npr--2020-02-16--5 Years After Indiana's Historic HIV Outbreak, Many Rural Places Remain At Risk

5 Years After Indiana 's Historic HIV Outbreak , Many Rural Places Remain At Risk Ethan Howard cradled his prized Martin-brand guitar , strumming gently as he sang of happiness he thought he 'd never find .
With support from his family and community , the 26-year-old is making his way as a musician after emerging from the hell of addiction , disease and stigma .
The former intravenous drug user was among the first of 235 people in the southern Indiana community of Austin , Ind.
, to be diagnosed in the worst drug-fueled HIV outbreak ever to hit @ @ @ @ @ @ @ after the outbreak , Howard counts himself among the three-quarters of patients here whose HIV is so well controlled it 's undetectable , meaning they ca n't spread it through sex .
He 's sober in a place that has new addiction treatment centers , a syringe exchange and five times more addiction support groups than before the outbreak .
But as this city of 4,100 recovers , much of the rest of the country fails to apply its lessons .
The Centers for Disease Control and Prevention deemed 220 U.S. counties vulnerable @ @ @ @ @ @ @ rates , the volume of prescription opioid sales and other statistics tied to injecting drugs .
Yet a Kaiser Health News analysis shows that fewer than a third of them have working syringe exchanges .
Such programs , which make clean needles available to drug users , have been found to reduce the spread of HIV and Hepatitis C and are supported in the Trump administration 's national effort to end the HIV epidemic within a decade .
Still , local backlash often stymies efforts to start such exchanges , even in Indiana @ @ @ @ @ @ @ one , and this , despite the fact that there 's federal funding up for grabs that could help them expand .
And rural places in states such as Missouri , West Virginia and Kentucky are still plagued by the raw ingredients that led to Austin 's tragedy : addiction , despair , poverty , doctor shortages and sparse drug treatment .
All this threatens to stall the administration 's HIV goals , which are championed by two prominent figures who responded to Austin 's outbreak : Indiana 's former governor Vice President @ @ @ @ @ @ @ commissioner , Dr. Jerome Adams , now the U.S. surgeon general .
Since Austin 's 2015 crisis , drug-fueled outbreaks have occurred other communities , some with syringe exchanges and some without .
`` When you have these outbreaks , they affect other states and counties .
It 's a domino effect , '' says Dr. Rupa Patel , an HIV prevention researcher at Washington University in St. Louis .
`` We have to learn from them .
Once you fall behind , you ca n't catch up . ''
Fields of corn @ @ @ @ @ @ @ off Interstate 65 between Louisville , Kentucky , and Indianapolis .
The city has been battered by decades of economic blows , but it retains a small-town charm , with its shop-lined , one-stoplight Main Street .
Before the outbreak , addiction to the potent opioid painkiller Opana swept through the community .
People took to melting pills and injecting them , and needle sharing was common .
Local women were caught up in sex work to pay for drugs .
In some homes nearby , health officials later discovered , three generations @ @ @ @ @ @ @ adults , their parents and grandparents .
Yet help was scarce .
Austin had no addiction treatment centers and just one doctor .
Dwindling government funding in 2013 led Planned Parenthood in nearby Scottsburg to close after years of providing HIV testing and education .
So , for residents like Ethan Howard , addiction led to getting infected with HIV .
After he was prescribed the painkiller Lortab for a football injury in high school , the teen began craving opioids .
Eventually , he discovered Opana , which was plentiful on the @ @ @ @ @ @ @ .
His mom sent him for addiction treatment during his senior year , and he got sober .
But after his girlfriend gave birth to a stillborn boy in 2014 , he turned back to drugs .
He tested positive for HIV in March 2015 .
He cried with his mom in her car .
That was the month after Indiana health officials said they 'd identified 30 HIV cases in the county that previously reported three within a decade .
Austin was the outbreak 's epicenter .
The initial response was slow @ @ @ @ @ @ @ syringe exchange programs , which were illegal in Indiana .
It took him 29 days after the outbreak was announced to sign an executive order allowing a state-supervised syringe program .
By then , HIV cases had risen to 79 .
`` He waited till it was too little , too late .
These needle exchanges were put into place in the most grudging manner , '' says Gregg Gonsalves , an HIV researcher at Yale University .
`` It was a disaster that did n't need to happen . ''
Gonsalves cited @ @ @ @ @ @ @ having a syringe exchange before the outbreak could have decreased HIV incidence there by 90 % .
A study he led , published in 2018 , estimated that simply testing for and tracking HIV when hepatitis C spiked around 2010 could have kept HIV cases there below 10 .
Instead , cases skyrocketed .
The rate of infection was so high that Dr. Tom Frieden , then the CDC director , said at the time that Austin 's HIV incidence rate exceeded those of countries in sub-Saharan Africa .
He estimated lifetime treatment @ @ @ @ @ @ @ were diagnosed — would reach $ 100 million .
What ultimately curbed the outbreak were solutions rooted in the community .
Scott County 's syringe exchange was part of a `` one-stop shop , '' where people could also get drug treatment referrals , free HIV testing and other services .
More people were referred to Medicaid , which had recently been expanded in Indiana .
Police , health and recovery workers , community activists and faith leaders joined forces .
`` More connections are being made , '' says Jacob Howell , @ @ @ @ @ @ @ pastor of the Church of the New Covenant in Austin .
`` The message to other communities is to tear down your walls , put your prejudices aside . ''
Surgeon General Adams has said lasting change happens locally .
When he traveled to Austin as Indiana 's health commissioner , he listened to the sheriff 's concerns about needles littering public property and met with church leaders to ease worries that syringe programs might enable drug use .
Dealing with the outbreak was more about relationships than science , he said during @ @ @ @ @ @ @ , a Washington-based free-market think tank .
`` I knew we 'd never be successful without ensuring that those trusted community leaders and advocates were invested in part of the solution . ''
Lessons learned — and not learned in other states Austin 's outbreak became a catalyst for action in some places .
Kentucky 's legislature voted to allow syringe programs in 2015 , and Ohio subsequently made it easier for local health boards to develop them .
Officials said that helped them respond to a cluster of HIV cases in the @ @ @ @ @ @ @ County , West Virginia , by contrast , recently pulled back on its preventive efforts .
Cabell was among counties that the CDC deemed vulnerable to an outbreak .
Dr. Michael Kilkenny , physician director of the Cabell-Huntington Health Department , says Austin 's experience spurred his community to open a syringe program in September 2015 that eventually averaged 1,000 to 1,200 visits a month .
But after political backlash halted a program in nearby Charleston , Cabell imposed restrictions on its program in 2018 to stave off a similar closure .
People @ @ @ @ @ @ @ others or use the exchange if they lived outside the county or the city of Huntington .
Visits dropped by half .
Looking back , Kilkenny says it was `` the worst time we could 've done that . ''
Cabell wound up with more than 75 HIV cases , one of the biggest rural outbreaks other than the one in Austin , Indiana .
Officials then lifted the restrictions , scaled up efforts linking people to testing and treatment and launched an HIV anti-stigma campaign .
Other places on the CDC 's @ @ @ @ @ @ @ an outbreak .
Missouri , for instance , has 13 vulnerable counties and a ban on syringe exchanges .
Washington University 's Patel says Missouri 's failure to expand Medicaid leaves some at-risk people uninsured .
Missouri health officials say they are taking several steps to prevent HIV , such as counseling residents in vulnerable counties , providing HIV testing at health agencies and having disease intervention specialists connect people who are tested to additional help .
But legislation to allow syringe exchanges was unsuccessful in Missouri last year , as were similar @ @ @ @ @ @ @ many people vulnerable in these places .
Avoiding another HIV crisis is not rocket science , Gonsalves says : `` We need to use everything we have that we know works . ''
In Austin , that multipronged approach is underway as those affected reclaim their lives .
Howard is well enough that he can practice his music every day until his voice gets hoarse and his fingers hurt .
He performs around the region and dreams of touring nationally .
And he 's writing a song about moving through addiction and toward @ @ @ @ @ @ @ proven a lot of people wrong , '' he says , fiddling with his guitar pick .
`` I 'm making my grandpa happy and my grandma happy .
They 're both in heaven now , but I know they 're proud of me . ''
Kaiser Health News is a nonprofit news service covering health issues .
It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente .

