npr--2020-12-30--California Is Overriding Its Limits On Nurse Workloads As COVID-19 Surges

California Is Overriding Its Limits On Nurse Workloads As COVID-19 Surges California 's telemetry nurses , who specialize in the electronic monitoring of critically ill patients , normally take care of four patients at once .
But ever since the state relaxed California 's mandatory nurse-to-patient ratios in mid-December , Nerissa Black has had to keep track of six .
And these six patients are really sick : they all need constant electronic heart monitoring and many of them are being treated simultaneously for a stroke and COVID-19 , or a heart attack and COVID-19 .
With more patients than @ @ @ @ @ @ @ says she 's worried she 'll miss something or make a mistake .
`` We are given 50 % more patients and we 're expected to do 50 % more things with the same amount of time , '' says Black , who has worked at the Henry Mayo Newhall Hospital in Valencia , Calif. , for the past seven years .
`` I go home and I feel like I could have done more .
I do n't feel like I 'm giving the care to my patients like a human being @ @ @ @ @ @ @ to flood California emergency rooms , hospitals are increasingly desperate to find enough staff to care for all them .
The state is asking nurses to take care of more patients simultaneously than they normally would , watering down what many nurses and their unions consider their most sacrosanct job protection : a law existing only in California that puts legal restrictions on the nurse-to-patient ratio .
`` We need to temporarily — very short-term , temporarily — look a little bit differently in terms of our staffing needs , '' said Gov @ @ @ @ @ @ @ allowed hospitals to adjust their nurse-to-patient ratios on Dec. 11 .
Normally , California law requires a hospital to first get approval from the state before tinkering with those ratios ; Newsom 's move gave hospitals presumptive approval to work outside the ratio rules immediately .
Since then , 170 hospitals , mainly in Southern California , have been operating under the new pandemic ratios : They can require ICU nurses to care for three patients instead of two .
Emergency room and telemetry nurses may now be asked to care for six @ @ @ @ @ @ @ are looking after seven patients instead of five .
Nurses have taken to the streets in protest , holding socially distanced demonstrations across the state , shouting and carrying posters that read : `` Ratios Save Lives . ''
The union , the California Nurses Association , says the staffing shortage is a result of bad hospital management , of taking a reactive approach to staffing rather than proactive : laying nurses off over the summer , then not hiring or training enough for winter .
`` What we 're seeing in these @ @ @ @ @ @ @ pandemic that they never prepared for : just-in-time staffing , just-in-time resources , not staffing up , calling nurses in on a shift at the very last minute — to boost profits , '' says Stephanie Roberson , the government relations director for the California Nurses Association .
`` And we 're seeing how nurses are being stretched even thinner . ''
But hospitals say this is an unprecedented crisis that has spiraled beyond their control .
In the current surge , four times as many Californians are testing positive for the coronavirus @ @ @ @ @ @ @ many as 7,000 new patients could soon be coming to California hospitals every day , according to Carmela Coyle , who heads the California Hospital Association .
`` This is catastrophic and we can not dodge this math , '' she says .
`` We are simply out of nurses , out of doctors , out of respiratory therapists . ''
The state has asked the federal government for staff , including 200 medical personnel from the U.S. Department of Defense , and it 's tried to reactivate the California Health Corps , @ @ @ @ @ @ @ to come back to work , but that has yielded few people with the qualifications needed to care for hospitalized COVID-19 patients .
Hiring contract nurses from temporary staffing agencies or other states is all but impossible right now , Coyle says .
`` Because California surged early during the summer and other parts of the United States then surged afterward , '' she says , `` those travel nurses are taken . ''
Hospitals ' next step is to try `` team nursing , '' Coyle says , pulling nurses from other @ @ @ @ @ @ @ for example , and partnering them with experienced critical care nurses to help care for COVID-19 patients .
Joanne Spetz is an economics professor who studies health care workforce issues at the University of California , San Francisco .
She says hospitals should have started training nurses for team care over the summer , in anticipation of a winter surge , but they did n't , either because of costs — hospitals lost a lot of revenue from canceled elective surgeries that could have paid for that training — or because of excessive @ @ @ @ @ @ @ well , '' she says .
`` It was easy for all of us to believe that we kind of got it under control , and I think there was a lot of belief that we would be able to maintain that . ''
The California Nurses Association has good reason to be defensive when it comes to the integrity of the patient ratio law , Spetz says .
It took 10 years of lobbying and activism before the bill passed the state legislature in 1999 , then several more years to overcome @ @ @ @ @ @ @ then-Gov .
Arnold Schwarzenegger .
`` I 'm always kicking their butt , that 's why they do n't like me , '' Schwarzenegger famously said of nurses , drawing broad ire from the nurse 's union and its allies .
Nurses prevailed in the court of public opinion and in law ; rules that put a legal cap on the number of patients per nurse finally took effect in 2004 .
But the long battle has made nurses fiercely protective of their win .
They 've even accused hospitals of using the @ @ @ @ @ @ @ for good .
`` This is the exercise of disaster capitalism at its finest , where [ hospital administrators ] are completely maximizing their opportunity to take advantage of this crisis , '' says Roberson .
Hospitals deny they want to change the ratio law permanently , and Spetz says it 's unlikely that they 'd succeed if they tried .
The public can see that nurses are overworked and burned out by the pandemic , she adds , so there would be little support for cutting back their job protections once it @ @ @ @ @ @ @ and say , 'Oh , you clearly did so well without ratios when we let you waive them , so let 's just eliminate them entirely , ' I think , would be just adding insult to moral injury , '' Spetz says .

