

I got my second shot of Pfizer yesterday, and although I did not get the jab at a particularly memorable, Only-In-New-York place—at the Javits Center, say, or Citi Field, or under the whale at the Museum of Natural History—it felt, nonetheless, quite momentous. I had a bacon, egg, and cheese on a scallion pancake to celebrate, went for a long walk, and promptly slept for 10 hours. I had been waiting for this day ever since I got my first shot, three week earlier, and I had been waiting for that day ever since I started working from home last March 15th. The side effects, for me, were annoying in a pleasant sort of way, like I’d gone for a very long run without drinking enough water. I call that “pleasant,” because I know this means it’s working.

But according to the New York Times, an alarming number of Americans have missed out on their second doses of Pfizer or Moderna:

More than five million people, or nearly 8 percent of those who got a first shot of the Pfizer or Moderna vaccines, have missed their second doses, according to the most recent data from the Centers for Disease Control and Prevention. That is more than double the rate among people who got inoculated in the first several weeks of the nationwide vaccine campaign.

The piece offers a number of reasons for why this is. There is some apprehension about the side-effects or a false sense security about much protection one shot provides. Logistical hassles inevitably arise in people’s lives—car trouble, or an issue with work or childcare, can mean the difference between making and missing a date with Moderna. And according to the Times, there’s also been another factor outside of people’s control—some people who have signed up for their second doses have been let down by the places that were supposed to provide them. For instance, “Walgreens, one of the biggest vaccine providers, sent some people who got a first shot of the Pfizer or Moderna vaccine to get their second doses at pharmacies that only had the other vaccine on hand.” Woof.

Earlier in the vaccination campaign, some experts were arguing for prioritizing first doses and delaying second doses in order to get more people some degree of resistance faster. But that was back when scheduling a vaccine appointment was still a bit like getting good seats on Ticketmaster. Right now, the United States has a ton of shots, and the benefits of two shots over one are clear. While the first shot of Pfizer and Moderna does provide some temporary protection against Covid, studies found that two shots gave a much fuller immunity, by helping the body produce a lot more antibodies and T-cells. It’s designed to be a two-part process; your body has to learn how to respond. Per The Ohio State University Medical Center:

It’s not unusual for vaccines to require back-to-back doses to be most effective. The first dose primes the immune system while the second dose induces a vigorous immune response and production of antibodies. The bottom line is that you want your immune system to produce a robust enough level of antibodies that if you’re exposed to a virus, your body can effectively fight it. Sometimes that means taking two vaccine doses.

The good news is that if you missed your second shot appointment for whatever reason, you might still have a window to fix it—although the CDC recommends getting the second shot as soon as it’s allowed, you can get it up to 42 days after the first shot, and it’s never been easier. So check with your doctor, and as always, check in on your loved ones. And if you got a shot from Johnson & Johnson, congratulations and ignore all of this—you’re good with just one.

This story was co-published in partnership with the Center for Public Integrity and the Kansas City Star.

Darryl Answer knows a lot of entrepreneurs in the majority-Black East Side of Kansas City, Missouri, people running companies or side gigs. But the local pastor couldn’t think of even one who’s received help from the federal government’s pandemic lifeline for small businesses.

That’s because most hadn’t.

In Kansas City neighborhoods seared by decades of government-imposed racial discrimination, the Paycheck Protection Program’s forgivable loans arrived last year at lower rates than in the rest of the city. East Side areas “redlined” in the 1930s because Black people lived there—a federal decision that effectively blocked investment—received 17% fewer PPP loans than if they’d gotten an amount proportionate to their share of the city’s small employers. Affluent, largely white ZIP codes given preferential treatment by redlining received 23% more.

“Sometimes we look at this as an isolated situation,” said Answer, who is active in community development in addition to his work with New Community Church. “But I think all of these things have to be experienced in light of history.”

This pattern keeps repeating—here and across the country. In Kansas City, your level of wealth and even the length of your life are often defined by whether you live east or west of Troost Avenue, a longstanding racial dividing line. It’s a similar story in many other once-redlined cities.

At the same time, most of the government incentives intended to combat blight and joblessness in Kansas City flow downtown rather than to the East Side. Variations on that theme keep happening around the nation, too, an eerie—and legal—echo of what the 1930s federal Home Owners’ Loan Corp. wrought with its red pen.

“You can’t call it anything but redlining: public sector reinforcing private-sector discrimination,” said Greg LeRoy, executive director of Good Jobs First, which tracks and researches economic subsidies. “The net effect is reverse Robin Hood. You’re favoring places that need help the least.”

In Kansas City, people determined to put a stop to this may be making some headway. In 2017, Black community leaders convinced voters to earmark a slice of sales-tax revenue for economic development and stability efforts in a portion of the East Side. Some of that money has flowed as COVID-19 relief to small businesses that largely missed out on the federal help.

And after a years-long pressure campaign by public school leaders, civic groups and others alarmed at the loss of tax revenue that would otherwise fund public services, the City Council imposed modest limits on tax incentives in February.

But what happened with the Paycheck Protection Program is just the latest reminder that equal opportunity remains miles off. Congress asked the Small Business Administration to prioritize small firms in “underserved” markets for PPP loans, which should have quickly boosted places like Kansas City’s East Side. And yet assumptions in the program design—about business owners’ access to banking or certain documents or even clear information about who qualifies—didn’t account for the reality that many firms in such markets face, according to interviews with several dozen experts and entrepreneurs.

Sixty-three percent of eligible applicants for the East Side coronavirus relief grants from Kansas City sales tax revenue did not get a PPP loan. A handful were turned down for PPP help, according to a survey by LISC Greater Kansas City, a field office of the Local Initiatives Support Corp., which administered the city’s grants. Ten percent applied and got no response. Many didn’t apply at all, in most cases because they hadn’t heard about it.

It’s a finding that LISC said befuddled some regional business leaders. Never heard of the much-discussed PPP?

But that’s west-of-Troost thinking. For people living and working east of Troost, the LISC survey results show what officials should have known from the start: A program that isn’t designed to counteract the effect of decades-long discrimination will probably replicate it.

“You can write it in the law that you’re supposed to [beneficially] target Black and brown businesses, but then it gets out into the system,” said Melissa Patterson Hazley, vice chair of the board overseeing the economic development sales tax. “And the system isn’t designed to do that.”

Darrian Davis co-founded a fledgling industrial hemp business and an urban farm cooperative. He also owns a construction contracting business, holds rental properties in a limited liability corporation and runs a side effort buying items from auctions to resell. 

He received a PPP loan for none of them.

“I remember thinking that I wasn’t going to be eligible,” he said. He kept hearing references to payroll, and he doesn’t have employees, so he didn’t apply.

It’s possible he could have gotten PPP money. One-person operations can qualify, and the SBA tweaked the program in January and again in February and March to try to make it more equitable. Even so, Davis might have fallen through the eligibility cracks — or ended up like a small dessert maker near him who jumped through the hoops last year and received just $416.

The East Side ZIP code where Davis lives, 64128, was one of the few places in Kansas City where Black people were permitted to live during the redlining era. Even today, there’s just one bank branch. Nearly a third of residents live below the poverty line. Home values are low, making it hard to build generational wealth. 

When the SBA handed out PPP loans last year, only 59 made it to 64128. Compared with its share of small employers, that’s one of the lowest levels in the city. 

Public Integrity, which itself received PPP loans, sued the SBA last year to release the information about recipients that made this analysis possible. The newsroom melded that dataset with Census Bureau figures and redlining-map information from a team led by the University of Richmond. It’s not a perfect measure because the federal government doesn’t track the universe of potentially PPP-eligible businesses at a local level, but comparing loans to the share of small employers helps show which areas are getting more or less than expected.

For some very small businesses in 64128, both a lack of assistance and a process that seemed to be continually changing acted as barriers. As she attempted to keep renovations going on a transitional house for women leaving prison, Monecia Smith contacted the SBA for help. She said she didn’t get anywhere. Then she reached out to Bank of America, but at that point last year the PPP funding was gone.

“I don’t know anyone that applied for it,” said Answer, the pastor, who lives in that ZIP code. Some “have multiple hustles, whether it be lawn care, catering, different things to survive. No one’s making a ton of money.”

About two-and-a-half miles southwest, across the Troost Avenue divide, sits the 64113 ZIP code. Here, prohibitions on Black residents were written into deeds in a pre-redlining practice that Kansas City developer J.C. Nichols helped spread around the country. The Home Owners’ Loan Corp. graded these neighborhoods highly desirable in the 1930s, a stand-out green on a map pockmarked with red.

Today, 90 percent of residents in 64113 are white. The typical household makes $138,000, five times the figure in Davis’s community. And 64113’s access to PPP loans, 262 in all, was among the highest in Kansas City compared with its share of small employers — 92 loans more than would have been expected.

Davis was not surprised to hear it. Just as the consequences of redlining still linger in his neighborhood, he said, marking some communities green has also compounded over time.

“Any disparity you can think of,” he said, “you’ll see the same pattern.”

