Covid News: Germany Bans Most Travel From Britain Over Variant Fears

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Here’s what you need to know: In London this week.Credit…Tom Jamieson for The New York Times Germany is banning most travel from Britain starting on Sunday amid concerns about the spread of a coronavirus variant first discovered in India, the German authorities said on Friday. German citizens and residents will […]

In London this week.
Credit…Tom Jamieson for The New York Times

Germany is banning most travel from Britain starting on Sunday amid concerns about the spread of a coronavirus variant first discovered in India, the German authorities said on Friday.

German citizens and residents will still be allowed to enter the country from Britain but will be required to quarantine for two weeks upon arrival, Germany’s public health institution said as it classified Britain as an area of concern because of the variant.

The move came just days after Britain reopened its museums and cinemas and resumed allowing indoor service in pubs and restaurants. Many people in Britain have been looking forward to traveling abroad in the coming months, and Spain is set to welcome visitors arriving from Britain without a coronavirus test starting on Monday.

The spread in Britain of the variant first detected in India, known as B.1.617, could serve as an early warning for other European countries that have relaxed restrictions. This month, the World Health Organization declared the mutation a “variant of concern,” and although scientists’ knowledge about it remains limited, it is believed to be more transmissible than the virus’s initial form.

Brazil, India and South Africa are among the dozen or so other countries that Germany considers areas of concern because of variants. As of Thursday, Britain has reported 3,424 cases of the variant first discovered in India, according to government data, up from 1,313 cases the previous week.

Dozens of nations, including European countries and the United States, suspended travel from Britain or imposed strict restrictions earlier in the pandemic amid concerns about the spread of the highly contagious and deadly B.1.1.7 variant, which began surging in Britain in December and is now dominant in the United States.

In India, the B.1.617 variant has been blamed for a devastating second virus wave. But researchers outside of India say the limited data so far suggests instead that B.1.1.7 may be a more considerable factor.

The B.1.617 variant seems to be taking off outside India but its growth can be studied in countries like Britain with genetic sequencing, said Stacia Wyman, a senior genomics scientist at the University of California, Berkley and a member of the Innovative Genomics Institute.

“I’m of the camp where I think we need to monitor all the variants very carefully and be really vigilant, but not freak out about them and blow them out of proportion,” she said. “With sufficient sequencing, we’re able to monitor them and watch the trajectory much more carefully.”

The Office for National Statistics in the United Kingdom said on Friday that the percentage of people testing positive for the coronavirus in Britain had showed “early signs of a potential increase” in the week ending on May 15, although it said rates remained low compared with earlier this year.

The country’s inoculation campaign is continuing apace, with an increased focus on second doses in an effort to thwart the sort of spikes that led to restrictions imposed this year.

More than 37 million people, or 56 percent of the country’s population, have received a first dose of a Covid-19 vaccine in Britain. Yet most people under 30 have yet to receive a dose, and less than a third of the population has been fully vaccinated. Health Minister Matt Hancock said on Saturday that people over 32 could now book an appointment.

Prime Minister Boris Johnson has vowed to proceed with a plan to lift all restrictions by June 21, although scientists have warned that the spread of the B.1.617 variant could delay such plans. Most cases of the variant have been found in northwestern England, with some in London.

In Germany, the restrictions on travel from Britain come as outdoor service resumed on Friday in cafes, restaurants and beer gardens after months of closure. Chancellor Angela Merkel urged people to “treat these opportunities very responsibly.”

“The virus,” she said, “has not disappeared.”

United States › United StatesOn May 23 14-day change
New cases 14,144 –38%
New deaths 189 –15%

World › WorldOn May 23 14-day change
New cases 490,132 –26%
New deaths 9,751 –7%

U.S. vaccinations ›

Where states are reporting vaccines given

Prisoners received Covid-19 vaccine shots in April at the Bolivar County Correctional Facility in Cleveland, Miss.
Credit…Spencer Platt/Getty Images

Vaccinations in many American prisons, jails and detention centers are lagging far behind the United States as a whole, prompting public health officials to worry that these settings will remain fertile ground for frequent, fast-spreading coronavirus outbreaks for a long time to come.

Nationally, more than 61 percent of people ages 18 or older have received at least one dose of vaccine so far. But only about 40 percent of federal prison inmates, and half of those in the largest state prison systems, have done so. And in immigration detention centers, the figure is just 20 percent.