5 Years After Indiana's Historic HIV Outbreak, Many Rural Places Remain At Risk
Enlarge this image toggle caption Luke Sharrett/Kaiser Health News Luke Sharrett/Kaiser Health News
Ethan Howard cradled his prized Martin-brand guitar, strumming gently as he sang of happiness he thought he'd never find.
With support from his family and community, the 26-year-old is making his way as a musician after emerging from the hell of addiction, disease and stigma. The former intravenous drug user was among the first of 235 people in the southern Indiana community of Austin, Ind., to be diagnosed in the worst drug-fueled HIV outbreak ever to hit rural America.
Now, five years after the outbreak, Howard counts himself among the three-quarters of patients here whose HIV is so well controlled it's undetectable, meaning they can't spread it through sex. He's sober in a place that has new addiction treatment centers, a syringe exchange and five times more addiction support groups than before the outbreak.
But as this city of 4,100 recovers, much of the rest of the country fails to apply its lessons. The Centers for Disease Control and Prevention deemed 220 U.S. counties vulnerable to similar outbreaks because of overdose death rates, the volume of prescription opioid sales and other statistics tied to injecting drugs.
Yet a Kaiser Health News analysis shows that fewer than a third of them have working syringe exchanges. Such programs, which make clean needles available to drug users, have been found to reduce the spread of HIV and Hepatitis C and are supported in the Trump administration's national effort to end the HIV epidemic within a decade.
Still, local backlash often stymies efforts to start such exchanges, even in Indiana where only 9 of 92 counties have one, and this, despite the fact that there's federal funding up for grabs that could help them expand. And rural places in states such as Missouri, West Virginia and Kentucky are still plagued by the raw ingredients that led to Austin's tragedy: addiction, despair, poverty, doctor shortages and sparse drug treatment.
toggle caption Luke Sharrett/Kaiser Health News
All this threatens to stall the administration's HIV goals, which are championed by two prominent figures who responded to Austin's outbreak: Indiana's former governor Vice President Mike Pence and the former state health commissioner, Dr. Jerome Adams, now the U.S. surgeon general.
Since Austin's 2015 crisis, drug-fueled outbreaks have occurred other communities, some with syringe exchanges and some without.
"When you have these outbreaks, they affect other states and counties. It's a domino effect," says Dr. Rupa Patel, an HIV prevention researcher at Washington University in St. Louis. "We have to learn from them. Once you fall behind, you can't catch up."
Hard lessons from Austin, Ind.
Fields of corn and soybeans surround Austin, located just off Interstate 65 between Louisville, Kentucky, and Indianapolis. The city has been battered by decades of economic blows, but it retains a small-town charm, with its shop-lined, one-stoplight Main Street.
Before the outbreak, addiction to the potent opioid painkiller Opana swept through the community. People took to melting pills and injecting them, and needle sharing was common. Local women were caught up in sex work to pay for drugs. In some homes nearby, health officials later discovered, three generations had shot up Opana together: young adults, their parents and grandparents.
Yet help was scarce. Austin had no addiction treatment centers and just one doctor. Dwindling government funding in 2013 led Planned Parenthood in nearby Scottsburg to close after years of providing HIV testing and education.
So, for residents like Ethan Howard, addiction led to getting infected with HIV. After he was prescribed the painkiller Lortab for a football injury in high school, the teen began craving opioids. Eventually, he discovered Opana, which was plentiful on the streets of Austin and surrounding Scott County.
His mom sent him for addiction treatment during his senior year, and he got sober. But after his girlfriend gave birth to a stillborn boy in 2014, he turned back to drugs. He tested positive for HIV in March 2015. He cried with his mom in her car.
That was the month after Indiana health officials said they'd identified 30 HIV cases in the county that previously reported three within a decade. Austin was the outbreak's epicenter.
The initial response was slow. Pence, then governor, opposed syringe exchange programs, which were illegal in Indiana. It took him 29 days after the outbreak was announced to sign an executive order allowing a state-supervised syringe program. By then, HIV cases had risen to 79.
"He waited till it was too little, too late. These needle exchanges were put into place in the most grudging manner," says Gregg Gonsalves, an HIV researcher at Yale University. "It was a disaster that didn't need to happen."
Gonsalves cited a recent Brown University study that found having a syringe exchange before the outbreak could have decreased HIV incidence there by 90%. A study he led, published in 2018, estimated that simply testing for and tracking HIV when hepatitis C spiked around 2010 could have kept HIV cases there below 10.
Instead, cases skyrocketed. The rate of infection was so high that Dr. Tom Frieden, then the CDC director, said at the time that Austin's HIV incidence rate exceeded those of countries in sub-Saharan Africa. He estimated lifetime treatment costs — even before all 235 people were diagnosed — would reach $100 million.
What ultimately curbed the outbreak were solutions rooted in the community. Scott County's syringe exchange was part of a "one-stop shop," where people could also get drug treatment referrals, free HIV testing and other services. More people were referred to Medicaid, which had recently been expanded in Indiana. Police, health and recovery workers, community activists and faith leaders joined forces.
"More connections are being made," says Jacob Howell, a former drug user who is now pastor of the Church of the New Covenant in Austin. "The message to other communities is to tear down your walls, put your prejudices aside."
Surgeon General Adams has said lasting change happens locally. When he traveled to Austin as Indiana's health commissioner, he listened to the sheriff's concerns about needles littering public property and met with church leaders to ease worries that syringe programs might enable drug use.
Dealing with the outbreak was more about relationships than science, he said during a January talk at the CATO Institute, a Washington-based free-market think tank. "I knew we'd never be successful without ensuring that those trusted community leaders and advocates were invested in part of the solution."
Lessons learned — and not learned in other states
Austin's outbreak became a catalyst for action in some places. Kentucky's legislature voted to allow syringe programs in 2015, and Ohio subsequently made it easier for local health boards to develop them. Officials said that helped them respond to a cluster of HIV cases in the Cincinnati-Northern Kentucky area in 2018.
Cabell County, West Virginia, by contrast, recently pulled back on its preventive efforts.
Cabell was among counties that the CDC deemed vulnerable to an outbreak. Dr. Michael Kilkenny, physician director of the Cabell-Huntington Health Department, says Austin's experience spurred his community to open a syringe program in September 2015 that eventually averaged 1,000 to 1,200 visits a month.
But after political backlash halted a program in nearby Charleston, Cabell imposed restrictions on its program in 2018 to stave off a similar closure. People could no longer pick up needles for others or use the exchange if they lived outside the county or the city of Huntington. Visits dropped by half.
Looking back, Kilkenny says it was "the worst time we could've done that." Cabell wound up with more than 75 HIV cases, one of the biggest rural outbreaks other than the one in Austin, Indiana.
Officials then lifted the restrictions, scaled up efforts linking people to testing and treatment and launched an HIV anti-stigma campaign.
Other places on the CDC's vulnerable counties list have so far escaped an outbreak. Missouri, for instance, has 13 vulnerable counties and a ban on syringe exchanges. Washington University's Patel says Missouri's failure to expand Medicaid leaves some at-risk people uninsured.
Missouri health officials say they are taking several steps to prevent HIV, such as counseling residents in vulnerable counties, providing HIV testing at health agencies and having disease intervention specialists connect people who are tested to additional help.
But legislation to allow syringe exchanges was unsuccessful in Missouri last year, as were similar bills in Iowa and Arizona, leaving many people vulnerable in these places.
Avoiding another HIV crisis is not rocket science, Gonsalves says: "We need to use everything we have that we know works."
In Austin, that multipronged approach is underway as those affected reclaim their lives.
Howard is well enough that he can practice his music every day until his voice gets hoarse and his fingers hurt. He performs around the region and dreams of touring nationally. And he's writing a song about moving through addiction and toward hope.
"I feel I've proven a lot of people wrong," he says, fiddling with his guitar pick. "I'm making my grandpa happy and my grandma happy. They're both in heaven now, but I know they're proud of me."
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.


npr--2020-02-15--Storm Dennis, Massive Bomb Cyclone, Hits United Kingdom

Across the United Kingdom , people are experiencing another weekend of strong winds , heavy rain and potential flooding as Storm Dennis hits the region .
Two people have died off the coast of southeast England , The Associated Press reports .
Their bodies were recovered from the storm 's rough seas .
The U.K. national meteorological service , known as the Met Office , issued several heavy rain warnings for areas of England and Wales .
`` Storm Dennis will bring another very unsettled spell of weather this weekend with a risk of flooding , particularly in parts of @ @ @ @ @ @ @ , where snowmelt will add to the flood risk , '' Steve Willington , chief meteorologist for the Met Office , said in a statement .
Travel disruptions are also expected to increase .
Hundreds of flights to and from Britain were canceled .
Planes arriving earlier on Saturday faced tough landing conditions .
The Met Office also said that bus and train services are likely to be delayed or canceled .
Difficult driving conditions and road closures are also expected .
Storm Dennis is now one of the five strongest nontropical cyclones @ @ @ @ @ @ @ , according to The Washington Post .
The storm intensified rapidly over the ocean after combining with another bomb cyclone that had hit Iceland .
A minimum central air pressure of 920 millibars was recorded on Saturday , according to the National Oceanic and Atmospheric Administration 's Ocean Prediction Center .
Lower air pressures mean stronger storms .
The current pressure is similar to that seen in Category 4 hurricanes .
The Ocean Prediction Center reportedly said that as the storm strengthens into Sunday , the region can expect to see winds up @ @ @ @ @ @ @ heights of more than 100 feet .
Storm Dennis comes just days after Storm Ciara hit northern England , causing flooding and power outages .
At least eight people died across Europe from that storm .
With the ground still saturated , officials worry that Storm Dennis will cause even more flooding and property damage .
On Saturday , about 145 British army personnel and reservists helped set up barricades and repair others that were damaged in the West Yorkshire region in northern England , the AP reports .
`` Our armed forces @ @ @ @ @ @ @ and communities whenever they need it , '' British Defense Secretary Ben Wallace said told the news service .
`` The rapid response of the army today will help with provision of flood relief to local communities in West Yorkshire . ''

