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In the Northeast, where case counts are on the rise, adults will be able to register for appointments starting April 1 in Connecticut and April 2 in New Hampshire. On the opposite coast, California announced Thursday that adults ages 50 and older will be eligible for appointments starting April 1, with individuals 16 and older to follow on April 15.Other states are moving to make more groups eligible ahead of schedule, based on age or underlying conditions.

More states will join that list in the coming days. Starting March 29, for example, eligibility will expand to all adults in places like North Dakota, Louisiana, Ohio and Texas. Minnesota and Indiana will similarly expand access before the end of the month.

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.

New Jersey's governor said on Friday that people ages 55 and older, individuals over the age of 16 with intellectual and developmental disabilities, higher education employees and other essential workers will qualify starting April 5. Floridians ages 40 and older will be eligible beginning March 29, officials announced Thursday.

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.

Noting the trajectory with concern, she implored listeners to "take this moment very seriously" and continue following public health guidance.

Friday's announcement comes a day after Biden declared a new goal of getting 200 million shots in arms by his 100th day in office, or the end of April. Federal officials said the country hit his initial target of 100 million doses last Friday, which was his 58th day in office.

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. Zients expressed confidence that it will, and, in doing so, meet its goal of 20 million doses for the month of March.

what the administration should have been doing in January to prepare us for today.

She cites the delay on tests, without which “cases go undetected and people continue to circulate” as a leading issue along with other missed federal government responses—many of which are still not fully operational

The prescient recommendations from experts across disciplines in the period before COVID-19 reached American shores—about testing, equipment, and distancing—make clear that more than any single factor, it was Trump’s squandering of out lead-time which should have been used to prepare for the pandemic that has exacerbated this crisis.

What follows is an annotated timeline revealing the warning signs the administration received and showing how slow the administration was to act on these recommendations.

The Early Years: Warnings Ignored

2017: Trump administrations officials are briefed on an intelligence document titled “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.” That’s right. The administration literally had an actual playbook for what to do in the early stages of a pandemic

February 2018: The Washington Post writes “CDC to cut by 80 percent efforts to prevent global disease outbreak.” The meat of the story is “Countries where the CDC is planning to scale back include some of the world’s hot spots for emerging infectious disease, such as China, Pakistan, Haiti, Rwanda and Congo.”

May 2018: At an event marking the 100 year anniversary of the 1918 pandemic, Borio says “pandemic flu” is the “number 1 health security issue” and that the U.S. is not ready to respond.

One day later her boss, Rear Adm. Timothy Ziemer is pushed out of the administration and the global health security team is disbanded

Beth Cameron, former senior director for global health security on the National Security Council adds: “It is unclear in his absence who at the White House would be in charge of a pandemic,” Cameron said, calling it “a situation that should be immediately rectified.” Note: It was not

January 2019: The director of National Intelligence issues the U.S. Intelligence Community’s assessment of threats to national security. Among its findings:

A novel strain of a virulent microbe that is easily transmissible between humans continues to be a major threat, with pathogens such as H5N1 and H7N9 influenza and Middle East Respiratory Syndrome Coronavirus having pandemic potential if they were to acquire efficient human-to-human transmissibility.”

Page 21: “We assess that the United States and the world will remain vulnerable to the next flu pandemic or large scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.”

September, 2019: The Trump Administration ended the pandemic early warning program, PREDICT, which trained scientists in China and other countries to identify viruses that had the potential to turn into pandemics. According to the Los Angeles Times, “field work ceased when funding ran out in September,” two months before COVID-19 emerged in Wuhan Province, China.

2020: COVID-19 Arrives

anuary 3, 2020: The CDC is first alerted to a public health event in Wuhan, China

January 6, 2020: The CDC issues a travel notice for Wuhan due to the spreading coronavirus

Note: The Trump campaign claims that this marks the beginning of the federal government disease control experts becoming aware of the virus. It was 10 weeks from this point until the week of March 16 when Trump began to change his tone on the threat.

January 10, 2020: Former Trump Homeland Security Advisor Tom Bossert warns that we shouldn’t “jerk around with ego politics” because “we face a global health threat…Coordinate!”

January 18, 2020: After two weeks of attempts, HHS Secretary Alex Azar finally gets the chance to speak to Trump about the virus. The president redirects the conversation to vaping, according to the Washington Post. 

January 21, 2020: Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Disease at the CDC tells reporters, “We do expect additional cases in the United States.”

January 27, 2020: Top White House aides meet with Chief of Staff Mick Mulvaney to encourage greater focus on the threat from the virus. Joe Grogan, head of the White House Domestic Policy Council warns that “dealing with the virus was likely to dominate life in the United States for many months.”

January 28, 2020: Two former Trump administration officials—Gottlieb and Borio—publish an op-ed in the Wall Street Journal imploring the president to “Act Now to Prevent an American Epidemic.” They advocate a 4-point plan to address the coming crisis:

(1) Expand testing to identify and isolate cases. Note: This did not happen for many weeks. The first time more than 2,000 tests were deployed in a single day was not until almost six weeks later, on March 11.

(3) Prepare hospital units for isolation with more gowns and masks. Note: There was no dramatic ramp-up in the production of critical supplies undertaken. As a result, many hospitals quickly experienced shortages of critical PPE materials. Federal agencies waited until Mid-March to begin bulk orders of N95 masks.

January 29, 2020: Trump trade advisor Peter Navarro circulates an internal memo warning that America is “defenseless” in the face of an outbreak which “elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”

January 30, 2020: Dr. James Hamblin publishes another warning about critical PPE materials in the Atlantic, titled “We Don’t Have Enough Masks.”

January 29, 2020: Republican Senator Tom Cotton reaches out to President Trump in private to encourage him to take the virus seriously.

Late January, 2020:  HHS sends a letter asking to use its transfer authority to shift $136 million of department funds into pools that could be tapped for combating the coronavirus. White House budget hawks argued that appropriating too much money at once when there were only a few U.S. cases would be viewed as alarmist.

Trump’s Chinese travel ban only banned “foreign nationals who had been in China in the last 14 days.” This wording did not—at all—stop people from arriving in America from China. In fact, for much of the crisis, flights from China landed in America almost daily filled with people who had been in China, but did not fit the category as Trump’s “travel ban” defined it.

January 31, 2020: On the same day Trump was enacting his fake travel ban, Foreign Policy reports that face masks and latex gloves are sold out on Amazon and at leading stores in New York City and suggests the surge in masks being sold to other countries needs “refereeing” in the face of the coming crisis.

February 4, 2020: Gottlieb and Borio take to the WSJ again, this time to warn the president that “a pandemic seems inevitable” and call on the administration to dramatically expand testing, expand the number of labs for reviewing tests, and change the rules to allow for tests of people even if they don’t have a clear known risk factor.

Note: Some of these recommendations were eventually implemented—25 days later.

February 5, 2020: HHS Secretary Alex Azar requests $2 billion to “buy respirator masks and other supplies for a depleted federal stockpile of emergency medical equipment.” He is rebuffed by Trump and the White House OMB who eventually send Congress a $500 million request weeks later.

February 4 or 5, 2020: Robert Kadlec, the assistant secretary for preparedness and response, and other intelligence officials brief the Senate Intelligence Committee that the virus poses a “serious” threat and that “Americans would need to take actions that could disrupt their daily lives.”

February 5, 2020: Senator Chris Murphy tweets: Just left the Administration briefing on Coronavirus. Bottom line: they aren't taking this seriously enough. Notably, no request for ANY emergency funding, which is a big mistake. Local health systems need supplies, training, screening staff etc. And they need it now.

February 9, 2020: The Washington Post reports that a group of governors participated in a jarring meeting with Dr. Anthony Fauci and Dr. Robert Redfield that was much more alarmist than what they were hearing from Trump. “The doctors and the scientists, they were telling us then exactly what they are saying now,” Maryland Gov. Larry Hogan (R) said.

the administration lifted CDC restrictions on tests. This is a factually true statement. But it elides that fact that they did so on March 3—two critical weeks after the third Borio/Gottlieb op-ed on the topic, during which time the window for intervention had shrunk to a pinhole.

February 20, 2020: Borio and Gottlieb write in the Wall Street Journal that tests must be ramped up immediately “while we can intervene to stop spread.”