With the overall pace of vaccinations slowing in the United States — down to about 1.87 million doses a day on average, according to federal data — the Biden administration has been stepping up efforts to win over the hesitant and to reach people in underserved and vulnerable communities and those facing access issues.

Over the course of the pandemic, prison inmates have been more than three times as likely as other Americans to become infected with the virus, according to a New York Times database. The virus has killed prisoners at higher rates than the general population, the data shows, and at least 2,700 have died in custody.

No racial breakdown is available for coronavirus cases in prisons, but health officials say African-Americans are likely to be overrepresented, since they account for a much larger share of inmates (33 percent) than they do of the overall population (13 percent), and the pandemic has disproportionately hit Black Americans in general.

Black and Hispanic people across the United States have received a disproportionately smaller share of vaccinations to date, according to a New York Times analysis of state-reported race and ethnicity information, though some progress has been made.

High vaccination rates in another kind of high-risk setting, nursing homes, have greatly reduced the spread of the virus there. But unlike nursing home residents, prisoners were generally not a high priority for early vaccination. By April 19, the 50 states, the District of Columbia and Puerto Rico had expanded eligibility to all adults. Still, refusal rates in prisons have been high.

Many inmates say they mistrust both the vaccine and the prison authorities who try to persuade them to get inoculated. Beyond that, some prison vaccination efforts have been hampered by mistakes.

Prison officials in some states have tried offering inmates incentives to be vaccinated, including extra food — with varying degrees of success.

Jonathan Brooks, who is incarcerated at Wake Correctional Center in North Carolina, said incentives like free phone calls and approval priority for family visits were insulting.

“That’s something that we are required to have anyway — phone calls and receiving visits from our loved ones — so to actually recommend something like that to get us to take the vaccine, I feel like that’s really a slap in the face,” he said. Mr. Brooks said he did not intend to get the vaccine.

Prison guards have also tended to be skeptical about getting vaccinated. Colorado began offering correctional officers $500 bonuses to get inoculated.

A review of seven of the largest state prison systems found a wide range in vaccination rates. Pennsylvania has gotten at least one shot into 71 percent of inmates, while neighboring New York has managed just 35 percent. In California the figure is 68 percent; in Texas, 50 percent.

Michael Carvajal, director of the federal prison system, told the Senate Judiciary Committee in April that each of the system’s 126,000 inmates would have access to the vaccine by mid-May. But as of Thursday morning, only 40 percent of inmates and 50 percent of employees had been vaccinated.

Emily Wang, a professor at the Yale School of Medicine who studies prison health care, said it is often difficult to gauge prison vaccination rates with certainty because inmates are often transferred, and many state prison systems do not disclose vaccine rates at all.

“If the best estimates are 50 percent, I’ll bet it’s lower,” Dr. Wang said. “And we’re not close to the mark. There’s no question in my mind, this hasn’t gone well.”

Ann Hinga Klein and

People being vaccinated at the Coney Island/Stillwell Avenue subway station in Brooklyn last week.
Credit…James Estrin/The New York Times

When Covid-19 vaccines first became available, it was considered bad form or worse to travel to another city or state to get a shot. Florida, New York and other states banned the practice, limiting access to vaccines to their own residents and workers.

But now that vaccine supply is more abundant, many cities and states are making the shots available to all comers, even tourists. Next week, New York plans to open pop-up vaccination sites at seven airports in the state, including Kennedy International Airport and La Guardia Airport in New York City.

Offering the vaccine to travelers is an extension of the campaign to reach the unvaccinated that has been championed by the Biden administration and state and local officials. Gov. Andrew M. Cuomo of New York said the shots would be offered from Monday through Friday to people who were “traveling through or working at one of these airports or just happen to be passing through.”

New York City has set up sites at a number of places that are popular with tourists, including Times Square and the Bronx Zoo, as well as used buses and vans to bring vaccines into residential neighborhoods. Some visitors from other countries have gotten shots at pop-up sites set up at Grand Central Terminal and other transit hubs, according to the Metropolitan Transportation Authority, which runs the city’s subways.

Already, more than 700,000 out-of-towners have received at least one dose of their vaccine in New York City, according to the city’s Health Department. And Mayor Bill de Blasio has invited more, suggesting the abundance of doses in the city could help revive its stagnant tourist trade.

