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late-life care for the chronically sick is not only expensive but also, much too often, ineffective and inhumane. For years, the system seemed impervious to change.

Thanks to modern treatment, people commonly live into their 70s and 80s and even 90s, many of them with multiple chronic ailments.

five or more chronic conditions account for less than a fourth of Medicare’s beneficiaries but more than two-thirds of its spending—and they are the fastest-growing segment of the Medicare population. What to do with this burgeoning population of the frail elderly?

“On average, Medicare spends $20,870 per beneficiary who dies while in the hospital.”

Home-based primary care comes in many varieties, but they share a treatment model and a business model. The treatment model begins from the counterintuitive premise that health care should not always be medical care.

by keeping patients out of the hospital whenever possible, saves Medicare upwards of $2,000 a month on each patient, maybe more

program collects whatever payment it can from Medicare and private insurance, it operates at a loss, and is run as a community service and a form of R&D.

Under the new health-care law, Medicare has begun using its financial clout to penalize hospitals that frequently readmit patients. Suddenly, hospitals are not so eager to see Grandma return for the third, fourth, or fifth time.

home-based model of primary care will be a challenge.

That would be like spiritual suicide right now,” he told me, “because there is so much going on. I’m more hopeful all the time. We’ve rolled the rock all the way to the top of the hill, and now we have to run to keep up as it rolls down the other side.”

"This is a senior citizen for whom English is not her first language. She doesn't have the resources to fight this,"

Nonetheless, that slight location change allowed the hospital system to bill what's called a "facility fee," laid out on Lee's bill as "operating room services."

comes without warning, as hospitals are not required to inform patients of it ahead of time.

But she's worried her mom will delay getting the shots now, putting up with the pain longer, as she knows they are more expensive.

as more private practices have been bought by hospitals and facility fees are tacked on to their charges.

Ohio, where Lee lives, is considering legislation that would prohibit facility fees for telehealth services.

it's difficult to fight powerful hospital lobbyists in a pandemic political climate, where hospitals are considered heroic.

"Even if it was a lot of money for services properly rendered, then of course she would pay it. But that's not the case here."

"Facility fees are designed by hospitals in particular to grab more revenue from the weakest party in health care: namely, the individual patient,"

Ask outright if there will be a facility fee — and how much — even if there has not been one before.

Mr. Trachtenberg understood the centrality of the university as a physical place. New structures were a visceral sign of progress. They told visitors, donors and civic leaders that the institution was, like beams and scaffolding rising from the earth, ascending. He added new programs, recruited more students, and followed the dictate of constant expansion.

the American research university had evolved into a complicated and somewhat peculiar organization. It was built to be all things to all people: to teach undergraduates, produce knowledge, socialize young men and women, train workers for jobs, anchor local economies, even put on weekend sports events. And excellence was defined by similarity to old, elite institutions. Universities were judged by the quality of their scholars, the size of their endowments, the beauty of their buildings and the test scores of their incoming students.

John Silber embarked on a huge building campaign while bringing luminaries like Saul Bellow and Elie Wiesel on board to teach and lend their prestige to the B.U. name, creating a bigger, more famous and much more costly institution. He had helped write a game plan for the aspiring college president.

GWU is, for all intents and purposes, a for-profit organization. Best example: study abroad. Their top program, a partnering with Sciences Po, costs each student (30 of them, on a program with 'prestige' status?) a full semester's tuition. It costs GW, according to Sciences Po website, €1000. A neat $20,000 profit per student (who is in digging her/himself deeper and deeper in debt.) Moreover, the school takes a $500 admin fee for the study abroad application! With no guarantee that all credits transfer. Students often lose a partial semester, GW profits again. Nor does GW offer help with an antiquated, one-shot/no transfers, tricky registration process. It's tough luck in gay Paris.Just one of many examples. Dorms with extreme mold, off-campus housing impossible for freshmen and sophomores. Required meal plan: Chick-o-Filet etc. Classes with over 300 students (required).This is not Harvard, but costs same.Emotional problems? Counselors too few. Suicides continue and are not appropriately addressed. Caring environment? Extension so and so, please hold.It's an impressive campus, I'm an alum. If you apply, make sure the DC experience is worth the price: good are internships, a few colleges like Elliot School, post-grad.GWU uses undergrad $$ directly for building projects, like the medical center to which students have NO access. (Student health facility is underfunded, outsourced.)Outstanding professors still make a difference. But is that enough?

Mr. Trachtenberg, however, understood something crucial about the modern university. It had come to inhabit a market for luxury goods. People don’t buy Gucci bags merely for their beauty and functionality. They buy them because other people will know they can afford the price of purchase. The great virtue of a luxury good, from the manufacturer’s standpoint, isn’t just that people will pay extra money for the feeling associated with a name brand. It’s that the high price is, in and of itself, a crucial part of what people are buying.

Mr. Trachtenberg convinced people that George Washington was worth a lot more money by charging a lot more money. Unlike most college presidents, he was surprisingly candid about his strategy. College is like vodka, he liked to explain.

The Absolut Rolex plan worked. The number of applicants surged from some 6,000 to 20,000, the average SAT score of students rose by nearly 200 points, and the endowment jumped from $200 million to almost $1 billion.

The university became a magnet for the children of new money who didn’t quite have the SATs or family connections required for admission to Stanford or Yale. It also aggressively recruited international students, rich families from Asia and the Middle East who believed, as nearly everyone did, that American universities were the best in the world.

U.S. News & World Report now ranks the university at No. 54 nationwide, just outside the “first tier.”

The watch and vodka analogies are correct. Personally, I used car analogies when discussing college choices with my kids. We were in the fortunate position of being able to comfortably send our kids to any college in the country and have them leave debt free. Notwithstanding, I told them that they would be going to a state school unless they were able to get into one of about 40 schools that I felt, in whatever arbitrary manner I decided, that was worth the extra cost. They both ended up going to state schools.College is by and large a commodity and you get out of it what you put into it. Both of my kids worked hard in college and were involved in school life. They both left the schools better people and the schools better schools for them being there. They are both now successful adults.I believe too many people look for the prestige of a named school and that is not what college should be primarily about.

In 2013, only 14 percent of the university’s 10,000 undergraduates received a grant — a figure on a par with elite schools but far below the national average. The average undergraduate borrower leaves with about $30,800 in debt.

When I talk to the best high school students in my state I always stress the benefits of the honors college experience at an affordable public university. For students who won't qualify for a public honors college. the regular pubic university experience is far preferable to the huge debt of places like GW.

Carey would do well to look beyond high ticket private universities (which after all are still private enterprises) and what he describes as the Olympian heights of higher education (which for some reason seems also to embitter him) and look at the system overall . The withdrawal of public support was never a policy choice; it was a political choice, "packaged and branded" as some tax cutting palaver all wrapped up in the argument that a free-market should decide how much college should cost and how many seats we need. In such an environment, trustees at private universities are no more solely responsible for turning their degrees into commodities than the administrations of state universities are for raising the number of out-of-state students in order to offset the loss of support from their legislatures. No doubt, we will hear more about market based solutions and technology from Mr. Carey

I went to GW back in the 60s. It was affordable and it got me away from home in New York. While I was there, Newsweek famously published a article about the DC Universities - GW, Georgetown, American and Catholic - dubbing them the Pony league, the schools for the children of wealthy middle class New Yorkers who couldn't get into the Ivy League. Nobody really complained. But that wasn't me. I went because I wanted to be where the action was in the 60s, and as we used to say - "GW was literally a stone's throw from the White House. And we could prove it." Back then, the two biggest alumni names were Jackie Kennedy, who's taken some classes there, and J. Edgar Hoover. Now, according to the glossy magazine they send me each month, it's the actress Kerry Washington. There's some sort of progress there, but I'm a GW alum and not properly trained to understand it.

This explains a lot of the modern, emerging mentality. It encompasses the culture of enforced grade inflation, cheating and anti-intellectualism in much of higher education. It is consistent with our culture of misleading statistics and information, cronyism and fake quality, the "best and the brightest" being only schemers and glad handers. The wisdom and creativity engendered by an honest, rigorous academic education are replaced by the disingenuous quick fix, the winner-take-all mentality that neglects the common good.

I attended nearby Georgetown University and graduated in 1985. Relative to state schools and elite schools, it was expensive then. I took out loans. I had Pell grants. I had work-study and GSL. I paid my debt of $15,000 off in ten years. Would I have done it differently? Yes: I would have continued on to graduate school and not worried about paying off those big loans right after college. My career work out and I am grateful for the education I received and paid for. But I would not recommend to my nieces and nephews debts north of $100,000 for a BA in liberal arts. Go community. Then go state. Then punch your ticket to Harvard, Yale or Stanford — if you are good enough.