February 23, 2020: Harvard School of Public Health professor issues warning on lack of test capability: “As of today, the US remains extremely limited in#COVID19 testing. Only 3 of ~100 public health labs haveCDC test kits working and CDC is not sharing what went wrong with the kits. How to know if COVID19 is spreading here if we are not looking for it.

February 24, 2020: The Trump administration sends a letter to Congress requesting a small dollar amount—between $1.8 billion and $2.5 billion—to help combat the spread of the coronavirus. This is, of course, a pittance

February 25, 2020: Messonier says she expects “community spread” of the virus in the United States and that “disruption to everyday life might be severe.” Trump is reportedly furious and Messonier’s warnings are curtailed in the ensuing weeks.

Trump mocks Congress in a White House briefing, saying “If Congress wants to give us the money so easy—it wasn’t very easy for the wall, but we got that one done. If they want to give us the money, we’ll take the money.”

February 26, 2020: Congress, recognizing the coming threat, offers to give the administration $6 billion more than Trump asked for in order to prepare for the virus.

February 27, 2020: In a leaked audio recording Sen. Richard Burr, chairman of the Intelligence Committee and author of the Pandemic and All-Hazards Preparedness Act (PAHPA) and the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (reauthorization of PAHPA), was telling people that COVID-19 “is probably more akin to the 1918 pandemic.”

March 4, 2020: HHS says they only have 1 percent of respirator masks needed if the virus became a “full-blown pandemic.”

March 3, 2020: Vice President Pence is asked about legislation encouraging companies to produce more masks. He says the Trump administration is “looking at it.”

March 7, 2020: Fox News host Tucker Carlson, flies to Mar-a-Lago to implore Trump to take the virus seriously in private rather than embarrass him on TV. Even after the private meeting, Trump continued to downplay the crisis

March 9, 2020: Tom Bossert, Trump’s former Homeland Security adviser, publishes an op-ed saying it is “now or never” to act. He advocates for social distancing and school closures to slow the spread of the contagion.

Trump says that developments are “good for the consumer” and compares COVID-19 favorably to the common flu.

March 17, 2020: Facing continued shortages of the PPE equipment needed to prevent healthcare providers from succumbing to the virus, Oregon Senators Jeff Merkeley and Ron Wyden call on Trump to use the Defense Production Act to expand supply of medical equipment

March 18, 2020: Trump signs the executive order to activate the Defense Production Act, but declines to use it

At the White House briefing he is asked about Senator Chuck Schumer’s call to urgently produce medical supplies and ventilators. Trump responds: “Well we’re going to know whether or not it’s urgent.” Note: At this point 118 Americans had died from COVID-19.

March 20, 2020: At an April 2nd White House Press Conference, President Trump’s son-in-law Jared Kushner who was made ad hoc point man for the coronavirus response said that on this date he began working with Rear Admiral John Polowczyk to “build a team” that would handle the logistics and supply chain for providing medical supplies to the states. This suggestion was first made by former Trump Administration officials January 28th

March 22, 2020: Six days after calling for a 15-day period of distancing, Trump tweets that this approach “may be worse than the problem itself.”

March 24, 2020: Trump tells Fox News that he wants the country opened up by Easter Sunday (April 12)

As Trump was speaking to Fox, there were 52,145 confirmed cases in the United States and the doubling time for daily new cases was roughly four days.

In the bid to lock in new rules before Jan. 20, Mr. Trump’s team is limiting or sidestepping requirements for public comment on some of the changes and swatting aside critics who say the administration has failed to carry out sufficiently rigorous analysis.

Every administration pushes to complete as much of its agenda as possible when a president’s term is coming to an end, seeking not just to secure its own legacy but also to tie the hands of any successor who tries to undo its work.

If Democrats take control of Congress, they will have the power to reconsider some of these last-minute regulations, through a law last used at the start of Mr. Trump’s tenure by Republicans to repeal certain rules enacted at the end of the Obama administration.

Two main hallmarks of a good regulation is sound analysis to support the alternatives chosen and extensive public comment to get broader opinion

Administration officials said they were simply completing work on issues they have targeted since Mr. Trump took office in 2017 promising to curtail the reach of federal regulation.

Editors’ Picks

But the Trump administration is also working to fill key vacancies on scientific advisory boards with members who will hold their seats far into the next presidential term, committees that play an important role in shaping federal rule making

almost

Workers across the country deserve a chance to fully examine and properly respond to these potentially radical changes,

The Departments of Labor and Homeland Security are using a tactic known as an interim final rule, more typically reserved for emergencies, to skip the public comment period entirely and to immediately enact two regulations that put much tougher restrictions on work visas for immigrants with special skills. The rule change is part of the administration’s longstanding goal of limiting immigration.

The Homeland Security Department is also moving, again with an unusually short 30-day comment period, to adopt a rule that will allow it to collect much more extensive biometric data from individuals applying for citizenship, including voice, iris and facial recognition scans, instead of just the traditional fingerprint scan.

A third proposed new Homeland Security rule would require sponsors of immigrants to do more to prove they have the financial means to support the individual they are backing, including three years’ worth of credit reports, credit scores, income tax returns and bank records.

Unlike most of the efforts the administration has pushed, the rules intended to tighten immigration standards would expand federal regulations, instead of narrowing them

The Environmental Protection Agency, which since the start of the Trump administration has been moving at a high speed to rewrite federal regulations, is expected to complete work in the weeks that remain in Mr. Trump’s term on two of the nation’s most important air pollution rules: standards that regulate particulates and ozone emitted by factories, power plants, car exhaust and other sources.

But it is nonetheless pushing to have the rule finished before the end of Mr. Trump’s first term, limiting the period of public comment to 30 days, half the amount of time that agencies are supposed to offer.

Mr. Trump signed an executive order last year directing the Transportation Department to enact the rule within 13 months — even before it had been formally proposed.

The change was backed by the railroad and natural gas industry, which has donated millions of dollars to Mr. Trump, after construction of pipelines had been blocked or slowed after protests by environmentalists.

the proposal provoked an intense backlash from a diverse array of prominent public safety officials.

"China has really been at the forefront of success in conversion of all vehicles to electric vehicles, especially buses," says Heather Thompson, chief executive officer of the Institute for Transportation and Development Policy (ITDP), a non-profit focusing on sustainable transport solutions. "The rest of the world is trying to do the same, but I think China is really out ahead."

At the time of China's 2001 entry into the World Trade Organisation, the international automotive industry was dominated by European, US and Japanese brands. These companies had spent decades perfecting internal combustion engine technology. To compete, Beijing decided to find a new track for its auto industry: making cars that did not use conventional engines.

That same year, the central government launched the so-called "863 plan" for EV research and development. There were numerous practical challenges, however, in the way of mass electrification. Not many manufacturers were making new energy vehicles, buyers were few and there was a lack of charging infrastructure in existence. The answer? Buses.

"The Chinese government adopted a very smart strategy," says Liu Daizong, ITDP's East Asia director. "They realised quite early on that they should drive [the EV industry] through electric buses," he notes, since their public service status meant Beijing "could have a strong hand on their electrification".

"Bus routes were fixed. This means when an electric bus finished a round, it could return to the depot to recharge," explains Xue Lulu, a mobility manager at the World Resources Institute (WRI) China. The typical daily mileage of a Chinese bus ­– 200km (120 miles) – was a realistic range for battery makers to meet.

The following year, the country began its large-scale rollout of new energy buses, with the "Ten Cities and Thousand Vehicles" programme. Over three years, the programme aimed to provide 10 cities with financial subsidies to promote 1,000 public-sector new energy vehicles in each, annually. Its goal was to have 10% new energy vehicles in the country by the end of 2012.

Strong policy support from both central and regional governments "gave manufacturers confidence in setting up production lines and stepping up research efforts," says Liu.

Together, these strong and consistent government signals encouraged Chinese manufacturers to expand their EV production capacity, bring down costs and improve their technologies. One such company was Build Your Dream, better known as BYD. The Shenzhen-based firm, the world's largest EV maker in 2022, ballooned its business a decade before by supplying electric buses and taxis for China's EV pilot cities.

"Back then, most buses used diesel, which was a main source of nitrogen oxides (NOx) emissions," says Xue, referring to the air pollution that smothered Beijing and other Chinese cities in the early 2010s. Yet in 2013, a new plan from central government cited tackling air pollution as one of the reasons for rolling out EVs.