“This is a positive message to tourists: Come here. It’s safe. It’s a great place to be, and we’re going to take care of you,” Mr. de Blasio said this month while announcing plans to offer vaccinations at Brooklyn Bridge Park, the High Line and other gathering places. “We’re going to make sure you get vaccinated while you’re here with us.”

City and state agencies said they did not have statistics to show how effective offering vaccines might be as a lure to visitors. But Abbey Collins, a spokeswoman for the transportation authority, said the pop-up sites in the subways and at commuter railroad stations had been very successful.

Nearly 9,000 people have received Johnson & Johnson’s one-shot vaccine at those stations since May 12, Ms. Collins said. Part of the appeal, she admitted, was the complimentary seven-day MetroCard, a popular perk with short-term visitors.

“A lot of people come for the free MetroCard,” Ms. Collins said. “There’s also the ease and convenience of meeting people where they are.”

On Friday, one of the buses that were sent by the city to communities where vaccination rates were lagging was parked in Sunset Park, a lower-income Brooklyn neighborhood filled with immigrants. “People are lining up — it’s doing terrific,” said Patrick Gallahue, a spokesman for the city’s Health Department who was there. “The goal is to make it convenient as possible and to make it fun and to make it attractive to people.”

A teenager in San Antonio receiving the Pfizer vaccine this month.
Credit…Tamir Kalifa for The New York Times

The Centers for Disease Control and Prevention is looking into reports that a very small number of teenagers and young adults vaccinated against the coronavirus may have experienced heart problems, according to the agency’s vaccine safety group.

The group’s statement was sparse in details, saying only that there were “relatively few” cases and that they may be entirely unrelated to vaccination. The condition, called myocarditis, is an inflammation of the heart muscle, and can occur following certain infections.

The C.D.C.’s review of the reports is in the early stages, and the agency has yet to determine whether there is any evidence that the vaccines caused the heart condition. It has posted some guidance on its website for doctors and clinicians to be alert to unusual heart symptoms among young people who had just received their shots.

“It may simply be a coincidence that some people are developing myocarditis after vaccination,” said Dr. Celine Gounder, an infectious disease specialist at Bellevue Hospital Center in New York. “It’s more likely for something like that to happen by chance, because so many people are getting vaccinated right now.”

The cases seem to have occurred predominantly in adolescents and young adults about four days after their second dose of one of the mRNA vaccines, which are Moderna and Pfizer-BioNTech. And the cases were more common in males than in females.

“Most cases appear to be mild, and follow-up of cases is ongoing,” the vaccine safety group said. The C.D.C. strongly recommends Covid vaccines for Americans ages 12 and older.

Experts emphasized that the potentially rare side effect of myocarditis paled in comparison to the potential risks of Covid, including the persistent syndrome called “long Covid.” Acute Covid itself can cause myocarditis.

As of May 13, the coronavirus has infected more than 3.9 million children and sent more than 16,000 to hospitals, more than are hospitalized for flu in an average year, according to data collected by the A.A.P. About 300 children have died of Covid-19 in the United States, making it one of the top 10 causes of death in children since the pandemic began.

People protesting Pennsylvania’s stay-at-home order last year. Some state legislatures have tried to roll back the emergency powers that governors wielded during the coronavirus pandemic.
Credit…Matt Slocum/Associated Press

As the threat from the coronavirus pandemic grew in early 2020, so did many governors’ executive powers. Without a federal plan, it fell to the states to issue lockdown and stay-at-home orders, mandate masks, and close schools and businesses.

Nearly 14 months later, with states moving to reopen amid a drastic drop in new cases, legislators have been asking about the current need for restrictions, and just how much sweeping authority governors need to have during a public health emergency.

Voters in Pennsylvania this week became the first in the United States to help check an executive’s authority during an emergency period. The state’s Democratic governor, Tom Wolf, and its Republican-controlled legislature sparred over Mr. Wolf’s emergency actions, which included closing schools and many businesses, during the pandemic.

Two measures passed on Tuesday in Pennsylvania, both with about 54 percent approval. The state’s Constitution will be amended to end a governor’s emergency disaster declaration after 21 days. And lawmakers, with a simple majority, will be given the only authority to extend or end the emergency disaster declaration. The ballot questions had been pushed forward by Republican legislators.

