Six on History: the 'Rona
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"By early July 2021, nearly two-thirds of all U.S. residents 12 years and older had received at least one dose of a COVID-19 vaccine; 55% were fully vaccinated. But uptake varies drastically by region – and it is lower on average among non-white people.
Many blame the relatively lower vaccination rates in communities of color on “vaccine hesitancy.” But this label overlooks persistent barriers to access and lumps together the varied reasons people have for refraining from vaccination. It also places all the responsibility for getting vaccinated on individuals. Ultimately, homogenizing peoples’ reasons for not getting vaccinated diverts attention away from social factors that research shows play a critical role in health status and outcomes.
As medical anthropologists, we take a more nuanced view. Working together as lead site investigators for CommuniVax, a national initiative to improve vaccine equity, we and our teams in Alabama, California and Idaho, along with CommuniVax teams elsewhere in the nation, have documented a variety of stances toward vaccination that simply can’t be cast as “hesitant.”
Limited access hampers vaccination ratesPeople of color have long suffered an array of health inequities. Accordingly, due to a combination of factors, these communities have experienced higher hospitalization due to COVID-19, higher disease severity upon admission, higher chances for being placed on breathing support and progression to the intensive care unit, and higher rates of death.
CommuniVax data, including some 200 in-depth interviews within such communities, confirm that overall, those who have directly experienced this kind of COVID-19-related trauma, are not hesitant. They dearly want vaccinations. For example, in San Diego’s heavily Latino and very hard-hit “South Region,” COVID-19 vaccine uptake is remarkably high – about 84% as of July 6, 2021.
However, vaccine uptake is far from universal in these communities. This is in part due to access issues that go beyond the well documented challenges of transportation, internet access and skills gaps, and a lack of information on how to get vaccinated. For example, some CommuniVax participants had heard of non-resident white people usurping doses that were meant for communities of color. African American participants, in particular, reported feeling that the Johnson & Johnson vaccines promoted in their communities were the least safe and effective.
Our participant testimony shows that many unvaccinated people are not “vaccine hesitant” but rather “vaccine impeded.” And exclusion can happen not just in a physical sense; providers’ attitudes towards vaccines matter too.
For instance, Donna, a health care worker in Idaho, said, “I chose not to get it because if I were to get sick, I think I would recover mostly or more rapidly.” This kind of attitude by health care providers can have downstream effects. For example, Donna may not encourage vaccination when on duty or to people she knows; some, just observing her choices, may follow suit. Here, what appears as a community’s hesitancy to vaccinate is instead a reflection of vaccine hesitancy within its health care system.
More directly impeded are community members who, like Angela in Idaho, skipped vaccination because she couldn’t risk having a negative reaction that might require intervention. Although a trip to the doctor is a highly unlikely outcome after a vaccine, it remains a concern for some. “My insurance doesn’t cover as much as it possibly, you know, should,” she noted. And we have encountered many reports of undocumented individuals who fear deportation although, according to current laws, immigration status should not be questioned in relation to the vaccine.
Christina, in San Diego, illustrates another type of practical barrier. She cannot get vaccinated, she said, because she has no one to care for her babies should she fall ill with side effects. Her husband, similarly, can’t take time off from his job – “It doesn’t work that way.” Likewise, Carlos – who made sure that his centenarian father got vaccinated – says he can’t take the vaccine himself due to his dad’s deep dementia: “If I took my vaccine and I got sick, he’d be screwed.”
Indifference, resilience and ambivalenceAnother segment of unvaccinated people obscured by the “hesitant” label are the “vaccine indifferent.” For various reasons, they remain relatively untouched by the pandemic: COVID-19 just isn’t on their radar. This might include people who are self-employed or working under the table, people living in rural and remote places, and those whose children are not in the public school system.
Such people thus are not consistently connected to COVID-19-related information. This is particularly true if they forego social or news media and socialize with others who do the same, and if there are significant language barriers.
We also learned that, among some of our participants, the initial messaging about prioritizing high-risk groups backfired, leaving some under 65 and in relatively good health with the impression it wasn’t necessary for them to get the vaccine. Without incentives – travel plans, being accepted to a college or having an employer that mandates vaccination – inertia carries the day.
The indifferent are not against vaccination. Rather, “if it ain’t broke, don’t fix it” and “you do you” tend to typify their views. As Jose from Idaho reported, “I’m not worried because I’ve always taken care of myself.”
We also saw a modified form of indifference in those who believed that the protective steps they already were taking would be enough to keep them COVID-19-free. A janitor said, “I am an essential worker… So from the beginning we took … all the precautions … face masks, taking [social] distance [and using] natural medicines and vitamins for the immune system.” He had, indeed, so far avoided contracting COVID-19.