Storm Dennis, Massive Bomb Cyclone, Hits United Kingdom
Enlarge this image toggle caption Jeff J. Mitchell/Getty Images Jeff J. Mitchell/Getty Images
Across the United Kingdom, people are experiencing another weekend of strong winds, heavy rain and potential flooding as Storm Dennis hits the region.
Two people have died off the coast of southeast England, The Associated Press reports. Their bodies were recovered from the storm's rough seas.
The U.K. national meteorological service, known as the Met Office, issued several heavy rain warnings for areas of England and Wales.
"Storm Dennis will bring another very unsettled spell of weather this weekend with a risk of flooding, particularly in parts of England and Wales and also southern Scotland, where snowmelt will add to the flood risk," Steve Willington, chief meteorologist for the Met Office, said in a statement.
Travel disruptions are also expected to increase. Hundreds of flights to and from Britain were canceled. Planes arriving earlier on Saturday faced tough landing conditions.
The Met Office also said that bus and train services are likely to be delayed or canceled. Difficult driving conditions and road closures are also expected.
Enlarge this image toggle caption Oli Scarff/AFP via Getty Images Oli Scarff/AFP via Getty Images
Storm Dennis is now one of the five strongest nontropical cyclones on record in the Northern Atlantic Ocean, according to The Washington Post.
The storm intensified rapidly over the ocean after combining with another bomb cyclone that had hit Iceland.
A minimum central air pressure of 920 millibars was recorded on Saturday, according to the National Oceanic and Atmospheric Administration's Ocean Prediction Center. Lower air pressures mean stronger storms. The current pressure is similar to that seen in Category 4 hurricanes.
The Ocean Prediction Center reportedly said that as the storm strengthens into Sunday, the region can expect to see winds up to 98 mph and waves with possible heights of more than 100 feet.
Storm Dennis comes just days after Storm Ciara hit northern England, causing flooding and power outages. At least eight people died across Europe from that storm.
Enlarge this image toggle caption Oli Scarff/AFP via Getty Images Oli Scarff/AFP via Getty Images
Enlarge this image toggle caption Geoff Caddick/AFP via Getty Images Geoff Caddick/AFP via Getty Images
With the ground still saturated, officials worry that Storm Dennis will cause even more flooding and property damage.
On Saturday, about 145 British army personnel and reservists helped set up barricades and repair others that were damaged in the West Yorkshire region in northern England, the AP reports.
"Our armed forces are always ready to support local authorities and communities whenever they need it," British Defense Secretary Ben Wallace said told the news service. "The rapid response of the army today will help with provision of flood relief to local communities in West Yorkshire."
Enlarge this image toggle caption Christopher Furlong/Getty Images Christopher Furlong/Getty Images


npr--2020-02-15--U.S. To Evacuate Americans From Virus-Struck Diamond Princess Cruise Ship

U.S. To Evacuate Americans From Virus-Struck Diamond Princess Cruise Ship The U.S. State Department is sending a charter plane to evacuate Americans aboard the Diamond Princess cruise ship that is in quarantine in Japan because of the spread of the coronavirus named COVID-19 .
On Saturday , the U.S. Embassy in Tokyo sent a letter to U.S. citizens aboard the ship informing them of the planned extraction scheduled for Sunday night .
Once back in the U.S. , passengers from the cruise ship will be forced to undergo another period of quarantine at either Travis Air Force Base in California @ @ @ @ @ @ @ .
According to the embassy letter : John Montgomery and his wife , Carol , from San Clemente , Calif. , are among the nearly 400 U.S. citizens on the Diamond Princess .
They will be taking the State Department 's charter plane and said they are `` excited and relieved '' to return to the U.S. '' We just did n't think this quarantine is a valid quarantine , and we felt it would be much safer for us to get off this ship and be quarantined somewhere else , '' Montgomery @ @ @ @ @ @ @ of quarantine on the ship , Montgomery said he and his wife feel fine .
Despite it being `` a bit of a bummer '' that they 'll have to undergo 14 more days of quarantine in the U.S. , he said they understand the precaution .
`` Because we 've been kind of mixed up with all the people on the ship ... we understand why , through an abundance of caution , that an additional testing and evaluation and quarantine would guarantee that we 're not bringing it back to the @ @ @ @ @ @ @ 67 people aboard the ship tested positive for the coronavirus , Japanese Health Minister Katsunobu Kato announced Saturday .
In all , nearly 300 people aboard the ship have tested positive .
At least 50,580 cases of the coronavirus have been identified globally as of Saturday , according to the World Health Organization .
The total number of deaths stands at 1,526 , with all but two fatalities occurring in China .
The quarantine of the cruise ship and its 3,600 passengers is set to end Wednesday .
But as more cases have @ @ @ @ @ @ @ whether Japan 's ministry of health will extend the quarantine .
If U.S. citizens wait for the ship 's quarantine to end and choose not take the charter flight , the State Department said , they `` will be unable to return to the United States for a period of time . ''
The State Department said the Centers for Disease Control and Prevention would make a final decision on when passengers would be allowed to return to the U.S. if they did not take the charter plane .
The Department of Health @ @ @ @ @ @ @ on Saturday that the returning cruise ship passengers `` will be housed separately from individuals already in quarantine from previous Wuhan repatriation flights . ''
All travelers from Japan will be screened multiple times during the repatriation process , including before leaving the ship , before the plane takes off , in flight and again upon arrival in the U.S. HHS added that the risk of exposure and infection to the coronavirus remains low in the U.S .
The Department of Defense announced Saturday that it is extending the use of temporary housing @ @ @ @ @ @ @ repatriation through March 15 .

U.S. To Evacuate Americans From Virus-Struck Diamond Princess Cruise Ship
Enlarge this image toggle caption Charly Triballeau/AFP via Getty Images Charly Triballeau/AFP via Getty Images
Updated at 4:28 p.m. ET
The U.S. State Department is sending a charter plane to evacuate Americans aboard the Diamond Princess cruise ship that is in quarantine in Japan because of the spread of the coronavirus named COVID-19.
On Saturday, the U.S. Embassy in Tokyo sent a letter to U.S. citizens aboard the ship informing them of the planned extraction scheduled for Sunday night.
Once back in the U.S., passengers from the cruise ship will be forced to undergo another period of quarantine at either Travis Air Force Base in California or Lackland Air Force Base in Texas. According to the embassy letter:
"Travelers returning to the United States from high-risk areas are required to undergo quarantine. Accordingly, you will need to undergo further quarantine of 14 days when you arrive in the United States. We understand this is frustrating and an adjustment, but these measures are consistent with the careful policies we have instituted to limit the potential spread of the disease. We appreciate your understanding and cooperation and will provide all the assistance we can to support the quarantine process."
John Montgomery and his wife, Carol, from San Clemente, Calif., are among the nearly 400 U.S. citizens on the Diamond Princess. They will be taking the State Department's charter plane and said they are "excited and relieved" to return to the U.S.
"We just didn't think this quarantine is a valid quarantine, and we felt it would be much safer for us to get off this ship and be quarantined somewhere else," Montgomery told NPR.
After undergoing 10 days of quarantine on the ship, Montgomery said he and his wife feel fine. Despite it being "a bit of a bummer" that they'll have to undergo 14 more days of quarantine in the U.S., he said they understand the precaution.
"Because we've been kind of mixed up with all the people on the ship ... we understand why, through an abundance of caution, that an additional testing and evaluation and quarantine would guarantee that we're not bringing it back to the states," he said.
Another 67 people aboard the ship tested positive for the coronavirus, Japanese Health Minister Katsunobu Kato announced Saturday. In all, nearly 300 people aboard the ship have tested positive.
At least 50,580 cases of the coronavirus have been identified globally as of Saturday, according to the World Health Organization. The total number of deaths stands at 1,526, with all but two fatalities occurring in China.
The quarantine of the cruise ship and its 3,600 passengers is set to end Wednesday. But as more cases have been identified onboard, it's unclear whether Japan's ministry of health will extend the quarantine.
If U.S. citizens wait for the ship's quarantine to end and choose not take the charter flight, the State Department said, they "will be unable to return to the United States for a period of time."
The State Department said the Centers for Disease Control and Prevention would make a final decision on when passengers would be allowed to return to the U.S. if they did not take the charter plane.
The Department of Health and Human Services said in a statement on Saturday that the returning cruise ship passengers "will be housed separately from individuals already in quarantine from previous Wuhan repatriation flights."
All travelers from Japan will be screened multiple times during the repatriation process, including before leaving the ship, before the plane takes off, in flight and again upon arrival in the U.S.
HHS added that the risk of exposure and infection to the coronavirus remains low in the U.S.
The Department of Defense announced Saturday that it is extending the use of temporary housing facilities to quarantine travelers and passengers undergoing repatriation through March 15.