California Is Overriding Its Limits On Nurse Workloads As COVID-19 Surges
Enlarge this image toggle caption Nerissa Black Nerissa Black
California's telemetry nurses, who specialize in the electronic monitoring of critically ill patients, normally take care of four patients at once. But ever since the state relaxed California's mandatory nurse-to-patient ratios in mid-December, Nerissa Black has had to keep track of six.
And these six patients are really sick: they all need constant electronic heart monitoring and many of them are being treated simultaneously for a stroke and COVID-19, or a heart attack and COVID-19. With more patients than usual needing more complex care, Black says she's worried she'll miss something or make a mistake.
"We are given 50% more patients and we're expected to do 50% more things with the same amount of time," says Black, who has worked at the Henry Mayo Newhall Hospital in Valencia, Calif., for the past seven years. "I go home and I feel like I could have done more. I don't feel like I'm giving the care to my patients like a human being deserves."
We are given 50% more patients and we're expected to do 50% more things with the same amount of time.
As COVID-19 patients continue to flood California emergency rooms, hospitals are increasingly desperate to find enough staff to care for all them. The state is asking nurses to take care of more patients simultaneously than they normally would, watering down what many nurses and their unions consider their most sacrosanct job protection: a law existing only in California that puts legal restrictions on the nurse-to-patient ratio.
"We need to temporarily — very short-term, temporarily — look a little bit differently in terms of our staffing needs," said Gov. Gavin Newsom, after he quietly allowed hospitals to adjust their nurse-to-patient ratios on Dec. 11. Normally, California law requires a hospital to first get approval from the state before tinkering with those ratios; Newsom's move gave hospitals presumptive approval to work outside the ratio rules immediately.
Since then, 170 hospitals, mainly in Southern California, have been operating under the new pandemic ratios: They can require ICU nurses to care for three patients instead of two. Emergency room and telemetry nurses may now be asked to care for six patients instead of four. Medical-surgical nurses are looking after seven patients instead of five.
This is catastrophic and we cannot dodge this math. We are simply out of nurses, out of doctors, out of respiratory therapists.
Nurses have taken to the streets in protest, holding socially distanced demonstrations across the state, shouting and carrying posters that read: "Ratios Save Lives." The union, the California Nurses Association, says the staffing shortage is a result of bad hospital management, of taking a reactive approach to staffing rather than proactive: laying nurses off over the summer, then not hiring or training enough for winter.
"What we're seeing in these hospitals is their just-in-time response to a pandemic that they never prepared for: just-in-time staffing, just-in-time resources, not staffing up, calling nurses in on a shift at the very last minute — to boost profits," says Stephanie Roberson, the government relations director for the California Nurses Association. "And we're seeing how nurses are being stretched even thinner."
Enlarge this image toggle caption Nerissa Black Nerissa Black
But hospitals say this is an unprecedented crisis that has spiraled beyond their control. In the current surge, four times as many Californians are testing positive for the coronavirus compared to the summer peak. As many as 7,000 new patients could soon be coming to California hospitals every day, according to Carmela Coyle, who heads the California Hospital Association.
"This is catastrophic and we cannot dodge this math," she says. "We are simply out of nurses, out of doctors, out of respiratory therapists."
The state has asked the federal government for staff, including 200 medical personnel from the U.S. Department of Defense, and it's tried to reactivate the California Health Corps, an initiative to recruit retired health workers to come back to work, but that has yielded few people with the qualifications needed to care for hospitalized COVID-19 patients.
Hiring contract nurses from temporary staffing agencies or other states is all but impossible right now, Coyle says.
"Because California surged early during the summer and other parts of the United States then surged afterward," she says, "those travel nurses are taken."
Hospitals' next step is to try "team nursing," Coyle says, pulling nurses from other departments, like the operating room, for example, and partnering them with experienced critical care nurses to help care for COVID-19 patients.
Joanne Spetz is an economics professor who studies health care workforce issues at the University of California, San Francisco. She says hospitals should have started training nurses for team care over the summer, in anticipation of a winter surge, but they didn't, either because of costs — hospitals lost a lot of revenue from canceled elective surgeries that could have paid for that training — or because of excessive optimism.
"California was doing so well," she says. "It was easy for all of us to believe that we kind of got it under control, and I think there was a lot of belief that we would be able to maintain that."
The California Nurses Association has good reason to be defensive when it comes to the integrity of the patient ratio law, Spetz says. It took 10 years of lobbying and activism before the bill passed the state legislature in 1999, then several more years to overcome multiple court challenges, including one from then-Gov. Arnold Schwarzenegger.
"I'm always kicking their butt, that's why they don't like me," Schwarzenegger famously said of nurses, drawing broad ire from the nurse's union and its allies.
Nurses prevailed in the court of public opinion and in law; rules that put a legal cap on the number of patients per nurse finally took effect in 2004. But the long battle has made nurses fiercely protective of their win. They've even accused hospitals of using the pandemic to try to roll back ratios for good.
"This is the exercise of disaster capitalism at its finest, where [hospital administrators] are completely maximizing their opportunity to take advantage of this crisis," says Roberson.
Hospitals deny they want to change the ratio law permanently, and Spetz says it's unlikely that they'd succeed if they tried.
The public can see that nurses are overworked and burned out by the pandemic, she adds, so there would be little support for cutting back their job protections once it's over.
"To go in and say, 'Oh, you clearly did so well without ratios when we let you waive them, so let's just eliminate them entirely,' I think, would be just adding insult to moral injury," Spetz says.