American universities appear to have more and more drifted away from educating individuals and citizens to becoming high priced trade schools and purveyors of occupational licenses. Lost in the process is the concept of expanding a student's ability to appreciate broadly and deeply, as well as the belief that a republican democracy needs an educated citizenry, not a trained citizenry, to function well.Both the Heisman Trophy winner and the producer of a successful tech I.P.O. likely have much in common, a college education whose rewards are limited to the financial. I don't know if I find this more sad on the individual level or more worrisome for the future of America.

This is now a consumer world for everything, including institutions once thought to float above the Shakespearean briars of the work-a-day world such as higher education, law and medicine. Students get this. Parents get this. Everything is negotiable: financial aid, a spot in the nicest dorm, tix to the big game. But through all this, there are faculty - lots of 'em - who work away from the fluff to link the ambitions of the students with the reality and rigor of the 21st century. The job of the student is to get beyond the visible hype of the surroundings and find those faculty members. They will make sure your investment is worth it

My experience in managing or working with GW alumni in their 20's or 30's has not been good. Virtually all have been mentally lazy and/or had a stunning sense of entitlement. Basically they've been all talk and no results. That's been quite a contrast to the graduates from VA/MD state universities.

More and more, I notice what my debt-financed contributions to the revenue streams of my vendors earn them, not me. My banks earned enough to pay ridiculous bonuses to employees for reckless risk-taking. My satellite tv operator earned enough to overpay ESPN for sports programming that I never watch--and that, in turn, overpays these idiotic pro athletes and college sports administrators. My health insurer earned enough to defeat one-payor insurance; to enable the opaque, inefficient billing practices of hospitals and other providers; and to feed the behemoth pharmaceutical industry. My church earned enough to buy the silence of sex abuse victims and oppose progressive political candidates. And my govt earned enough to continue ag subsidies, inefficient defense spending, and obsolete transportation and energy policies.

as the parent of GWU freshman I am grateful for every opportunity afforded her. She has a generous merit scholarship, is in the honors program with some small classes, and has access to internships that can be done while at school. GWU also gave her AP credits to advance her to sophomore status. Had she attended the state flagship school (where she was accepted into that exclusive honors program) she would have a great education but little else. It's not possible to do foreign affairs related internship far from D.C. or Manhattan. She went to a very competitive high school where for the one or two ivy league schools in which she was interested, she didn't have the same level of connections or wealth as many of her peers. Whether because of the Common Application or other factors, getting into a good school with financial help is difficult for a middle class student like my daughter who had a 4.0 GPA and 2300 on the SAT. She also worked after school.The bottom line - GWU offered more money than perceived "higher tier" universities, and brought tuition to almost that of our state school system. And by the way, I think she is also getting a very good education.

This article reinforces something I have learned during my daughter's college application process. Most students choose a school based on emotion (reputation) and not value. This luxury good analogy holds up.

The entire education problem can be solved by MOOCs lots and lots of them plus a few closely monitored tests and personal interviews with people. Of course many many people make MONEY off of our entirely inefficient way of "educating" -- are we even really doing that -- getting a degree does NOT mean one is actually educated

As a first-generation college graduate I entered GW ambitious but left saddled with debt, and crestfallen at the hard-hitting realization that my four undergraduate years were an aberration from what life is actually like post-college: not as simple as getting an [unpaid] internship with a fancy titled institution, as most Colonials do. I knew how to get in to college, but what do you do after the recess of life ends?I learned more about networking, resume plumping (designated responses to constituents...errr....replied to emails), and elevator pitches than actual theory, economic principles, strong writing skills, critical thinking, analysis, and philosophy. While relatively easy to get a job after graduating (for many with a GW degree this is sadly not the case) sustaining one and excelling in it is much harder. It's never enough just to be able to open a new door, you also need to be prepared to navigate your way through that next opportunity.

this is a very telling article. Aimless and directionless high school graduates are matched only by aimless and directionless institutes of higher learning. Each child and each parent should start with a goal - before handing over their hard earned tuition dollars, and/or leaving a trail of broken debt in the aftermath of a substandard, unfocused education.

it is no longer the most expensive university in America. It is the 46th.Others have been implementing the Absolut Rolex Plan. John Sexton turned New York University into a global higher-education player by selling the dream of downtown living to students raised on “Sex and the City.” Northeastern followed Boston University up the ladder. Under Steven B. Sample, the University of Southern California became a U.S. News top-25 university. Washington University in St. Louis did the same.

I currently attend GW, and I have to say, this article completely misrepresents the situation. I have yet to meet a single person who is paying the full $60k tuition - I myself am paying $30k, because the school gave me $30k in grants. As for the quality of education, Foreign Policy rated GW the #8 best school in the world for undergraduate education in international affairs, Princeton Review ranks it as one of the best schools for political science, and U.S. News ranks the law school #20. The author also ignores the role that an expanding research profile plays in growing a university's prestige and educational power.

And in hundreds of regional universities and community colleges, presidents and deans and department chairmen have watched this spectacle of ascension and said to themselves, “That could be me.” Agricultural schools and technical institutes are lobbying state legislatures for tuition increases and Ph.D. programs, fitness centers and arenas for sport. Presidents and boards are drawing up plans to raise tuition, recruit “better” students and add academic programs. They all want to go in one direction — up! — and they are all moving with a single vision of what they want to be.

this is the same playbook used by hospitals the past 30 years or so. It is how Hackensack Hospital became Hackensack Medical Center and McComb Hospital became Southwest Mississippi Regional Medical Center. No wonder the results have been the same in healthcare and higher education; both have priced themselves out of reach for average Americans.

a world where a college is rated not by the quality of its output, but instaed, by the quality of its inputs. A world where there is practically no work to be done by the administration because the college's reputation is made before the first class even begins! This is isanity! But this is the swill that the mammoth college marketing departments nationwide have shoved down America's throat. Colleges are ranked not by the quality of their graduates, but rather, by the test scores of their incoming students!

The Pew Foundation has been doing surveys on what students learn, how much homework they do, how much time they spend with professors etc. All good stuff to know before a student chooses a school. It is called the National Survey of Student Engagement (NSSE - called Nessy). It turns out that the higher ranked schools do NOT allow their information to be released to the public. It is SECRET.Why do you think that is?

The article blames "the standard university organizational model left teaching responsibilities to autonomous academic departments and individual faculty members, each of which taught and tested in its own way." This is the view of someone who has never taught at a university, nor thought much about how education there actually happens. Once undergraduates get beyond the general requirements, their educations _have_ to depend on "autonomous departments" because it's only those departments know what the requirements for given degree can be, and can grant the necessary accreditation of a given student. The idea that some administrator could know what's necessary for degrees in everything from engineering to fiction writing is nonsense, except that's what the people who only know the theory of education (but not its practice) actually seem to think. In the classroom itself, you have tremendously talented people, who nevertheless have their own particular strengths and approaches. Don't you think it's a good idea to let them do what they do best rather than trying to make everyone teach the same way? Don't you think supervision of young teachers by older colleagues, who actually know their field and its pedagogy, rather than some administrator, who knows nothing of the subject, is a good idea?

it makes me very sad to see how expensive some public schools have become. Used to be you could work your way through a public school without loans, but not any more. Like you, I had the advantage of a largely-scholarship paid undergraduate education at a top private college. However, I was also offered a virtually free spot in my state university's (then new) honors college

My daughter attended a good community college for a couple of classes during her senior year of high school and I could immediately see how such places are laboratories for failure. They seem like high schools in atmosphere and appearance. Students rush in by car and rush out again when the class is over.The four year residency college creates a completely different feel. On arrival, you get the sense that you are engaging in something important, something apart and one that will require your full attention. I don't say this is for everyone or that the model is not flawed in some ways (students actually only spend 2 1/2 yrs. on campus to get the four yr. degree). College is supposed to be a 60 hour per week job. Anything less than that and the student is seeking himself or herself

This. Is. STUNNING. I have always wondered, especially as my kids have approached college age, why American colleges have felt justified in raising tuition at a rate that has well exceeded inflation, year after year after year. (Nobody needs a dorm with luxury suites and a lazy river pool at college!) And as it turns out, they did it to become luxury brands. Just that simple. Incredible.I don't even blame this guy at GWU for doing what he did. He wasn't made responsible for all of American higher ed. But I do think we all need to realize what happened, and why. This is front page stuff.

I agree with you, but, unfortunately, given the choice between low tuition, primitive dorms, and no athletic center VS expensive & luxurious, the customers (and their parents) are choosing the latter. As long as this is the case, there is little incentive to provide bare-bones and cheap education.