In fact, only one Kansas City ZIP code that was predominantly redlined with Black residents in the 1930s did not have worse-than-average access to the PPP last year. A key secret to its success: It’s almost entirely west of Troost Avenue, benefiting from years of investments in and around downtown. 

The stark differences between neighborhoods in Kansas City can be found throughout America. That’s why Bruce Katz, director of the Nowak Metro Finance Lab at Drexel University, said the federal government must stop assuming that programs like the PPP are enough. What’s often missing in communities is a robust small-business support system to make sure people without banking connections or much money get the help, too.

“Unless you’re thinking about delivery of this locally, it falls flat,” Katz said. “We’re trying to get it embedded in every part of Biden policy that we can.”

Michael L. Barrera, director of the SBA’s Kansas City district office, said that since he stepped into the job in February, he’s been on an outreach tear. A former president of both the Hispanic Chamber of Commerce of Greater Kansas City and U.S. Hispanic Chamber of Commerce, he’s been repeatedly talking to local business groups—including the Asian, Black and Hispanic chambers—about the PPP and other pandemic assistance programs.

“We can’t contact every business in our district, so we have to rely on our partners to do that,” he said. “And having relationships with these partners is going to be critical going forward.”

PPP data for January through March shows the once-redlined areas of Kansas City’s East Side still falling short, though the gap has narrowed. City Councilwoman Melissa Robinson, whose district includes 64128, traces those better results to all-hands-on-deck efforts by people on the East Side. She said she pressed to get funding for the local Prospect Business Association so it could help more firms with PPP applications.

And the Heartland Black Chamber of Commerce, headquartered in Kansas City and covering four Midwestern states, pieced together government funding and donations to launch its own program in February. By the third day, about 100 businesses had applied for the help.

“The need is so great,” said Kim Randolph, chief executive of the organization.

There’s still time, though not a lot: The program’s application deadline is May 31. And the money might run out before then.

Kansas City Mayor Quinton Lucas, who grew up on the East Side, said the local experience with the PPP illustrates a broader national problem: The federal government keeps relying on local advocates to fix inequities that should have been anticipated from the start. “Rarely are there ever exceptions, particularly when you see the initial rollout of programs,” he said. “It is, as a Black man, incredibly frustrating.”

Not many of Randolph’s members obtained a PPP loan last year, when quick help was most needed. It was clear last spring that the pandemic was hitting U.S. communities of color particularly hard and fast — the number of Black small business owners dropped 41 percent nationally between February and April 2020, compared with 17 percent for white entrepreneurs. Randolph thinks the country should be ashamed of how the PPP rolled out.

“When the dust settles, we’re going to have a desert,” she said. “If we don’t do something about it now, we’re going to be in a worse situation than we ever thought we could be.”

For every dollar on which Kansas City collects sales tax, half a cent goes to parks. A quarter-cent flows to public-safety services. In two of the city’s counties, an eighth of a cent goes to the zoo.

Leaders of the local Urban Summit wondered: What if an eighth of a cent also went to economic development east of Troost?

Among the people posing that question was Karen E. Curls, president of a real estate services company. Her father, one of the city’s first African American real estate brokers, founded the firm in 1952—four years after the U.S. Supreme Court declared racist restrictions in deeds legally unenforceable and 16 years before Congress passed the federal Fair Housing Act. 

Those bans on real estate discrimination did not redress the damage already done. Areas like 64128 are caught in a vicious cycle, unable to get much investment because they were blocked from it for so long.

In theory, the city’s tax incentives for economic development could disrupt that cycle. But a 2018 report for Kansas City pointed out what East Side residents knew years earlier: Most incentives go to projects in already “high-value” parts of the city, particularly downtown.

If Kansas City voters agreed to charge themselves an eighth-of-a-cent sales tax for East Side efforts, that money couldn’t get diverted. It would be a step, Urban Summit leaders thought, toward banishing redlining’s ghosts.

“Let’s say that: a step,” Curls said. “But this staircase is very long.”

Supporters of the tax gathered signatures to put the measure on the ballot, then went door to door in 2017, urging people on both sides of the Troost divide to vote yes.

They did.

That’s generated more than $32 million over three-and-a-half years for an area that stretches from a street just east of Troost to the western quarter of 64128. Money is flowing to projects ranging from a shopping center renovation to a new childcare center, filling gaps in financing.

“The one-eighth-cent sales tax is really a godsend for us,” said Marquita Taylor, president of the Santa Fe Area Council, whose neighborhood is receiving $610,000 to help residents fix roofs and make other home repairs. What Santa Fe pieced together for the project isn’t enough, Taylor said, but still, “the impact is going to be so great.”

The sales tax is an idea people in other cities could try. But it’s no cure-all, as Curls warned. It runs out in 2027 unless voters reauthorize it for another decade. Work was painfully slow to get started. And the amount of money pales compared with development needs, frustrating residents as proposed projects lose out.

The city tax incentives that largely go elsewhere, meanwhile, are far larger.

Those incentives drained nearly $100 million in revenue from the city in 2019 alone, according to a calculation by Good Jobs First. That’s mostly through programs that let developers put money they would have paid in taxes toward project costs instead.

The Kansas City Public Schools district serves a portion of the city that includes both the heavily subsidized downtown and the 64128 ZIP code. Its officials calculated that the district lost $1,069 per student to tax abatements in the 2018-19 school year — far more than other, mostly whiter districts in the city.

“Enough is enough,” Superintendent Mark T. Bedell wrote in a 2020 letter after a firm that had its property tax wiped out for two decades asked for 13 years more. That “speaks loudly to the systemically racist real estate practices we have allowed to exist here.”

Amid growing outrage, the City Council denied the firm’s request and recently reduced the level of incentives developers can get. The council also tweaked rules to better target tax breaks to the distressed neighborhoods that keep missing out. But exceptions in the new law could undermine that goal. 

Robinson, the councilwoman, wants more reform because she sees no practical difference between redlining and modern-day decisions about where to funnel investment. “It’s just much more covert,” she said.

Ajia Morris, an East Side resident who rehabs houses locally, would like efforts that invest “directly in the people who live there.” Support for small businesses, for instance, or a mortgage pool to help renters buy. Her company, The Greenline Initiative, named in reaction to redlining, finds that East Side rents are just as high as — or higher than — a mortgage would be.

Morris, a lawyer and former school board member, said what gets classified as “investment” in the area often extracts money from the people there rather than going to them.

One program launched by the city’s health department and a local community development corporation last year does get funds into the hands of startups on the East Side, though the grants are small—$2,000 maximum. Kansas City and the Community Capital Fund see entrepreneurship as a way to increase well-being in an area where, in the case of 64128, people die nearly 18 years younger on average than in the greenlined 64113. (The reason for that disparity, the health department says in a blunt assessment: racism, including the “devastating & lasting impact” of redlining and later practices.)

Megan Crook, who led the Community Capital Fund when the program launched, said residents “know what’s going on in their neighborhood, they want to address it, they have the energy and ideas to address it. There’s just a lack of resources, a lack of a platform.”

Davis, whose industrial hemp startup received one of those microgrants, said lack of resources is exactly what makes the PPP harder to get in his community. Businesses without a lawyer or an accountant are at a disadvantage—and it’s no accident that his community has so many like that. 

He sees redlining at the root.

“Access to capital is the main thing,” he said. “Access to capital. That’s what we need.”

Jamie Smith Hopkins is a senior reporter and editor at the Center for Public Integrity, a nonprofit investigative news organization in Washington, D.C. She can be reached at jhopkins@publicintegrity.org. Public Integrity data journalist Pratheek Rebala contributed to this article.

 

About the data analysis

The Center for Public Integrity, a nonprofit newsroom based in Washington, D.C., relied on multiple datasets for the analysis in this story.

The key comparison uses Paycheck Protection Program data from the Small Business Administration by ZIP code alongside small employer figures from the Census Bureau’s ZIP Codes Business Patterns. We calculated each area’s share of Kansas City small employers, firms with fewer than 500 employees. Then we determined how many more — or fewer — PPP loans each ZIP code received than it would have gotten had it received the same share of loans as its share of small employers.

There’s no way to determine what percentage of eligible businesses received a loan. That’s because entrepreneurs without employees can apply for help from the PPP, too, and the Census Bureau doesn’t track their numbers by ZIP code. But our comparison shows which areas got a lot of access to the program, or just a little, compared with their employer base.

Public Integrity also relied on census demographic figures and “redlining” maps from the University of Richmond, which led a team that digitized documents from the federal Home Owners’ Loan Corp. These detail the U.S. government’s Depression-era redlining grades around the country.

This practice hardened patterns of real estate discrimination, with long-lasting effects. As the University of Richmond notes on its “Mapping Inequality” site, “HOLC assumed and insisted that the residency of African Americans and immigrants, as well as working-class whites, compromised the values of homes and the security of mortgages.”

As a result, the university said, the federal government “directed both public and private capital to native-born white families and away from African American and immigrant families.”

Areas colored green on HOLC maps, graded “A,” were deemed a good risk for bank investment. Areas given the lowest grade, “D,” were colored red and declared “hazardous” for investment. In Kansas City, not all redlined areas had Black residents. But all areas with more than a handful of Black residents were redlined. Black residents still make up many of the residents in these investment-starved neighborhoods today.