At polling stations, many voters told Pennsylvania news outlets that they had been driven to vote in particular because of the ballot questions on executive power. Previously, a governor could issue a declaration for up to 90 days and extend it indefinitely and the legislature would need a two-thirds majority to stop a declaration. Mr. Wolf’s first 90-day virus emergency went into effect in March 2020, and his latest extension ends this week. But all of the remaining capacity restrictions on businesses and social gatherings in Pennsylvania end on May 31.

“We had a long period to see how the current system works, and there was some thought that we could do better,” Mr. Wolf said this week. “So I’m looking forward to working with the legislature to figure out how to make this work.”

In New Jersey, a Democratic-led legislature took the initial step this week to roll back dozens of Covid-related orders issued by Gov. Phil Murphy, also a Democrat. But the bill that was introduced also leaves the governor with expansive powers to apply new measures in an emergency. Mr. Murphy is one of two governors to keep an indoor mask mandate, even for vaccinated people; the other is Hawaii’s.

New executive orders related to the pandemic are still being announced. Gov. Greg Abbott of Texas, a Republican, said on Tuesday that counties, cities, public health authorities and local government officials in his state would be prohibited from requiring people to wear masks. His order came days after federal health officials announced new guidance that encouraged people who were fully vaccinated to forgo masks in most situations.

Democratic lawmakers in Connecticut, though, supported an extension this week of Gov. Ned Lamont’s expanded pandemic powers through mid-July. They were set to expire this week. Lawmakers argued that executive orders were still needed to manage the vaccine rollout and federal relief funds.

But perhaps no governor more than Andrew M. Cuomo, Democrat of New York, has faced a bigger rebuke in his use of emergency powers by a Democratic-controlled legislature. In February, the body curtailed Mr. Cuomo’s emergency powers, and in late April, it suspended some of his pandemic directives, including a rule that required New Yorkers to order food with their alcohol orders at bars and restaurants.

Mr. Cuomo also faces federal and state investigations, including one looking into his reporting of deaths at nursing homes during the pandemic.

A vaccination center in Karachi, Pakistan, this month. Critics say private sales in Pakistan and around the world make inoculations available only to the wealthy.
Credit…Asif Hassan/Agence France-Presse — Getty Images

In Pakistan, an inoculation push is making doses available to those who can pay for them. But most Pakistanis can’t afford them, and even those who can are being stymied by tight global supplies.

Access to coronavirus vaccines has thrown a stark light on global inequality. The United States and other rich countries have bought up most of the world’s vaccine supplies to protect their own people, leaving millions of doses stockpiled and in some places unused. Less developed countries are scrambling over what’s left, with some — like Pakistan — turning to private sales.

“The Pakistani example is a microcosm of what has gone wrong with the global response — where wealth alone has primarily shaped who gets access,” Zain Rizvi, an expert on medicine access at Public Citizen, a Washington, D.C., advocacy group, said in an email. “Ending the pandemic will require the global community to do much more than just that.”

Pakistan says the private program could make more free shots available to low-income people. By purchasing doses of the Russian-made Sputnik 5 vaccine, the country’s wealthy wouldn’t need to get the free doses, which are made by Sinopharm of China.

The need for vaccines in Pakistan is growing. The country of nearly 220 million people is reporting more than 2,500 new infections a day, but its low rate of testing suggests many more cases remain undetected.

For those who can afford the doses, frustration is growing. Junaid Jahangir, an Islamabad-based lawyer, said several of his friends got private inoculations. He registered with a private lab for Sputnik V but got a text message later saying that the vaccination drive was on hold.

“I am being denied a fair chance to fight this virus if I end up getting infected,” he said.

IN CASE YOU MISSED IT

Two people taking a selfie together in a field of flowers in Holland, Mich., this month.
Credit…Emily Elconin for The New York Times

After almost a year and a half of sickness, there is a chance that the coronavirus pandemic could be entering a permanent retreat in the United States. The country is adding fewer than 30,000 cases a day for the first time since June, and deaths are as low as they’ve been since July. Nearly everywhere, the outlook is improving.

More than 60 percent of American adults have received at least one vaccine shot, and though the pace has slowed, the share is still growing by about two percentage points per week.

“In the United States, there is now an excellent chance that the retreat is permanent,” David Leonhardt wrote in his Morning newsletter on Friday.