npr--2020-02-15--PHOTOS: Scenes From The Epicenter Of The Coronavirus Outbreak

PHOTOS : Scenes From The Epicenter Of The Coronavirus Outbreak Wuhan is a ghost town , yet there are still definite signs of life .
That 's the status of this city of 11 million , which has seen strict quarantine measures imposed in an effort to prevent the spread of COVID-19 , the new coronavirus disease .
As of Feb. 10 , every compound , or residential complex , in Wuhan has been put under `` closed-off management '' orders by the government .
The goal is to keep healthy people from getting infected by going out and about @ @ @ @ @ @ @ gates or other barricades , with only one gate to let people out .
Each family in the compound can send one person out to purchase necessities once every three days .
That person must register with an official before leaving , explain the purpose of their trip and give the time of departure .
The individual 's temperature is taken as well .
When people leave the compound , they must wear masks .
Because public transportation has been shut down , they drive , take cabs or ride bikes and scooters @ @ @ @ @ @ @ Anyone showing symptoms that could indicate infection with the coronavirus — fever , for example , can not leave and will be reported to the local community office as a suspected case .
Delivery services are still operating .
Restaurants , convenience stores , florists and supermarkets all will deliver their goods to customers .
With these extraordinary measures in place , the streets are virtually empty and the mood can be somber .
Yet people find ways to carry on , even if it 's something as simple as playing a card @ @ @ @ @ @ @ of humor as well — like the masks attached to a city statue of a mother and child .
A prize-winning international photojournalist who lives in Wuhan has captured scenes of life under lockdown .
The photographer asked not to be named because of concerns of being targeted by the government .

PHOTOS: Scenes From The Epicenter Of The Coronavirus Outbreak
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Wuhan is a ghost town, yet there are still definite signs of life.
That's the status of this city of 11 million, which has seen strict quarantine measures imposed in an effort to prevent the spread of COVID-19, the new coronavirus disease.
As of Feb. 10, every compound, or residential complex, in Wuhan has been put under "closed-off management" orders by the government.
The goal is to keep healthy people from getting infected by going out and about.
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Every compound is closed off with gates or other barricades, with only one gate to let people out. Each family in the compound can send one person out to purchase necessities once every three days. That person must register with an official before leaving, explain the purpose of their trip and give the time of departure. The individual's temperature is taken as well.
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
When people leave the compound, they must wear masks. Because public transportation has been shut down, they drive, take cabs or ride bikes and scooters during the three-hour window for errands.
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Anyone showing symptoms that could indicate infection with the coronavirus — fever, for example, cannot leave and will be reported to the local community office as a suspected case.
Delivery services are still operating. Restaurants, convenience stores, florists and supermarkets all will deliver their goods to customers.
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
With these extraordinary measures in place, the streets are virtually empty and the mood can be somber. Yet people find ways to carry on, even if it's something as simple as playing a card game. And there's a measure of humor as well — like the masks attached to a city statue of a mother and child.
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
A prize-winning international photojournalist who lives in Wuhan has captured scenes of life under lockdown. The photographer asked not to be named because of concerns of being targeted by the government.
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Enlarge this image toggle caption Stringer for NPR Stringer for NPR
Yuhan Xu contributed research to this story.


npr--2020-02-15--Why Pakistanis In The Otherworldly Highlands Aren't Happy To See Pakistani Tourists

Why Pakistanis In The Otherworldly Highlands Are n't Happy To See Pakistani Tourists The residents of Murtazabad , a village in the highlands of Pakistan , are welcoming of strangers .
On a recent day , they proffered passing visitors a yak meat porridge they had made for a religious celebration .
They indulgently smiled as a horde of Thai tourists raced into one of their orchards and posed with piles of red and yellow apples .
But some days , their patience wears thin .
And those days are happening more often as this once-remote province becomes a wildly @ @ @ @ @ @ @ posing in their apple orchards , but also for Pakistanis who come from the plains below .
`` Most tourists are wonderful , but some are just so dirty .
They come here to see our beautiful region , and they leave their trash behind , '' says Benazir Jamal , a 25-year-old gym teacher , who said her village organized a committee to clean up after tourists .
`` Not all fingers of the hand are the same , '' Jamal said , referring to Pakistanis visiting the area .
Pointed opinions @ @ @ @ @ @ @ the far northern territory of Gilgit-Baltistan , an otherworldly place of snow-capped peaks , glaciers , rivers and orchards .
It spotlights the frictions between Pakistan 's multiple ethnic and religious groups , and the challenges facing the country as it tries to lure more visitors .
Signs are pasted throughout residential areas forbidding photography and entrance to tourists .
Other signs urge them , in English and Urdu , to pick up their trash .
`` The problem is basically , unfortunately , and I am sorry to say this , especially @ @ @ @ @ @ @ right manners , '' says Aqeela Bano , who heads the Ciqam Project , a network of organizations run by women , including a carpentry workshop and a café and hotel .
Tensions emerged after domestic tourists nearly outnumbered the territory 's 1.5 million locals over the past two summers , according to Usman Ahmed , commissioner of the Gilgit division , one of the area 's highest-ranking officials .
There were no official figures for this past summer , but it was even busier , officials said .
`` We were not @ @ @ @ @ @ @ .
He noted that a decade ago , just over 50,000 domestic tourists visited .
Only one town in the territory has a sewage system .
So more visitors means more human waste washes into the tributaries that feed the Indus River , Pakistan 's main water source .
The area does not have regular trash collection , so the extra garbage generated by tourists was dumped into the river or incinerated at an informal dump near a glacial lake — frequented by the same tourists .
On a recent day , crows @ @ @ @ @ @ @ fumes .
To accommodate tourists , there is a construction boom .
Enormous hotels now loom over some villages .
Concrete flophouses flash neon signs .
Ahmed is worried , he says , because the construction industry is loosely regulated .
`` We do n't want to become a concrete jungle , '' he says .
Domestic tourists began pouring in about six years ago , Ahmed says .
The sudden surge is owed to a convergence of factors : sectarian violence between Sunnis and Shiites in far northern Pakistan was quelled by @ @ @ @ @ @ @ visitors .
The road itself — a highway of hairpin turns — was improved , making it easier to drive up .
And tales of the area 's beauty spread through word of mouth and social media , according to both tourists and officials .
The tourists include Mohammad Afzal and his wife , Nazira , from the southern city of Larkana , who said they had brought their extended family of 22 people for a weeklong stay in the region .
`` We saw a video and were like , 'Let 's @ @ @ @ @ @ @ as they passed around hot mugs of chai on a freezing day .
`` We went to the China border , and the kids saw snow .
They were so excited , '' she says .
Nazira , like many Pakistani tourists interviewed , says she was horrified to hear that locals found them to be unclean .
`` We throw our trash in the bin , '' she insists .
But at the next table , another group of Pakistani tourists left their pizza boxes and plastic cups of tea on a @ @ @ @ @ @ @ nearby .
Regardless of how the majority of Pakistani tourists behave , clearly there are problems .
Some of the city 's bazaars are pasted with signs pleading with tourists to use trash cans and to not take photos .
Residents said that during the summer , visiting Pakistani men snapped photos of local women without their permission and shared them online .
`` We did n't put [ these warning signs ] up when it was just foreign tourists , '' says Nazir Ali , who guards a mosque .
`` But @ @ @ @ @ @ @ the pictures .
A lot of women were n't comfortable .
They were scared .
They do n't know how the picture will be used . ''
Ali says the issue really emerged when residents found images of local women on social media with commentary that suggested they were not honorable .
Women in far northern Pakistan do n't always cover their hair , they have a tradition of working in public as farmers , shopkeepers and shepherds , and their girls play sports in public — a stark contrast to the far @ @ @ @ @ @ @ other communities in the mountains .
The patron of a tiny restaurant , Lal Shehzadi , 38 , acknowledged cultural tensions with domestic tourists .
She says some of them have asked if her husband was dead , and if not , why she worked , because it was so unusual in the plains .
As she served local delicacies like savory apricot soup , yak curry , salty tea and mutton pies , Shehzadi says she often retorted : `` Why do you cover your women ? ''
Other residents noted the @ @ @ @ @ @ @ the Ciqam Project said the influx has allowed the network to employ 25 female carpenters to supply window frames , doors and wooden designs for new buildings .
Musician Zia Ul Karim , 25 , says the tourists helped revive interest in folkloric music by requesting it to be performed at local shows .
He talks of `` melodies which are almost dying '' because of the `` lack of importance given to them by people . ''
Speaking after a performance , he said sometimes it takes a stranger to remind people @ @ @ @ @ @ @ In a territory once nearly entirely reliant on farming , Mubaraka , 13 , listed the ways tourism has bettered the lives of residents in their poor , one-road village , where children ran around in flip-flops in heavy-jacket weather .
Tourists bought their farm produce .
Shops sold more goods .
There was work in the industry .
But domestic tourists also upset her , she said .
She gestured to a meadow where goats graze , overlooking pointy , snowy peaks .
A few weeks ago , she cleaned it up @ @ @ @ @ @ @ also trying to lure high-dollar foreign visitors — with some success , like the Thai tourists who tumbled into that apple orchard in Murtazabad .
Piayooan Yuentiakul , 55 , from Bangkok , said Pakistan was a `` top of the bucket list '' among his friends because of the stunning red and yellow fall colors .
To attract more visitors from other Asian countries , authorities advertise the area 's ancient Buddhist heritage .
To lure adventure tourists , they host activities like a desert car rally , yak polo and one @ @ @ @ @ @ @ , as well as offer the chance to climb some of the world 's tallest mountains .
Figures given by Ahmed , the commissioner , suggested a slow but steady climb of foreign tourists to Murtazabad , reaching just over 10,000 last year — a tiny proportion of the 1.2 million foreign tourists who arrived in Pakistan in total , according to the country 's 2018 Travel & Tourism Economic Impact report .
Foreign tourists say they are delighted by Pakistan , like German visitor Carsten Korfmacher .
He had been hiking on @ @ @ @ @ @ @ some of the world 's tallest mountains .
The best part was `` people are so friendly , '' he says .
Twice , he said , he had been invited to attend local weddings .
`` I wish people were so friendly in my country , '' he says .
Nothing though , could beat the enthusiasm of Daniel Porter , from Britain , who just finished a boat ride on a glacial lake .
Smoothing back his dreadlocks , Porter said people kept inviting him to stay with them .
`` @ @ @ @ @ @ @ .
`` Everyone wants to help you . ''
Locals agree .
As long as you pick up your own trash .