Wesleyan University in CT is one school that is moving down the rankings. Syracuse University is another. Reed College is a third. Why? Because these schools try hard to stay out of the marketing game. (With its new president, Syracuse has jumped back into the game.) Bryn Mawr College, outside Philadelphia hasn't fared well over the past few decades in the rankings, which is true of practically every women's college. Wellesley is by far the highest ranked women's college, but even there the acceptance rate is significantly higher than one finds at comparable coed liberal arts colleges like Amherst & Williams. University of Chicago is another fascinating case for Mr. Carey to study (I'm sure he does in his forthcoming book, which I look forward to reading). Although it has always enjoyed an illustrious academic reputation, until recently Chicago's undergraduate reputation paled in comparison to peer institutions on the two coasts. A few years ago, Chicago changed its game plan to more closely resemble Harvard and Stanford in undergraduate amenities, and lo and behold, its rankings shot up. It was a very cynical move on the president's part to reassemble the football team, but it was a shrewd move because athletics draw more money than academics ever can (except at engineering schools like Cal Tech & MIT), and more money draws richer students from fancier secondary schools with higher test scores, which lead to higher rankings - and the beat goes on.

College INDUSTRY is out of control. Sorry, NYU, GW, BU are not worth the price. Are state schools any better? We have the University of Michigan, which is really not a state school, but a university that gives a discount to people who live in Michigan. Why? When you have an undergraduate body 40+% out-of-state that pays tuition of over $50K/year, you tell me?Perhaps the solution is two years of community college followed by two at places like U of M or Michigan State - get the same diploma at the end for much less and beat the system.

In one recent yr., the majority of undergrad professors at Harvard, according to Boston.com, where adjuncts. That means low pay, no benefits, no office, temp workers. Harvard.Easily available student loans fueled this arms race of amenities and frills that in which colleges now engage. They moved the cost of education onto the backs of people, kids, who don't understand what they are doing.Students in colleges these days are customers and the customers must be able to get through. If it requires dumbing things down, so be it. On top of tuition, G.W. U. is known by its students as the land of added fees on top of added fees. The joke around campus was that they would soon be installing pay toilets in the student union. No one was laughing.

You could written the same story about my alma mater, American University. The place reeked of ambition and upward mobility decades ago and still does. Whoever's running it now must look at its measly half-billion-dollar endowment and compare it to GWU's $1.5 billion and seethe with envy, while GWU's president sets his sights on an Ivy League-size endowment. And both get back to their real jobs: 24/7 fundraising,Which is what university presidents are all about these days. Money - including million-dollar salaries for themselves (GWU's president made more than Harvard's in 2011) - pride, cachet, power, a mansion, first-class all the way. They should just be honest about it and change their university's motto to Ostende mihi pecuniam! (please excuse my questionable Latin)Whether the students are actually learning anything is up to them, I guess - if they do, it's thanks to the professors, adjuncts and the administrative staff, who do the actual work of educating and keep the school running.

When I was in HS (70s), many of my richer friends went to GW and I was then of the impression that GW was a 'good' school. As I age, I have come to realize that this place is just another façade to the emptiness that has become America. All too often are we faced with a dilemma: damned if we do, damned if we don't. Yep, 'education' has become a trap for all too many of our citizen.

I transferred to GWU from a state school. I am forever grateful that I did. I wanted to get a good rigorous education and go to one of the best International Affairs schools in the world. Even though the state school I went to was dirt-cheap, the education and the faculty was awful. I transferred to GW and was amazed at the professors at that university. An ambassador or a prominent IA scholar taught every class. GW is an expensive school, but that is the free market. If you want a good education you need to be willing to pay for it or join the military. I did the latter and my school was completely free with no debt and I received an amazing education. If young people aren't willing to make some sort of sacrifice to get ahead or just expect everything to be given to then our country is in a sad state.We need to stop blaming universities like GWU that strive to attract better students, better professors, and better infrastructure. They are doing what is expected in America, to better oneself.

"Whether the students are actually learning anything is up to them, I guess." How could it possibly be otherwise??? I am glad that you are willing to give credit to teachers and administrators, but it is not they who "do the actual work of educating." From this fallacy comes its corollary, that we should blame teachers first for "under-performing schools". This long-running show of scapegoating may suit the wallets and vanity of American parents, but it is utterly senseless. When, if ever, American culture stops reeking of arrogance, greed and anti-intellectualism, things may improve, and we may resume the habit of bothering to learn. Until then, nothing doing.

Universities sell knowledge and grade students on how much they have learned. Fundamentally, there is conflict of interest in thsi setup. Moreover, students who are poorly educated, even if they know this, will not criticize their school, because doing so would make it harder for them to have a career. As such, many problems with higher education remain unexposed to the public.

I've lectured and taught in at least five different countries in three continents and the shortest perusal of what goes on abroad would totally undermine most of these speculations. For one thing American universities are unique in their dedication to a broad based liberal arts type education. In France, Italy or Germany, for example, you select a major like mathematics or physics and then in your four years you will not take even one course in another subject. The amount of work that you do that is critically evaluated by an instructor is a tiny fraction of what is done in an American University. While half educated critics based on profoundly incomplete research write criticism like this Universities in Germany Italy, the Netherlands, South Korea and Japan as well as France have appointed committees and made studies to explain why the American system of higher education so drastically outperforms their own system. Elsewhere students do get a rather nice dose of general education but it ends in secondary school and it has the narrowness and formulaic quality that we would just normally associate with that. The character who wrote this article probably never set foot on a "campus" of the University of Paris or Rome

The university is part of a complex economic system and it is responding to the demands of that system. For example, students and parents choose universities that have beautiful campuses and buildings. So universities build beautiful campuses. State support of universities has greatly declined, and this decline in funding is the greatest cause of increased tuition. Therefore universities must compete for dollars and must build to attract students and parents. Also, universities are not ranked based on how they educate students -- that's difficult to measure so it is not measured. Instead universities are ranked on research publications. So while universities certainly put much effort into teaching, research has to have a priority in order for the university to survive. Also universities do not force students and parents to attend high price institutions. Reasonably priced state institutions and community colleges are available to every student. Community colleges have an advantage because they are funded by property taxes. Finally learning requires good teaching, but it also requires students that come to the university funded, prepared, and engaged. This often does not happen. Conclusion- universities have to participate in profile raising actions in order to survive. The day that funding is provided for college, ranking is based on education, and students choose campuses with simple buildings, then things will change at the university.

This is the inevitable result of privatizing higher education. In the not-so-distant past, we paid for great state universities through our taxes, not tuition. Then, the states shifted funding to prisons and the Federal government radically cut research support and the GI bill. Instead, today we expect universities to support themselves through tuition, and to the extent that we offered students support, it is through non-dischargeable loans. To make matters worse, the interest rates on those loans are far above the government's cost of funds -- so in effect the loans are an excise tax on education (most of which is used to support a handful of for-profit institutions that account for the most student defaults). This "consumer sovereignty" privatized model of funding education works no better than privatizing California's electrical system did in the era of Enron, or our privatized funding of medical service, or our increasingly privatized prison system: it drives up costs at the same time that it replace quality with marketing.

There are data in some instances on student learning, but the deeper problem, as I suspect the author already knows, is that there is nothing like a consensus on how to measure that learning, or even on when is the proper end point to emphasize (a lot of what I teach -- I know this from what students have told me -- tends to come into sharp focus years after graduation).

Michael (Baltimore) has hit the nail on the head. Universities are increasingly corporatized institutions in the credentialing business. Knowledge, for those few who care about it (often not those paying for the credentials) is available freely because there's no profit in it. Like many corporate entities, it is increasingly run by increasingly highly paid administrators, not faculty.

GWU has not defined itself in any unique way, it has merely embraced the bland, but very expensive, accoutrements of American private education: luxury dorms, food courts, spa-like gyms, endless extracurricular activities, etc. But the real culprit for this bloat that students have to bear financially is the college ranking system by US News, Princeton Review, etc. An ultimately meaningless exercise in competition that has nevertheless pushed colleges and universities to be more like one another. A sad state of affairs, and an extremely expensive one for students

It is long past time to realize the failure of the Reagonomics-neoliberal private profits over public good program. In education, we need to return to public institutions publicly funded. Just as we need to recognize that Medicare, Social Security, the post office, public utilities, fire departments, interstate highway system, Veterans Administration hospitals and the GI bill are models to be improved and expanded, not destroyed.