npr--2020-12-30--Coronavirus World Map: Tracking The Spread Of The Outbreak

Coronavirus World Map : Tracking The Spread Of The Outbreak Explore the chart below to find a country-by-country breakdown of new and total cases since January .
In late spring and early summer , new COVID-19 cases were largely driven by cases in the Americas .
While the U.S. has consistently had the most new daily cases of coronavirus in the region , Brazil 's new daily cases increased rapidly between May and August .
However , in September , several countries that had previously flattened their curve saw a resurgence in cases , including Spain and France .
In @ @ @ @ @ @ @ swiftly since June .
Explore how the number of coronavirus cases have shifted in different parts of the world over time .
The first chart compares each continent to each other , while the next charts highlight the number of cases in select countries by region .
To compare country outbreaks , the chart below graphs trend lines for average new daily cases and deaths against each country 's totals to date .
This type of visualization highlights a state 's daily growth or decline relative to the overall size of its outbreak @ @ @ @ @ @ @ and death counts grow quickly , the curves bend upward .
As new cases and deaths slow , the curves level or bend down .
In countries like Israel , which is seeing a second wave of case growth after an initial wave in April , the line forms a V-shape , as the initially bent curve spikes upwards again .
Click here to see the state-by-state breakdown of cases in the United States .
This story was originally published on March 30 , 2020 .

Coronavirus world map: We've now passed the 600 million mark for infections
Editor's note: This page is no longer being updated. The last update was Sept. 5, 2022. For current data about COVID-19 cases and deaths around the world, Johns Hopkins University and Our World in Data are useful resources.
In late January 2020 only a few dozen COVID-19 infections had been identified outside of China. A year later, the world tallied its first 100 million cases. It took the globe just 7 more months to pass the 200 million mark— then another 5 months to hit 300 million, according to researchers at Johns Hopkins University. Now the virus has spread to every corner of the globe and has been blamed for more than 6 million deaths.
The United States, India and Brazil in that order have had the most COVID cases and the three nations collectively account for almost half of all recorded infections so far in the pandemic.
Explore the chart below to find a country-by-country breakdown of new and total cases since January 2020.
Loading...
Loading...
Explore how the number of coronavirus cases have shifted in different parts of the world over time. The first chart compares each continent to each other, while the next charts highlight the number of cases in select countries by region.
Loading...
Loading...
This story was originally published on March 30, 2020.


npr--2020-12-31--Coronavirus Is Surging: How Severe Is Your State's Outbreak?