Why Pakistanis In The Otherworldly Highlands Aren't Happy To See Pakistani Tourists
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
The residents of Murtazabad, a village in the highlands of Pakistan, are welcoming of strangers. On a recent day, they proffered passing visitors a yak meat porridge they had made for a religious celebration. They indulgently smiled as a horde of Thai tourists raced into one of their orchards and posed with piles of red and yellow apples.
But some days, their patience wears thin.
And those days are happening more often as this once-remote province becomes a wildly popular destination not only for foreign tourists posing in their apple orchards, but also for Pakistanis who come from the plains below.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
"Most tourists are wonderful, but some are just so dirty. They come here to see our beautiful region, and they leave their trash behind," says Benazir Jamal, a 25-year-old gym teacher, who said her village organized a committee to clean up after tourists. "Not all fingers of the hand are the same," Jamal said, referring to Pakistanis visiting the area.
Pointed opinions about Pakistani tourists can be heard across the far northern territory of Gilgit-Baltistan, an otherworldly place of snow-capped peaks, glaciers, rivers and orchards. It spotlights the frictions between Pakistan's multiple ethnic and religious groups, and the challenges facing the country as it tries to lure more visitors. Signs are pasted throughout residential areas forbidding photography and entrance to tourists. Other signs urge them, in English and Urdu, to pick up their trash.
"The problem is basically, unfortunately, and I am sorry to say this, especially our Pakistani tourists. They have not right manners," says Aqeela Bano, who heads the Ciqam Project, a network of organizations run by women, including a carpentry workshop and a café and hotel.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
Tensions emerged after domestic tourists nearly outnumbered the territory's 1.5 million locals over the past two summers, according to Usman Ahmed, commissioner of the Gilgit division, one of the area's highest-ranking officials. There were no official figures for this past summer, but it was even busier, officials said.
"We were not ready for that," Ahmed says. He noted that a decade ago, just over 50,000 domestic tourists visited.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
Only one town in the territory has a sewage system. So more visitors means more human waste washes into the tributaries that feed the Indus River, Pakistan's main water source. The area does not have regular trash collection, so the extra garbage generated by tourists was dumped into the river or incinerated at an informal dump near a glacial lake — frequented by the same tourists. On a recent day, crows picked through smoldering trash that emitted foul fumes.
To accommodate tourists, there is a construction boom. Enormous hotels now loom over some villages. Concrete flophouses flash neon signs. Ahmed is worried, he says, because the construction industry is loosely regulated.
"We don't want to become a concrete jungle," he says.
Domestic tourists began pouring in about six years ago, Ahmed says. The sudden surge is owed to a convergence of factors: sectarian violence between Sunnis and Shiites in far northern Pakistan was quelled by authorities, making the road safe for visitors. The road itself — a highway of hairpin turns — was improved, making it easier to drive up. And tales of the area's beauty spread through word of mouth and social media, according to both tourists and officials.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
The tourists include Mohammad Afzal and his wife, Nazira, from the southern city of Larkana, who said they had brought their extended family of 22 people for a weeklong stay in the region. "We saw a video and were like, 'Let's go!' " Nazira says, as they passed around hot mugs of chai on a freezing day.
"We went to the China border, and the kids saw snow. They were so excited," she says.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
Nazira, like many Pakistani tourists interviewed, says she was horrified to hear that locals found them to be unclean.
"We throw our trash in the bin," she insists. But at the next table, another group of Pakistani tourists left their pizza boxes and plastic cups of tea on a table, ignoring the large trash can nearby.
Regardless of how the majority of Pakistani tourists behave, clearly there are problems. Some of the city's bazaars are pasted with signs pleading with tourists to use trash cans and to not take photos. Residents said that during the summer, visiting Pakistani men snapped photos of local women without their permission and shared them online.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
"We didn't put [these warning signs] up when it was just foreign tourists," says Nazir Ali, who guards a mosque. "But when domestic tourists came, they misused the pictures. A lot of women weren't comfortable. They were scared. They don't know how the picture will be used."
Ali says the issue really emerged when residents found images of local women on social media with commentary that suggested they were not honorable. Women in far northern Pakistan don't always cover their hair, they have a tradition of working in public as farmers, shopkeepers and shepherds, and their girls play sports in public — a stark contrast to the far more conservative plains below and even to other communities in the mountains.
The patron of a tiny restaurant, Lal Shehzadi, 38, acknowledged cultural tensions with domestic tourists. She says some of them have asked if her husband was dead, and if not, why she worked, because it was so unusual in the plains.
As she served local delicacies like savory apricot soup, yak curry, salty tea and mutton pies, Shehzadi says she often retorted: "Why do you cover your women?"
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
Other residents noted the upside to domestic tourism. Bano of the Ciqam Project said the influx has allowed the network to employ 25 female carpenters to supply window frames, doors and wooden designs for new buildings.
Musician Zia Ul Karim, 25, says the tourists helped revive interest in folkloric music by requesting it to be performed at local shows.
He talks of "melodies which are almost dying" because of the "lack of importance given to them by people." Speaking after a performance, he said sometimes it takes a stranger to remind people of what they should hold dear.
In a territory once nearly entirely reliant on farming, Mubaraka, 13, listed the ways tourism has bettered the lives of residents in their poor, one-road village, where children ran around in flip-flops in heavy-jacket weather. Tourists bought their farm produce. Shops sold more goods. There was work in the industry.
But domestic tourists also upset her, she said. She gestured to a meadow where goats graze, overlooking pointy, snowy peaks. A few weeks ago, she cleaned it up after tourists.
Officials said they were also trying to lure high-dollar foreign visitors — with some success, like the Thai tourists who tumbled into that apple orchard in Murtazabad. Piayooan Yuentiakul, 55, from Bangkok, said Pakistan was a "top of the bucket list" among his friends because of the stunning red and yellow fall colors.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
To attract more visitors from other Asian countries, authorities advertise the area's ancient Buddhist heritage. To lure adventure tourists, they host activities like a desert car rally, yak polo and one of the world's highest-altitude bike races, as well as offer the chance to climb some of the world's tallest mountains.
Figures given by Ahmed, the commissioner, suggested a slow but steady climb of foreign tourists to Murtazabad, reaching just over 10,000 last year — a tiny proportion of the 1.2 million foreign tourists who arrived in Pakistan in total, according to the country's 2018 Travel & Tourism Economic Impact report.
Enlarge this image toggle caption Diaa Hadid/NPR Diaa Hadid/NPR
Foreign tourists say they are delighted by Pakistan, like German visitor Carsten Korfmacher. He had been hiking on glaciers and trekking through base camps of some of the world's tallest mountains. The best part was "people are so friendly," he says. Twice, he said, he had been invited to attend local weddings. "I wish people were so friendly in my country," he says.
Nothing though, could beat the enthusiasm of Daniel Porter, from Britain, who just finished a boat ride on a glacial lake. Smoothing back his dreadlocks, Porter said people kept inviting him to stay with them. "Everyone just smiles," he says. "Everyone wants to help you."
Locals agree. As long as you pick up your own trash.
Nazim Ullah Baig contributed to this report.