The share of coronavirus tests coming back positive has fallen below 3 percent for the first time since widespread testing began, and the number of hospitalized patients has fallen to the lowest point in 11 months, Dr. Eric Topol of the Scripps Research Translational Institute noted. For the first time since March 5 of last year, San Francisco General Hospital on Thursday had no Covid-19 patients — “a truly momentous day,” Dr. Vivek Jain, the hospital’s co-director of infection control, said on Twitter.

Michigan, the state that reported one of the largest surges in the spring, has rapidly improved. About 1,600 cases are being identified there each day, compared with about 7,800 cases a day in mid-April.

Important caveats remain: Covid-19 is still especially dangerous in communities with low vaccination rates, and it’s becoming clearer that getting vaccines into these communities is crucial in continuing to curb the virus.

Around the world, however, the situation is not as encouraging although it is slowly getting better. Most low- and middle-income countries are struggling because they lack access to vaccines. In Africa, only 1.4 percent of people have received a shot, according to Oxford University’s Our World in Data project, and the numbers are only modestly higher in much of Latin America, the Middle East and Southeast Asia. Even the European Union struggled until recently to ramp up vaccinations.

Here’s what else you may have missed:

The University of California, Davis, recreation center was turned into a Covid testing site for students and faculty in January.
Credit…Max Whittaker for The New York Times

For more than 400 colleges and universities, it’s being billed as the ticket to a normal year on campus: Require all students to be vaccinated for the coronavirus before they can matriculate next fall.

From just one university in March, to a dozen by the first week of April, the floodgates have now opened with at least 403 colleges announcing a mandatory vaccine.

Yet a look at the geographic spread of the universities reveals a stark, if unsurprising, divide: The overwhelming majority of the colleges that are requiring the immunization are in blue states.

Only 32 — 8 percent — are in states that voted for Donald Trump, according to a tracker created by The Chronicle of Higher Education. Seven of those were added Friday, when Indiana University and its satellite campuses became rare public universities in Republican-controlled states mandating vaccines.

With many colleges facing falling enrollments and financial pressure, the decision whether to require vaccinations can have huge consequences. Particularly in Republican-controlled states, college presidents are weighing a delicate equation part safety, part politics, part peer pressure and part economic self-interest.

On weekly conference calls with presidents of other universities, the subject has become a frequent topic of discussion, said Katie Conboy, the president of Saint Mary’s College, a private all-women college in Indiana.

“People are waiting for a tipping point. They’re not saying ‘We’re going to be out on the leading edge of this,’ but ‘We are watching and waiting and hoping it will make sense for us,’” Ms. Conboy said.

Palestinian children and their families took refuge on Wednesday at a school in Gaza City run by the United Nations, which has warned of a potential virus surge after nearly two weeks of fighting between Israel and Hamas militants.
Credit…Haitham Imad/EPA, via Shutterstock

Health officials and international aid groups are watching to see whether nearly two weeks of fighting between Israel and Hamas militants led to a wave of new coronavirus cases in Gaza.

The United Nations warned on Monday, at the start of the second week of fighting, of a potential surge in new cases as tens of thousands of Gazans took shelter in 50 U.N.-run schools. A cease-fire was declared on Friday.

“The schools were overcrowded and there was basically no social distancing in them,” said Dr. Majdi Dhair, director of preventive medicine for the Palestinian health ministry in Gaza. “If someone was sick in any one school, that person could have infected everyone around them.”

A majority of Gazans most likely hunkered down in their homes during the two weeks of fighting and had less contact than usual with others, which could ultimately temper the size of any new outbreak, Dr. Dhair said. It would take several days for the case data to show the extent of a possible spike.

The only laboratory in the Gaza Strip that processes coronavirus tests was damaged in an Israeli airstrike, but it reopened on Thursday. In the Rimal clinic in Gaza City, windows were replaced, rooms were cleaned and the machines, which were lightly damaged, were examined and approved for use, Dr. Dhair said.

The lab processed 547 tests on Thursday and Friday, of which 202 were positive.

Michael Lynk, the U.N. special rapporteur on Palestinian human rights, said preserving vaccine access was crucial in Gaza, where inoculations were temporarily halted by the fighting. Gaza remains highly vulnerable to an outbreak, with less than 4 percent of its population fully or partially vaccinated. That’s far below the 60 percent in Israel, one of the highest rates in the world.

“Israel is the occupying power in the West Bank and in Gaza, and it has very strict obligations,” Mr. Lynk said. He said the United Nations has reminded Israel of those obligations.