Coronavirus Is Surging : How Severe Is Your State 's Outbreak ?
More than 19 million people in the U.S. have had confirmed coronavirus infections and more than 330,000 have died of COVID-19 .
Tens of thousands of new cases are reported daily nationwide .
In the graphics below , explore the trends in your state .
View the data via a heat map ( immediately below ) , curve charts , a table of state-by-state trends over four weeks , or a map of total cases and deaths .
The map above shows the risk of infection in each @ @ @ @ @ @ @ capita .
The consortium of researchers and public health experts who developed these risk levels advises states in the red category to issue stay-home orders .
They advise orange states to consider stay-home orders , along with increased testing and contact tracing .
Yellow states need to keep up social distancing and mask usage , and all states should continue testing and contact tracing .
To compare state outbreaks , the chart above graphs trend lines for average new daily cases and deaths against each state 's totals to date .
This type @ @ @ @ @ @ @ growth or decline relative to the overall size of its outbreak .
When both new and total case and death counts grow quickly , the curves bend upward .
As new cases and deaths slow , the curves level or bend down .
In New York , the curve rose sharply before reaching over 170,000 total cases in April .
New cases fell from about 10,000 per day in mid-April to under 900 a day most of the summer , before starting to rise in the fall .
Explore the map above to @ @ @ @ @ @ @ the country for both new confirmed cases and reported deaths from COVID-19 .
New York was the original epicenter of the pandemic in the U.S. As of mid October , California , Florida and Texas surpass New York for total cases to date , though New York still has the highest death total .
Click here to see a global map of confirmed cases and deaths .
To show trends , the table below shows the change in average new cases per day in each state , week over week for the last @ @ @ @ @ @ @ of red have growing outbreaks ; those in shades of green , are declining .
The graphics on this page pull from data compiled by the Center for Systems Science and Engineering at Johns Hopkins University from several sources , including the Centers for Disease Control and Prevention ; the World Health Organization ; national , state and local government health departments ; 1point3acres ; and local media reports .
The JHU team automates its data uploads and regularly checks them for anomalies .
This may result in occasional data discrepancies on this @ @ @ @ @ @ @ and updates its feeds .
State-by-state recovery data are unavailable at this time .
There may be discrepancies between what you see here and what you see on your local health department 's website .
Figures shown do not include cases on cruise ships .
Fluctuations in the numbers may happen as health authorities review old cases and or update their methodologies .
For example , in early June , Michigan health authorities started including probable cases in its totals .
This resulted in a brief spike in the state 's daily numbers @ @ @ @ @ @ @ reconcile the historical data .
On June 25 , New Jersey included 1,854 previously-unreported probable deaths in its totals , resulting in a spike in the state 's daily death numbers .
On Sept. 2 , Massachusetts changed its methodology for counting probable cases , which lowered its overall case and death numbers .
The JHU team maintains a list of such changes .
This story was originally published on March 16 , 2020 .
Elena Renken was a co-author on that version .
Sean McMinn and Audrey Carlsen contributed to this story @ @ @ @ @ @ @

Tracking the coronavirus around the U.S.: See how your state is doing
Loading...
Note: This page was last updated on Feb. 1, 2023. It will no longer be updated. For current data on COVID cases and deaths, demographics, and hospitalizations, consult the Centers for Disease Control and Prevention.
As of Feb. 1, there have been more than 101 million confirmed coronavirus infections in the U.S. and more than 1 million people have died of COVID-19. In the graphics below, explore the trends in your state.
Loading...
The above charts show average new cases per 100,000 people for each state over the last 12 months.
Note: Actual cases may be substantially higher, since many who test positive with at-home tests don't report their cases.
For additional data about COVID-19 in the U.S, including cases and deaths, demographics, and hospitalizations, consult the Centers for Disease Control and Prevention website.
To show trends, the table below shows the change in average new cases per day in each state, week over week for the last 28 days. States marked in shades of red have growing outbreaks; those in shades of green, are declining.
Loading...
Methodology
The graphics on this page pull from data compiled by the Center for Systems Science and Engineering at Johns Hopkins University from several sources, including the Centers for Disease Control and Prevention; the World Health Organization; national, state and local government health departments; 1point3acres; and local media reports.
The JHU team automates its data uploads and regularly checks them for anomalies. This may result in occasional data discrepancies on this page as the JHU team resolves anomalies and updates its feeds. There may be discrepancies between what you see here and what you see on your local health department's website. Figures shown do not include cases on cruise ships.
Fluctuations in the numbers may happen as health authorities review old cases, process testing backlogs or update their methodologies. The JHU team maintains a list of such changes.
This story was originally published on March 16, 2020. Elena Renken was a co-author on that version. Sean McMinn and Audrey Carlsen contributed to this story. Carmel Wroth edited this story.


npr--2020-12-31--Coronavirus World Map: Tracking The Spread Of The Outbreak


npr--2020-12-31--Health Care Workers Try To Bring COVID-19 Patients Joy, Less Isolation As Life Ends