Public Integrity determined which ZIP code each graded area fell into, then identified each ZIP with a recorded number of Black residents at the point of redlining (that is, more than “few”) and more than half of the land area graded “D.” Four of the five are on the city’s East Side, the geographic focus of our story, and together these four received substantially less access to the PPP than if the loans had been equally distributed around the city. ZIP codes where more than half the land area was graded “A” or “B” —both west of Troost—received markedly more.

So, what about that single ZIP code, 64108, that sits against the city’s western boundary but was also largely graded D and had a recorded number of Black residents at the time? All but a small piece is west of Troost Avenue, which became the city’s de facto racial dividing line, and it’s had a different trajectory than the East Side—with far easier access to lending, including the PPP.

Victoria Orozco at Drexel University’s Nowak Metro Finance Lab, Robert Nelson at the University of Richmond, Brent Never at the University of Missouri-Kansas City and the National Community Reinvestment Coalition’s Bruce Mitchell, Jason Richardson and Jad Edlebi offered feedback and advice at various stages of the analysis.

We may have moved on from the time of obsessively disinfecting our groceries before we brought them inside, but hyper-vigilance over germs has been one of the major side-effects of the global pandemic. Even with the knowledge that the airborne coronavirus is less likely to be transmitted on what we touch, the many surfaces in our lives—from our hands to airplanes—have spent the last year being scrubbed like never before. 

But that may not necessarily be a good thing. In fact, as science journalist Markham Held writes in the New York Times today:

…We continue to annihilate every microbe in our midst, even though most are harmless. The New York City subway, for example, has been undergoing a 24-hour cleaning protocol that includes ultraviolet light and a variety of disinfecting solutions. Survey data shows most subway riders feel safer because of it.

But some health experts are watching this ongoing onslaught with a mounting sense of dread. They fear that many of the measures we’ve employed to stop the virus, even some that are helpful and necessary, may pose a threat to human health in the long run if they continue.

Their worries center on the human microbiome—the trillions of bacteria that live on and inside our bodies. They say that excessive hygiene practices, inappropriate antibiotic use and lifestyle changes such as distancing may weaken those communities going forward in ways that promote sickness and imperil our immune systems. By sterilizing our bodies and spaces, they argue, we may be doing more harm than good.

The microbiome exists in all parts of our bodies—famously our guts, but also our mouths, noses, skin, lungs, brains, and, among many people, vaginas. Our bodies’ interaction with them serves an essential purpose in keeping our systems sufficiently strong to keep dangerous external bacterial invaders at bay as well as helping to mitigate or prevent diabetes, asthma, obesity, and autoimmune diseases. But, as with most things, this system needs to be exercised to remain robust, and therein lies the problems with pandemic cleanliness. Held writes:

In January, a global consortium of health researchers published a paper in the Proceedings of the National Academy of Sciences (PNAS) in which they raise the alarm about the microbial fallout that may follow in the pandemic’s wake. “We’re starting to realize that there’s collateral damage when we get rid of good microbes, and that has major consequences for our health,” says B. Brett Finlay, first author of the PNAS paper and a professor in the department of microbiology and immunology at the University of British Columbia.

So what is the alternative? Put simply, Held notes, “[W]e’re going to have to live with germs again.” But balancing the urgency of doing so, with the urgency of controlling a global pandemic is not so easy. Given what we’ve gone through over the last year, it may be worth starting to nurture our depleted microbiomes by indulging in some nice, unwashed, organic carrots. 

A Centers for Disease Control and Prevention advisory panel recommended Friday that distribution of the Johnson & Johnson coronavirus vaccine resume.

The CDC and the Food and Drug Administration recommended halting J&J inoculations on April 13 following reports of rare, serious blood clots in people who had received the vaccine. Out of nearly 8 million vaccines administered, there have been 15 confirmed cases of blood clots, all in women. Three have died, and seven remain hospitalized.

As my colleague Kiera Butler reported last week, although the J&J pause came as a blow to vaccination efforts, it was ultimately the right decision:

My reporting on vaccine hesitancy and public health messaging has taught me that trying to hide bad news from the public not only doesn’t work but is seriously counterproductive. As infectious disease expert Monica Gandhi told me last week, we learned during the HIV/AIDS epidemic that people thrive when they have access to nuanced and accurate information. We learned from other vaccine rollouts that downplaying side effects has a way of coming to back to bite you. For example, in 2002, when the George W. Bush administration rolled out a smallpox vaccine, it sought to downplay rare but serious side effects, which included potentially fatal inflammation of the heart. Naturally, the news got out anyway. The result was that the administration ended up vaccinating just 10 percent of its goal.

The CDC’s Advisory Committee on Immunization Practices determined that vaccination should resume and that the vaccine should carry a warning about the risk of blood clots. CDC director Rochelle Walensky will need to give final approval before vaccinations can begin again.

Michigan is in the midst of a brutal surge of COVID-19 infections. ICUs are nearing capacity, and thousands of infections are hitting each day. The B.1.1.7 variant has driven this surge: The more transmissible variant accounts for 99 percent of new cases in the state. Though the increase in new cases seems to have slowed in the last few days, the state still leads the country in new cases per capita in the last week, and Centers for Disease Control and Prevention head Rochelle Walensky recently said the state should impose restrictions to curtail the virus’ spread once again—a move the state’s governor, Gretchen Whitmer, has resisted.

As the state races to vaccinate residents and reopen its economy and schools, it appears that, like the beginning of the pandemic, Black communities across generations are getting infected and dying of COVID at higher rates than their white peers, according to a Mother Jones analysis of state data. Likely because older residents received the early share of vaccinations, this surge has unevenly afflicted younger residents—young Black men and women in particular.

Last March, Black Michigan residents, who made up 14 percent of the state’s population, accounted for 41 percent of deaths. A year later, as of April 12, Black Michiganders account for 22 percent of deaths.

 

The latest outbreak is especially acute among children and young adults. A Mother Jones analysis found that in Michigan, residents between 20 and 39 years old account for the highest case rates statewide, and people under 19 years old have contracted COVID at a rate higher than any other time during the pandemic.

Younger Black residents are also dying at disproportionately higher rates than white residents, taking years of life from an entire generation of Black Michigan residents. In the last year, Black Michiganders between 20 and 39 years old account for around 17 percent of the state’s Black residents but 44 percent of deaths. It reflects a startling national trend that Black and Latino Americans throughout the pandemic have died of COVID at younger ages than their white peers.

Because of the surge, in mid-April, Governor Whitmer called on schools to pause in-person learning and youth sports and pleaded with residents to avoid eating indoors at restaurants and bars. Her power to impose stricter restrictions was limited, thanks to a state Supreme Court ruling last October curtailing her executive authority.

On NBC’s Meet the Press this week, Whitmer conceded that she lacked the “exact same tools” she had a year earlier after being sued by Republicans. “At the end of the day this is going to come down to whether or not everyone does their part,” Whitmer said on Sunday.

But for some cities, the race for vaccinations and personal responsibility plea only goes so far. Dr. Lawrence Reynolds, a pediatrician in Flint who has been chief health adviser to Flint mayor Sheldon Neeley since last March, points to the state’s dedication to “home rule,” the notion that every school district and city government operates on its own, even as the state offers resources and direction. Reynolds, who sits on the Greater Flint Coronavirus Taskforce on Racial Inequities, saw Flint’s high coronavirus burden as an example of how home rule can perpetuate segregation and the unequal allocation of resources. That, along with Republican resistance against Whitmer, creates a “recipe for moving backward and not responding appropriately” to the pandemic, he added.

Flint is in Genessee County, which has a daily case rate of 89.2 per 100,000 people—the second-highest rate of all metropolitan areas in the United States over the last two weeks, according to the New York Times. During the pandemic’s early days, Black Flint residents, who make up 53 percent of the city’s population, were nearly four times more likely to get infected by COVID than their white peers and six times more likely to die, according to county data provided to Mother Jones.

By the end of last summer, through a concerted effort to eliminate testing barriers, expand community testing sites, impose a moratorium on water shutoffs, and leverage pre-existing networks of community groups, activists, church leaders, public health officials, philanthropists, and business leaders for aid, among other initiatives, the city managed to close that gap in infections and deaths between white and Black residents. So did the rest of the state: An interim report from the state’s Coronavirus Task Force on Racial Disparities noted that in March and April 2020, Black residents averaged 176 new confirmed cases for every million residents per day—a stark departure from 39 per day for white residents.

By September and October, the trend nearly flipped: Black residents accounted for 59 cases per million while white residents made up 130 per million. Nationally, although disparities in COVID infections and deaths among communities have narrowed over time, Black, Latino, Native American, and Pacific Islander people are still dying of COVID at at least twice the rate of white people when adjusted for age, according to APM Research Lab. 