George Washington is actually not a Rolex watch, it is a counterfeit Rolex. The real Rolexes of higher education -- places like Hopkins, Georgetown, Duke, the Ivies etc. -- have real endowments and real financial aid. No middle class kid is required to borrow $100,000 to get a degree from those schools, because they offer generous need-based financial aid in the form of grants, not loans. The tuition at the real Rolexes is really a sticker price that only the wealthy pay -- everybody else on a sliding scale. For middle class kids who are fortunate enough to get in, Penn actually ends up costing considerably less than a state university.The fake Rolexes -- BU, NYU, Drexel in Philadelphia -- don't have the sliding scale. They bury middle class students in debt.And really, though it is foolish to borrow $100,000 or $120,000 for an undergraduate degree, I don't find the transaction morally wrong. What is morally wrong is our federal government making that loan non-dischargeable in bankruptcy, so many if these kids will be having their wages garnished for the REST OF THEIR LIVES.There is a very simple solution to this, by the way. Cap the amount of non-dischargeable student loan debt at, say, $50,000

The slant of this article is critical of the growth of research universities. Couldn't disagree more. Modern research universities create are incredibly engines of economic opportunity not only for the students (who pay the bills) but also for the community via the creation of blue and white collar jobs. Large research university employ tens of thousands of locals from custodial and food service workers right up to high level administrators and specialist in finance, computer services, buildings and facilities management, etc. Johns Hopkins University and the University of Maryland system employ more people than any other industry in Maryland -- including the government. Research universities typically have hospitals providing cutting-edge medical care to the community. Local business (from cafes to property rental companies) benefit from a built-in, long-term client base as well as an educated workforce. And of course they are the foundry of new knowledge which is critical for the future growth of our country.Check out the work of famed economist Dr. Julia Lane on modeling the economic value of the research university. In a nutshell, there are few better investments America can make in herself than research universities. We are the envy of the world in that regard -- and with good reason. How many *industries* (let alone jobs) have Stanford University alone catalyzed?

What universities have the monopoly on is the credential. Anyone can learn, from books, from free lectures on the internet, from this newspaper, etc. But only universities can endow you with the cherished degree. For some reason, people are will to pay more for one of these pieces of paper with a certain name on it -- Ivy League, Stanford, even GW -- than another -- Generic State U -- though there is no evidence one is actually worth more in the marketplace of reality than the other. But, by the laws of economics, these places are actually underpriced: after all, something like 20 times more people are trying to buy a Harvard education than are allowed to purchase one. Usually that means you raise your price.

Overalll a good article, except for - "This comes on the heels of Richard Arum and Josipa Roksa’s “Academically Adrift,” a study that found “limited or no learning” among many college students." The measure of learning you report was a general thinking skills exam. That's not a good measure of college gains. Most psychologists and cognitive scientists worth their salt would tell you that improvement in critical thinking skills is going to be limited to specific areas. In other words, learning critical thinking skills in math will make little change in critical thinking about political science or biology. Thus we should not expect huge improvements in general critical thinking skills, but rather improvements in a student's major and other areas of focus, such as a minor. Although who has time for a minor when it is universally acknowledged that the purpose of a university is to please and profit an employer or, if one is lucky, an investor. Finally, improved critical thinking skills are not the end all and be all of a college education even given this profit centered perspective. Learning and mastering the cumulative knowledge of past generations is arguably the most important thing to be gained, and most universities still tend to excel at that even with the increasing mandate to run education like a business and cultivate and cull the college "consumer".

As for community colleges, there was an article in the Times several years ago that said it much better than I could have said it myself: community colleges are places where dreams are put on hold. Without making the full commitment to study, without leaving the home environment, many, if not most, community college students are caught betwixt and between, trying to balance work responsibilities, caring for a young child or baby and attending classes. For males, the classic "end of the road" in community college is to get a car, a job and a girlfriend, one who is not in college, and that is the end of the dream. Some can make it, but most cannot.

as a scientist I disagree with the claim that undergrad tuition subsidizes basic research. Nearly all lab equipment and research personnel (grad students, technicians, anyone with the title "research scientist" or similar) on campus is paid for through federal grants. Professors often spend all their time outside teaching and administration writing grant proposals, as the limited federal grant funds mean ~%85 of proposals must be rejected. What is more, out of each successful grant the university levies a "tax", called "overhead", of 30-40%, nominally to pay for basic operations (utilities, office space, administrators). So in fact one might say research helps fund the university rather than the other way around. Flag

It's certainly overrated as a research and graduate level university. Whether it is good for getting an undergraduate education is unclear, but a big part of the appeal is getting to live in D.C..while attending college instead of living in some small college town in the corn fields.

“The social isolation since then, over all this time, it just got to him,”

“This is a charming, funny kid, also sensitive and anxious,” she said. “He couldn’t find a job; he couldn’t really go out. And he started using marijuana again, and Xanax.”

The teenager’s frustration finally boiled over this month, when he deliberately cut himself.

The doctors sent him home, she said, “with no support, no therapy, nothing.”

Surveys and statistics show that for young people who are anxious by nature, or feeling emotionally fragile already, the pandemic and its isolation have pushed them to the brink

Rates of suicidal thinking and behavior are up by 25 percent or more from similar periods in 2019, according to a just-published analysis of surveys of young patients coming into the emergency room.

For these teenagers, there aren’t many places to turn.

Finally, when a crisis hits, many of these teenagers end up in the local emergency department — the one place desperate families so often go for help.

“This is a national crisis we’re facing,”

For the young people coming undone, however, pandemic life presents unusual challenges, pediatricians say

“What parents and children are consistently reporting is an increase in all symptoms — a child who was a little anxious before the pandemic became very anxious over this past year,”

“This giant boy, crying — it’s terrible to see.” The young man has had panic attacks, twice followed by a blackout. During one, he fell and injured his face.

These young people do not necessarily qualify for a psychiatric diagnosis, nor are they “traumatized” in the strict sense of having had a life-threatening experience (or the perception of one).

Rather, they are trying to manage an interruption in their

The result is grief, but grief without a name or a specific cause, an experience some psychologists call “ambiguous loss.”

“Everything that used to be familiar and give structure to their lives, and predictability, and normalcy, is gone,” said Sharon Young, a therapist in Hendersonville. “Kids need all these things even more than adults do, and it’s hard for them to feel emotionally safe when they’re no longer there.”

Nationwide Children’s Hospital in Columbus, Ohio, has an emergency department that is a decent size for a pediatric hospital, with capacity for 62 children or adolescents

“This was huge problem pre-pandemic,” said Dr. David Axelson, chief of psychiatry and behavioral health at the hospital. “We were seeing a rise in emergency department visits for mental health problems in kids, specifically for suicidal thinking and self-harm. Our emergency department was overwhelmed with it, having to board kids on the medical unit while waiting for psych beds.”

“We have to say no,” Dr. Axelson said.

Like many other parents, she is now looking after an unstable child and wondering where to go next. A drug rehab program may be needed, as well as regular therapy.

“Covid has put our system under a microscope in terms of the things that don’t work,”

“We had a shaky system of care in pediatric mental health prior to this pandemic, and now we have all these added stressors on it, all these kids coming in for pandemic-related issues. Hospitals everywhere are scrambling to adjust.”

I was relieved -- we wouldn't have to make what felt like an impossible decision -- but then I kept reading. My father had noted that he did not want to be supported by a ventilator or hooked up to a feeding tube for any length of time. He had been connected to both for nearly two weeks.

There was grief on her face, but also curiosity. What had finally gotten to her younger son, the one who so rarely showed emotion during his father's hospitalization?

I called the hospital and approved the DNR. They told me his status was still dire. I called my dad's closest friends and started preparing them for the worst.

My father's lungs showed no signs of progress. The double pneumonia they diagnosed days before was worsening. His kidneys were failing. Dialysis was required but would put a strain on his blood pressure, which was already dangerously low. There was a special form of dialysis designed for delicate situations like this -- continuous veno-venous hemofiltration -- but it wasn't available at Lawrence

The morning after I searched for my father's health directive and drafted his obituary, I woke up and tried to turn on my laptop. It wouldn't start. When it eventually booted up, it asked if I wanted to restore an unsaved document. No, I thought, let's see what happens today.

It was the same doctor as yesterday, the one who asked about the DNR. "Look, your dad is on a ventilator. That's a form of life support. He's experiencing kidney failure and requires dialysis. His situation is still very acute. He was in good health before the Covid, but his kidney, heart, and lungs are 69 years old. It's tough for them to recover. But the numbers from today are undeniably better than yesterday. There's been an improvement at almost every level. Your dad is a tough guy."

One of my close friends, a nurse practitioner, would help me understand all the terminology and its implications. He was treating Covid patients at an ICU upstate. At the end of our calls I'd ask him how he was doing. "We ran out of gowns," he told me one day. "My ICU is out of ventilators -- we're diverting people to Albany," he said another time.

"There's a difference between good intentions and good outcomes," I explained to her. She would wave me away and pick up. Inevitably the call would bring her tears. I stewed on the porch. My brother, uncle and I would spend hours trying to ease her mind and pacify her anxiety. Any inquiry or outreach was like sticking a finger in the open wound of her anguish.