Health Care Workers Try To Bring COVID-19 Patients Joy , Less Isolation As Life Ends When the coronavirus hit the U.S. , hospitals issued strict limitations on visitors .
Nurses and doctors started acting as liaisons to the sick and dying for family members not allowed at bedsides .
As deaths reach new daily highs , that work is not getting any easier .
The emotional toil of adapting to new dynamics with patients and families at one rural hospital in Livingston , Mont.
, is a case study of what health care workers are grappling with all over the @ @ @ @ @ @ @ in south-central Montana , Livingston HealthCare looks more like an upscale ski chalet than a medical facility .
It 's one of more than 1,300 critical access hospitals in the U.S. , which are federally designated to increase health care access in rural areas .
Here , the hospital has 25 beds and serves a huge region — about twice the size of Rhode Island — but with a population just shy of 17,000 .
It 's about an hour drive north of Yellowstone National Park , and the walls are dotted with @ @ @ @ @ @ @ On this windy , wintry mid-December day , three beds here are occupied by COVID-19 patients .
Jenn Schmid , the assistant director of nursing , is standing outside large windows that offer a view inside the hospital 's two ICU rooms .
This is the epicenter of the pandemic in the hospital — where the worst cases are .
The beds are empty and neatly made .
Soft , yellow light is pouring in from outside .
But a few weeks ago , the scene here would have looked very different .
@ @ @ @ @ @ @ in the area ebbed and flowed — and they were in the midst of the biggest spike they 'd seen so far .
`` My job consisted of 24/7 begging people to try to come in to get help , coming in to try to staff it myself , just because we did n't have enough nurses , '' Schmid says .
The CDC recommends that hospitals limit visitation , especially during times of community spread .
Figuring out how to do so requires balancing safety with the emotion and trauma faced by @ @ @ @ @ @ @ the hospital banned visitors , but there are exceptions .
When patients near the end of their lives , their closest relatives are allowed to say their goodbyes from a distance — through those windows that look into the ICU .
Schmid sat outside the room with families .
She says that glass barrier between patients and their loved ones made farewells an even more emotionally devastating experience .
`` Having to sit out here with family and try to be their support and give them that affection or that caring when you @ @ @ @ @ @ @ and they ca n't see their dad or their husband for the last time and you have to watch that , it 's gut-wrenching , '' she says .
`` And I do n't think I 'll ever get used to that .
I 've seen a lot of death and I 've held multiple peoples ' hands while they 're dying .
But I 've never had anything that has affected me like that .
It 's so foreign .
And it 's tragic . ''
Respiratory therapist Mary Graham says all @ @ @ @ @ @ @ are taking on more responsibility to care for patients .
`` The hardest thing is watching them go without their family members , '' she says .
She 's been in the room twice when this happened .
She says she holds the patient 's hand and says a prayer .
She hopes that can give families an ounce of closure .
`` It 's tough , '' she says .
Doctors and nurses experience that isolation very differently than patients and family members , who maintain connection with each other only through @ @ @ @ @ @ @ Lori Schmidt 's husband Jerry was in one of those ICU rooms .
`` If I had known that I would never get to hold his hand or anything again , oh my gosh , I would 've done things so differently , '' Schmidt says .
`` But I guess naively I really did n't think Jerry was gon na die from this . ''
She 's 59 , a retired banker , and calls herself a `` glass-half-full '' kind of person .
Her husband was 74 .
`` He was @ @ @ @ @ @ @ .
`` He could build , fix , wire .
He was an electrician .
He could do anything — he could rebuild a Mustang from start to finish . ''
One night in early November , her husband fell down in their house .
He had a fever and was throwing up .
She called the paramedics , who took him to the hospital .
It was the last time she saw him face-to-face .
Schmidt says at Livingston HealthCare , nurses would call her from her husband 's cellphone on Facetime @ @ @ @ @ @ @ my phone , there 's a big daisy and when I would see that , no matter how bad I felt , I felt renewed , '' she says .
`` It was like 'Jerry 's calling ! '
I was so excited . ''
With her husband in isolation , it was the closest she could get to human contact .
When it became clear it was the end , the hospital brought the family into the ICU , where they could see Jerry through the window .
She says nurses were @ @ @ @ @ @ @ songs to help him feel at ease , and helped relay what Schmidt and her family were saying .
`` [ They were ] trying to make him feel like he did n't have to hold on anymore because he was so tired , '' she says .
Schmidt says Jerry passed peacefully on Nov. 15 after 12 days in the hospital .
As we talk , it 's been one month , to the minute , since his death .
Schmidt 's thankful for the health care workers who made sure her @ @ @ @ @ @ @ windows , and all the small efforts of health care workers are a saving grace for Schmidt and people like her .
`` I mean that made all the difference in the world . ''
`` Nursing is touching and interaction , '' says Per Gunness , an ICU and medical surgical nurse at Livingston HealthCare .
`` To hide the part of your face which shows your emotions , your intentions , your fear , your humor .
You try to smile really hard so your eyes show it .
That 's @ @ @ @ @ @ @ workers layer up in masks , protective glasses , and other gear to stave off the spread of the disease .
Instead of smiles and facial expressions , only their eyes — perched above an N95 — can show emotion and establish connection .
`` It makes me sick to my stomach thinking about that , like , so many people are dying alone and their nurse has maybe known 'em or a couple of days is the last person they see , '' medical floor nurse Kristy Blaine says .
She says @ @ @ @ @ @ @ to keep patients feeling connected .
`` You also , you know , feel bad for your patients because these Martians are coming in , looking so different , '' Blaine says .
`` You know , you literally look like an alien and you 're trying to care for your patients , and they just feel like lepers . ''
Blaine does what she can to make the hospital feel less sterile for her patients .
She keeps a squishy , pink-haired unicorn dangling from a keychain on her ID badge .
@ @ @ @ @ @ @ , a little brown bubble forms on its backside .
`` It poops , '' she whispers , laughing . ''
I like to joke around and I like to have fun and I feel like we all only get one trip on this Earth and it might as well be part of a good old laugh .
You know nurses always ask about poop . ''
Blaine says that for nurses , adaptability is part of the job description .
With only eyes peering out behind a mask , that pooping unicorn @ @ @ @ @ @ @ a world of isolation .
Limits on visitations in hospitals across the country are unlikely to change much until this spring or summer , when vaccines are widely available .
Until then , health care workers will continue to adapt , to innovate , and to find reasons to smile .