This addition proved to be critical: it not only connected EV uptake with people's health, it also indirectly tied the e-bus campaign to local officials' political performance, as the central government would soon hand air-quality targets to all provinces.

The years 2013 and 2014 proved to be important for China's EV push. For the first time, the central government made EV purchase subsidies available to individual consumers, not just the public sector, opening the floodgate to private ownership. Additionally, it offered discounted electricity tariffs to bus operators to make sure the cost of running electric buses would be "significantly lower than" that of their oil or gas-powered equivalents.

The new economic push, plus local government's determination to battle air pollution, generated great enthusiasm for e-buses. By the end of 2015, the number of EV pilot cities rocketed from 25 to 88. In the same year, the central government set a target of 200,000 new energy buses on the road by 2020 and announced a plan to phase out its subsidies for fossil-fuel-powered buses.

To further stimulate the market, many cities devised various local policies on top of national incentives. For example, Shenzhen, a southern city with a population of more than 17 million, encouraged government agencies to work with private companies to create a full range of renting mechanisms for bus operators

Different cities' bus operators also designed different charging strategies. "Buses in Shenzhen had bigger batteries, so they normally charged overnight," says Xue, of WRI China. Between 2016 and 2020, Shanghai, another electric bus hub, subsidised the electricity e-buses used -- regardless of the hours of the day -- to give them more flexibility in charging.

Generous financial support did lead to problems. In 2016, an EV subsidy fraud shook China, with some bus operators found to have exaggerated the number of e-buses they had purchased. So that same year Beijing shifted its EV subsidy rules so bus operators could only receive financial support when a bus's mileage reached 30,000km (19,000 miles).

one year later, the government announced the so-called "dual-credit" policy. This allowed new energy vehicle makers to rake up credits which they could sell for cash to those needing to offset "negative credits" generated from making conventional cars.

it wasn't only China's buses that had benefitted.China's e-bus campaign helped create a big and stable market for its wider EV industry, brought down the costs and created economies of scale. In 2009, the year the e-bus campaign was rolled out, the total number of new energy vehicles sold stood at 2,300; by 2022, it was 6.9 million, analysis by Huang Zheng,

By 2022, the country had also built the world's largest EV charging network, with 1.8 million public charging stations – or two-thirds of the global total – and 3.4 million private equivalents. This means that on average, there is one charging pillar for every 2.5 of China's 13.1 million new energy vehicles.

Cold weather is a problem, too, as it can make a battery's charging time longer and its range shorter. The reason China has not achieved 100% electrification for its buses is its northern regions, which have harsh winters, says Xue.

To make e-buses truly "green", they should also be charged with renewable power, Wang says. But last year coal power still accounted for 58.4% of China's energy mix, according to the China Electricity Council, a trade body..

Globally, however, China is now in a league of its own in uptake of e-buses. By 2018, about 421,000 of the world's 425,000 electric buses were located in China; Europe had about 2,250 and the US owned around 300. A

But earlier this year, the European Commission announced a zero-emission target for all new city buses by 2030. And some countries are increasing their overall funding for the transition.

In 2020, the European Commission approved Germany's plan to double its aid for e-buses to €650m (£558m/$707m), then again in 2021 to €1.25 billion euros (£1.07m/$1.3bn). And the UK, which last year had the largest electric bus fleet in Europe with 2,226 pure electric and hybrid buses, has announced another £129m ($164m) to help bus operators buy zero-emissions fleets.

Countries have thus responded to China's manufacturing lead in divergent ways. "While the US has opted for a more competitive angle by fostering its own e-bus production, regions like Latin America are more open to trade with China due to a more friendly trading setup through [China's] Belt and Road Initiative,"

In order to avoid direct competition from Chinese manufacturers, the US has come up with a "school-bus strategy", says Liu. The Chinese don't make the iconic yellow vehicles, so this could ignite American e-bus manufacturing and create a local industry chain, he suggests. Backed by the US Environmental Protection Agency's $5bn (£3.9bn) Clean School Bus Programme, the national effort has so far committed to providing 5,982 buses.

In contrast, many Latin American cities, such as the Colombian capital of Bogota and the Chilean capital of Santiago, are greening their traditional bus sectors with the help of Chinese manufacturers, who are the largest providers to the region. In 2020, Chile became the country that had the most Chinese e-buses outside of China, and this year Santiago's public transport operator announced it has ordered 1,022 e-buses from Beijing-based Foton Motor, the biggest overseas deal the firm had received.

Chinese manufacturers are likely to receive a lot more orders from Chile and its neighbours in this decade. According to latest research by the global C40 Cities network, the number of electric buses in 32 Latin American cities is expected to increase by more than seven times by 2030, representing an investment opportunity of over $11.3bn (£8.9bn)

In June 2023, BloombergNEF forecast half of the world's buses to be entirely battery-powered by 2032, a decade ahead of cars. And by 2026, 36% and 24% of municipal bus sales in Europe and the US, respectively, are expected to be EVs as they begin to catch up with China

To meet the global climate goals set by the Paris Agreement, simply switching the world's existing bus fleets might not be enough. According to ITDP, the cumulative greenhouse gas emissions from urban passenger transport globally must stay below the equivalent of 66 gigatonnes CO2 between 2020 and 2050 for the world to meet the 1.5C temperature goal. This emissions limit will only be possible when the world not only adopts electric buses, but goes through a broader shift away from private transport

"We can't just focus on [replacing] the buses that exist, we need to actually get many, many more buses on the streets," Thompson adds. She and her team estimate that the world would need about 10 million more buses through 2030, and 46 million more buses cumulatively through 2050, to make public transport good enough to have a shot at achieving the Paris Agreement. And all those buses will need to be electric.

In China therefore, even though EVs are being sold faster than ever, its central government has instructed cities to encourage public transport use, as well as walking and riding bikes.

In Wang's hometown, meanwhile, which has just over three million residents, the local government has gone one step further and made all bus rides free. All citizens need to do is to swipe an app, with no charge, to get onto the bus. "My aunt loves taking buses now," says Wang. "She says it is so convenient."

“It’s disappointing that after months of engagement, we still do not have the documents and information necessary to answer those basic questions,”

On Twitter, many of Mr. Trump’s followers used the site to amplify and spread false allegations of election fraud, while connecting with other Trump supporters and conspiracy theorists using the site. And on YouTube, some users broadcast the events of Jan. 6 using the platform’s video streaming technology.

In the year since the events of Jan. 6, social media companies have been heavily scrutinized for whether their sites played an instrumental role in organizing the attack.

In the months surrounding the 2020 election, employees inside Meta raised warning signs that Facebook posts and comments containing “combustible election misinformation” were spreading quickly across the social network, according to a cache of documents and photos reviewed by The New York Times.

Frances Haugen, a former Facebook employee turned whistle-blower, said the company relaxed its safeguards too quickly after the election, which then led it to be used in the storming of the Capitol.

In the days after the attack, Reddit banned a discussion forum dedicated to former President Donald J. Trump, where tens of thousands of Mr. Trump’s supporters regularly convened to express solidarity with him.

After months of discussions with the companies, only the four large corporations were issued subpoenas on Thursday, because the committee said the firms were “unwilling to commit to voluntarily and expeditiously” cooperating with its work.

The committee said letters to the four firms accompanied the subpoenas.The panel said YouTube served as a platform for “significant communications by its users that were relevant to the planning and execution of Jan. 6 attack on the United States Capitol,” including livestreams of the attack as it was taking place.

The panel said Facebook and other Meta platforms were used to share messages of “hate, violence and incitement; to spread misinformation, disinformation and conspiracy theories around the election; and to coordinate or attempt to coordinate the Stop the Steal movement.”

“Meta has declined to commit to a deadline for producing or even identifying these materials,” Mr. Thompson wrote to Mark Zuckerberg, Meta’s chief executive.

The panel said it was focused on Reddit because the platform hosted the r/The_Donald subreddit community that grew significantly before migrating in 2020 to the website TheDonald.win, which ultimately hosted significant discussion and planning related to the Jan. 6 attack.

“Unfortunately, the select committee believes Twitter has failed to disclose critical information,” the panel stated.

In recent years, Big Tech and Washington have had a history of butting heads. Some Republicans have accused sites including Facebook, Instagram and Twitter of silencing conservative voices.