I called my friend, the nurse practitioner, and gave him the latest update. He seemed upset. "You OK, dude?" "A nurse from my hospital died," he explained.

The nurses and doctors who took care of my father -- first for four days at NewYork-Presbyterian Lawrence Hospital, then for nearly a month at NewYork-Presbyterian/Columbia -- were always empathetic, straightforward and willing to trust me with complicated details.

About a week after writing -- then refusing to recover -- my father's obituary, his condition was continuing to improve.

"He's only improving," I told her, "because of the life-saving care you guys have given him. The whole city is in awe of you. They should have a parade for you down the Canyon of Heroes."

Covid-19 was new and largely unstudied. Maybe one of these seemingly odd treatments would work.

"Yesterday was a stumble, but we're getting back on course," I emailed the group. "We always knew this recovery wasn't going to be a straight line. It's important to remain resilient and optimistic even when there are temporary setbacks."

"Oh Lou, I've been waiting for your call. I have such good news. They are planning to extubate him tomorrow. They are going to take your father off the ventilator!" She was practically screaming with excitement. I was speechless.

I had been withholding certain information from my family and friends during this whole ordeal. My dad had developed a blood clot two weeks into his hospitalization. Clots are extremely dangerous, of course, but it was small and in a relatively manageable location.

I called my brother and told him about the plan to get my father off the ventilator. Since there were a number of contingencies, we debated telling my mother. She was living and dying with every update.

My father's breathing was labored on the morning they were planning to extubate. They delayed the procedure a day. That next morning, April 16, a doctor called. I was in the shower and rushed out to answer my cell. He said they were doing the extubation within the hour. What do we want to do if the extubation fails?

"It went as well as we could have hoped for," the doctor said. "His vitals are stable and he's breathing well. He's resting now." She explained that my father was disoriented and it probably wasn't a great idea to speak with him that day. Whatever, I thought, I'll speak with him when he gets home. He had been on a ventilator for 28 days.

I called the doctor later in the day. She told me my dad seemed distressed. He was trying to speak, but his vocal cords were too swollen. "It's so frustrating," she told me. "I don't know what he wants to tell me."

"Each facility has their own Covid rules," she explained. "I'll send you over a list." On the list was the nursing home where my grandfather had died several years before. My father had visited him every day.

I called the step-down unit where he had been the past three days. They transferred me to his nurse. "He's doing better, love. We took him off the pressor and his blood pressure is in a good range. His heart rate is good. He's breathing fine. The doctors decided he didn't need to go back to the ICU. He's ok."

"I've repeatedly said that recovery isn't a straight line. ... Yesterday we managed the roller coaster ride as a family. My brother, uncle and I were with my mother the entire day. We never lost hope or confidence in my dad's medical care and ultimate recovery. If there's a light at the end of the tunnel, it's a blinking one. Right now, it shines again."

I drove back to my mom's house. I scanned the block for my brother's car. He had not arrived. I parked. I have to wait for him and then tell my mother, brother and uncle all at once, right? Should I call my wife first? Should I call my dad's best friend?

I called my wife. I called my dad's best friend. I called the guys he grew up with. I called his former colleagues. I began every conversation the same way, "This is that call." I listened to each of them yell and cry and ask if I was serious. Then I said I had to make another call.

I wrote about my father's career. How he got his law degree at night school and became a prosecutor at the city, state, and federal level. How he convicted mobsters, drug dealers, and those who abused power.

I wrote about my dad's volunteer work -- at the Special Olympics, at an organization he founded that helps police families with special needs, and at just about any Italian-American group that needed a lawyer. He was so proud of his Italian-American heritage. He loathed the mafioso caricatures and stereotypes found on TV -- he wrote countless op-eds attacking those -- but he revered the old-school virtues he associated with his Italian-American upbringing: loyalty, humility, hard work, dedication to family.

He was a Covid patient for 31 days. It was a painful experience, but ultimately unimportant. It doesn't matter how a man dies. It matters how he lives.

This pervasive claim that “I have my rights” but “I don’t have responsibilities” is unraveling our country today.

But societal immunity “is a function of trust,”

“When trust in institutions, leaders and each other is high, people — in a crisis — are more willing to sublimate their cherished rights and demonstrate their sense of shared responsibilities toward others, even others they disagree with on important issues and even if it means making sacrifices.”

When our trust in each other erodes, though, as is happening in America today, fewer people think they have responsibilities to the other — only rights that protect them from being told by the other what to do.

completely ignored the four most important statistical facts about Covid-19 today that highlight our responsibilities — to our fellow citizens and, even more so, to the nurses and doctors risking their lives to take care of us in a pandemic.

First, unvaccinated adults 18 years and older are 16 times more likely to be hospitalized for Covid than fully vaccinated adults

Second: Adults 65 and older who are not vaccinated are around 50 times more likely to be hospitalized for Covid than those who have received a full vaccine course and a booster.

Third: Unvaccinated people are 20 times more likely to die of Covid than people who are vaccinated and boosted.

the emotional toll and other work conditions brought on by the pandemic contributed to some two-thirds of nurses giving thought to leaving the profession.

many hospitals today are experiencing an unprecedented 20 percent annual turnover rate of nurses — more than double the historical baseline. The more nurses leave, the more those left behind have had to work overtime.

Especially when so many dying unvaccinated patients tell their nurses, “I wish I had gotten vaccinated,”

none of these statistics were mentioned during that podcast

“You can listen to the entire 186-minute lovefest between Rogan and Malone and have no idea that our hospitals are overloaded with Covid cases,” wrote Levy, “and that on the day their conversation transpired, 7,559 people worldwide died of Covid, 1,410 of which were in the United States. The vast majority of them were unvaccinated.”

“When Malone uncorks questionable allegations about disastrous vaccine effects and the global cabal of politicians and drugmakers pulling strings, Rogan responds with uh-huhs and wows.”

That was Rogan’s right. That was Spotify C.E.O. Daniel Ek’s right.

But who was looking out for the doctors and nurses on the pandemic front lines whose only ask is that the politicians and media influencers who are privileged enough to have public platforms — especially one like Rogan with an average of 11 million listeners per episode — use them to reinforce our responsibilities to one another, not just our rights.

He could start by offering his listeners a 186-minute episode with intensive care nurses and doctors about what this pandemic of the unvaccinated has done to them.

That would be a teaching moment, not only about Covid, but also about putting our responsibilities to one another — and especially to those who care for us — at least on a par with our right to be as dumb and selfish as we want to be.

The living, breathing source of the data and images we juggle, meanwhile, is in the bed and left wondering: Where is everyone? What are they doing? Hello! It’s my body, you know

Our $3.4 trillion health care system is responsible for more than a quarter of a million deaths per year because of medical error, the rough equivalent of, say, a jumbo jet’s crashing every day.

I can get cash and account details all over America and beyond. Yet I can’t reliably get a patient record from across town, let alone from a hospital in the same state, even if both places use the same brand of E.H.R

the leading E.H.R.s were never built with any understanding of the rituals of care or the user experience of physicians or nurses. A clinician will make roughly 4,000 keyboard clicks during a busy 10-hour emergency-room shift

In the process, our daily progress notes have become bloated cut-and-paste monsters that are inaccurate and hard to wade through. A half-page, handwritten progress note of the paper era might in a few lines tell you what a physician really thought

so much of the E.H.R., but particularly the physical exam it encodes, is a marvel of fiction, because we humans don’t want to leave a check box empty or leave gaps in a template.

For a study, my colleagues and I at Stanford solicited anecdotes from physicians nationwide about patients for whom an oversight in the exam (a “miss”) had resulted in real consequences, like diagnostic delay, radiation exposure, therapeutic or surgical misadventure, even death. They were the sorts of things that would leave no trace in the E.H.R. because the recorded exam always seems complete — and yet the omission would be glaring and memorable to other physicians involved in the subsequent care. We got more than 200 such anecdotes.

The reason for these errors? Most of them resulted from exams that simply weren’t done as claimed. “Food poisoning” was diagnosed because the strangulated hernia in the groin was overlooked, or patients were sent to the catheterization lab for chest pain because no one saw the shingles rash on the left chest.

I worry that such mistakes come because we’ve gotten trapped in the bunker of machine medicine. It is a preventable kind of failure

How we salivated at the idea of searchable records, of being able to graph fever trends, or white blood counts, or share records at a keystroke with another institution — “interoperability”

The seriously ill patient has entered another kingdom, an alternate universe, a place and a process that is frightening, infantilizing; that patient’s greatest need is both scientific state-of-the-art knowledge and genuine caring from another human being. Caring is expressed in listening, in the time-honored ritual of the skilled bedside exam — reading the body — in touching and looking at where it hurts and ultimately in localizing the disease for patients not on a screen, not on an image, not on a biopsy report, but on their bodies.