Health Care Workers Try To Bring COVID-19 Patients Joy, Less Isolation As Life Ends
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
When the coronavirus hit the U.S., hospitals issued strict limitations on visitors. Nurses and doctors started acting as liaisons to the sick and dying for family members not allowed at bedsides. As deaths reach new daily highs, that work is not getting any easier. The emotional toil of adapting to new dynamics with patients and families at one rural hospital in Livingston, Mont., is a case study of what health care workers are grappling with all over the country.
Framed by the rugged Absaroka Mountains in south-central Montana, Livingston HealthCare looks more like an upscale ski chalet than a medical facility. It's one of more than 1,300 critical access hospitals in the U.S., which are federally designated to increase health care access in rural areas. Here, the hospital has 25 beds and serves a huge region — about twice the size of Rhode Island — but with a population just shy of 17,000.
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
It's about an hour drive north of Yellowstone National Park, and the walls are dotted with images of trout and breathtaking vistas.
On this windy, wintry mid-December day, three beds here are occupied by COVID-19 patients.
End-of-life care
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
Jenn Schmid, the assistant director of nursing, is standing outside large windows that offer a view inside the hospital's two ICU rooms. This is the epicenter of the pandemic in the hospital — where the worst cases are. The beds are empty and neatly made. Soft, yellow light is pouring in from outside. But a few weeks ago, the scene here would have looked very different. Over the past several months, cases in the area ebbed and flowed — and they were in the midst of the biggest spike they'd seen so far.
"My job consisted of 24/7 begging people to try to come in to get help, coming in to try to staff it myself, just because we didn't have enough nurses," Schmid says.
The CDC recommends that hospitals limit visitation, especially during times of community spread. Figuring out how to do so requires balancing safety with the emotion and trauma faced by patients and their families.
Here, the hospital banned visitors, but there are exceptions. When patients near the end of their lives, their closest relatives are allowed to say their goodbyes from a distance — through those windows that look into the ICU. Schmid sat outside the room with families. She says that glass barrier between patients and their loved ones made farewells an even more emotionally devastating experience.
"Having to sit out here with family and try to be their support and give them that affection or that caring when you yourself have to stay 6 feet away and they can't see their dad or their husband for the last time and you have to watch that, it's gut-wrenching," she says. "And I don't think I'll ever get used to that. I've seen a lot of death and I've held multiple peoples' hands while they're dying. But I've never had anything that has affected me like that. It's so foreign. And it's tragic."
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
Respiratory therapist Mary Graham says all 265 health care workers at the hospital are taking on more responsibility to care for patients. "The hardest thing is watching them go without their family members," she says.
She's been in the room twice when this happened. She says she holds the patient's hand and says a prayer. She hopes that can give families an ounce of closure. "It's tough," she says.
Patients and families
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
Doctors and nurses experience that isolation very differently than patients and family members, who maintain connection with each other only through screens and glass. Last month, Lori Schmidt's husband Jerry was in one of those ICU rooms.
"If I had known that I would never get to hold his hand or anything again, oh my gosh, I would've done things so differently," Schmidt says. "But I guess naively I really didn't think Jerry was gonna die from this."
She's 59, a retired banker and calls herself a "glass-half-full" kind of person. Her husband was 74.
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
"He was an amazing man," she says. "He could build, fix, wire. He was an electrician. He could do anything — he could rebuild a Mustang from start to finish."
One night in early November, her husband fell down in their house. He had a fever and was throwing up. She called the paramedics, who took him to the hospital. It was the last time she saw him face to face.
Schmidt says at Livingston HealthCare, nurses would call her from her husband's cellphone on FaceTime.
"When Jerry pops up on my phone, there's a big daisy and when I would see that, no matter how bad I felt, I felt renewed," she says. "It was like 'Jerry's calling!' I was so excited."
With her husband in isolation, it was the closest she could get to human contact. When it became clear it was the end, the hospital brought the family into the ICU, where they could see Jerry through the window.
She says nurses were at his side. They sang him songs to help him feel at ease, and helped relay what Schmidt and her family were saying.
"[They were] trying to make him feel like he didn't have to hold on anymore because he was so tired," she says.
Schmidt says Jerry passed peacefully on Nov. 15 after 12 days in the hospital. As we talk, it's been one month, to the minute, since his death.
Schmidt's thankful for the health care workers who made sure her husband felt less isolated. Screens, windows and all the small efforts of health care workers are a saving grace for Schmidt and people like her.
"I mean, that made all the difference in the world."
Bedside manner
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
"Nursing is touching and interaction," says Per Gunness, an ICU and medical surgical nurse at Livingston HealthCare. "To hide the part of your face which shows your emotions, your intentions, your fear, your humor. You try to smile really hard so your eyes show it. That's been incredibly bizarre."
Health care workers layer up in masks, protective glasses and other gear to stave off the spread of the disease. Instead of smiles and facial expressions, only their eyes — perched above an N95 — can show emotion and establish connection.
"It makes me sick to my stomach thinking about that, like, so many people are dying alone and their nurse has maybe known 'em or a couple of days is the last person they see," medical floor nurse Kristy Blaine says.
She says she recognizes the emotional work it takes to keep patients feeling connected.
Enlarge this image toggle caption Nick Mott for NPR Nick Mott for NPR
"You also, you know, feel bad for your patients because these Martians are coming in, looking so different," Blaine says. "You know, you literally look like an alien and you're trying to care for your patients, and they just feel like lepers."
Blaine does what she can to make the hospital feel less sterile for her patients. She keeps a squishy, pink-haired unicorn dangling from a keychain on her ID badge. When you squeeze it, she demonstrates, a little brown bubble forms on its backside.
"It poops," she whispers, laughing." I like to joke around and I like to have fun and I feel like we all only get one trip on this Earth and it might as well be part of a good old laugh. You know nurses always ask about poop."
Blaine says that for nurses, adaptability is part of the job description. With only eyes peering out behind a mask, that pooping unicorn is one way of bringing joy into a world of isolation.
Limits on visitations in hospitals across the country are unlikely to change much until this spring or summer, when vaccines are widely available. Until then, health care workers will continue to adapt, to innovate, and to find reasons to smile.