The Federal Trade Commission is investigating whether a number of tech companies have grown too big, and in the process abused their market power to stifle competition. And a bipartisan group of senators and representatives continues to say sites like Facebook and YouTube are not doing enough to curb the spread of misinformation and conspiracy theories.

Meta said that it had “produced documents to the committee on a schedule committee staff requested — and we will continue to do so.”

The panel has interviewed more than 340 witnesses and issued dozens of subpoenas, including for bank and phone records.

But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.

by next year, more than half of Medicare recipients will be in a private plan.

a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers

Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete

Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist

Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.

Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

few analysts expect major legislative or regulatory changes to the program.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

Dr. Shi’s group was fascinated by how coronaviruses jump from species to species. To find viruses, they took samples from bats and other animals, as well as from sick people living near animals carrying these viruses or associated with the wildlife trade. Much of this work was conducted in partnership with the EcoHealth Alliance, a U.S.-based scientific organization that, since 2002, has been awarded over $80 million in federal funding to research the risks of emerging infectious diseases.

Their research showed that the viruses most similar to SARS‑CoV‑2, the virus that caused the pandemic, circulate in bats that live roughly 1,000 miles away from Wuhan. Scientists from Dr. Shi’s team traveled repeatedly to Yunnan province to collect these viruses and had expanded their search to Southeast Asia. Bats in other parts of China have not been found to carry viruses that are as closely related to SARS-CoV-2.

When the Covid-19 outbreak was detected, Dr. Shi initially wondered if the novel coronavirus had come from her laboratory, saying she had never expected such an outbreak to occur in Wuhan.

The SARS‑CoV‑2 virus is exceptionally contagious and can jump from species to species like wildfire. Yet it left no known trace of infection at its source or anywhere along what would have been a thousand-mile journey before emerging in Wuhan.

The year before the outbreak, the Wuhan institute, working with U.S. partners, had proposed creating viruses with SARS‑CoV‑2’s defining feature

The laboratory pursued risky research that resulted in viruses becoming more infectious: Coronaviruses were grown from samples from infected animals and genetically reconstructed and recombined to create new viruses unknown in nature. These new viruses were passed through cells from bats, pigs, primates and humans and were used to infect civets and humanized mice (mice modified with human genes). In essence, this process forced these viruses to adapt to new host species, and the viruses with mutations that allowed them to thrive emerged as victors.

Worse still, as the pandemic raged, their American collaborators failed to publicly reveal the existence of the Defuse proposal. The president of EcoHealth, Peter Daszak, recently admitted to Congress that he doesn’t know about virus samples collected by the Wuhan institute after 2015 and never asked the lab’s scientists if they had started the work described in Defuse.

By 2019, Dr. Shi’s group had published a database describing more than 22,000 collected wildlife samples. But external access was shut off in the fall of 2019, and the database was not shared with American collaborators even after the pandemic started, when such a rich virus collection would have been most useful in tracking the origin of SARS‑CoV‑2. It remains unclear whether the Wuhan institute possessed a precursor of the pandemic virus.

In 2021, The Intercept published a leaked 2018 grant proposal for a research project named Defuse, which had been written as a collaboration between EcoHealth, the Wuhan institute and Ralph Baric at the University of North Carolina, who had been on the cutting edge of coronavirus research for years. The proposal described plans to create viruses strikingly similar to SARS‑CoV‑2.

Coronaviruses bear their name because their surface is studded with protein spikes, like a spiky crown, which they use to enter animal cells. The Defuse project proposed to search for and create SARS-like viruses carrying spikes with a unique feature: a furin cleavage site — the same feature that enhances SARS‑CoV‑2’s infectiousness in humans, making it capable of causing a pandemic. Defuse was never funded by the United States.

owever, in his testimony on Monday, Dr. Fauci explained that the Wuhan institute would not need to rely on U.S. funding to pursue research independently.

While it’s possible that the furin cleavage site could have evolved naturally (as seen in some distantly related coronaviruses), out of the hundreds of SARS-like viruses cataloged by scientists, SARS‑CoV‑2 is the only one known to possess a furin cleavage site in its spike. And the genetic data suggest that the virus had only recently gained the furin cleavage site before it started the pandemic.

Ultimately, a never-before-seen SARS-like virus with a newly introduced furin cleavage site, matching the description in the Wuhan institute’s Defuse proposal, caused an outbreak in Wuhan less than two years after the proposal was drafted.

When the Wuhan scientists published their seminal paper about Covid-19 as the pandemic roared to life in 2020, they did not mention the virus’s furin cleavage site — a feature they should have been on the lookout for, according to their own grant proposal, and a feature quickly recognized by other scientists.

At the Wuhan Institute of Virology, a team of scientists had been hunting for SARS-like viruses for over a decade, led by Shi Zhengl

In May, citing failures in EcoHealth’s monitoring of risky experiments conducted at the Wuhan lab, the Biden administration suspended all federal funding for the organization and Dr. Daszak, and initiated proceedings to bar them from receiving future grants. In his testimony on Monday, Dr. Fauci said that he supported the decision to suspend and bar EcoHealth.

Separately, Dr. Baric described the competitive dynamic between his research group and the institute when he told Congress that the Wuhan scientists would probably not have shared their most interesting newly discovered viruses with him. Documents and email correspondence between the institute and Dr. Baric are still being withheld from the public while their release is fiercely contested in litigation.

In the end, American partners very likely knew of only a fraction of the research done in Wuhan. According to U.S. intelligence sources, some of the institute’s virus research was classified or conducted with or on behalf of the Chinese military.

In the congressional hearing on Monday, Dr. Fauci repeatedly acknowledged the lack of visibility into experiments conducted at the Wuhan institute, saying, “None of us can know everything that’s going on in China, or in Wuhan, or what have you. And that’s the reason why — I say today, and I’ve said at the T.I.,” referring to his transcribed interview with the subcommittee, “I keep an open mind as to what the origin is.”

The Wuhan lab pursued this type of work under low biosafety conditions that could not have contained an airborne virus as infectious as SARS‑CoV‑2.

Labs working with live viruses generally operate at one of four biosafety levels (known in ascending order of stringency as BSL-1, 2, 3 and 4) that describe the work practices that are considered sufficiently safe depending on the characteristics of each pathogen. The Wuhan institute’s scientists worked with SARS-like viruses under inappropriately low biosafety conditions.

​​Biosafety levels are not internationally standardized, and some countries use more permissive protocols than others.

In one experiment, Dr. Shi’s group genetically engineered an unexpectedly deadly SARS-like virus (not closely related to SARS‑CoV‑2) that exhibited a 10,000-fold increase in the quantity of virus in the lungs and brains of humanized mice. Wuhan institute scientists handled these live viruses at low biosafety levels, including BSL-2.

Even the much more stringent containment at BSL-3 cannot fully prevent SARS‑CoV‑2 from escaping. Two years into the pandemic, the virus infected a scientist in a BSL-3 laboratory in Taiwan, which was, at the time, a zero-Covid country. The scientist had been vaccinated and was tested only after losing the sense of smell. By then, more than 100 close contacts had been exposed. Human error is a source of exposure even at the highest biosafety levels, and the risks are much greater for scientists working with infectious pathogens at low biosafety.

An early draft of the Defuse proposal stated that the Wuhan lab would do their virus work at BSL-2 to make it “highly cost-effective.” Dr. Baric added a note to the draft highlighting the importance of using BSL-3 to contain SARS-like viruses that could infect human cells, writing that “U.S. researchers will likely freak out.”

Years later, after SARS‑CoV‑2 had killed millions, Dr. Baric wrote to Dr. Daszak: “I have no doubt that they followed state determined rules and did the work under BSL-2. Yes China has the right to set their own policy. You believe this was appropriate containment if you want but don’t expect me to believe it. Moreover, don’t insult my intelligence by trying to feed me this load of BS.”

SARS‑CoV‑2 is a stealthy virus that transmits effectively through the air, causes a range of symptoms similar to those of other common respiratory diseases and can be spread by infected people before symptoms even appear. If the virus had escaped from a BSL-2 laboratory in 2019, the leak most likely would have gone undetected until too late.