Getting vaccine supplies into the territory has been hard enough. Gaza lacks funds to buy the doses, and although the territory is supposed to get aid from Covax, the global vaccine sharing program has been slow to deliver them. Recently, the Chinese government said that it would donate doses to the U.N. agency that focuses on aid to Palestinian refugees.

“If there was a surge again, it would require a huge rapid infusion of international donors to find vaccines going into Gaza, and making sure you have enough trained health care staff to administer mass inoculation,” Mr. Lynk said.

Israeli bombs have damaged several hospitals and clinics, hindering an already crumbling health care system, and it is not clear how long it will take to repair them. Fresh water and sewage systems have also been damaged, which could lead to disease outbreaks.

After a surge in cases in April, which was attributed mostly to the highly transmissible coronavirus variant first identified in Britain, new cases in Gaza had recently fallen. As of Thursday, the territory of more than two million people reported 26 critical cases and 68 serious cases.

Waiting to be vaccinated in San Antonio this month. Some coronavirus patients and their families have been left mired in debt despite rules meant to protect them from exorbitant health care costs.
Credit…Tamir Kalifa for The New York Times

Americans with serious illnesses regularly face exorbitant and confusing bills after treatment, but things were supposed to be different for coronavirus patients.

Many large health plans wrote special rules, waiving co-payments and deductibles for coronavirus hospitalizations. When doctors and hospitals accepted bailout funds, Congress barred them from “balance billing” patients — the practice of seeking additional payment beyond what the insurer has paid.

Interviews with more than a dozen patients suggest those efforts have fallen short.

For 10 months, The New York Times has tracked the high costs of coronavirus testing and treatment through a crowdsourced database that includes more than 800 medical bills submitted by readers.

Those bills show that some hospitals are not complying with the ban on balance billing. Some are incorrectly coding visits, meaning the special coronavirus protections that insurers put in place are not applied. Others are going after debts of patients who died from the virus, pursuing estates that would otherwise go to family members.

The United States is estimated to have spent over $30 billion on coronavirus hospitalizations since the pandemic began, according to Chris Sloan, a principal at the health research firm Avalere. The average cost of each hospital stay is $23,489. Little research has been published on how much of that cost is billed to patients.

Some patients are postponing additional medical care for long-term side effects until they can resolve their existing debts. They are finding that long-haul coronavirus often requires visits to multiple specialists and many scans to resolve lingering symptoms, but they worry about piling up more debt.

A Covid patient being treated on Saturday outside a hospital in Kathmandu, Nepal, where wards are full. 
Credit…Narendra Shrestha/EPA, via Shutterstock

Nepal’s Parliament was dissolved on Saturday for the second time in five months, deepening a political crisis in the Himalayan nation as it struggles with a devastating Covid-19 outbreak.

President Bidya Devi Bhandari announced the move shortly after midnight, saying that new elections would be held in November. Prime Minister K.P. Sharma Oli and various opposition groups have been trying unsuccessfully for weeks to form a government.

Opposition politicians expressed surprise, apparently daunted by the prospect of planning for an election while the coronavirus is wreaking havoc. Nepal, an impoverished nation of 30 million that borders India, has been recording about 7,000 new infections per day, and because testing is limited, experts believe that is a significant undercount.

“We may not be able to organize big rallies because of Covid right now,” said Prakash Sharan Mahat, an opposition leader. “But these sorts of unconstitutional and undemocratic acts will be challenged at the court of law again, and we will politically campaign across the country.”

Nepal’s health infrastructure is so overwhelmed that people have been dying in hospital corridors and courtyards, and some hospitals have stopped admitting new patients. In total, about half a million coronavirus infections and 6,000 deaths have been reported.

“People are dying without getting oxygen and treatment at health facilities in these trying times, and this political Covid has just begun,” said Ayodhee Prasad Yadav, a former head of Nepal’s election commission.

NYU Langone Health, which received over $500 million in relief during the pandemic, recently said it was seeking to merge with Long Island Community Hospital, the last remaining independent hospital on Long Island.
Credit…Gabby Jones for The New York Times

Billions of dollars in Covid aid cushioned financial losses caused by the pandemic at some of the largest hospital chains in the United States. But those bailouts also helped to sustain the big chains’ spending sprees as they expanded even more by scooping up weakened competitors and doctors’ practices.