What if the computer gave the nurse the big picture of who he was both medically and as a person?

a professor at M.I.T. whose current interest in biomedical engineering is “bedside informatics,” marvels at the fact that in an I.C.U., a blizzard of monitors from disparate manufacturers display EKG, heart rate, respiratory rate, oxygen saturation, blood pressure, temperature and more, and yet none of this is pulled together, summarized and synthesized anywhere for the clinical staff to use

What these monitors do exceedingly well is sound alarms, an average of one alarm every eight minutes, or more than 180 per patient per day. What is our most common response to an alarm? We look for the button to silence the nuisance because, unlike those in a Boeing cockpit, say, our alarms are rarely diagnosing genuine danger.

By some estimates, more than 50 percent of physicians in the United States have at least one symptom of burnout, defined as a syndrome of emotional exhaustion, cynicism and decreased efficacy at work

It is on the increase, up by 9 percent from 2011 to 2014 in one national study. This is clearly not an individual problem but a systemic one, a 4,000-key-clicks-a-day problem.

The E.H.R. is only part of the issue: Other factors include rapid patient turnover, decreased autonomy, merging hospital systems, an aging population, the increasing medical complexity of patients. Even if the E.H.R. is not the sole cause of what ails us, believe me, it has become the symbol of burnou

burnout is one of the largest predictors of physician attrition from the work force. The total cost of recruiting a physician can be nearly $90,000, but the lost revenue per physician who leaves is between $500,000 and $1 million, even more in high-paying specialties.

I hold out hope that artificial intelligence and machine-learning algorithms will transform our experience, particularly if natural-language processing and video technology allow us to capture what is actually said and done in the exam room.

as with any lab test, what A.I. will provide is at best a recommendation that a physician using clinical judgment must decide how to apply.

True clinical judgment is more than addressing the avalanche of blood work, imaging and lab tests; it is about using human skills to understand where the patient is in the trajectory of a life and the disease, what the nature of the patient’s family and social circumstances is and how much they want done.

Much of that is a result of poorly coordinated care, poor communication, patients falling through the cracks, knowledge not being transferred and so on, but some part of it is surely from failing to listen to the story and diminishing skill in reading the body as a text.

As he was nearing death, Avedis Donabedian, a guru of health care metrics, was asked by an interviewer about the commercialization of health care. “The secret of quality,” he replied, “is love.”/•/

"Previous small-scale studies have failed to identify robust evidence of a benefit and larger, randomised controlled trials are not yet completed," Dr. Frank Ruschitzka, director of the Heart Center at University Hospital Zurich and the study's coauthor, said in a statement.

President Donald Trump has repeatedly touted hydroxychloroquine as a potential coronavirus cure. Earlier this week he claimed he was taking daily doses of it as a prophylaxis to prevent infection.

Additionally, the study found serious cardiac arrhythmias were more common among patients who received any of the four treatments. The largest increase was among the group treated with hydroxychloroquine and an an antibiotic -- 8% of those patients developed a heart arrythmia, compared to 0.3% of the control group.

Items such as masks and hand sanitizer will be familiar sights in stuffed backpacks. Classes and school buses will have fewer people while some office meetings will be conducted by video conference, experts say.

Children with underlying health conditions are especially vulnerable, and it's crucial that people follow rules to keep everyone safe, Altmann said. She shared other things US schools must address before unlatching their doors.

"We need to quickly test them, diagnose, isolate and then contact trace, which is a lot easier when there's fewer kids they've come into contact with throughout the day," Altmann added.

In New York, 16.6% of people have been infected, compared with 1% in California, the researchers said.

In the most severe scenario, the CDC assumes that 1% of people overall with Covid-19 and symptoms will die. In the least severe scenario, it puts that number at 0.2%.

"Go out, wear a mask, stay six feet away from anyone so you have the physical distancing," he said. "Go for a run. Go for a walk. Go fishing. As long as you're not in a crowd and you're not in a situation where you can physically transmit the virus."

Alaska is allowing all businesses to reopen, as well as houses of worship, libraries, museums and sporting activities, starting at 8 a.m. Alaska has the fewest cases of all states and has reported single-digit new cases since mid-April.

The UK is not alone. Many other nations were slow to respond to the threat at care home facilities, and the consequences have been devastating.

Comparing death tolls can be difficult: some countries have separate data covering elderly care homes, while others include facilities for those with disabilities. Some countries do not include in their data those residents who die in hospitals, some have regional variation​, and some have no data at all.

There had been 1,661 coronavirus deaths among care home residents out of 3,395 total coronavirus deaths in Sweden by May 14, or 49%, according to LTCcovid's report.

19 residents out of 110 had died in the past two months, but only five were confirmed Covid-19 deaths -- the rest were "undetermined," he said. He said he thought there had been "slight under-reporting" of deaths in the UK because of a lack of testing, and said the situation had been "harrowing."

Raffaele Antonelli Incalzi, head of the Italian geriatric society SIGG, said in a statement in early April that care homes were "biological time bombs," in part because overcrowded hospitals were moving elderly patients to unprepared homes.

Elderly care sector professionals and care home workers published a letter to Health Minister Olivier Véran on March 20 expressing alarm and requesting 500,000 masks per week in affected areas, to which he agreed.

By March 24, the Spanish army was drafted in to help and found "abandoned" ​care home residents dead in their beds, according to Defense Minister Margarita Robles. The government said at its briefing the next day that the information had been passed to the public prosecutor, who was investigating. New care home guidelines called for extended isolation measures, but some homes said they would now have to send all staff home to comply.

She said the DHSC was prioritizing testing in care homes and had provided £3.2 billion ($3.9 billion) to local authorities to ease pressure on services including care homes, as well as an additional £600 million ($730 million) for homes last week. "Since the start of this pandemic we have worked to ensure our care homes and frontline care workforce get the support they need. Almost two thirds of care homes have not had an outbreak and deaths in all settings, including care homes, are falling."

A similar story played out in France, where coronavirus fatalities among care home residents in all settings make up more than half of all coronavirus deaths recorded as of May 18, according to health ministry data used in the LTCcovid report.

The UK initially did not record care home deaths. While the latest official ONS data for England and Wales shows that 38% of coronavirus deaths occurred in care homes, LTCcovid said the figure could be far higher.

LTCcovid's report found that 3,890 of Canada's 4,740 coronavirus-linked deaths took place among care home residents as of May 8, or 82%, and Health Canada told CNN the percentage was nearly 80% on May 19. Canada's largest province, Ontario, has announced an independent inquiry.

Of the 247 total Covid-19 deaths in South Korea that had been confirmed as of April 30, 84 were care home residents -- a share of 34%. No large care home outbreaks have occurred since the measures were implemented.

“My first and biggest wish is that we had known early that Covid-19 was airborne,”

, “Once you’ve realized that, it informs an entirely different strategy for protection.” Masking, ventilation and air cleaning become key, as well as avoiding high-risk encounters with strangers, he says.

Instead of washing our produce and wearing hand-sewn cloth masks, we could have made sure to avoid superspreader events and worn more-effective N95 masks or their equivalent. “We could have made more of an effort to develop and distribute N95s to everyone,” says Dr. Volckens. “We could have had an Operation Warp Speed for masks.”

We didn’t realize how important clear, straight talk would be to maintaining public trust. If we had, we could have explained the biological nature of a virus and warned that Covid-19 would change in unpredictable ways.  

We didn’t know how difficult it would be to get the basic data needed to make good public-health and medical decisions. If we’d had the data, we could have more effectively allocated scarce resources

In the face of a pandemic, he says, the public needs an early basic and blunt lesson in virology

and mutates, and since we’ve never seen this particular virus before, we will need to take unprecedented actions and we will make mistakes, he says.

Since the public wasn’t prepared, “people weren’t able to pivot when the knowledge changed,”

By the time the vaccines became available, public trust had been eroded by myriad contradictory messages—about the usefulness of masks, the ways in which the virus could be spread, and whether the virus would have an end date.

, the absence of a single, trusted source of clear information meant that many people gave up on trying to stay current or dismissed the different points of advice as partisan and untrustworthy.

“The science is really important, but if you don’t get the trust and communication right, it can only take you so far,”

people didn’t know whether it was OK to visit elderly relatives or go to a dinner party.

Doctors didn’t know what medicines worked. Governors and mayors didn’t have the information they needed to know whether to require masks. School officials lacked the information needed to know whether it was safe to open schools.

Had we known that even a mild case of Covid-19 could result in long Covid and other serious chronic health problems, we might have calculated our own personal risk differently and taken more care.

just months before the outbreak of the pandemic, the Council of State and Territorial Epidemiologists released a white paper detailing the urgent need to modernize the nation’s public-health system still reliant on manual data collection methods—paper records, phone calls, spreadsheets and faxes.