The view of vaccines as not immediately necessary is magnified among some Latino people by the cultural value placed on the need to endure – “aguantar” in Spanish — to bear up, push through and avoid complaining about daily struggles. This perspective can be seen in many immigrant or impoverished populations, where getting sick or injured can be a precursor to household ruin through job loss and exorbitant, unpayable medical bills.
Yet another dynamic we learned of is what we term “vaccine ambivalence.” Some participants who view COVID-19 as a significant health threat believe the vaccine poses an equivalent risk. We saw this particularly among African Americans in Alabama – not necessarily surprising given that the health care system has not always had these communities’ best interests at heart. The perceived conundrum leaves people stuck on the fence. Given the legacy of unequal treatment in communities of color, when balancing the “known” of COVID-19 against the unknown of vaccination, their inaction may seem reasonable – especially when coupled with mask-wearing and social distancing.
Attending to blind spotsAt this point in the pandemic, those with the means and will to get vaccinated have done so. Providing viable counternarratives to misinformation can help bring more people on board. But continuing to focus solely on individual mistrustfulness toward vaccines or so-called hesitancy obscures the other complex reasons people have for being wary of the system and bypassing vaccination.
Moreover, an overly narrow focus on the vaccine leaves a lot outside the frame. A wider view reveals that the problems leading to inequitable vaccination coverage are the same structural problems that have, historically, prevented people of color from having a fair shot at good health and economic outcomes to begin with – problems that even a 100% vaccination rate cannot resolve."
"SAN FRANCISCO — The article that appeared online on Feb. 9 began with a seemingly innocuous question about the legal definition of vaccines. Then over its next 3,400 words, it declared coronavirus vaccines were “a medical fraud” and said the injections did not prevent infections, provide immunity or stop transmission of the disease.
Instead, the article claimed, the shots “alter your genetic coding, turning you into a viral protein factory that has no off-switch.”
Its assertions were easily disprovable. No matter. Over the next few hours, the article was translated from English into Spanish and Polish. It appeared on dozens of blogs and was picked up by anti-vaccination activists, who repeated the false claims online. The article also made its way to Facebook, where it reached 400,000 people, according to data from CrowdTangle, a Facebook-owned tool.
The entire effort traced back to one person: Joseph Mercola.
Dr. Mercola, 67, an osteopathic physician in Cape Coral, Fla., has long been a subject of criticism and government regulatory actions for his promotion of unproven or unapproved treatments. But most recently, he has become the chief spreader of coronavirus misinformation online, according to researchers.
An internet-savvy entrepreneur who employs dozens, Dr. Mercola has published over 600 articles on Facebook that cast doubt on Covid-19 vaccines since the pandemic began, reaching a far larger audience than other vaccine skeptics, an analysis by The New York Times found. His claims have been widely echoed on Twitter, Instagram and YouTube.
The activity has earned Dr. Mercola, a natural health proponent with an Everyman demeanor, the dubious distinction of the top spot in the “Disinformation Dozen,” a list of 12 people responsible for sharing 65 percent of all anti-vaccine messaging on social media, said the nonprofit Center for Countering Digital Hate. Others on the list include Robert F. Kennedy Jr., a longtime anti-vaccine activist,
and Erin Elizabeth, the founder of the website Health Nut News, who is also Dr. Mercola’s girlfriend. ... "The Most Influential Spreader of Coronavirus Misinformation Online
Researchers and regulators say Joseph Mercola, an osteopathic physician, creates and profits from misleading cla...
Many universities, including the University of California, are requiring vaccination for all students, staff and faculty returning to campus. Many employers, public and private, are doing so as well. These policies are essential to protect public health. The virulent Delta variant of the coronavirus has made it imperative to ensure vaccination of as many people as possible.
Laws that require vaccination are the epitome of a neutral law of general applicability: a requirement that applies to everyone and that was not motivated by a desire to interfere with religion. Even if this were not so, the government can infringe on religious freedom if its action is necessary to achieve a compelling interest.
Stopping the spread of a deadly communicable disease is obviously a compelling interest and vaccinations are the best way to reach that goal. No one, in practicing his or her religion, has a constitutional right to endanger others.
Indeed, a number of states, before COVID-19, created mandates for children to be vaccinated against other communicable diseases without making exemptions for religious beliefs. Without exception, the lower courts have upheld these mandates as constitutional.