npr--2020-02-15--Nevada Voters Begin Early Caucusing On Saturday. Here's What You Need To Know

Nevada Voters Begin Early Caucusing On Saturday .
Here 's What You Need To Know Early caucusing begins on Saturday in Nevada as the race for the Democratic presidential nomination moves west .
Democrats in the state have been scrambling the past two weeks to adjust their plans in the wake of the caucusing debacle in Iowa .
The Hawkeye State 's Democrats are still digging through paper records to answer questions about inconsistencies in the reported results , and their state party chairman announced his resignation this week .
In Nevada , party leaders say they 're trying to @ @ @ @ @ @ @ We understand just how important it is that we get this right and protect the integrity of Nevadans ' votes , '' wrote Alana Mounce , the Nevada Democratic Party 's executive director , in a memo detailing the new plan .
`` We are confident in our backup plans and redundancies . ''
Here 's the party 's agenda for the coming week .
For the first time ever , in an effort to increase accessibility to the caucus process , Nevada Democrats will be able to participate even if they ca @ @ @ @ @ @ @ the normal caucus day on Feb. 22 .
So from Saturday through Tuesday , registered Democrats can go to an early vote site in the county in which they 're registered .
Same-day registration is allowed .
At the early vote site , voters will receive a voter card and fill out a paper ballot , both of which will have an identification number that correlates the two items .
After filling out the ballot with their preferences , voters will return both the voter card and the ballot to a designated ballot @ @ @ @ @ @ @ integrated on caucus day ?
Democrats in Nevada were originally planning to use an app designed by the same company that designed the faulty system used in Iowa .
After the problems there , they designed to go a different direction .
The new plan still involves some technology but Democrats say there will be backup plans too , as well as simple ways to transition to a paper and pen process should problems arise .
Precinct chairs on Feb. 22 , the day of the statewide caucus , are set to use @ @ @ @ @ @ @ .
They 'll then have access to the early voting data that 's applicable to their precinct .
As chairs input data from their day-of caucusing and perform the `` caucus math '' involved with figuring out how many supporters are necessary to reach the 15 % viability threshold , the iPad calculator will integrate the results of early voting .
Each precinct also will have paper records of the early-vote data .
If they 're unable to log in to Google Forms or if the calculator malfunctions , the precinct chairs will @ @ @ @ @ @ @ their worksheets to do the caucus math and integrate the early vote data , state Democrats say .
Each precinct chair also will have a larger , poster-style worksheet so that caucusgoers can follow along as precinct chairs perform the necessary math .
How will the precinct chairs get the results to the state party ?
This is the point in the process that could be the most vulnerable , cybersecurity experts worry .
Precinct leaders will have completed their work but they must then get it to the state party , in @ @ @ @ @ @ @ say they 've instituted a two-step process that allows for speed and verification .
After caucus attendees are all done , precinct chairs will be able to transmit the final results of their caucusing via the iPad Google Form .
But they will also be required to either call in those results or deliver them in person in some way .
Precinct chairs also can choose not to transmit their results using the iPads .
If they choose to use the telephone as their first reporting mechanism , they 'll also have to @ @ @ @ @ @ @ the party too .
The party says the private hotline that precinct chairs will call to turn in results will require some sort of verification .
A similar setup in Iowa meant for precinct chairs to phone in results became clogged after the phone number surfaced publicly online .
Nevada Democrats will also have separate hotlines set up to report voter protection issues and for precinct volunteers to troubleshoot reporting-related issues .
What could go wrong ?
Doug Jones , a cybersecurity expert at the University of Iowa and a former caucus precinct @ @ @ @ @ @ @ been impressed by Nevada 's paper-based backup plans .
What worries him about the caucus , he said , is the prospect for human error , either when chairs type in the responses in the iPads or in some part other part of the caucus process .
`` We 're all experts at making typos , '' Jones said .
`` It 's one thing humans are good at . ''
Such errors happen in every election , but the fact that so many processes are being arranged in the final days leaves @ @ @ @ @ @ @ or some caucusgoers could end up confused , Jones said .
`` That 's the challenge of anything where the procedures are only just being established , '' he said .

Nevada Voters Begin Early Caucusing On Saturday. Here's What You Need To Know
Enlarge this image toggle caption Matt Rourke/AP Matt Rourke/AP
Early caucusing begins on Saturday in Nevada as the race for the Democratic presidential nomination moves west.
Democrats in the state have been scrambling the past two weeks to adjust their plans in the wake of the caucusing debacle in Iowa.
The Hawkeye State's Democrats are still digging through paper records to answer questions about inconsistencies in the reported results, and their state party chairman announced his resignation this week.
In Nevada, party leaders say they're trying to make sure things go differently.
"We understand just how important it is that we get this right and protect the integrity of Nevadans' votes," wrote Alana Mounce, the Nevada Democratic Party's executive director, in a memo detailing the new plan. "We are confident in our backup plans and redundancies."
Here's the party's agenda for the coming week.
How does early-caucusing work?
For the first time ever, in an effort to increase accessibility to the caucus process, Nevada Democrats will be able to participate even if they can't or don't want to attend the normal caucus day on Feb. 22.
So from Saturday through Tuesday, registered Democrats can go to an early vote site in the county in which they're registered. Same-day registration is allowed.
At the early vote site, voters will receive a voter card and fill out a paper ballot, both of which will have an identification number that correlates the two items.
After filling out the ballot with their preferences, voters will return both the voter card and the ballot to a designated ballot box.
How will those results be integrated on caucus day?
Democrats in Nevada were originally planning to use an app designed by the same company that designed the faulty system used in Iowa. After the problems there, they decided to go in a different direction.
The new plan still involves some technology but Democrats say there will be backup plans too, as well as simple ways to transition to a paper and pen process should problems arise.
Precinct chairs on Feb. 22, the day of the statewide caucus, are set to use an iPad to log into Google Forms. They'll then have access to the early voting data that's applicable to their precinct.
As chairs input data from their day-of caucusing and perform the "caucus math" involved with figuring out how many supporters are necessary to reach the 15% viability threshold, the iPad calculator will integrate the results of early voting.
Each precinct also will have paper records of the early-vote data. If they're unable to log into Google Forms or if the calculator malfunctions, the precinct chairs will be expected to follow the steps on their worksheets to do the caucus math and integrate the early vote data, state Democrats say.
Each precinct chair also will have a larger, poster-style worksheet so that caucus goers can follow along as precinct chairs perform the necessary math.
How will the precinct chairs get the results to the state party?
This is the point in the process that could be the most vulnerable, cyber security experts worry. Precinct leaders will have completed their work but they must then get it to the state party, in some cases over the internet.
Democrats say they've instituted a two-step process that allows for speed and verification.
After caucus attendees are all done, precinct chairs will be able to transmit the final results of their caucusing via the iPad Google Form. But they will also be required to either call in those results or deliver them in person in some way.
Precinct chairs also can choose not to transmit their results using the iPads. If they choose to use the telephone as their first reporting mechanism, they'll also have to either hand deliver or mail their results to the party too.
The party says the private hotline that precinct chairs will call to turn in results will require some sort of verification. A similar setup in Iowa meant the process for precinct chairs to phone in results became clogged after the phone number surfaced publicly online.
Nevada Democrats will also have separate hotlines set up to report voter protection issues and for precinct volunteers to troubleshoot reporting-related issues.
What could go wrong?
Doug Jones, a cyber security expert at the University of Iowa and a former caucus precinct chair in Iowa, said he's been impressed by Nevada's paper-based backup plans.
What worries him about the caucus, he said, is the prospect for human error, either when chairs type in the responses in the iPads or in some part other part of the caucus process.
"We're all experts at making typos," Jones said. "It's one thing humans are good at."
Such errors happen in every election, but the fact that so many processes are being arranged in the final days leaves open the possibility that some precinct leaders or some caucus goers could end up confused, Jones said.
"That's the challenge of anything where the procedures are only just being established," he said.


npr--2020-02-15--Early Novel Written By Free Black Woman Called Out Racism Among Abolitionists