While the U.K. and Israel were collecting and disseminating Covid case data promptly, in the U.S. the CDC couldn’t. It didn’t have a centralized health-data collection system like those countries did, but rather relied on voluntary reporting by underfunded state and local public-health systems and hospitals.

doctors and scientists say they had to depend on information from Israel, the U.K. and South Africa to understand the nature of new variants and the effectiveness of treatments and vaccines. They relied heavily on private data collection efforts such as a dashboard at Johns Hopkins University’s Coronavirus Resource Center that tallied cases, deaths and vaccine rates globally.

For much of the pandemic, doctors, epidemiologists, and state and local governments had no way to find out in real time how many people were contracting Covid-19, getting hospitalized and dying

To solve the data problem, Dr. Ranney says, we need to build a public-health system that can collect and disseminate data and acts like an electrical grid. The power company sees a storm coming and lines up repair crews.

If we’d known how damaging lockdowns would be to mental health, physical health and the economy, we could have taken a more strategic approach to closing businesses and keeping people at home.

t many doctors say they were crucial at the start of the pandemic to give doctors and hospitals a chance to figure out how to accommodate and treat the avalanche of very sick patients.

The measures reduced deaths, according to many studies—but at a steep cost.

The lockdowns didn’t have to be so harmful, some scientists say. They could have been more carefully tailored to protect the most vulnerable, such as those in nursing homes and retirement communities, and to minimize widespread disruption.

Lockdowns could, during Covid-19 surges, close places such as bars and restaurants where the virus is most likely to spread, while allowing other businesses to stay open with safety precautions like masking and ventilation in place.  

The key isn’t to have the lockdowns last a long time, but that they are deployed earlier,

If England’s March 23, 2020, lockdown had begun one week earlier, the measure would have nearly halved the estimated 48,600 deaths in the first wave of England’s pandemic

If the lockdown had begun a week later, deaths in the same period would have more than doubled

It is possible to avoid lockdowns altogether. Taiwan, South Korea and Hong Kong—all countries experienced at handling disease outbreaks such as SARS in 2003 and MERS—avoided lockdowns by widespread masking, tracking the spread of the virus through testing and contact tracing and quarantining infected individuals.

With good data, Dr. Ranney says, she could have better managed staffing and taken steps to alleviate the strain on doctors and nurses by arranging child care for them.

Early in the pandemic, public-health officials were clear: The people at increased risk for severe Covid-19 illness were older, immunocompromised, had chronic kidney disease, Type 2 diabetes or serious heart conditions

t had the unfortunate effect of giving a false sense of security to people who weren’t in those high-risk categories. Once case rates dropped, vaccines became available and fear of the virus wore off, many people let their guard down, ditching masks, spending time in crowded indoor places.

it has become clear that even people with mild cases of Covid-19 can develop long-term serious and debilitating diseases. Long Covid, whose symptoms include months of persistent fatigue, shortness of breath, muscle aches and brain fog, hasn’t been the virus’s only nasty surprise

In February 2022, a study found that, for at least a year, people who had Covid-19 had a substantially increased risk of heart disease—even people who were younger and had not been hospitalized

respiratory conditions.

Some scientists now suspect that Covid-19 might be capable of affecting nearly every organ system in the body. It may play a role in the activation of dormant viruses and latent autoimmune conditions people didn’t know they had

 A blood test, he says, would tell people if they are at higher risk of long Covid and whether they should have antivirals on hand to take right away should they contract Covid-19.

If the risks of long Covid had been known, would people have reacted differently, especially given the confusion over masks and lockdowns and variants? Perhaps. At the least, many people might not have assumed they were out of the woods just because they didn’t have any of the risk factors.

"We have robust systems in place to manage patients with suspected infectious diseases and follow agreed and tested national guidelines."

"As a precautionary measure, and in line with agreed procedures, the patient will be screened for possible infections and will be kept in isolation.

deadly virus.

The suspected Ebola case in Edinburgh comes around 24 hours after Northampton General Hospital said it was treating a possible case.

that the female patient, who has a history of travel to west Africa, tested negative for the virus.

"Scotland has a robust health protection surveillance system which monitors global disease outbreaks and ensures that we are fully prepared to respond to such situation

ondon's Royal Free Hospital and was in a critical condition although she has since improved.

The virus has killed more than 8,400 people, almost all in West Africa, since it broke out a year ago.

Globally, the numbers can be even worse, and the stakes often higher. “Say a person comes into the hospital in Sierra Leone with a fever and flulike symptoms,” DeRisi says. “After a few days, or a week, they die. What caused that illness? Most of the time, we never find out. Because if the cause isn’t something that we can culture and test for” — like hepatitis, or strep throat — “it basically just stays a mystery.”

It would be better, DeRisi says, to watch for rare cases of mystery illnesses in people, which often exist well before a pathogen gains traction and is able to spread.

Based on a retrospective analysis of blood samples, scientists now know that H.I.V. emerged nearly a dozen times over a century, starting in the 1920s, before it went global.

Zika was a relatively harmless illness before a single mutation, in 2013, gave the virus the ability to enter and damage brain cells.

The beauty of this approach” — running blood samples from people hospitalized all over the world through his system, known as IDseq — “is that it works even for things that we’ve never seen before, or things that we might think we’ve seen but which are actually something new.”

In this scenario, an undiscovered or completely new virus won’t trigger a match but will instead be flagged. (Even in those cases, the mystery pathogen will usually belong to a known virus family: coronaviruses, for instance, or filoviruses that cause hemorrhagic fevers like Ebola and Marburg.)

And because different types of bacteria require specific conditions in order to grow, you also need some idea of what you’re looking for in order to find it.

The same is true of genomic sequencing, which relies on “primers” designed to match different combinations of nucleotides (the building blocks of DNA and RNA).

Even looking at a slide under a microscope requires staining, which makes organisms easier to see — but the stains used to identify bacteria and parasites, for instance, aren’t the same.

The practice that DeRisi helped pioneer to skirt this problem is known as metagenomic sequencing

Unlike ordinary genomic sequencing, which tries to spell out the purified DNA of a single, known organism, metagenomic sequencing can be applied to a messy sample of just about anything — blood, mud, seawater, snot — which will often contain dozens or hundreds of different organisms, all unknown, and each with its own DNA. In order to read all the fragmented genetic material, metagenomic sequencing uses sophisticated software to stitch the pieces together by matching overlapping segments.

The assembled genomes are then compared against a vast database of all known genomic sequences — maintained by the government-run National Center for Biotechnology Information — making it possible for researchers to identify everything in the mix

Traditionally, the way that scientists have identified organisms in a sample is to culture them: Isolate a particular bacterium (or virus or parasite or fungus); grow it in a petri dish; and then examine the result under a microscope, or use genomic sequencing, to understand just what it is. But because less than 2 percent of bacteria — and even fewer viruses — can be grown in a lab, the process often reveals only a tiny fraction of what’s actually there. It’s a bit like planting 100 different kinds of seeds that you found in an old jar. One or two of those will germinate and produce a plant, but there’s no way to know what the rest might have grown into.

Such studies have revealed just how vast the microbial world is, and how little we know about it

“The selling point for researchers is: ‘Look, this technology lets you investigate what’s happening in your clinic, whether it’s kids with meningitis or something else,’” DeRisi said. “We’re not telling you what to do with it. But it’s also true that if we have enough people using this, spread out all around the world, then it does become a global network for detecting emerging pandemics

One study found more than 1,000 different kinds of viruses in a tiny amount of human stool; another found a million in a couple of pounds of marine sediment. And most were organisms that nobody had seen before.

After the Biohub opened in 2016, one of DeRisi’s goals was to turn metagenomics from a rarefied technology used by a handful of elite universities into something that researchers around the world could benefit from

metagenomics requires enormous amounts of computing power, putting it out of reach of all but the most well-funded research labs. The tool DeRisi created, IDseq, made it possible for researchers anywhere in the world to process samples through the use of a small, off-the-shelf sequencer, much like the one DeRisi had shown me in his lab, and then upload the results to the cloud for analysis.

he’s the first to make the process so accessible, even in countries where lab supplies and training are scarce. DeRisi and his team tested the chemicals used to prepare DNA for sequencing and determined that using as little as half the recommended amount often worked fine. They also 3-D print some of the labs’ tools and replacement parts, and offer ongoing training and tech support

The metagenomic analysis itself — normally the most expensive part of the process — is provided free.

But DeRisi’s main innovation has been in streamlining and simplifying the extraordinarily complex computational side of metagenomics

IDseq is also fast, capable of doing analyses in hours that would take other systems weeks.

“What IDseq really did was to marry wet-lab work — accumulating samples, processing them, running them through a sequencer — with the bioinformatic analysis,”

“Without that, what happens in a lot of places is that the researcher will be like, ‘OK, I collected the samples!’ But because they can’t analyze them, the samples end up in the freezer. The information just gets stuck there.”