Nor do federal employment discrimination laws require a religious exception for employees. In the 1977 case Trans World Airlines vs. Hardison, the Supreme Court said that employers do not have to bear more than a “de minimus” cost in accommodating employees’ religious beliefs. Vaccine exemptions could impose a significant cost on employers in terms of illness and therefore clearly are not required.
Religious exemptions, like in the University of California policy, are for those with “sincerely held religious beliefs.” But how can this possibly be determined?
The Supreme Court has said that religious beliefs are personal and it does not matter whether they are in accord with the teachings and dictates of a particular faith. Under this broad principle, any person could get a vaccination exemption merely by stating that he or she has a religious objection against it.
Such an easy opt-out could make the mandate illusory. That is why the only way to have a meaningful vaccination requirement is to apply it to everyone — except those for whom vaccination is not medically advisable.
As people return to the workplace and to campuses the spread of COVID-19 remains a great danger, especially with the highly transmissible Delta variant circulating. The unvaccinated not only endanger themselves and other unvaccinated people, but also those who cannot get the vaccine for medical reasons. And now, there are growing reports of breakthrough infections of fully vaccinated individuals.
Universities and employers have the legal right to make sure that everyone is vaccinated. And they have the moral duty to protect health and lives."
Erwin Chemerinsky is dean of the UC Berkeley School of Law and a contributing writer to Opinion. He is the author of a forthcoming book, “Presumed Guilty: How the Supreme Court Empowered the Police and Subverted Civil Rights.”
"Fox News host Tucker Carlson suggested that he should be criminally investigated. Republican members of Congress introduced a “Fire Fauci Act” to remove his salary.
Now White House medical adviser Anthony S. Fauci — a polarizing figure in the U.S. response to the coronavirus — is also part of a rising GOP star’s political branding.
“Don’t Fauci My Florida,” read drink koozies and T-shirts that Florida Gov. Ron DeSantis’s campaign team rolled out just as his state sees some of the highest coronavirus hospitalizations, new infections and deaths per capita in the country. It’s the latest example of Republicans running on their opposition to virus-fueled shutdowns and mask mandates. A pandemic hero to some and villain to others, Fauci has become a high-profile target.
While discussing the Florida budget this summer, DeSantis said his state’s rosy financial outlook would not have been possible “if we had followed Fauci.”
“Instead we followed freedom,” he said.
The campaign team did not respond to The Washington Post’s questions Tuesday, and Fauci did not respond to a request for comment.
“When you’re dealing with community spread, and you have the kind of congregate setting where people get together, particularly without masks, you’re really asking for trouble,” Fauci said at the time on ABC’s “Good Morning America.” “Now’s the time actually to double down a bit, and I don’t mean close.”
DeSantis avoided statewide mask requirements even as leaders across the political spectrum embraced them amid growing evidence of their effectiveness. This spring, he suspended all virus-based local rules for businesses and individuals.
With the new merchandise, DeSantis is trying to cash in on a growing conservative backlash toward Fauci, a longtime government scientist who has advised seven presidents and directs the National Institute of Allergy and Infectious Diseases.
Throughout the pandemic, Fauci has drawn ire from the right for advocating restrictions and changing stances on whether the general public should wear masks. Fauci says he and other public health leaders flipped positions as they learned more about the effectiveness of face coverings and after initially fearing that the public would snap up masks needed for health workers.
Fauci has called criticisms from high-profile Republicans “bizarre.”
“I’ve become sort of, for some reason or another, a symbol of anything they don’t like” related to anything “contrary to them or outside of their own realm,” he said this spring.
About 47 percent of Floridians are fully vaccinated, and the state is projected to reach 70 percent vaccination — the Biden administration’s original nationwide goal for July 4 — in late August, according to a Post analysis. Most covid-19 deaths are occurring among the unvaccinated.
To critics, DeSantis spurned medical experts in a public health crisis that overwhelmed hospitals and has led to nearly 39,000 deaths in his state. But others have cheered DeSantis for prioritizing the economy.
"Tiffany Nazaire felt her first Covid symptoms last October and was diagnosed—along with many of her colleagues at the hospital where she worked—later that month. In the nine months that have passed since then, shortness of breath has landed the 38-year-old in the emergency room multiple times; persistent brain fog, memory loss, and fatigue have made her unable to return to work as a nurse in the Baltimore area.