Early Novel Written By Free Black Woman Called Out Racism Among Abolitionists Here 's one thing historians know to be true about Harriet Wilson : Some indomitable part of her spirit allowed her to survive a life on the margins of American society .
In 1859 , Wilson published a book that she gave a provocative title : Our Nig .
That name is a derivative of a racist nickname given to the book 's protagonist , a little girl of mixed race who grows up as an indentured servant to a white family .
The girl is tortured by @ @ @ @ @ @ @ to sleep in a frigid crawl space .
Even the kindest members of the family call her `` nig . ''
`` Some of the things she wrote in her book were shocking , '' says JerriAnne Boggis , founder and director of The Harriet Wilson Project .
`` But it 's not any more shocking than anything that you did n't know about slavery .
It was shocking that it happened in the North because that 's not our story .
Our story is the abolitionist movement . ''
Wilson 's book @ @ @ @ @ @ @ North .
It 's also emblematic of how important pieces of African American history can be forgotten — and then rediscovered .
In the novel , Wilson did not say much about the story 's setting or about herself .
But Our Nig 's long subtitle gave clues historians would later pick apart : `` Sketches from the Life of a Free Black in a Two-Story White House , North ; Showing That Slavery 's Shadow Falls Even There . ''
Wilson 's book never sold well in the 1800s , and it @ @ @ @ @ @ @ Then in the 1980s , her story intersected with a historian who was destined to become one of America 's most famous storytellers : Henry Louis Gates Jr. Gates is now the host of Finding Your Roots on PBS and the director of the Hutchins Center for African and African American Research at Harvard University .
But in the early 1980s , he had just finished his doctoral dissertation and was wandering the aisles of a rare-book store in New York City .
He saw a title that jumped off the shelf .
@ @ @ @ @ @ @ spirit , ' `` says Gates .
`` She used the N-word in the title . ''
`` When I read the preface , '' Gates continues , `` the woman said that she was black and that she was writing this book because she was in such dire straits that she had had to put her son into a foster home .
She was hoping that her colored brethren would rally around her universally to purchase this book . ''
Gates dove into historical archives looking for a Harriet E. Wilson , @ @ @ @ @ @ @ mother and black father in Milford , N.H. , in 1825 .
Among the facts Gates discovered about Wilson that corroborated details from the novel were that she had a child in a poorhouse at the time she wrote the story .
Sadly , Gates learned , her son passed away shortly after she published her book .
Wilson would likely have been familiar with slave narratives — books such as Twelve Years A Slave by Solomon Northup — which were popular at the time among Northern abolitionists .
Ironically , Milford , @ @ @ @ @ @ @ abolitionist activity .
At the time that Wilson was surviving what Gates describes as `` what we could only call a period of harsh indenture , '' just up the road lived some of the most prominent abolitionist families of the mid-1800s .
`` [ Wilson 's ] teaching us in a spiritual way , '' says Alice Walker , the Pulitzer Prize-winning author , `` about the paucity of substance in people who claim to see your suffering , but then they do absolutely nothing .
And that is so American in @ @ @ @ @ @ @ my God , that 's me '' Since Gate 's rediscovery of Our Nig , the book has been republished three times .
Each edition contains new details uncovered by historians about Wilson 's life — details that further suggest the harsh story she wrote was in fact her own experience as a black woman in Milford , N.H .
It seems likely that Wilson was the little girl in her book who was so terribly mistreated .
She hinted as much in the book ; in the earliest pages , she writes @ @ @ @ @ @ @ the third person .
Of all the discoveries about Wilson 's life , JerriAnne Boggis may have made the most extraordinary one .
Boggis found the house where Wilson grew up — the house where she was likely indentured to a white family .
Boggis did n't read Our Nig until 2002 .
When she did , she felt like Wilson had written the book just for her .
`` I really empathized with that sense of isolation , being a black woman in Milford , '' Boggis says .
`` That really @ @ @ @ @ @ @ that 's me . '
`` Boggis began to study the text of Our Nig .
She searched Milford for homes that matched descriptions from the book .
Eventually , she found a match .
It 's now owned by a family , whom Boggis has befriended , and working with them , she has located the crawl space where Wilson likely slept as a child .
`` That is the story of black history in the country , '' Boggis says .
`` You have to keep telling it , keep telling @ @ @ @ @ @ @ it .
Or else it disappears . ''
Our Nig inspired Boggis to learn more about black history in New England .
Now , she 's the executive director of the Black Heritage Trail of New Hampshire .
She has also done her part to honor her town 's forgotten literary hero , including erecting a monument in Wilson 's honor .
In that statue , Wilson stands with her book in one hand , and she protects her son with her other hand .
Her back is to a historical church — @ @ @ @ @ @ @ church that did not allow her to enter because of her skin color .

Early Novel Written By Free Black Woman Called Out Racism Among Abolitionists
Enlarge this image toggle caption Jack Rodolico /New Hampshire Public Radio Jack Rodolico /New Hampshire Public Radio
Editor's note: This report contains a racial slur.
Here's one thing historians know to be true about Harriet Wilson: Some indomitable part of her spirit allowed her to survive a life on the margins of American society.
Our Nig or, Sketches from the Life of a Free Black by Harriet E. Wilson and Henry Louis Gates Jr. Paperback, 140 pages | purchase close overlay Buy Featured Book Your purchase helps support NPR programming. How?
In 1859, Wilson published a book that she gave a provocative title: Our Nig. That name is a derivative of a racist nickname given to the book's protagonist, a little girl of mixed race who grows up as an indentured servant to a white family. The girl is tortured by the family matriarch, beaten and forced to sleep in a frigid crawl space. Even the kindest members of the family call her "nig."
"Some of the things she wrote in her book were shocking," says JerriAnne Boggis, founder and director of The Harriet Wilson Project. "But it's not any more shocking than anything that you didn't know about slavery. It was shocking that it happened in the North because that's not our story. Our story is the abolitionist movement."
Wilson's book called out racism among abolitionists in the North. It's also emblematic of how important pieces of African American history can be forgotten — and then rediscovered.
In the novel, Wilson did not say much about the story's setting or about herself. But Our Nig's long subtitle gave clues historians would later pick apart: "Sketches from the Life of a Free Black in a Two-Story White House, North; Showing That Slavery's Shadow Falls Even There."
"A period of harsh indenture"
Wilson's book never sold well in the 1800s, and it disappeared for more than 100 years. Then in the 1980s, her story intersected with a historian who was destined to become one of America's most famous storytellers: Henry Louis Gates Jr.
Gates is now the host of Finding Your Roots on PBS and the director of the Hutchins Center for African and African American Research at Harvard University. But in the early 1980s, he had just finished his doctoral dissertation and was wandering the aisles of a rare-book store in New York City. He saw a title that jumped off the shelf.
"I thought, 'This woman has spirit,' " says Gates. "She used the N-word in the title."
"When I read the preface," Gates continues, "the woman said that she was black and that she was writing this book because she was in such dire straits that she had had to put her son into a foster home. She was hoping that her colored brethren would rally around her universally to purchase this book."
Enlarge this image toggle caption Lee Marriner /AP Lee Marriner /AP
Gates dove into historical archives looking for a Harriet E. Wilson, and discovered one born to a white mother and black father in Milford, N.H., in 1825. Among the facts Gates discovered about Wilson that corroborated details from the novel were that she had a child in a poorhouse at the time she wrote the story. Sadly, Gates learned, her son passed away shortly after she published her book.
Wilson would likely have been familiar with slave narratives — books such as Twelve Years A Slave by Solomon Northup — which were popular at the time among Northern abolitionists. Ironically, Milford, N.H., was also a hotbed of abolitionist activity. At the time that Wilson was surviving what Gates describes as "what we could only call a period of harsh indenture," just up the road lived some of the most prominent abolitionist families of the mid-1800s.
"[Wilson's] teaching us in a spiritual way," says Alice Walker, the Pulitzer Prize-winning author, "about the paucity of substance in people who claim to see your suffering, but then they do absolutely nothing. And that is so American in so many ways."
"Oh my God, that's me"
Since Gate's rediscovery of Our Nig, the book has been republished three times. Each edition contains new details uncovered by historians about Wilson's life — details that further suggest the harsh story she wrote was in fact her own experience as a black woman in Milford, N.H.
It seems likely that Wilson was the little girl in her book who was so terribly mistreated. She hinted as much in the book; in the earliest pages, she writes in the first person before pivoting to the third person.
Of all the discoveries about Wilson's life, JerriAnne Boggis may have made the most extraordinary one. Boggis found the house where Wilson grew up — the house where she was likely indentured to a white family.
Boggis didn't read Our Nig until 2002. When she did, she felt like Wilson had written the book just for her.
"I really empathized with that sense of isolation, being a black woman in Milford," Boggis says. "That really was like, 'Oh my God, that's me.' "
Boggis began to study the text of Our Nig. She searched Milford for homes that matched descriptions from the book. Eventually, she found a match. It's now owned by a family, whom Boggis has befriended, and working with them, she has located the crawl space where Wilson likely slept as a child.
"That is the story of black history in the country," Boggis says. "You have to keep telling it, keep telling it, keep telling it, reviving it. Or else it disappears."
Our Nig inspired Boggis to learn more about black history in New England. Now, she's the executive director of the Black Heritage Trail of New Hampshire. She has also done her part to honor her town's forgotten literary hero, including erecting a monument in Wilson's honor.
In that statue, Wilson stands with her book in one hand, and she protects her son with her other hand. Her back is to a historical church — a church where abolitionists prayed and a church that did not allow her to enter because of her skin color.