One alarming detail — leaked to The Wall Street Journal and confirmed by current and former U.S. government officials — is that scientists on Dr. Shi’s team fell ill with Covid-like symptoms in the fall of 2019. One of the scientists had been named in the Defuse proposal as the person in charge of virus discovery work. The scientists denied having been sick.

The hypothesis that Covid-19 came from an animal at the Huanan Seafood Market in Wuhan is not supported by strong evidence.

In December 2019, Chinese investigators assumed the outbreak had started at a centrally located market frequented by thousands of visitors daily. This bias in their search for early cases meant that cases unlinked to or located far away from the market would very likely have been missed

To make things worse, the Chinese authorities blocked the reporting of early cases not linked to the market and, claiming biosafety precautions, ordered the destruction of patient samples on January 3, 2020, making it nearly impossible to see the complete picture of the earliest Covid-19 cases. Information about dozens of early cases from November and December 2019 remains inaccessible.

A pair of papers published in Science in 2022 made the best case for SARS‑CoV‑2 having emerged naturally from human-animal contact at the Wuhan market by focusing on a map of the early cases and asserting that the virus had jumped from animals into humans twice at the market in 2019

More recently, the two papers have been countered by other virologists and scientists who convincingly demonstrate that the available market evidence does not distinguish between a human superspreader event and a natural spillover at the market.

Furthermore, the existing genetic and early case data show that all known Covid-19 cases probably stem from a single introduction of SARS‑CoV‑2 into people, and the outbreak at the Wuhan market probably happened after the virus had already been circulating in humans.

Not a single infected animal has ever been confirmed at the market or in its supply chain. Without good evidence that the pandemic started at the Huanan Seafood Market, the fact that the virus emerged in Wuhan points squarely at its unique SARS-like virus laboratory.

With today’s technology, scientists can detect how respiratory viruses — including SARS, MERS and the flu — circulate in animals while making repeated attempts to jump across species. Thankfully, these variants usually fail to transmit well after crossing over to a new species and tend to die off after a small number of infections

investigators have not reported finding any animals infected with SARS‑CoV‑2 that had not been infected by humans. Yet, infected animal sources and other connective pieces of evidence were found for the earlier SARS and MERS outbreaks as quickly as within a few days, despite the less advanced viral forensic technologies of two decades ago.

Even though Wuhan is the home base of virus hunters with world-leading expertise in tracking novel SARS-like viruses, investigators have either failed to collect or report key evidence that would be expected if Covid-19 emerged from the wildlife trade. For example, investigators have not determined that the earliest known cases had exposure to intermediate host animals before falling ill.

No antibody evidence shows that animal traders in Wuhan are regularly exposed to SARS-like viruses, as would be expected in such situations.

In previous outbreaks of coronaviruses, scientists were able to demonstrate natural origin by collecting multiple pieces of evidence linking infected humans to infected animals

In contrast, virologists and other scientists agree that SARS‑CoV‑2 required little to no adaptation to spread rapidly in humans and other animals. The virus appears to have succeeded in causing a pandemic upon its only detected jump into humans.

it was a SARS-like coronavirus with a unique furin cleavage site that emerged in Wuhan, less than two years after scientists, sometimes working under inadequate biosafety conditions, proposed collecting and creating viruses of that same design.

a laboratory accident is the most parsimonious explanation of how the pandemic began.

Given what we now know, investigators should follow their strongest leads and subpoena all exchanges between the Wuhan scientists and their international partners, including unpublished research proposals, manuscripts, data and commercial orders. In particular, exchanges from 2018 and 2019 — the critical two years before the emergence of Covid-19 — are very likely to be illuminating (and require no cooperation from the Chinese government to acquire), yet they remain beyond the public’s view more than four years after the pandemic began.

it is undeniable that U.S. federal funding helped to build an unprecedented collection of SARS-like viruses at the Wuhan institute, as well as contributing to research that enhanced them.

Advocates and funders of the institute’s research, including Dr. Fauci, should cooperate with the investigation to help identify and close the loopholes that allowed such dangerous work to occur. The world must not continue to bear the intolerable risks of research with the potential to cause pandemics.

A successful investigation of the pandemic’s root cause would have the power to break a decades-long scientific impasse on pathogen research safety, determining how governments will spend billions of dollars to prevent future pandemics. A credible investigation would also deter future acts of negligence and deceit by demonstrating that it is indeed possible to be held accountable for causing a viral pandemic

Last but not least, people of all nations need to see their leaders — and especially, their scientists — heading the charge to find out what caused this world-shaking event. Restoring public trust in science and government leadership requires it.

The U.S. logs fewer than 1,000 annual deaths out of millions of documented cases

this is more a nauseating nuisance than a public-health crisis. In most people, norovirus triggers, at most, a few miserable days of GI distress that can include vomiting, diarrhea, and fevers, then resolves on its own; the keys are to stay hydrated and avoid spreading it to anyone vulnerabl

norovirus is the most common cause of foodborne illness in the United States.)

the virus is far more deadly in parts of the world with limited access to sanitation and potable water.

Still, fighting norovirus isn’t easy, as plenty of parents can attest. The pathogen, which prompts the body to expel infectious material from both ends of the digestive tract, is seriously gross and frustratingly hardy. Even the old COVID standby, a spritz of hand sanitizer, doesn’t work against it—the virus is encased in a tough protein shell that makes it insensitive to alcohol.

At an extreme, a single gram of feces—roughly the heft of a jelly bean—could contain as many as 5.5 billion infectious doses, enough to send the entire population of Eurasia sprinting for the toilet.

norovirus mainly targets the gut, and spreads especially well when people swallow viral particles that have been released in someone else’s vomit or stool.

direct contact with those substances, or the food or water they contaminate, may not even be necessary: Sometimes people vomit with such force that the virus gets aerosolized; toilets, especially lidless ones, can send out plumes of infection

If the spittle finding holds for humans, then talking, singing, and laughing in close proximity could be risky too.

Once emitted into the environment, norovirus particles can persist on surfaces for days—making frequent hand-washing and surface disinfection key measures to prevent spread

Handshakes and shared meals tend to get dicey during outbreaks, along with frequently touched items such as utensils, door handles, and phones.

One 2012 study pointed to a woven plastic grocery bag as the source of a small outbreak among a group of teenage soccer players; the bag had just been sitting in a bathroom used by one of the girls when she fell sick the night before.

Once a norovirus transmission chain begins, it can be very difficult to break. The virus can spread before symptoms start, and then for more than a week after they resolve

Once the virus arrives, the entire family is almost sure to be infected. Baldridge, who has two young children, told me that her household has weathered at least four bouts of norovirus in the past several years.

Roughly 20 percent of European populations, for instance, are genetically resistant to common norovirus strains. “So you can hope,” Frenck told me. For the rest of us, it comes down to hygiene

Altan-Bonnet recommends diligent hand-washing, plus masking to ward off droplet-borne virus. Sick people should isolate themselves if they can. “And keep your saliva to yourself,” she told me.

The family fastidiously scrubbed their hands with hot water and soap, donned disposable gloves when touching shared surfaces, and took advantage of the virus’s susceptibility to harsh chemicals and heat. When her son threw up on the floor, Cameron sprayed it down with bleach; when he vomited on his quilt, she blasted it twice in the washing machine on the sanitizing setting, then put it through the dryer at a super high temp

After three years of COVID, the world has gotten used to thinking about infections in terms of airways. “We need to recalibrate,” Bhumbra told me, “and remember that other things exist.”

In the 19th century, the secularization of Western society led to the secularization of pain. It was no longer a passion to be endured but a sensation to be quashed.

The concept of pain as a purely physical phenomenon reached its zenith in the 1990s

having pain designated a “fifth vital sign,” alongside blood pressure, temperature and breathing and heart rate.

This coincided with the release of long-acting opioids like OxyContin. Doctors believed they now had an effective remedy for their patients’ suffering

looking back it’s clear that using opioids to treat chronic pain — backaches, bum knees and the like — might well be considered the worst medical mistake of our era.

ecades of research suggests that opiates provide little to no benefit for chronic noncancer pain

Why is this? Studies have shown that opioids can reduce patients’ pain thresholds.

They can also result in a condition called opioid-induced hyperalgesia, in which people feel more and more pain as they are prescribed higher and higher doses of opioids

the mind does play a pivotal role in the experience of pain. After a pain signal reaches the brain, it undergoes significant reprocessing.