More consolidation by several major hospital systems enhanced their market prowess in many regions of the country, even as rural hospitals and underserved communities were overwhelmed with Covid-19 patients and struggled to stay afloat.

The buying spree is likely to prompt further debate and scrutiny of the Provider Relief Fund, a package of $178 billion in congressional aid that drew sharp criticism early on for allocating so much to the wealthiest hospital systems, and that had no limits on mergers and acquisitions.

The Biden administration is now weighing which hospitals and health providers will get the remaining $25 billion.

“It was not the intent to be a capital infusion to the largest and most financially stable providers to allow them to simply grow their slice of market share,” Representative Katie Porter, Democrat of California, said. She is calling for hearings and for the Federal Trade Commission to review whether the funds have been properly used for patient care and operations.

A lone person getting vaccinated in April in Elizabethton, Tenn., at a center that can accommodate 300 people a day. Several southern states are lagging in vaccinations.
Credit…Erin Schaff/The New York Times

Almost half of Americans have received at least one dose of a Covid-19 vaccine. But the U.S. vaccination story varies widely across regions, with New England surging ahead of the national average and much of the South lagging far behind.

In five of the six New England states, more than 60 percent of residents are at least partly vaccinated, according to data from the Centers for Disease Control and Prevention. It’s a different story in the South, where Mississippi, Alabama, Arkansas, Georgia, Louisiana and Tennessee have the country’s lowest rates of residents who have received at least one shot. The rates in those states are all below 40 percent, with Mississippi, at 33 percent, at the bottom of the list.

The White House and state governments, after relying on mass vaccination sites for months, are turning their focus to more targeted, smaller-scale efforts to vaccinate underserved, harder-to-reach communities.

“This next phase of the vaccination campaign was — will be driven, more than anything, by the people and organizations and communities who help to vaccinate their families, their friends and others in their neighborhoods,” Dr. Vivek Murthy, the surgeon general, said on Friday during a White House news conference. “It’s why we’ve been saying that addressing access, motivation and vaccine confidence requires an all-hands-on-deck approach.”

That strategy has been employed by Dr. John B. Waits, the chief executive of Cahaba Medical Care, which has 17 clinics in underserved communities in Alabama.

“Conversations with people you trust have always been important to us,” he said on Friday. “I’ve been on Facebook Live. I say: ‘Ask us the hard questions. Let’s talk.’ We pivot to the individual exam room, where they trust me to answer. We’re having success with that approach, but it’s not at the speed that the pandemic needs.”

The low rate in the South worries Thomas A. LaVeist, an expert on health equity and dean of the School of Public Health and Tropical Medicine at Tulane University in New Orleans.

“You have the carrot and stick,” he said. “I’m beginning to think that the stick is the more likely scenario.”

Dr. LaVeist said the incentive that would work fastest for adults would be mandates by employers, who are uniquely positioned to require large numbers of Americans who otherwise would not receive a vaccination to do so because their employment depends on it. The federal government has issued guidance that says employers can require workers to get a Covid-19 vaccine and bar them from the workplace if they refuse.

Dr. Murthy cited a Kaiser Family Foundation survey that found 28 percent of those who were employed said they would be more likely to get vaccinated if they were given time off to receive and recover from the vaccine. Another 20 percent said they would be more likely to get vaccinated if their shot was administered at their workplace. The survey looked at those who are unvaccinated but wanted to get a vaccine as soon as possible.

Dr. LaVeist and other experts, however, say the biggest hurdle among the vaccine hesitant is anxiety over possible side effects. “How was it possible to deploy the vaccine so quickly? If more people understand that, then more people will take the vaccine,” Dr. LaVeist said. “Corners were not cut.”

A recent New York Times report from Greene County, a rural area in northeastern Tennessee, revealed the most common reason for vaccine apprehension was fear that the vaccine was developed in haste and that long-term side effects were unknown. These decisions are also entangled in a web of views about autonomy, science and authority, as well as a powerful regional and somewhat romanticized self-image: We don’t like outsiders messing in our business.

Vaccine hesitancy in any U.S. region poses a threat to all Americans, experts warn, because the longer it takes to vaccinate people, the more time that the virus has to spread, mutate and possibly gain the ability to evade vaccines.

“My big concern is that there is going to be a variant that’s going to outsmart the vaccine,” Dr. LaVeist said. “Then we’ll have a new problem. We’ll have to revaccinate.”

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