npr--2020-12-31--A 2020 Surprise: Fewer Absentee Ballots Rejections Than Expected

Florida resident Kirk Nielsen was very careful when he went to vote this fall .
He did it early , and deposited his mail-in ballot in one of many drop boxes provided by his local election office in Miami-Dade County .
`` So early voting , drop box .
Checked the supervisor of elections website a couple of days later and it was tabulated , '' he said .
`` It worked swell . ''
That was a relief for Nielsen , whose vote did not count in 2018 .
His ballot arrived too late , despite being mailed more @ @ @ @ @ @ @ NPR reported earlier this year that more than a half million mail-in votes were rejected in the 2020 primaries for similar reasons .
The ballots arrived too late or had missing or mismatched signatures .
And with many more people voting by mail this fall , election officials feared that millions more ballots would be rejected in the general election .
It did n't happen .
Instead , rejection rates went down across the country , in states such as North Carolina , Georgia , Michigan , New Jersey , Ohio , and @ @ @ @ @ @ @ coming in .
Daniel Smith , a political scientist at the University of Florida , says out of almost five million mail-in ballots cast in his state this fall , fewer than 9,000 were rejected , a much lower rate than in previous elections .
He said it was n't because voters made fewer mistakes .
`` The rates of ballots being flagged for problems was n't any lower than in past elections .
It 's just that individuals were able to cure their ballots in a timely fashion to make sure that @ @ @ @ @ @ @ Smith .
As in many other states , Florida made it easier this year for voters to fix , or `` cure , '' their ballots .
For example , Florida 's mail-in ballot envelopes included space where voters could provide their e-mail address or phone number , allowing election officials to contact them more quickly about mistakes , so they could be fixed on time .
That change also provided crucial contact information for campaigns and interest groups , so they too could reach out to voters to make sure that their @ @ @ @ @ @ @ groups did just that , helping their supporters cure their ballots as part of aggressive get-out-the-vote campaigns .
Jared Dearing , executive director of Kentucky 's board of elections , says his state also took steps to help absentee voters after more than 25,000 ballots were rejected in the June primary .
Prior to the pandemic , only about two percent of Kentucky voters cast their ballots by mail , compared to 75 % this year , and there were some growing pains .
`` So what we tried to do is create @ @ @ @ @ @ @ , two , to give some pretty clear guidelines to the counties of what could be counted , what could n't be counted , '' said Dearing .
He said some counties were discarding ballots for reasons that others did not , such as a voter signing the envelope in the wrong place .
Under the new guidelines , such ballots would be accepted .
The state also created an on-line portal where voters were able to apply for an absentee ballot , track its progress and be alerted of potential problems .
@ @ @ @ @ @ @ about 2,500 votes in November .
`` Not waiting until the last day' Dearing said something else added to the decline .
He saw a monumental shift in voter behavior this year , as though all those warnings and news stories about tossed ballots and postal delays really sunk in .
`` For the first time , voters were not waiting until the last day to mail these things .
They were all mailing them weeks ahead of time , '' he said .
Amber McReynolds , CEO of the National Vote at @ @ @ @ @ @ @ official , saw another silver lining .
She said the fact that so many ballots were rejected in the primaries helped voters learn how to do it right .
Many of them were first-time absentee voters , in large part due to the pandemic .
`` It 's a teachable moment , right , '' she said .
`` You get your ballot rejected then you 're probably not going to make that mistake again . ''
Ironically , some election officials think President Trump 's repeated attacks on mail-in voting as insecure @ @ @ @ @ @ @ front and center .
Voters heard over and over again how important it was to follow the rules .
McReynolds hopes that states now learn from this year 's experiences and find ways to make mail voting easier and more problem-free .
She said there were many good examples of states educating their voters about the process and potential pitfalls .
Hawaii , for one , sent a card to every voter letting them know that election officials would use their signatures to validate mail-in ballots and giving voters a chance to update @ @ @ @ @ @ @ extended ballot receipt deadlines and gave voters more time to cure their ballots , sometimes as the result of litigation .
But initial signs are not encouraging .
Republican lawmakers in Pennsylvania , Wisconsin , Georgia , Arizona and elsewhere — citing Trump 's baseless claims that mail-in voting leads to widespread fraud — are already talking about ways to restrict absentee voting .
If only , they say , to restore voter confidence in the system .