How much something hurts can vary depending on factors like your expectations, your mood and how distracted you are

pain is contagious and transmittable.

Conditions like depression and anxiety greatly increase the chance of developing chronic pain, while patients who experience pain are at high risk of developing depression or anxiety

there is considerable overlap in the areas of the brain that deal with pain and emotion.

Objectively, there is no doubt that illnesses and injuries can cause immense suffering. The question is how severe that suffering is, and how long it lasts

pain sensitivity varies significantly among people, most likely as a result of genetic differences.

rug companies greatly underplayed the risks of opioids, while billions of dollars in marketing told people that pills were the only answer to their ailments.

future doctors should be taught that pain is part of the story of the person who suffers from it, not just a separate physical phenomenon.

this education should incorporate ways to avoid prescribing opioids for chronic use.

Perhaps the most important tool physicians need to manage pain is empathy.

Physical therapy that doesn’t just manipulate joints but also addresses the context pain comes alive in, encourages optimism and builds emotional resilience has been found to be more effective.

unfortunately our health system encourages doctors to see as many patients as possible as quickly as possible. We need to change how physicians are paid in order to give them the time to really talk with patients about their pain.

I felt that the pain was my body’s way of telling me that something was wrong, and I didn’t want to silence that voice with a temporary fix.

What pulled me out after almost a year of agony was not just rigorous physical therapy that molded my spine back into shape but also the kindness of my friends, my family and my future wife.

a spiritual and emotional experience alleviated through prayers rather than prescriptions.

The cost: The participating counties and municipalities are contributing to a $4bn statewide spend, including Miami Beach’s $400m Forever Bond, a $1bn stormwater plan and $250m of improvements to Broward county’s sewage systems to protect against flooding and seawater seepage. In the Keys, many consider the estimated $60m a mile cost of raising roads too expensive.

The threat: Saltwater from sea level rise is seeping further inland through Florida’s porous limestone bedrock and contaminating underground freshwater supplies, notably in the Biscayne aquifer, the 4,000-sq mile shallow limestone basin that provides drinking water to millions in southern Florida. Years of over-pumping and toxic runoff from farming and the sugar industry in central Florida and the Everglades have worsened the situation. The Florida department of environmental protection warned in March that “existing sources of water will not adequately meet the reasonable beneficial needs for the next 20 years”. A rising water table, meanwhile, has exacerbated problems with south Florida’s ageing sewage systems. Since December, millions of gallons of toxic, raw sewage have spilled on to Fort Lauderdale’s streets from a series of pipe failures.

The cost: The Everglades restoration plan was originally priced at $7.8bn, rose to $10.5bn, and has since ballooned to $16.4bn. Donald Trump’s proposed 2021 federal budget includes $250m for Everglades restoration. The estimated $1.8bn cost of the reservoir will be split between federal and state budgets.

Possible solutions

The cost: With homeowners and businesses largely bearing their own costs, the specific amount spent on “hurricane-proofing” in Florida is impossible to know. A 2018 Pew research study documented $1.3bn in hazard mitigation grants from federal and state funding in 2017, along with a further $8bn in post-disaster grants. Florida is spending another $633m from the US Department of Housing and Urban Development on resiliency planning.

Wildlife and habitat loss The threat: Florida’s native flora and fauna are being devastated by climate change, with the Florida Natural Areas Inventory warning that a quarter of the 1,200 species it tracks is set to lose more than half their existing habitat, and the state’s beloved manatees and Key deer are at risk of extinction. Warmer and more acidic seas reduce other species’ food stocks and exacerbate the deadly red-tide algal blooms that have killed incalculable numbers of fish, turtles, dolphins and other marine life. Bleaching and stony coral tissue disease linked to the climate crisis threaten to hasten the demise of the Great Florida Reef, the only living coral reef in the continental US. Encroaching saltwater has turned Big Pine Key, a crucial deer habitat, into a ghost forest.

As for the Key deer, of which fewer than 1,000 remain, volunteers leave clean drinking water to replace salt-contaminated watering holes as herds retreat to higher ground. A longer-term debate is under way on the merits and ethics of relocating the species to other areas of Florida or the US.

Coastal erosion The threat: Tourist brochures showcase miles of golden, sandy beaches in South Florida, but the reality is somewhat different. The Florida department of environmental protection deems the entire coastline from Miami to Cape Canaveral “critically eroded”, the result of sea level rise, historically high tides and especially storm surges from a succession of powerful hurricanes. In south-eastern Florida’s Palm Beach, Broward, Miami-Dade and Monroe counties, authorities are waging a continuous war on sand loss, eager to maintain their picture-perfect image and protect two of their biggest sources of income, tourism dollars and lucrative property taxes from waterfront homes and businesses.

In the devastating hurricane season just one year before, major storms named Harvey, Maria and Irma combined to cause damage estimated at $265bn. Scientists have evidence the climate crisis is causing cyclones to be more powerful, and intensify more quickly, and Florida’s position at the end of the Atlantic Ocean’s “hurricane alley” makes it twice as vulnerable as any other state.

With the other option abandoning beaches to the elements, city and county commissions have little choice but costly replenishment projects with sand replacement and jetty construction. Federal law prohibits the importation of cheaper foreign sand, so the municipalities must source a more expensive alternative from US markets, often creating friction with residents who don’t want to part with their sand. Supplementary to sand replenishment, the Nature Conservancy is a partner in a number of nature-based coastal defense projects from West Palm Beach to Miami.

benefited from 61,000 cubic yards of new sand this year at a cost of $16m. Statewide, Florida spends an average $50m annually on beach erosion.

The threat: “Climate gentrification” is a buzzword around south Florida, a region barely 6ft above sea level where land has become increasingly valuable in elevated areas. Speculators and developers are eyeing historically black, working-class and poorer areas, pushing out long-term residents and replacing affordable housing with upscale developments and luxury accommodations that only the wealthy can afford.

No study has yet calculated the overall cost of affordable housing lost to the climate crisis. Private developers will bear the expense of mitigating the impact on the neighborhood – $31m in Magic City’s case over 15 years to the Little Haiti Revitalization Trust, largely for new “green” affordable housing. The University of Miami’s housing solutions lab has a $300,000 grant from JPMorgan to report on the impact of rising seas to South Florida’s affordable housing stocks and recommend modifications to prevent it from flooding and other climate events. A collaboration of not-for-profit groups is chasing $75m in corporate funding for affordable housing along the 70-mile south Florida rail trail from Miami to West Palm Beach, with the first stage, a $5m project under way to identify, build and renovate 300 units.

Florida has long been plagued by political leadership more in thrall to the interests of big industry than the environment. As governor from 2011 to 2019, Rick Scott, now a US senator, slashed $700m from Florida’s water management budget, rolled back environmental regulations and enforcement, gave a free ride to polluters, and flip-flopped over expanding offshore oil drilling. The politician who came to be known as “Red Tide Rick”, for his perceived inaction over 2018’s toxic algae bloom outbreaks, reportedly banned the words “climate change” and “global warming” from state documents.

Last month, state legislators approved the first dedicated climate bill. It appears a promising start for a new administration, but activists say more needs to be done. In January, the Sierra Club awarded DeSantis failing grades in an environmental report card, saying he failed to protect Florida’s springs and rivers and approved new roads that threatened protected wildlife.

The cost: Florida’s spending on the environment is increasing. The state budget passed last month included $650m for Everglades restoration and water management projects (an instalment of DeSantis’s $2.5bn four-year pledge) and $100m for Florida Forever. A $100m bridge project jointly funded by the state and federal governments will allow the free flow of water under the Tamiami Trail for the first time in decades.

Florida has woken up to the threat of climate change but it is not yet clear how effective the response will be. The challenges are innumerable, the costs immense and the political will to fix or minimize the issues remains questionable, despite recent progress. At stake is the very future of one of the largest and most diverse states in the nation, in terms of both its population and its environment. Action taken now will determine its survival.

“It’s easy to misunderstand [medical information],” says Wolf, who is also founding director of the medical school’s Health Literacy and Learning Program. Some will be too ashamed to say so while others won’t realize they missed a critical detail

“Covid has brought to fore the vast inequities in society,” says cardiologist Jared W. Magnani, associate professor of medicine at the University of Pittsburgh School of Medicine. If you don’t understand words such as “immunocompromised” or “comorbidity,” for instance, you miss cautionary information that could save your life.