But sadly, much of that progress has been undermined in the most recent surge. As COVID sweeps through cities shaped by pre-existing inequities and political division, it takes advantage of structurally unequal systems that disproportionately afflict communities of color, many of whom are so-called essential workers who risk exposure in ways their peers don’t. The trajectory in Flint and the surrounding county is no different. Even the vaccine rollout has unfolded unequally. Though Black residents account for 14 percent of the state’s population, just 8 percent of all vaccinated people in Michigan so far are Black as of April 12. White people, who make up 80 percent of the population, account for 79 percent of vaccinated Michiganders.*

Debra Furr-Holden, a Flint epidemiologist and professor of Public Health at Michigan State University, told Mother Jones that the state’s decision to reopen in February, just as the B.1.1.7 variant collided with the state’s hopes for returning to normalcy, was a “big mistake.”

“It’s a really unfortunate state of affairs—despite people’s desire to return to business as usual, and what many are calling the new normal, we weren’t ready,” she says. “We didn’t give enough time for vaccinations to outpace spread and the impact of variants and communities. So now we are where we are. I’m pretty sure we ruined summer.”

This article has been updated to correct a mischaracterization of the racial breakdown of fully vaccinated Michigan residents.

All adults ages 16 and up in the United States are now eligible to receive the COVID vaccine, meeting the April 19 deadline set by President Biden last month. That critical milestone comes as the White House announced on Sunday that half of all US adults—about 128 million people—have received at least one dose of the vaccine, yet another stat that captures how quickly the rate of vaccinations in the US has ramped up in recent weeks. That pace is particularly striking when compared internationally; earlier this month, CNN reported that the US was vaccinating people at five times the global average.

But significant challenges persist. Vaccines are going unused in large pockets across the country, particularly in regions with strong evangelical communities. Almost half of Republicans, according to a poll released last week, say they will decline to receive the vaccine if possible. As I wrote last week, all this resistance poses a real threat to the US ever achieving herd immunity as highly contagious COVID variants continue to spread.

Still, the expansion of vaccine eligibility today is a real success for the Biden administration. To anyone 16 and over who had been waiting to get the jab, get out there!

Half of all adults in the United States have received at least one dose of a COVID-19 vaccine, White House senior adviser Andy Slavitt announced on Sunday. The news came one day before all Americans 16 and over become eligible for vaccination.

The Centers for Disease Control and Prevention reported that 50.4 percent of American adults—128 million people—had received at least one dose of a vaccine. The country crossed the 50 percent mark on Sunday after nearly 4 million new shots were reported. Among Americans 65 and older, the age group that has accounted for the large majority of COVID-19 deaths, more than 80 percent have gotten their first shot and nearly tw0-thirds are fully vaccinated.

Despite this country having one of the world’s highest vaccination rates, COVID-19 cases have increased by 5 percent over the past two weeks, according to a New York Times database. About 750 Americans are dying of COVID-19 infections each day, about as many as before cases started surging in the fall. 

That could soon change. In Israel, one of the few countries with a higher vaccination rate than the United State, cases have plummeted in the past month and fewer than 1 percent of tests are coming back positive. In response to that news, Israeli public health officials ended the country’s outdoor mask mandate this weekend.

In a series of Sunday show interviews, Dr. Anthony Fauci said he expects the pause on the Johnson & Johnson COVID-19 vaccine to end when the Centers for Disease Control and Prevention’s independent vaccine advisory committee meets on Friday to discuss the issue.

“I would be very surprised if we don’t have a resumption in some form by Friday,” Fauci said. “I don’t really anticipate that they’re going to want it stretch it out a bit longer.” 

On the Johnson & Johnson vaccine pause, Dr. Anthony Fauci tells @MarthaRaddatz: "We'll know by Friday where we're going with this." https://t.co/dU120vpKgd pic.twitter.com/TQ0dR423Yg

— This Week (@ThisWeekABC) April 18, 2021

On Tuesday, the CDC and Food and Drug Administration recommended that states temporarily stop using the J&J vaccine following reports that six women who had received the vaccine developed a rare blood clot. Potential complications from the vaccine, which is highly effective at protecting people from COVID-19, have been extremely rare. More than seven million Americans have received the J&J vaccine, and only one person is known to have died of a blood clot that may have been linked to it. Public health officials said this week that the pause was made “out of an abundance of caution.”

Fauci defended the initial pause, saying that it was important “to make sure that you have all the information that you need.” He explained that the pause provided additional time to study potential complications and inform physicians about how to treat them.

The CDC committee, not Fauci, who serves as President Joe Biden’s chief medical adviser, will decide whether to recommend resuming use of the J&J vaccine. In an appearance on CNN’s State of the Union, Fauci stressed that he didn’t want to get ahead of the CDC and Food and Drug Administration. But he did say, “I would imagine that what we will say is: that it would come back and it would come back in some sort of either warning or restriction.” On NBC’s Meet the Press, Facui told Chuck Todd that there would would probably be guidelines recommending caution about using the vaccine under soon to be specified circumstances. 

“My estimate is that we will continue to use it in some form,” he said. “I doubt very seriously if they just cancel it. I don’t think that’s going to happen.”

Today, the Food and Drug Administration recommended a “pause” in the use of Johnson & Johnson’s vaccine after six women who ranged in age from 18 to 48 reported suffering from a severe form of blood clot after receiving the shot. The news was a major blow to the Biden administration’s vaccination efforts: The J&J shot, which is highly effective, requires only one dose, and needs no specialized storage, has been given to nearly 7 million Americans so far.

Some media observers have wondered whether the pause will do more harm than good: The shot’s reputation will be permanently tarnished, they argue, over a side effect that is vanishingly rare. “I think it’s important though that there *hadn’t* been a particular public/media panic about blood clots and the J&J vaccine, at least not yet,” tweeted journalist Nate Silver. “So the FDA is sort of creating a Streisand Effect and giving these concerns more salience.” (“Streisand Effect” refers to a situation where a cover-up makes things worse.) Others opined that given the extreme rarity of the blood clots, the pause was overly and unnecessarily cautious. “On the general subject of abundance of caution, this paper finds 5.84 deaths per 100,000 induced by aging into legal driving age,” tweeted journalist Matt Yglesias.

But these criticisms miss an important point: the critical role of transparency as a public health tool. My reporting on vaccine hesitancy and public health messaging has taught me that trying to hide bad news from the public not only doesn’t work but is seriously counterproductive. As infectious disease expert Monica Gandhi told me last week, we learned during the HIV/AIDS epidemic that people thrive when they have access to nuanced and accurate information. We learned from other vaccine rollouts that downplaying side effects has a way of coming to back to bite you. For example, in 2002, when the George W. Bush administration rolled out a smallpox vaccine, it sought to downplay rare but serious side effects, which included potentially fatal inflammation of the heart. Naturally, the news got out anyway. The result was that the administration ended up vaccinating just 10 percent of its goal.

It’s easier to imagine what the cost of a “nothing to see here!” approach would be if we look at some scenarios of how it could actually play out. Suppose the federal government tried to downplay the instances of blood clots so far, and vaccination sites continued to use the Johnson & Johnson vaccine. Perhaps the clots would remain truly rare, the rollout of the shot would continue to work as planned, and the American public would be none the wiser.

Another possibility is that the clots would keep happening at the current (extremely rare) rate. It would only be a matter of time before people who are skeptical of the vaccines would point out that the government had covered them up. This outcome would inevitably foment a certain amount of distrust among some Americans.

A very bad possible outcome would be that because of widespread news coverage of the blood clots, the American public would perceive them as a far more common side effect than they actually are. In this case, we could also expect that blood clots that are not connected to the vaccine—the kind that are relatively common in people who have traveled on long plane trips and somewhat common in smokers and people who take hormonal birth control—would be incorrectly attributed to the vaccine. The incidence of the clots would then appear to be dramatically higher than it actually is—and it would make the government look incredibly irresponsible in failing to intervene. In this nightmare scenario, perhaps reports of blood clots after the Pfizer and Moderna shots would also start cropping up, and the public’s trust in a miraculously effective public health tool would be forever damaged.

Saad Omer, a Yale University epidemiologist and infectious disease expert who studies vaccine hesitancy, told me he also thought the pause made sense. He said the government needed time to assess risk factors. Also, it was important to make sure that clinicians knew how to recognize the symptoms of these blood clots—which require different treatment from the most common kinds of blood clots—and  how to treat them. Omer also emphasized the importance of transparency. “When the government doesn’t share with the public, in the long run, this becomes problematic, because people lose trust,” he said. “We saw that during this outbreak, when the government tried to downplay the severity of the disease.”

Other public health experts are also expressing support for the pause. “Pausing to investigate this is the right thing to do. Clinical trials get paused for the same reason,” tweeted Georgetown University virologist Angela Rasmussen. “This is the regulatory system working as it is supposed to.” Leana Wen, Milken Institute School of Public Health at the George Washington University, tweeted, “This is exactly the right move. All possibly concerning safety signals should be immediately & transparently investigated.”

A very good question to ask is if this pause will have some serious consequences for our vaccine rollout. Even if it’s just a few days, highly transmissible variants are driving case counts up in many states. Most experts believe that our only way out of a crushing fourth wave, is robust vaccination. It’s true that the timing of the pause isn’t great, but it may be smarter to sacrifice short-term rollout speed to build long-term trust in the government’s vaccine messaging. If the public begins to lose faith in the COVID-19 vaccines overall, the fourth wave will certainly not be the last.