Meningitis itself isn’t a disease, just a description meaning that the tissues around the brain and spinal cord have become inflamed. In the United States, bacterial infections can cause meningitis, as can enteroviruses, mumps and herpes simplex. But a high proportion of cases have, as doctors say, no known etiology: No one knows why the patient’s brain and spinal tissues are swelling.

When Saha and her team ran the mystery meningitis samples through IDseq, though, the result was surprising. Rather than revealing a bacterial cause, as expected, a third of the samples showed signs of the chikungunya virus — specifically, a neuroinvasive strain that was thought to be extremely rare. “At first we thought, It cannot be true!” Saha recalls. “But the moment Joe and I realized it was chikungunya, I went back and looked at the other 200 samples that we had collected around the same time. And we found the virus in some of those samples as well.”

Until recently, chikungunya was a comparatively rare disease, present mostly in parts of Central and East Africa. “Then it just exploded through the Caribbean and Africa and across Southeast Asia into India and Bangladesh,” DeRisi told me. In 2011, there were zero cases of chikungunya reported in Latin America. By 2014, there were a million.

Chikungunya is a mosquito-borne virus, but when DeRisi and Saha looked at the results from IDseq, they also saw something else: a primate tetraparvovirus. Primate tetraparvoviruses are almost unknown in humans, and have been found only in certain regions. Even now, DeRisi is careful to note, it’s not clear what effect the virus has on people. “Maybe it’s dangerous, maybe it isn’t,” DeRisi says. “But I’ll tell you what: It’s now on my radar.

it reveals a landscape of potentially dangerous viruses that we would otherwise never find out about. “What we’ve been missing is that there’s an entire universe of pathogens out there that are causing disease in humans,” Imam notes, “ones that we often don’t even know exist.”

“The plan was, Let’s let researchers around the world propose studies, and we’ll choose 10 of them to start,” DeRisi recalls. “We thought we’d get, like, a couple dozen proposals, and instead we got 350.”

Metagenomic sequencing is especially good at what scientists call “environmental sampling”: identifying, say, every type of bacteria present in the gut microbiome, or in a teaspoon of seawater.

“When you draw blood from someone who has a fever in Ghana, you really don’t know very much about what would normally be in their blood without fever — let alone about other kinds of contaminants in the environment. So how do you interpret the relevance of all the things you’re seeing?”

Such criticisms have led some to say that metagenomics simply isn’t suited to the infrastructure of developing countries. Along with the problem of contamination, many labs struggle to get the chemical reagents needed for sequencing, either because of the cost or because of shipping and customs holdups

we’re less likely to be caught off-guard. “With Ebola, there’s always an issue: Where’s the virus hiding before it breaks out?” DeRisi explains. “But also, once we start sampling people who are hospitalized more widely — meaning not just people in Northern California or Boston, but in Uganda, and Sierra Leone, and Indonesia — the chance of disastrous surprises will go down. We’ll start seeing what’s hidden.”

Alaska became the first state to make vaccinations available to all adults over the age of 16 earlier this month, followed by Mississippi. Several others have since followed suit, including Arizona, Utah, Indiana, Georgia and West Virginia.

Other states are moving to make more groups eligible ahead of schedule, based on age or underlying conditions.

According to a map released by the White House COVID-19 Response Team on Friday, four states have yet to confirm plans to expand eligibility ahead of the May 1 deadline: New York, Wyoming, Arkansas and South Carolina, where officials have said they are not on track to hit that threshold until May 3.

Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention, said at the briefing that the country has seen an uptick in case counts and hospital admissions, with the most recent 7-day averages showing about 57,000 cases and 4,700 hospitalizations per day, and hospitalizations hovering around 1,000.

The U.S. is administering 2.5 million shots a day at its current pace, Zients said, adding that vaccine makers are "setting and hitting targets." Some 27 million doses went to states, tribes and territories this week.

Johnson & Johnson has accelerated production of its single-shot vaccine and is on track to deliver 11 million doses next week.

Ketamine has been used illegally as a club drug. The medication, which is used in hospitals primarily as an anesthetic, generates an intense high and dissociative effects.

McClain is heard in footage from an officer's body camera telling the officers, "I'm an introvert, please respect the boundaries that I am speaking."

Paramedics arrived and administered ketamine, the letter said. McClain was taken to a hospital but suffered a heart attack on the way, and he was declared brain dead three days later, the letter said.

The report noted McClain's history of asthma and the carotid hold, though the autopsy did not determine whether it contributed to McClain's death.

many who work in meatpacking, farm work and other front-line industries don’t have the option to work from home, and their employers don’t provide them with paid sick leave. 

Biden and Harris’ platform includes a commitment to work with Congress to pass legislation to create a path to citizenship for all undocumented immigrants in the U.S.  

As the coronavirus surges, Latinx and Black people are around four times as likely to be hospitalized as white people, and nearly three times as likely to die,

Last month, France fast-tracked citizenship processes for hundreds of immigrant front-line workers, including health care workers, garbage collectors, housekeepers and cashiers. 

Undocumented immigrants are among those hardest hit by the pandemic since they are disproportionately represented among workers deemed “essential” — from farmworkers to building cleaners — who are risking their lives while millions of Americans stay home.

Patrice Lawrence, co-director of the immigrant group UndocuBlack Network, said legislation recognizing immigrants’ “humanity and our contributions to this country is long overdue” and that a bill protecting undocumented essential workers is “the bare minimum this country can do.”

SEIR models start to fall apart when you think about the underlying causes of the data. You need models that can allow for all possible states, and assess which ones matter for shaping the pandemic’s trajectory over time.

These techniques have enjoyed enormous success ever since they moved out of physics. They’ve been running your iPhone and nuclear power stations for a long time. In my field, neurobiology, we call the approach dynamic causal modelling (DCM). We can’t see brain states directly, but we can infer them given brain imaging data

Epidemiologists currently tackle the inference problem by number-crunching on a huge scale, making use of high-performance computers. Imagine you want to simulate an outbreak in Scotland. Using conventional approaches, this would take you a day or longer with today’s computing resources. And that’s just to simulate one model or hypothesis – one set of parameters and one set of starting conditions.

Using DCM, you can do the same thing in a minute. That allows you to score different hypotheses quickly and easily, and so to home in sooner on the best one.

This is like dark matter in the universe: we can’t see it, but we know it must be there to account for what we can see. Knowing it exists is useful for our preparations for any second wave, because it suggests that targeted testing of those at high risk of exposure to Covid-19 might be a better approach than non-selective testing of the whole population.

Our response as individuals – and as a society – becomes part of the epidemiological process, part of one big self-organising, self-monitoring system. That means it is possible to predict not only numbers of cases and deaths in the future, but also societal and institutional responses – and to attach precise dates to those predictions.

How well have your predictions been borne out in this first wave of infections?For London, we predicted that hospital admissions would peak on 5 April, deaths would peak five days later, and critical care unit occupancy would not exceed capacity – meaning the Nightingale hospitals would not be required. We also predicted that improvements would be seen in the capital by 8 May that might allow social distancing measures to be relaxed – which they were in the prime minister’s announcement on 10 May. To date our predictions have been accurate to within a day or two, so there is a predictive validity to our models that the conventional ones lack.

What do your models say about the risk of a second wave?The models support the idea that what happens in the next few weeks is not going to have a great impact in terms of triggering a rebound – because the population is protected to some extent by immunity acquired during the first wave. The real worry is that a second wave could erupt some months down the line when that immunity wears off.

the important message is that we have a window of opportunity now, to get test-and-trace protocols in place ahead of that putative second wave. If these are implemented coherently, we could potentially defer that wave beyond a time horizon where treatments or a vaccine become available, in a way that we weren’t able to before the first one.

We’ve been comparing the UK and Germany to try to explain the comparatively low fatality rates in Germany. The answers are sometimes counterintuitive. For example, it looks as if the low German fatality rate is not due to their superior testing capacity, but rather to the fact that the average German is less likely to get infected and die than the average Brit. Why? There are various possible explanations, but one that looks increasingly likely is that Germany has more immunological “dark matter” – people who are impervious to infection, perhaps because they are geographically isolated or have some kind of natural resistance

Any other advantages?Yes. With conventional SEIR models, interventions and surveillance are something you add to the model – tweaks or perturbations – so that you can see their effect on morbidity and mortality. But with a generative model these things are built into the model itself, along with everything else that matters.

Are generative models the future of disease modelling?That’s a question for the epidemiologists – they’re the experts. But I would be very surprised if at least some part of the epidemiological community didn’t become more committed to this approach in future, given the impact that Feynman’s ideas have had in so many other disciplines.