But low health literacy cuts across all demographics

“Given the right headache or stress about a sick child, [gaps in comprehension] can happen to anyone. When you don’t feel well, you don’t think as clearly.”

Health literacy is not about reading skills or having a college degree. It means you know how to ask a doctor the right questions, read a food label, understand what you’re signing on a consent form, and have the numeric ability to analyze relative risks when making treatment decisions.

“None of this is intuitive,”

Magnani has patients who don’t believe they have high blood pressure because their lives aren’t stressful. Or respond with “Great news!” when he tells them a test result was “positive.”

Misunderstandings over hospital discharge or medication instructions can undo the best medical care. Yet, nearly 1 in 3 of the 17,309 people in a study by researchers from the Agency for Healthcare Research and Quality (AHRQ) responded that instructions from a health provider were “not easy to understand.”

Wolf says he was surprised during a study on reading prescription labels by how many high school graduates could not follow medication instructions. “Being able to read the label doesn’t mean you can interpret it,”

“Take two pills, twice daily” was frequently misunderstood. Replacing the awkward wording with “Take two in the morning and two at bedtime” would solve that, Wolf says. Health-care professionals “need to meet people where they’re at.”

Health literacy is the best predictor of someone’s health status, some physicians maintain. Decades of research consistently link low health literacy to poorer medical outcomes, more hospitalizations and emergency room visits, and higher health-care costs

Anatomy knowledge is another gap.

Explaining medical risk and probability is another challenge.

Over 3,000 studies found that health education materials far exceed the eighth-grade reading level of the average American, too. Beyond not using plain language (“joint pain,” not “arthritis”), texts assume the patient knows more than they do. Telling people to sanitize surfaces to kill the coronavirus means little if you don’t tell them what to use and how to do it, Caballero says. “What does it mean to practice good respiratory hygiene?” she asks. “These are not actionable instructions.”

Doctors are encouraged to employ the teach-back technique, meaning the doctor asks the patient to repeat what they’ve heard rather than simply asking, “Do you understand?”

In addition, “health care is becoming a harder test,” Wolf says. Health billing and insurance options can be impossible to navigate. We have an aging population with more chronic conditions and cognitive decline. And more is being asked of patients such as testing their own blood sugar or blood pressure.

University of Virginia law professor Michael Doran — who held tax policy roles at the Treasury Department under Presidents Bill Clinton and George W. Bush — calls the current state of affairs “the great American retirement fraud.”

Secure 2.0 would take the fraud to a new level: Its congressional supporters have engaged in Enron-style accounting gimmicks to mask the bill’s effects on deficit

from the outset, IRAs were a generous gift to the upper class. At the time, very few low- and middle-income individuals could afford to stash $1,500 in a retirement account each year — median income for U.S. households was $11,100 in 1974 — so the people taking full advantage of the new IRAs tended to be relatively rich

since the benefit was structured as a deduction, it was worth more to taxpayers in higher income brackets.

In the nearly half-century since, Congress has continually expanded the amount that individuals can pour into tax-deferred savings accounts.

Now, the JCT estimates that 401(k)s and other similar defined-contribution plans cost the federal government $200 billion per year.

individuals can contribute up to $6,000 per year to an IRA ($7,000 if age 50 or older), plus $20,500 to a 401(k) ($27,000 for 50-year-olds and up), with their employers potentially chipping in to bring the 401(k) total to $61,000 ($67,500 for the over-50 set).

In 2018, the most recent year for which data is available, 58 percent of taxpayers with wage income made no contribution to 401(k)-style plans, and less than 4 percent bumped up against the contribution cap.

As of 2020, approximately 63 percent of U.S. households had no such accounts.

(The very largest IRAs, like PayPal co-founder Peter Thiel’s reported $5 billion account, result from a different loophole: the ability of founders and early-stage investors to stuff IRAs with start-up stock

When JCT released data last summer showing that 28,615 taxpayers had accumulated $5 million or more in IRAs, lawmakers cried foul. Rep. Richard Neal (D-Mass.), who as chairman of the Ways and Means Committee is the top tax writer in the House, lamented the “exploitation” of IRAs. “IRAs are intended to help Americans achieve long-term financial security, not to enable those who already have extraordinary wealth to avoid paying their fair share in taxes,”

I calculated that an individual who made the maximum 401(k) contributions since 1990, investing exclusively in an S&P 500 index fund, would have more than $7 million in her account today.

Forbes revealed more than a decade ago that Thiel and another PayPal co-founder were using their IRAs to shelter entrepreneurial earnings; the Government Accountability Office flagged the IRA-stuffing phenomenon in 2014; and rather than clamping down, lawmakers from both parties sat on their hands.)

The Secure 2.0 bill, sponsored by Neal, doubles down on the inequities of the status quo. It will inevitably result in even more of the mega-IRAs that Neal and other Democrats decry.

Under current law, taxpayers must begin to take withdrawals from their 401(k)s and traditional IRAs at age 72. (It had been 70½ before Secure 1.0, signed into law by President Donald Trump in 2019, raised the age by a year and a half.

Secure 2.0 would bump that up to age 75. The change would mean that taxpayers with supersize IRAs could enjoy three extra years of tax-free growth before they needed to take money out

Lower-income retirees wouldn’t benefit because they don’t have the luxury of holding off on withdrawals, which they need to cover living expenses.

Another provision would lift the cap on 401(k) catch-up contributions at ages 62, 63 and 64 from $6,500 to $10,000. Factoring in employer matching contributions, that would raise the maximum 401(k) inflow to $71,000 per year.

if lawmakers were genuinely concerned about retirement security for people who need it, they wouldn’t start by aiding taxpayers who can afford to save more each year than most Americans earn. The higher limit on catch-up contributions will simply allow high-income taxpayers to race further ahead.

The top-weighted benefits of Secure 2.0 might be tolerable if they were offset by other tax increases on the rich — if this were all just moving money from one deep pocket to another. But the items audaciously labeled as “revenue provisions” in the bill generate revenue as real as Monopoly money.

The Rothification provisions in Secure 2.0 bring $35 billion of revenue into the 10-year window — ostensibly offsetting the cost of the bill’s giveaways — but the $35 billion is pure make-believe: It comes at the expense of an equivalent amount of revenue down the road.

If lawmakers from either party were truly concerned about the plight of low-income retirees, they would focus on strengthening Social Security, which actually provides a safety net for older people, rather than adding more deficit-financed bells and whistles to retirement accounts for the rich.

Leaders in the deeply conservative Utah say they need the law to protect women's sports. As cultural shifts raise LGBTQ visibility, the lawmakers argue that, without their intervention, more transgender athletes with apparent physical advantages could eventually dominate the field and change the nature of women's sports.

he team is also partially owned by NBA all-star Dwyane Wade, who has a transgender daughter.

The looming threat of a lawsuit worries school districts and the Utah High School Athletic Association, which has said it lacks the funds to defend the policy in court. Later Friday, lawmakers are expected to change the bill so state money would cover legal fees.

The group Visit Salt Lake, which hosts conferences, shows and events, said the override could cost the state $50 million in lost revenue. The Utah-based DNA-testing genealogy giant Ancestry.com also urged the Legislature to find another way. The American Principles Project is confident that states with bans won't face boycotts like North Carolina did after limiting public restrooms transgender people could use. It focused on legislation in populous, economic juggernaut states like Texas and Florida that would be harder to boycott, Schilling said.

Friday's deliberations came after more than a year of debate and negotiation between social conservatives and LGBTQ advocates. Republican sponsor Rep. Kera Birkeland worked with Cox and civil rights activists at Equality Utah before introducing legislation that would require transgender student-athletes to go before a government-appointed commission.

The proposal, although framed as a compromise, failed to gain traction on either side. LGBTQ advocates took issue with Republican politicians appointing commission members and evaluation criteria that included body measurements such as hip-to-knee ratio.

But the ban won support from a vocal conservative base that has particular sway in Utah's state primary season. Even with primaries looming, however, some Republicans stood with Cox to reject the ban.

Ready for more bad infectious diseases news? There's an outbreak of bird flu making its way into U.S. poultry flocks. If the virus continues to spread, it could affect poultry prices — already higher amid widespread inflation. The price of chicken breasts this week averaged $3.63 per pound at U.S. supermarkets — up from $3.01 a week earlier and $2.42 at this time last year, the Agriculture Department says.