At this point, it’s kind of hard to absorb good news about the pandemic. But here is some to brighten your weekend: More than one-third of all people in the United States have received at least one dose of a COVID vaccine as of Friday, according to CDC data. That’s not just one-third of eligible adults. It’s one-third of everyone—kids included.

We’re still a heck of a long way from “herd immunity,” a threshold for blocking most coronavirus transmission that probably requires about 60 to 70 percent of the population to be fully vaccinated. Whether we ever get there is complicated by variants and disparities in global vaccination rates, and so CDC guidelines on mask-wearing, physical distancing, and avoiding crowds are still very much in effect. But after 558,000 deaths and recent dire warnings about surging infections in a handful of states, I’ll take whatever positive signs I can get.

Accordingly, states and cities are expanding eligibility for who can get a shot. As of Saturday, Los Angeles opened up appointments to all people 16 and older. At least 39 states are now allowing all adults to get the vaccine. Oklahoma and New Hampshire plan to start vaccinating outside residents. (Republican New Hampshire Gov. Chris Sununu had previously been criticized for refusing to vaccinate out-of-state college students, insisting they travel home to get their vaccines.) 

With a little over two and a half weeks to go until the 100-day mark of President Joe Biden’s administration, some 183,467,709 first and second doses have been administered in the United States, leaving the country in spitting distance (but please do not) of the White House’s 200 million shots-in-arms goal. 

All in all, the US is administering an average of around 3 million vaccines each day. Less than .004 percent of people—fewer than 1 in 28,000—have reported serious adverse reactions to the vaccine, according to the Department of Health and Human Services.

But questions remain about whether the surge of vaccines are going where they are needed most. On Sunday morning, former Food and Drug Administration commissioner Scott Gottlieb estimated that the US would reach a point “where supply outstrips demand” for the vaccine in as few as three weeks. But for now, he recommended surging vaccine supplies to states like Michigan, currently in the throes of a COVID fourth wave. “I think a lot of states are going to see themselves with excess supply and excess appointments,” Gottlieb said on CBS. “So it’s going to be a shame to look back and in retrospect, realize that we probably should have put more vaccine into some of these hot spots to snuff them out.”

“It’s been sort of a Hunger Games for vaccines among states so far,” Gottlieb added. “And we need to think differently about this pandemic.”

As the world grapples with the devastation of the coronavirus, one thing is clear: The United States simply wasn’t prepared. Despite repeated warnings from infectious disease experts over the years, we lacked essential beds, equipment, and medication; public health advice was confusing; and our leadership offered no clear direction while sidelining credible health professionals and institutions. Infectious disease experts agree that it’s only a matter of time before the next pandemic hits, and that one could be even more deadly. So how do we fix what COVID-19 has shown was broken? In this Mother Jones series, we’re asking experts from a wide range of disciplines one question: What are the most important steps we can take to make sure we’re better prepared next time around?

After a year that, for must of us, has been a blur of panic-inducing headlines, good news about the coronavirus sounds like an oxymoron. Monica Gandhi, an infectious disease specialist and the associate division chief of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital, wants to change that. After decades of working on the HIV epidemic, Gandhi has learned that fear-based messaging isn’t always effective, and she hopes to help the public health community learn from past mistakes rather than repeating them. Her prolific Twitter feed is full reasons to be hopeful, even as the pandemic persists. But she’s no Pollyanna. “I’m not a fake optimist,” she says. “I’m just looking at data dispassionately.” I reached out to her to talk about the fourth wave, vaccines and variants, and how optimistic messaging could actually help slow the spread of the virus.

On the lessons from HIV that we should be applying to COVID-19: We learned about not using shame-based messaging. [Yet we’re still saying] “Look at all these young people on the beach, how awful that they want to kill the elderly.” [From HIV] we learned a lot about fear-based messaging—that it didn’t work. “You’re gonna die if you do this.” No! “Let me tell you how to keep yourself safe.” There were ways to say: “I am so sorry you miss your family so much. Let me tell you some ways to stay safe and still have some family time.” We have not put that all together. Instead, the message was, “Stay at home.” I think it’s because we’re hoping that people will be scared to death. It works for some people, but it sure has led to a lot of anxiety and depression, where we could have been more nuanced.

On the coming fourth wave of COVID-19: The data is really clearly showing us two things: One is that as cases rise in some states, hospitalizations, luckily, are not rising as much. The other is that those who are getting severe disease are those who aren’t vaccinated yet. So I find this surge fairly different from any other, where you could predictably say, “Oh, this many hospitalizations per case, let’s prepare for this terrible onslaught.” Two countries [the United Kingdom and Israel] are ahead of us in vaccination rates, and we are seeing encouraging signs in both of them. Importantly, in Israel, the cases were going up in January. Then, there was this moment when the vaccine stopping transmission caught up with the cases. Then the cases just came tumbling down. So all we have to do, in my mind, is just look at data in the two countries ahead of us. Everything is looking different and better.

On immunizations and variants: There are two arms of the immune system: There are antibodies that kind of go up and down, and there are T-cells that generate a super complex response. Why did we not think about this before? Because it’s hard to measure T-cells. It requires flow cytometry [highly specialized equipment used to analyze cells] in a big lab, so there were only a couple of studies on this. And luckily, they’ve been released in the last three weeks—one was just last week!—[and revealed] that our T-cells are going to work against those variants. I’m not too worried about [the variants escaping from vaccines]. I think about T-cells a lot, because I’m an HIV doctor, and we hate T-cells going away. That’s what HIV does—it hurts our T-cells.

On the importance of global access to vaccines: This is simply not an infection that we can ever just get through without thinking about the rest of the planet. Vaccine equity has always been an incredibly important principle of infectious disease. But this couldn’t be any more urgent, because unlike any other time in history, we’re rolling vaccines out in the middle of a pandemic. Each place in the world can threaten progress in every other. The United States can really be a world player on this. We haven’t yet, but we can change in a lot of ways. I think we should join the WHO COVID-19 Technology Access Pool, which allows other pharmaceutical companies and other countries to have the formula for vaccines. And the vaccine doses that we don’t need—give them away. This should be a constant, ongoing conversation—that we’re all in this together.

On vaccine equity in the United States: There has never been a time that I remember when there was a national reckoning with systemic racism going on at the same time as an infectious disease outbreak. This is the time to apply that reckoning with systemic racism to our response, which would be mobile vans and increased community access and having members of Black and Brown communities be the ones who convey the message. We need to take time out to ensure that we’re not just putting out vaccines in a way that white people and rich people can come in and get them. Those two things are colliding in the United States at once; we have to put them together.

On combatting vaccine hesitancy: Sometimes it’s just a matter of people who represent communities doing the messaging. The Tyler Perry campaign was really powerful, as was [Moderna vaccine lead scientist] Kizzy Corbett, an African American, talking about how she developed the vaccine. And Dr. Fauci joining with Lin-Manuel Miranda to do a campaign. We’ve learned this in HIV. We actually never had, a white man message to the Black community. (Well, we did at the beginning, but then we stopped.) This is the time to take all those innovative lessons from HIV. We need white male Republicans, many of whom, at the national level have gotten vaccinated—I think almost all of Congress is vaccinated. They didn’t decline it. I also think that we’re overblowing vaccine hesitancy a little bit. The more people who get a vaccine—then you have a friend and a neighbor and your family member. All these people have had it, and they’re fine. They’re safe. It’s effective. So I’m not as worried as others about that.

On applying the lessons from this pandemic to the next one: We get to learn from two pandemics, HIV and COVID. And what we would want to do with COVID is unlearn a lot of the things we did [with HIV]. I would unlearn shame-based and fear-based messaging. I would unlearn non-nuanced discussions. We’re a highly politicized nation, but the fault has to be on both sides. It doesn’t help to yell at each other or exaggerate when there’s data right in front of you. We have clear numbers about risk, age, how to keep people safe. We have all the data, we had the data quite early on, actually. What I would hope is that those who get to inform the field and inform policies don’t do it on cable news or on social media, but rather in a really serious way, by dispassionate, data-observing scientists. I don’t know if it’s just the politicization of this country, because I think it happened across the world. But we sure had a really difficult response and a lot of sad and hurt people.

On the Biden Administration’s COVID response so far: What I see as really hopeful is the signing of the Defense Production Act and getting the vaccines out quickly. I truly believe the rollout is going as well as it could be, except that I think we should get the first dose first and wait on the second. And I’m delighted with the attention on the economic insecurity of people that resulted from the pandemic. All of that is amazing. But I still see a somewhat non-nuanced look at the data. Last week was a very confusing week for the American people: “Impending doom” on Monday; by Friday, you could travel if you’re vaccinated. That was tremendously confusing; it was just amazingly confusing! We don’t have to use scary words or sound bites. We can just literally explain it: “Hey, here’s a map of the United States. Let’s admit it. Some places are surging, some are not actually, to be honest, and it’s very complicated why.” We’re not dumb. American people are very smart.