npr--2020-02-17--Lax Regulations And Vulnerable Residents 'A Recipe For Problems' In Eldercare Homes

Lax Regulations And Vulnerable Residents ' A Recipe For Problems ' In Eldercare Homes Some states call them assisted living facilities ; others , residential or personal care homes .
These state-licensed facilities promise peace of mind for families whose elders require long-term care .
In Vermont and elsewhere , investigations into these homes have revealed lax oversight , injuries and deaths .
Few understand the risks like June Kelly .
Her mother , Marilyn Kelly , was energetic and loved to go fishing when she moved into Our House Too , a 13-bed facility that advertised its memory-care expertise @ @ @ @ @ @ @ almost everything went wrong that could .
Often , her daughters arrived to find their 78-year-old mom in a stupor .
June arrived one day to discover Marilyn trying to feed herself but unable to find her mouth with her fork .
`` She was in her pajamas , and there was excrement down her arm , '' she recalled .
June , who held her mom 's power of attorney , eventually discovered that Our House Too was giving Marilyn daily doses of a sedating and controversial antipsychotic called Haldol without either @ @ @ @ @ @ @ of lice and a rotten tooth came the final blow : An overnight staffer was caught on camera shoving Marilyn to the floor .
Marilyn died a month later from pneumonia .
The staffer pleaded guilty to assault .
Now , the Kelly family is suing the care home and Marilyn 's prescribers , alleging neglect and wrongful death .
The defendants have denied all allegations .
`` We 're almost 19 years old , and I 'm still as passionate today as I 've always been about the work that we do @ @ @ @ @ @ @ , '' said Paula Patorti , the facility 's owner .
In an investigation , Vermont Public Radio and the alt-weekly Seven Days found that the kind of ordeals Marilyn Kelly endured are not uncommon in Vermont .
A review of nearly six years of inspection reports revealed troubling patterns of inadequate care .
At least five residents have died in accidents related to deficient care , and the majority of homes have been cited for severe infractions .
One home 's owner told regulators that it was easier to accept a citation @ @ @ @ @ @ @ of required annual training .
Homes that provide poor care are rarely fined by state regulators , who are acutely aware of their state 's need for long-term care beds .
Vermont has one of the oldest populations in the nation , and people with dementia , such as Marilyn Kelly , can wait months for placement at a facility .
`` We need to ensure that there is capacity across the state of Vermont to care for Vermonters , '' said Monica Hutt , the state 's top long-term care regulator .
@ @ @ @ @ @ @ of the highest quality .
There is an enormous amount of balancing that happens to make that true . ''
The state is currently revising its 20-year-old rules for residential care homes .
Hutt has said her department will incorporate changes based on this investigation .
Vermont is not the only place where journalists have uncovered inadequate care and oversight at state-licensed long-term care facilities .
The Atlanta Journal-Constitution , The Oregonian and PBS and ProPublica have published similar findings , with databases designed to help consumers .
`` It could have been @ @ @ @ @ @ @ after learning about VPR and Seven Day 's findings in Vermont .
Smetanka is executive director of the National Consumer Voice for Quality Long-Term Care , an advocacy group .
Nursing homes were designed for high-needs residents and are heavily regulated by the federal government .
Assisted living and other state-regulated homes were designed for healthier residents and are lightly regulated .
Yet increasingly , Smetanka said , families avoid nursing homes , choosing assisted living-type residences for vulnerable loved ones .
`` That is a recipe for problems , '' she said @ @ @ @ @ @ @ informed decisions .
Smetanka suggested visiting a place at different times of the day .
`` Do n't be wowed just by , like , the fancy chandeliers or the pretty decorations or things like that .
Really look at what 's going on in that facility , '' she said .
In particular , she said , watch out for unfriendly staff interactions , unpleasant smells and sounds of distress .
Confirm the staffing numbers .
And do research .
Ask your state 's long-term care ombudsman about what kinds of complaints @ @ @ @ @ @ @ read its contract for pricey add-ons ; and get a hold of the facility 's state inspection reports .
This investigation is a collaboration between Vermont Public Radio and Seven Days .

Lax Regulations And Vulnerable Residents 'A Recipe For Problems' In Eldercare Homes
Enlarge this image toggle caption James Buck/VPR/Seven Days James Buck/VPR/Seven Days
Some states call them assisted living facilities; others, residential or personal care homes. These state-licensed facilities promise peace of mind for families whose elders require long-term care. In Vermont and elsewhere, investigations into these homes have revealed lax oversight, injuries and deaths.
Few understand the risks like June Kelly. Her mother, Marilyn Kelly, was energetic and loved to go fishing when she moved into Our House Too, a 13-bed facility that advertised its memory-care expertise. Over the next eight months, almost everything went wrong that could.
Often, her daughters arrived to find their 78-year-old mom in a stupor. June arrived one day to discover Marilyn trying to feed herself but unable to find her mouth with her fork.
"She was in her pajamas, and there was excrement down her arm," she recalled.
June, who held her mom's power of attorney, eventually discovered that Our House Too was giving Marilyn daily doses of a sedating and controversial antipsychotic called Haldol without either woman's consent.
Enlarge this image toggle caption Courtesy of June Kelly Courtesy of June Kelly
After two bouts of lice and a rotten tooth came the final blow: An overnight staffer was caught on camera shoving Marilyn to the floor. Marilyn died a month later from pneumonia. The staffer pleaded guilty to assault.
Now, the Kelly family is suing the care home and Marilyn's prescribers, alleging neglect and wrongful death.
The defendants have denied all allegations.
"We're almost 19 years old, and I'm still as passionate today as I've always been about the work that we do and the way that we do it," said Paula Patorti, the facility's owner.
On Aging The White House Says Nursing Home Regulations Are Too Tough The White House Says Nursing Home Regulations Are Too Tough Listen · 3:56 3:56
In an investigation, Vermont Public Radio and the alt-weekly Seven Days found that the kind of ordeals Marilyn Kelly endured are not uncommon in Vermont.
A review of nearly six years of inspection reports revealed troubling patterns of inadequate care. At least five residents have died in accidents related to deficient care, and the majority of homes have been cited for severe infractions. One home's owner told regulators that it was easier to accept a citation than to give staff the dozen hours of required annual training.
Homes that provide poor care are rarely fined by state regulators, who are acutely aware of their state's need for long-term care beds. Vermont has one of the oldest populations in the nation, and people with dementia, such as Marilyn Kelly, can wait months for placement at a facility.
toggle caption James Buck/VPR/Seven Days
"We need to ensure that there is capacity across the state of Vermont to care for Vermonters," said Monica Hutt, the state's top long-term care regulator. "We need to ensure it's of the highest quality. There is an enormous amount of balancing that happens to make that true."
The state is currently revising its 20-year-old rules for residential care homes. Hutt has said her department will incorporate changes based on this investigation.
Vermont is not the only place where journalists have uncovered inadequate care and oversight at state-licensed long-term care facilities. The Atlanta Journal-Constitution, The Oregonian and PBS and ProPublica have published similar findings, with databases designed to help consumers.
"It could have been any state," said Lori Smetanka after learning about VPR and Seven Day's findings in Vermont. Smetanka is executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group.
Nursing homes were designed for high-needs residents and are heavily regulated by the federal government. Assisted living and other state-regulated homes were designed for healthier residents and are lightly regulated. Yet increasingly, Smetanka said, families avoid nursing homes, choosing assisted living-type residences for vulnerable loved ones.
toggle caption Courtesy of June Kelly
"That is a recipe for problems," she said.
There are ways consumers can make informed decisions. Smetanka suggested visiting a place at different times of the day.
"Don't be wowed just by, like, the fancy chandeliers or the pretty decorations or things like that. Really look at what's going on in that facility," she said.
In particular, she said, watch out for unfriendly staff interactions, unpleasant smells and sounds of distress. Confirm the staffing numbers. And do research. Ask your state's long-term care ombudsman about what kinds of complaints have come in about the facility; read its contract for pricey add-ons; and get a hold of the facility's state inspection reports.
This investigation is a collaboration between Vermont Public Radio and Seven Days.