The latest data from the USDA show 59 confirmed sites of avian flu across commercial and backyard flocks in 17 states since the start of the year. That figure includes chickens, turkey and other poultry. The USDA identified a case of avian flu in a wild bird in mid-January, the first detection of the virus in wild birds in the U.S. since 2016. Wild birds can spread the virus to commercial and backyard flocks. By Feb. 9, the virus had been identified in a commercial flock in Indiana.

The last major avian flu outbreak in the U.S. was from December 2014 to June 2015, when more than 50 million chickens and turkeys either died from highly pathogenic avian influenza (HPAI) or were destroyed to stop its spread.

Whether the 2022 avian flu will affect the price of eggs and poultry depends on how widespread it becomes, says Ron Kean, a poultry science expert at the University of Wisconsin-Madison Department of Animal and Dairy Sciences. "In 2015, we did see quite an increase in egg prices," Kean told Wisconsin Public Radio. "The chicken meat wasn't severely affected at that time. We did see quite a loss in turkeys, so turkey prices went up. So, we'll see. If a lot of farms contract this, then we could see some real increases in price."

For producers who suspect their flock may be affected by avian flu, the USDA has a guide to the warning signs, including a sudden increase in bird deaths, lack of energy and appetite, and a decrease in egg production. If a flock is found to be infected by bird flu, the USDA moves quickly — within 24 hours — to assist producers to destroy the flock and prevent the virus from spreading.

A new Virginia state law prohibiting mask mandates in public schools does not apply to 12 students with disabilities whose parents challenged the law, a federal judge has ruled. Last month, the parents of 12 students across Virginia asked the court to halt enforcement of the law, saying it violated their rights under the federal American with Disabilities Act. The law, signed by newly elected Republican Gov. Glenn Youngkin, went into effect March 1; it gives parents a say over whether their children should wear masks in school.

The group of parents have children whose health conditions range from cystic fibrosis to asthma that put them at heightened risk for COVID-19.

The American Civil Liberties Union, which was one of several legal organizations that filed on behalf of the plaintiffs, said the injunction served as a "blueprint."

In a statement, Virginia Attorney General Jason Miyares said the ruling affirms that "parents have the right to make choices for their children."

When Judge Katanji Brown Jackson entered the Senate chamber this week to face questions on her readiness to join the Supreme Court, she did so as the first Black woman in the nation's history to be nominated to that position. For many Black law students and professionals, including a group of 150 who traveled from across the country to watch the historic hearing, Jackson's rise to likely associate justice gives a message of profound hope for what they too might one day be able to accomplish.

Dudley was one of 100 law students selected nationwide to attend a series of events and watch parties for Jackson's nomination, hosted by the progressive organization, Demand Justice. The group also included 50 public defenders — a nod to Jackson's own background in that field. "I see a lot of myself in her. I see a lot of my friends in her, and I wanted to be there to support," Dudley said, calling Jackson "overly qualified to sit on the Supreme Court."

The cohort of legal professionals cheered on Jackson as she faced questions from Republicans about her past cases, particularly those relating to child sex abuse, and on what school of thought she would bring to determining the constitutionality of high-profile cases. Republicans had vowed to oppose President Joe Biden's nominees to the court, and when news of Justice Stephen Breyer's imminent retirement broke, the GOP quickly mobilized to attack potential nominees who might replace the longtime liberal justice on the bench.

Particularly, some sentencing decisions in child pornography cases drew GOP fire. But Jackson's measured responses throughout the three days of questioning solidified the support of many onlookers, who reveled in what it would mean to have a Black woman sit on the bench for the first time in the court's 233-year history. "The fact of the matter is that I'm the father of three black girls, right? And to be able to tell them that finally, someone who is Black — female nonetheless — is finally on the precipice of a mountain that has never been climbed before by any other Black woman, is huge," said Edrius Stagg, a third-year law student at Southern University Law Center in Baton Rouge.

Sen. Joe Manchin of West Virginia — whose break from Democrats on a number of politically fraught votes had worried some as to whether he would support Biden's nominee — announced on Friday he would vote in favor of Jackson's confirmation, all but assuring her path to join the bench.

For some, the optics of seeing Jackson — a Black woman — defend her credentials to a group of largely white, predominantly male detractors, was a familiar scene. It has played out, students said, in workplaces the world over and across the socioeconomic spectrum.

Booker called the attacks on Jackson's record "dangerous" and "disingenuous," noting the complexities of cases that had been boiled down to their basest points in order to damage Jackson's image.

"I'm not gonna let my joy be stolen," he continued. "Because I know, you and I, we appreciate something that we get that a lot of my colleagues don't." And while Jackson's opponents peppered her with politically polarizing questions, her supporters grew even more convinced that Jackson was qualified for the job. "To see her hold her composure and just answer the questions just to the best of her capabilities was just really great to see," said Jasmine McMillion, a third-year law student at Florida Agricultural and Mechanical University College of Law.

Granted, the 1980 act does not apply to the conduct of Supreme Court justices. But the act fails to say what to do when a judge engages in misconduct before becoming a Supreme Court justice. Here, the Judicial Council argued that Kavanaugh’s elevation to the Supreme Court was an “intervening event” under the 1980 act and its accompanying rules, and that “a misconduct proceeding can be concluded because of ‘intervening events.’ ”

Unfortunately, the Judicial Council truncated the relevant rule, which allows for a complaint to be dismissed if “intervening events render some or all of the allegations moot or make remedial action impossible.” Kavanaugh’s elevation to the Supreme Court did not render moot the questionable behavior that helped win him that seat. Nor is remedial action impossible now that Judge Kavanaugh is Justice Kavanaugh. Brett Kavanaugh can still issue the kind of full apology he has avoided up until now, and he can recuse himself from highly partisan cases (those with Trump as a party, for example).

In order to let Kavanaugh off the hook, the Judicial Council skipped around relevant commentary stating that “as long as the subject of a complaint performs judicial duties, a complaint alleging judicial conduct must be addressed.” Here, the Judicial Council interpreted “judicial duties” to refer only to duties of judges covered under the 1980 act — leading the council to the strained conclusion that a Supreme Court justice does not perform “judicial duties.” Instead of this tortured reasoning, I’d say we’ve appended yet another exception to the adage that no one is above the law.

"Women in West Virginia smoked during pregnancy more than five times as often as women in the states with the lowest prevalence,"

The researchers also found that prevalence of smoking during pregnancy varied by age and race. The prevalence was highest among women 20 to 24 at 10.7%, followed by women 15 to 19 at 8.5% and 25 to 29 at 8.2%.

The prevalence also was highest among non-Hispanic American Indian or Alaska Native women at 16.7%, followed by non-Hispanic white women at 10.5%, non-Hispanic black women at 6%, Hispanic women at 1.8% and non-Hispanic Asian women at 0.6%.

"We still have a serious issue with infant mortality -- prematurity and infant mortality are clearly linked to cigarette smoking, as is low birth weight -- and when you begin to explain these things to patients, it really does appear to make a difference to them," he said.Brown pointed out that some of the states in the new CDC report with the highest prevalence of smoking during pregnancy also tend to have high rates of infant mortality. A CDC data brief released in January showed that, between 2013 and 2015, West Virginia and Kentucky had infant mortality rates higher than the overall national rate.

they’re also used as talking points by politicians who are working to make it more difficult for the EPA and other federal agencies to use science in their regulatory decision-making, under the guise of basing policy on “sound science.” Science’s virtues are being wielded against it.

The sound science tactic exploits a fundamental feature of the scientific process: Science does not produce absolute certainty. Contrary to how it’s sometimes represented to the public, science is not a magic wand that turns everything it touches to truth. Instead, it’s a process of uncertainty reduction, much like a game of 20 Questions.

“Our criticisms are founded in a confidence in science,” said Steven Goodman, co-director of the Meta-Research Innovation Center at Stanford and a proponent of open science. “That’s a fundamental difference — we’re critiquing science to make it better. Others are critiquing it to devalue the approach itself.”

alls to base public policy on “sound science” seem unassailable if you don’t know the term’s history. The phrase was adopted by the tobacco industry in the 1990s to counteract mounting evidence linking secondhand smoke to cancer.