This story was published in partnership with ProPublica, a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

As the United States seeks to end its coronavirus crisis and outrun variants, public health officials recognize it is essential for as many people as possible to get vaccinated. Making that easy is a major part of the plan. According to the Coronavirus Aid, Relief, and Economic Security Act, the vaccine is supposed to be free to everyone, whether they’re insured or not. And the Biden administration has directed all vaccination sites to accept undocumented immigrants as a “moral and public health imperative.” But this promise has not always been fulfilled, ProPublica has found.

At vaccination sites around the country, people have been turned away after being asked for documentation that they shouldn’t need to provide, or asked to pay when they owed nothing.

In part, this has happened as businesses administering the vaccine try to recoup administrative fees they are allowed to charge to the government and private insurers. To aid them in passing along the bill, major pharmacies ask those being vaccinated for their Social Security numbers and insurance information. They aren’t supposed to deny a shot to people who aren’t covered or try to make them pay the fees. But both of those things have happened.

Workers at vaccine sites have also turned away people who they felt didn’t provide sufficient proof that they belonged to an eligible group, demanding to see medical records or other evidence of underlying conditions. While the vast majority of states don’t require such documentation, government officials haven’t always communicated that clearly.

The resulting barriers can be higher for those less equipped to advocate for themselves, such as undocumented people and those who do not speak English. Because of this, even as vaccines have become more widely available, they are still not easy for some of the most vulnerable people to access.

You Do Not Need a Social Security Number or Insurance to Get a Free COVID Vaccine. Your Immigration Status Does Not Matter, Either.

Camille lives in Baltimore with her 77-year-old mother. (She asked to be identified only by her first name for privacy reasons.) When a nonprofit organization helped her mother get a vaccination appointment an hour away in College Park, Maryland, Camille took time off from work to drive her there. They’d only brought along her mother’s state ID card. But when they went up to the counter at the CVS pharmacy, an employee asked for insurance information and a Social Security number. Camille’s mother, who is from Togo and is seeking asylum in the United States, doesn’t have either of those. Camille said the employee told her they’d have to pay if they wanted a vaccine.

No one is supposed to be charged for the COVID-19 vaccine, according to the CARES Act, and immigration status shouldn’t affect eligibility. Many vaccination sites ask for insurance and Social Security information so they can charge administrative fees to insurance companies or the federal government, but those aren’t requirements for being able to get vaccinated.

Camille told the CVS employee she wasn’t going to pay for a vaccine. Her mother, a French speaker who takes weekly English lessons, needed Camille to translate what was happening. “I felt so embarrassed, and my mom also when I was explaining to her,” she said. “She was like, ‘I’m not going to have it because of insurance?’”

Not wanting to drive an hour back without the vaccine, Camille called Tiffany Nelms, executive director of the Baltimore-based nonprofit Asylee Women Enterprise, which had set up the appointment for them. When Nelms asked the CVS employee why they were having trouble getting a vaccine without a Social Security number, the employee “quickly backpedaled,” Nelms said. The staffer told Nelms a supervisor would override the CVS computer system’s request for an insurance or Social Security number.

Nelms said she’s worried about others who have less access to support. “Not everyone has a bilingual relative to go with them who is even comfortable advocating in that way and also has an advocate that’s a phone call away,” Nelms said. “A lot of our clients, especially those who don’t have legal status yet, if they were asked a question like that, they would just leave.”

Camille said she’s thankful her mother got the one-dose Johnson & Johnson vaccine so they don’t have to go back to the CVS for a second shot.

“We are aware of these isolated incidents in Maryland and are committed to addressing inequities related to COVID-19 vaccine access in vulnerable communities, with a particular focus on Black and Hispanic populations,” a spokesperson for CVS said in a written statement regarding Camille’s experience and two other incidents that took place at Maryland CVS locations. “No patient, whether they are insured or uninsured, has been charged directly for a COVID-19 vaccine. If a patient does not have insurance, we are required by the Health Resources and Services Administration to ask the patient to provide either a Social Security number or valid driver’s license/state ID #. However, uninsured patients are not required to provide this information in order to receive a vaccine from us.”

Vaccination sites’ arbitrary documentation requirements have been a barrier for other Marylanders trying to get vaccinated as well. Several Montgomery County public school teachers formed Vaccine Hunters-Las Caza Vacunas to help find appointments for eligible Marylanders. In March, eight of their clients were initially denied vaccines when they showed up for appointments. Most were told they needed documentation that isn’t required by the state. All of them were immigrants, and most eventually got the vaccine after contacting someone from the group to advocate on their behalf.

In one incident Vaccine Hunters volunteers said they intervened in, a woman arrived for her appointment at a CVS in White Plains, Maryland, and presented her ID, a Salvadoran passport. She was told she would need an insurance card or Social Security number, which she does not have. In another, a woman who primarily speaks Spanish was initially turned away by a College Park CVS because she couldn’t respond when asked, in English, to identify her eligibility category.

The group’s volunteers have received complaints from local residents who were turned away for other reasons as well. At a Giant grocery store in Hyattsville, two Latina pastors were initially turned away because they did not have a letter from their employer, even though they brought W-2 forms proving their employment status.

“A COVID-19 vaccine provider may not refuse an individual a vaccine based on their citizenship or immigration status,” said Charles Gischlar, deputy director of communications for the Maryland Department of Health. However, Gischlar said, Maryland vaccine providers are required to take “reasonable steps” to determine whether someone is actually in a priority group: “A COVID-19 vaccine provider may require additional documentation or employee identification and may require that organizations submit institutional plans with identified individuals.”

A spokesperson for Giant Food said that its stores check patient information from their IDs or letters from their employers to identify who is being vaccinated and report demographics back to the Centers for Disease Control and Prevention. “Our goal is to assist in getting people immunized, not to police the vaccine by any means,” communications and community relations manager Daniel Wolk said. “As you can imagine, guidance from the state legislators and the Department of Health changes daily. We do our best to effectively communicate these changes to our over 400 pharmacists via email and weekly calls.”

Across the country in the Mission Hills neighborhood of Los Angeles, Rite Aid turned away a woman on March 14 after asking her to provide a Social Security number and a U.S.-issued ID, which she does not have. She had brought her consular ID, which Los Angeles County sites are supposed to accept for vaccination appointments.

“After being on a waitlist for a week, my mom was turned away because she has no social security and because she is UNDOCUMENTED,” her son Sebastian Araujo wrote on Instagram, adding on Twitter, “My mom was literally sobbing and I’m literally appalled.” After Araujo shared the incident on social media, Rite Aid responded to him on Twitter with an apology and reached out to reschedule a time to vaccinate his mother.

A Rite Aid spokesperson said the company advises its employees not to turn anyone away from a vaccine appointment, regardless of whether they have an ID, Social Security number or insurance. “This was an isolated incident, was a mistake and did not have anything to do with immigration status,” said Rite Aid public relations director Chris Savarese. “The store staff and regional teams have been retrained on our policy to not turn anyone away.”

A week after the Los Angeles incident, a Rite Aid in Orange County, California denied the vaccine to another woman who did not have a Social Security card or insurance, though she had brought her out-of-state ID and a letter from her employer.

At first, Araujo said, he was hesitant to post publicly about his mother’s experience because of the hateful comments he anticipated facing online. “But I think raising awareness is very, very important,” Araujo said in an interview with ProPublica. “If we would’ve just stayed quiet, honestly, nothing would have happened. Rite Aid probably would have continued rejecting people and LA County would’ve never brought this issue into a conversation.”

After Araujo and local media outlets publicized the incident, Los Angeles County officials spoke out and posted on social media to emphasize that proof of citizenship is not required to get a vaccine.

A COVID Vaccine Should Never Cost You Money — Ever. It’s the Law.

While the CDC has made it clear that vaccine providers should not charge patients anything, including administrative fees or copays, some patients have still received bills for the COVID-19 vaccine.

The day after Rosanne Dombek, 85, received her second shot at InterMed, a primary care practice in Maine, she opened her mail and found a bill. For “Covid-19 Pfizer Admin, 1st dose,” her charge was $71.01. “If your outstanding balance becomes 120 days past due, the balance will be transferred to the Thomas Agency for further collection action,” the bottom of the bill said. “It sounded rather final,” said Dombek, who is the mother of Lynn Dombek, ProPublica’s research editor. She immediately wrote out a check. “I was surprised to get the bill, but I’m old enough now that I don’t want any more battles.”

When asked about Dombek’s bill, InterMed spokesperson John Lamb first said that the $71 should have been billed to the patient’s insurance company, and that “the correspondence you referenced is likely a request for insurance information.” When shown a copy of Dombek’s bill, which did not include any such request, Lamb responded, “The statement should have included a notice to call us with her insurance information. We’re looking into why that was missing.” Yet InterMed’s website seemed to indicate that the bill was intentional. In its coronavirus FAQ section, the site said:

“The COVID vaccine will be provided to patients at no cost. However, there will be a vaccine administration fee charged to the patient.” When ProPublica questioned InterMed about this language, Lamb responded, “Good catch. It was confusing. We’ve corrected it to reflect the billing to the insurance provider.” The website was subsequently updated. Dombek did not end up mailing her check to InterMed. Some residents in New Mexico have also reported receiving bills after getting vaccinated. It’s unclear how the CDC or its parent agency, the Department of Health and Human Services, aims to prevent patients from being billed. A CDC spokesperson noted that individuals can call an HHS hotline to report any billing-related violations, but referred oversight questions to HHS. HHS didn’t respond to requests for comment.