Nazaire soon found doctors were slow to acknowledge her ongoing symptoms. Emergency room physicians dismissed her shortness of breath as panic, she said, sending her home with a prescription for anti-anxiety medication. When, in December, she visited the University of Maryland Comprehensive Care Clinic, she says the attending nurse did not take her long-haul symptoms seriously. She was told that because she hadn’t been hospitalized, other than her brief emergency room visit, her symptoms were too mild for her to be admitted to their clinic for long-haul patients. In a medical chart Nazaire shared with The New Republic, there is no documented mention of her post-infection symptoms, though they were the reason for her visit. (Contacted by The New Republic, University of Maryland Upper Chesapeake Health would not comment on the specifics of an individual patient’s care or recovery and did not provide eligibility criteria for receiving long-haul Covid treatment at its medical centers.)
Nazaire reached out to other clinics but either didn’t hear back or found there were state residency requirements that prevented her from enrolling. “There were so many roadblocks to care,” Nazaire told me. “That was one of the most depressing things about it.”
Nazaire’s challenges are not unique. Even as the worst of the pandemic subsides in much of the United States, a growing body of research points to an evolving, long-term crisis: Around a quarter of Americans who contracted Covid-19 face enduring symptoms that, for many, keep them out of work and struggling to cope with mounting medical bills. And although data is just starting to come in, experts say the “long Covid” crisis will mirror the pandemic itself, creating a “tsunami of disability” that will take a disproportionate toll on low-income people of color.
It’s become a common trope that the pandemic has exposed long-standing inequities in the U.S. health care system, but as the country begins to reckon with the scope of long Covid, there’s little indication it’s learning from past mistakes. Instead, Americans struggling with post-Covid symptoms face a highly unequal health care landscape, with the most vulnerable populations navigating labyrinthian barriers to treatment. For many, persistent and devastating symptoms have made it difficult to return to work—even as medical bills pile up. With many pandemic-era assistance programs set to expire by the end of the summer, this growing population of Covid long-haulers faces an especially uncertain future.
“All estimates indicate that low-income communities of color, who were disproportionately hit by Covid, will be disproportionately hit by long Covid,” said Sabrina Assoumou, an infectious diseases physician at Boston Medical Center and an assistant professor of medicine at Boston University School of Medicine. “And because some of the hardest-hit communities are in areas with a lot of disinvestment and limited access to health care, one of the biggest barriers will be finding someone to diagnose you and make sure you get the care you need.”
Indeed, access to the emerging long-Covid health care landscape—defined in large part by specialized, multidisciplinary clinics—is hardly straightforward. Clinics are overwhelmingly concentrated at large medical centers and beset by extensive waitlists, insurance constraints, and strict eligibility requirements. Until recently, most clinics required that patients present proof of a positive Covid test—a roadblock for individuals who got sick early in the pandemic, when testing was limited, especially in underserved communities. (A study from earlier this year indicated that 20 percent of U.S. counties lack a single test site, primarily in low-income rural and urban areas.)
And although testing became more widely available as the pandemic escalated, the difficulties some patients faced early on have followed them as their initial Covid infection has settled into a long-term illness. Chimére Smith, a former middle-school teacher in Baltimore, first felt Covid symptoms in March 2020, when the Centers for Disease Control and Prevention recommended using limited testing resources on patients who were hospitalized, had preexisting conditions, or had traveled to international hotspots.
“My doctor said, You don’t have a fever, you don’t have Covid,” Chimére told me. Instead, her doctor suggested she had a sinus infection. But Smith’s symptoms only worsened, from migraines and brain fog to, a month after she first felt sick, losing vision in her left eye. Last August, she says she sought care at Johns Hopkins’s long-Covid clinic but was told that absent a positive Covid test, she couldn’t be treated. Attending physicians noted on Smith’s medical documents, reviewed by The New Republic, that she was experiencing anxiety, and recommended psychiatric treatment. A physician with the Hopkins long-Covid clinic—where the waiting list is currently seven to nine months—told The New Republic that he does not require patients to present a positive Covid test for treatment, noting that he will see anyone who continues to experience chronic fatigue, elevated heart rate, or “disabling symptoms” more than three months after a Covid infection. But other clinics contacted by The New Republic said they continue to require a positive Covid test to receive care for long-haul symptoms. According to a National Institutes of Health study released last month, an estimated 17 million cases had gone undiagnosed by mid-July 2020. For those who face persistent symptoms but whose initial infections went undiagnosed—overwhelmingly those in low-income urban and rural communities, as well as undocumented people who avoided Covid tests due to immigration status concerns—a positive test requirement poses a significant barrier to treatment
“For a race of people who historically don’t like to go to the doctor because we’re not treated well,” said Smith, who is Black, “adding pieces to the puzzle isn’t going to encourage us to seek care.”