Fear of potential bills has kept others from getting vaccinated to begin with. Nancy Largo of Bellport, New York, doesn’t have insurance, already carries about $7,000 in medical debt and has been out of work for almost two years because of a workplace injury. She knows the vaccine is supposed to be free, but she’s still worried. “What happens if they charge me?” Largo asked in Spanish.

Largo doesn’t speak English, and medical providers don’t always have Spanish-speaking staff, so she’s not confident that she’ll be able to ask questions about billing and other details once she gets to a vaccination site.

Though nearby pharmacies are offering the vaccine, Largo is limiting herself to finding a shot through one clinic that she knows treats people without insurance and has Spanish-speaking staff. So far, they haven’t had an appointment for her.

In Nearly Every State, Providers Are Required to Believe What You Say About Underlying Conditions.

Sara Waldecker was worried about how she could prove that she was a high-risk patient eligible for a COVID-19 shot. Michigan had just opened up vaccinations to anyone ages 16 and up with disabilities or medical conditions that qualified. Waldecker, 37, said that a childhood illness left her with lung scarring and asthma, but she wasn’t sure how to get hold of those medical records because “the primary doctor I saw, up to five years ago, has died.” After that, Waldecker switched hospital systems, and her old records didn’t transfer with her. Then Waldecker’s husband lost his job during the pandemic, leaving them without health insurance. She said she couldn’t afford to see a doctor and have tests run to get diagnosed again. She’d spent the entirety of the pandemic isolated, buffeted by conflicted emotions. “If I catch it, there’s an overwhelming chance I’m not going to make it, but I also feel guilt from keeping my kid from her favorite places,” she said. “She’s healthy, the rest of my family is healthy — I’m the weak link. I’m the one keeping them in isolation.” In fact, Waldecker didn’t need to prove anything. In Michigan, “individuals attest to any medical conditions upon registration,” according to Lynn Sutfin, public information officer for the state’s

Department of Health and Human Services. “They do not need to provide proof.” That information is not evident on the state health department’s website, nor is it clear on the website of the health department for Macomb County, where Waldecker lives.

ProPublica surveyed all 50 states and found that, among those currently providing vaccines to individuals with underlying health conditions, almost all only require a patient to self-attest that they meet the criteria, and do not require any documentation or proof. Florida is one exception. It limits eligibility to “persons determined to be extremely vulnerable by a physician” and provides a form for doctors to fill out.

In Delaware, health providers and hospital systems are the only places where patients with health conditions can get a vaccine. “Delaware health providers, including hospitals, have been advised to use their clinical judgement to vaccinate individuals 16-64 with underlying health conditions, as they will have access to the patient’s medical information,” state public health department spokesperson Robin Bryson wrote in an email. Even in states that only require an attestation of someone’s underlying condition, that information was hard to find on state websites. Many did not mention it at all, and ProPublica was only able to learn about it by contacting press offices.

Whatever a state says, however, specific vaccination sites may sometimes ignore official guidelines. When Ric Galvan, 20, went to the Alamodome stadium in San Antonio, Texas, for his shot on March 2, he recalled, he was questioned by a firefighter who was helping with intake: “He first sort of condescendingly asked, ‘How old are you, buddy?’ — likely because I’m young.” Galvan provided his ID and stated that he had chronic asthma. “He then asked if I had an inhaler or some sort of proof of having asthma, to which I said, ‘No, not with me.’ He then told me that the vaccine is only for ‘real asthmatics’ who ‘need their inhaler with them at all times.’”“As someone who has been under pulmonologist care since I was 4 years old, this really upset me,” Galvan said. He tried to push back, telling the firefighter that none of the confirmation emails said anything about medical proof, but the firefighter told him to leave the site. A full-time student who also works part time, Galvan added that he was frustrated because it had been so hard to get an appointment in the first place, and now he had to start over again.

“We must ensure individuals that have registered do in fact meet the criteria set by the state of 1A and 1B. This process entails verification of name, age, and if under 65, qualified pre-existing conditions,” replied Michelle Vigil, a spokesperson for the city of San Antonio. “Unfortunately we have seen instances where these conditions cannot be verified. In order to ensure that we are in compliance we have had to turn a very small number of people away.”

But Texas sites aren’t supposed to ask for proof of underlying medical conditions, according to Douglas Loveday, spokesperson for Texas’ health department. People seeking vaccinations “can self-disclose their qualifying medical condition,” he said. “They do not need to provide documents to prove that they qualify.”

Juany Torres, a community organizer and advocate in San Antonio, said she’s heard of several similar cases at the Alamodome.“Some undocoumented folks that showed up were questioned about their diabetes or their asthma, and they were turned away and lost their appointment,” Torres said. They had been diagnosed in their home country and didn’t have their medical records on hand, she said. None have health insurance or a primary care doctor in the U.S. “They lost the time they had taken off work, they were embarrassed, and I had to re-convince them that they were worthy to go and that they should get their shot,” she said. In Texas, at least, requests for medical documentation should no longer be an issue: On March 29, the state transitioned to allow everyone age 16 and older to sign up for a vaccine.

Yellow fever is a deadly virus. Transmitted via infected mosquitoes, symptoms can be so mild that people don’t even know they’re sick. But serious cases are nasty. The whites of the eyes turn yellow. The skin grows yellow and hemorrhages. The liver, heart, and kidneys fail. There is no medicine to treat or cure yellow fever. But there is a highly effective vaccine, which is why 40 countries in sub-Saharan Africa and South and Central America, where yellow fever is endemic, require travelers to prove they’ve received the yellow fever vaccine. To do so, they require an official document created by the World Health Organization. It’s called International Certificate of Vaccination or Prophylaxis—or, colloquially, the “yellow card.” 

Vaccine passports are hardly a novel concept. Countries around the globe, to curb the spread of deadly diseases, require foreign visitors to present certificates of vaccination. Many of our own states have vaccination requirements for kids to attend school.

But a technology implementation that will allow people to present a QR code on their smartphone to prove they’ve been vaccinated is something new. The past two months have witnessed a proliferation of plans by states, countries, companies, and international consortia to develop digital vaccine passports. Though the building blocks for digital vaccine passes have been around for a while, such a technology has never been deployed on such a large scale, and with such a big potential impact on people’s lives. This is what has some people concerned. Equity-minded folks are concerned about stratifying society between vaccine haves and have-nots. Privacy activists are worried about increased surveillance. Republican politicians are crying government overreach.

Every vaccine passport technologist I’ve interviewed has asked me not to call them vaccine passports. Drummond Reed is the chief trust officer at Evernym—the technology underlying the International Air Transport Association (IATA)’s TravelPass initiative. He prefers “vaccine pass” because it’s more accurate. “Passports are inherently discriminatory,” says Reed. They have age and citizenship requirements, “and that’s not consistent with being able to get a vaccination or a COVID test.”  Unlike vaccine passes, passports also require strong proof of identity and are issued only by governments.

Vaccine passes, whether digital or analog, are a tool that people can use to prove that they have been vaccinated or have received a recent negative COVID-19 test. The idea is that they will gain people access to certain things that have been off-limits during the pandemic, like attending concerts at Madison Square Garden, eating in a crowded restaurant, or going to a packed sports event. 

This week, New York rolled out its Excelsior Pass, a branded version of IBM’s Digital Health Pass. President Joe Biden’s official pandemic strategy includes a paragraph about how the State Department, Health and Human Services, and Homeland Security will assess the feasibility of “linking COVID-19 vaccination to International Certificates of Vaccination or Prophylaxis (ICVP) and producing electronic versions of ICVPs.”

Biden administration officials have said that they are in the process of coming up with the criteria for vaccine passes, but will leave the tech development to private companies and nonprofits. Andy Slavitt, a White House senior adviser for COVID response, specified at a March 29 briefing that “unlike other parts of the world, the government here is not viewing its role as the place to create a passport, nor a place to hold the data of citizens.”

Vaccine credentials already exist in the United States in the form of the paper card people receive once vaccinated. You may have seen friends and family posting photos of their cards on social media, which the FTC strongly recommended not doing because the personal information printed on them is like catnip for identity fraudsters. 

Brian Behlendorf, general manager for blockchain, health care, and identity at the Linux Foundation and an active coordinator of the Good Health Pass Collaborative, points out that the paper cards are less secure than a digital solution, and were never meant as official vaccine passes. “The point was to help people keep track of if they’ve been immunized, if the batch that they took was a bad batch,” he says. “It wasn’t intended to be a high security type of document.” 

Given the accessibility barriers inherent to smartphone apps—not everyone has a smartphone or reliable cell service—vaccine pass developers are being careful to offer analog alternatives. “There are paper-based options,” notes Kaliya Young, an identity tech expert and the ecosystems director of COVID Credentials Initiative, which is also part of Good Health Pass Collaborative. “There’s a way to express digital information on paper so you don’t have to have a digital wallet. That’s going to be a really critical part of the solution.”

Sean McDonald, the CEO of a company called FrontlineSMS, is skeptical that deploying a relatively untested tech solution is the right move. During the 2014 Ebola outbreak, McDonald partnered with religious leaders in West Africa—his SMS platform was used to send people messages about how to participate in traditional burial practices without getting infected. He recalls there was a lot of buzz around using cellphone location data to track people spreading Ebola, but that was largely just big data hype—woefully inept at tracking transmissions. “Generally speaking, if you’re inventing the solution at the time you learn about the problem, you’re a little bit late,” he says.

The vaccine-pass technology is complicated and the process jargony, but it’s important to understand the basics to ask the right questions and be informed. Here’s a brief glossary of terms:

1. Issuer: The entity that gives out the vaccine certificate. In the case of COVID-19, it will likely be a health care provider, testing site, or health department.
2. Verifier: The entity that needs to verify that someone has been vaccinated or has received a negative test. This might be an airline, restaurant, concert venue, or school.
3. Verifiable credential: The information—namely, that you have been vaccinated or had a negative test result—that needs to be verified. The verification process is essential because some people will try to forge or falsify this information. Throughout the pandemic there have been reports of people buying falsified negative COVID-19 tests in Zimbabwe or showing screenshots of old QR codes on contact-tracing apps in China. Some vaccine passes are being developed based on the verifiable credentials standard from W3C, one of bodies that codifies the international standards that govern the internet.
4. QR codes: A matrix of squares that encode information like a word, phrase, URL, or long string of numbers. Vaccine pass projects use QR codes because they’re easy to store and scan from a smartphone, and can contain a digital signature.
5. Digital signatures: An algorithm that confirms that information is authentic and hasn’t been corrupted. Digital signatures can be embedded in QR codes and verify data about a vaccine certificate, such as who signed it and when.
6. Blockchain: A method of storing information about a transaction in a decentralized database, also known as a distributed ledger. For vaccine passes, the blockchain also stores the tools needed to verify that whoever dispensed that vaccine (such as a hospital) was authorized to do so. This allows a ticket-taker at an arena to verify a vaccine certificate. Vaccine passes needn’t use blockchain technology but as far as I can tell most of the digital ones in development do. Documents that describe how transactions on different blockchain platforms are validated—known in blockchain world as a consensus protocol—are public documents. 

Countries with digital vaccine certificates in the works include Israel, China, Japan, United Arab Emirates, the Philippines, Denmark, Sweden, Iceland, the UK, Estonia, Australia, France, and Singapore. Other projects are more international in scope. The EU Commission hopes to launch a Digital Green Certificate that will allow travel between EU countries by summer. Airlines and various international consortia are in the process of developing passes that would work across borders and facilitate international travel. (These include the IATA travel pass, the CommonPass, American Airlines’ VeriFly, the ICC AOKpass, and IBM’s Digital Health Pass.) 

Elizabeth Renieris, a technology and human rights fellow at Harvard’s Carr Center for Human Rights Policy and former policy counsel for Evernym, points out that governing bodies like the EU Commission have never rolled out technology close to this before—no interoperable digital passports, ID cards, or driver’s licenses. “How can there be such an accelerated rollout for something that has never been done before for any other purpose?” Renieris asks. “To attempt this for the first time, and to do it at such high stakes with such potentially severe risks to very fundamental freedoms, just feels like a very rash move.” 

Problems with the earliest iterations of the vaccine passes are to be expected, Behlendorf says. He encourages consumer watchdog groups and public health authorities to ask hard questions about how these apps work, and report any concerns. His expectations for the initial rollout “would be low,” he says, but he expects the apps to improve and move toward open-source solutions. “This will be a process. My hope is that through public pressure, and through technologists working together, we’ll have the second wave of apps towards the end of this year.”

I called New York’s Excelsior Pass hotline for more information on how the Excelsior Pass will work. The customer-service agent who answered told me the EP isn’t really a vaccine passport: “It’s completely voluntary, not mandatory at all. It’s just more or less a convenient app.” 

Earlier this week, CDC director Dr. Rochelle Walensky went off-script during a news conference to issue an emotional warning: a fourth coronavirus surge could be coming. She described a “recurring feeling I have of impending doom,” saying that while there was  “so much to look forward to,” the country was entering a dangerous new phase. “I’m scared,” she said.

Meanwhile, the country has seen week-on-week vaccination records tumble, and officials predict that half of Americans will be fully protected within the next two months. Nearly 150 million doses have been administered so far.

So Americans find themselves confronting yet another precarious era in the war on COVID-19, in which hope and fear are colliding. There’s light at the end of the tunnel, but many questions remain. Can we vaccinate fast enough to combat the threat of dangerous new variants? What’s the deal with the AstraZeneca vaccine drama? Why is the United States populations getting vaccinated at a much faster rate than the rest of the world? When—if ever—can we ditch the masks?

We try to answer some of those questions on this week’s episode of the Mother Jones Podcast, with Dr. Peter Hotez, a vaccine scientist and the founding dean of the national school of tropical medicine at the Baylor College of Medicine in Texas. He’s been leading a team that uses older vaccine technology to create a COVID-19 vaccine that would be cheaper to make and distribute.

“By the summer I think we could potentially vaccinate ourselves out of the epidemic,” Hotez told Kiera Butler, our senior editor and public health reporter, during a taped livestream event last week. But that doesn’t mean we are out of the woods. Though coronavirus cases have dropped 80 percent from the latest surge, case numbers are at the same level that they were last summer and variants are spreading quickly. “We’re at a dangerous time right now,” he said.

What about the variants? The B.1.1.7 variant, which was first identified in the UK, is spreading quickly in the United States. The P1 and B.1.351 variants, first identified in Brazil and South Africa respectively, though not as prevalent in the United States right now, are still concerning because they’ve shown to be less susceptible to the vaccines. “Don’t be surprised if later on this year we all wind up getting another booster,” Hotez said.

Hotez speaks to both the hope and the fear of the moment. While he says that the United States population could vaccinate itself out of the pandemic by the summer, he’s concerned about the slowness with which vaccines are reaching the global population. Current estimates are showing that vaccinating 70 percent of the global population, which is what it will take to reach herd immunity, could take years. 

“I’m worried because we know what happens if we only vaccinate the United States, the UK, and western Europe. That’s not going to go well because this virus will continue to circulate, we’ll sow more and more variants, and it will be a humanitarian catastrophe,” Hotez said.

Butler’s interview with Hotez was first recorded for a Mother Jones livestream event on March 24, 2021.

As spring begins to take hold across the United States and vaccination rates continue to improve, it might be tempting to think that the coronavirus pandemic is over and some semblance of normal can return.

But officials are warning that cases are actually going back up, and things could get worse if we’re not careful. In fact, the United States is averaging roughly 57,000 new cases per day, a seven percent increase from the week before.

“I remain deeply concerned about this trajectory,” US Centers for Disease Control and Prevention Director Rochelle Walensky said this week. “We have seen cases and hospitalizations from historic declines, to stagnations, to increases. And we know form prior surges that if we don’t control things now, there is a real potential for the epidemic curve to soar again.”

More than 1,200 new deaths were reported on Friday, according to the New York Times, along with 75,2724 new cases. Since early March, the United States has averaged between 54,000 and 59,000 new cases per day, and some states are seeing major rises in case numbers. On Wednesday, the Michigan Health & Hospital Association reported that between March 1 and March 24, coronavirus hospitalizations increased by 633 percent for those aged 30 to 39, and 800 percent for those aged 40 to 49, the Detroit Free Press reported this week. Even with rising vaccine rates in the state, Dr. Nick Gilpin, the medical director of infection prevention and epidemiology for Beaumont Health, one of the large health systems in the state, said cases are “rising at a pretty alarming rate” likely due to COVID-19 variants and eased restrictions. 

“It’s people gathering more amongst one another, and it’s also the presence of these variants,” he said. “I know people are starting to go crazy. I know the weather is starting to get warm. And I know people want to get outside and some restrictions have been lifted. But as we start to see these cases rise, people in Michigan … need to consider that there’s still a possibility of infection out there.”

Officials in Ohio reported Friday the largest single-day increase in a month. Numbers in more than a dozen other states are also going up, CNBC reported last week.

The news comes as vaccination rates continue to rise. More than 48 million people have been fully vaccinated—nearly 15 percent of the US population—with total vaccinations coming in at more 2 million per day, according to NPR. President Joe Biden said Thursday that he was setting a new vaccination goal of 200 million doses administered by his 100th day in office, doubling the previous goal. 

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and one of the US government’s main voices on coronavirus protocols, told the Washington Post in a story posted this morning that he believes the United States is on track to meet Biden’s aim of limited backyard gatherings for the July 4th holiday, but backsliding could happen. “It depends on how well we do in maintaining public health measures and continuing the vaccine program,” he said. “It’s possible that vaccine hesitancy won’t allow us to get enough people vaccinated.”