Long-Covid clinics are relatively new and continue to evolve with growing research on the illness. But so far, they’re concentrated at major medical centers—and out of reach to people in rural settings or areas otherwise cut off from transportation, said Ada Stewart, president of the American Academy of Family Physicians and a family physician with Cooperative Health in Columbia, South Carolina. “Once again, we’re missing the people in rural areas, the people I’m seeing every day,” she said.
The crisis for America’s rural hospitals is getting a lot worse.
Even as more hospitals launch clinics to serve long-haul patients, some states—North Dakota, South Dakota, Nebraska, West Virginia, Mississippi, Vermont, Alaska, and Maine—don’t have a single one.
Stewart points to additional factors driving disparities in access to long-Covid care: access not only to insurance but to a primary care physician who knows a patient’s medical history and, critically, can refer them to specialists for the litany of long-haul symptoms they might face. People of color—especially Black Americans—are significantly less likely than white Americans to see a primary care or family medicine doctor.
And nonprofit community health centers, where many low-income and underinsured Americans have long sought care, are emerging from the pandemic weaker than ever.“As a primary care physician, I take care of the total person, and we need to do everything we can to improve access to that type of care,” Stewart, who works at a community health center, said.
Carina Marquez, an assistant professor of medicine at the University of California, San Francisco, School of Medicine, has focused on increasing representation of nonwhite patients in research on long Covid. “For the most part, research cohorts have not reflected the ethnic and racial makeup of Covid, and undersamples Black and Latino patients, in particular,” she said.
That in part stems from who’s able even to enter clinical settings. “The first step is just getting in the door, and many patients don’t have a primary care doctor or don’t have insurance,” said Marquez. Without those resources, “you may not even enter the door. That’s one of the biggest issues we’re seeing all over the United States.”
Abha Agrawal, chief medical officer at Humboldt Park Health, a community health center on the west side of Chicago, launched a long-Covid clinic when she realized that the only long-haul treatment centers were at Northwestern and the University of Chicago. “These academic research centers have a very different mission, a different goal in the health care ecosystem,” she said. “They have a valuable role to play in advancing science. But clinics like ours have an invaluable role to play in making sure people can access care regardless of how they look, how they talk, or whether they have insurance or a positive Covid test.”
The many unknowns around long Covid exacerbate long-standing disparities in health care access. It wasn’t until mid-June that the CDC issued official guidance on treating “post-Covid conditions,” well over a year after advocates began sounding alarm bells over the scope of the growing crisis—and turning to online communities, such as Survivor Corps and Body Politic, for support. And while the CDC proposed a diagnostic code for long-haul symptoms—which patients can use to bill insurance for related treatment—one has not yet become available.
Diana Berrent, who founded Survivor Corps, worries that the slow response to an escalating crisis will have repercussions down the line, as the long-term effects of post-Covid symptoms continue to play out. Without a billable insurance code, she said, “there will be no way to track people longitudinally, to see who followed up later for long Covid. There needs to be a major effort, and soon, because the data will be lost.”
For long-haul survivors, struggle accessing care has fueled financial hardship. While dealing with her symptoms, Nazaire—who, by April, was finally admitted to Johns Hopkins’s long-Covid clinic—received worker’s compensation and “was able to make things work” financially. But when, after four months, she told her employer she wasn’t ready to go back, they terminated her job. She requested to work remotely, on her doctor’s suggestion, but her employer rejected the proposal. (She is currently taking legal action against her employer.)
And Smith has yet to return to her job teaching. “People ask me, am I going to go back to work? And I say, how? How can I work? I have memory loss, joint pain, back pain, brain fog I never had before I was sick.”
Even patients who were well placed to access care have still struggled to receive treatment and, months into their symptoms, are bearing the financial brunt. Davida Wynn, who was a nurse leader at an Atlanta-area hospital prior to contracting Covid-19, said she spent six months reporting symptoms to her primary care physician before she received referrals to specialists.
“That was the most painstaking part, getting the ball rolling for referrals,” she said, adding that she drew on information she learned from long-Covid support groups on Facebook to advocate for further care. Wynn has yet to return to work and has been receiving 60 percent of her salary in disability benefits. Her employer denied a recent request to extend disability, on the grounds that her ongoing symptoms stem from “behavioral health conditions”—depression and post-traumatic stress disorder. Wynn refutes this characterization of her illness, arguing that she still uses a walker to get around; she regularly paused during our conversation, to catch her breath.
Financially, she’s managed to stay “just above drowning level” but worries that won’t last; she’s considering selling her home, which she purchased in 2016. “To go from 38 and fully functioning,” she said, “to 39 and needing assistance for basic tasks, and unable to work, that takes a toll on you.”