A 2020 Surprise: Fewer Absentee Ballot Rejections Than Expected
Enlarge this image toggle caption Jeff Kowalsky/AFP via Getty Images Jeff Kowalsky/AFP via Getty Images
Florida resident Kirk Nielsen was very careful when he went to vote this fall. He did it early and deposited his mail-in ballot in one of many drop boxes provided by his local election office in Miami-Dade County.
"So early voting, drop box. Checked the supervisor of elections website a couple of days later and it was tabulated," he said. "It worked swell."
That was a relief for Nielsen, whose vote did not count in 2018. His ballot arrived too late, despite being mailed more than a week before Election Day.
NPR reported earlier this year that more than a half-million mail-in votes were rejected in the 2020 primaries for similar reasons. The ballots arrived too late or had missing or mismatched signatures.
And with many more people voting by mail this fall, election officials feared that millions more ballots would be rejected in the general election.
It didn't happen. Instead, rejection rates went down across the country, in states such as North Carolina, Georgia, Michigan, New Jersey, Ohio and Florida — although final numbers are still coming in.
Daniel Smith, a political scientist at the University of Florida, says that out of almost 5 million mail-in ballots cast in his state this fall, fewer than 9,000 were rejected, a much lower rate than in previous elections.
He said it wasn't because voters made fewer mistakes.
"The rates of ballots being flagged for problems wasn't any lower than in past elections. It's just that individuals were able to cure their ballots in a timely fashion to make sure that their ballots would count," said Smith.
Fixes and cures
As in many other states, Florida made it easier this year for voters to fix, or "cure," their ballots. For example, Florida's mail-in ballot envelopes included space where voters could provide their email address or phone number, allowing election officials to contact them more quickly about mistakes, so they could be fixed on time.
That change also provided crucial contact information for campaigns and interest groups, so they too could reach out to voters to make sure that their ballots counted. And indeed, many groups did just that, helping their supporters cure their ballots as part of aggressive get-out-the-vote campaigns.
Jared Dearing, executive director of Kentucky's board of elections, says his state also took steps to help absentee voters after more than 25,000 ballots were rejected in the June primary. Prior to the pandemic, only about 2% of Kentucky voters cast their ballots by mail, compared with 75% this year. There were some growing pains.
"So what we tried to do is create 1) uniformity of process and 2) to give some pretty clear guidelines to the counties of what could be counted, what couldn't be counted," said Dearing.
He said some counties were discarding ballots for reasons that others did not, such as a voter signing the envelope in the wrong place. Under the new guidelines, such ballots would be accepted.
The state also created an online portal where voters were able to apply for an absentee ballot, track its progress and be alerted of potential problems. That helped cut rejections dramatically, to about 2,500 votes in November.
"Not waiting until the last day"
Dearing said something else added to the decline. He saw a monumental shift in voter behavior this year, as though all those warnings and news stories about tossed ballots and postal delays really sunk in.
"For the first time, voters were not waiting until the last day to mail these things. They were all mailing them weeks ahead of time," he said.
Amber McReynolds, CEO of the National Vote at Home Institute and a former Colorado election official, saw another silver lining. She said the fact that so many ballots were rejected in the primaries helped voters learn how to do it right. Many of them were first-time absentee voters, in large part because of the pandemic.
"It's a teachable moment, right," she said. "You get your ballot rejected, then you're probably not going to make that mistake again."
Ironically, some election officials think President Trump's repeated attacks on mail-in voting as insecure also helped, by keeping the issue front and center. Voters heard over and over again how important it was to follow the rules.
McReynolds hopes that states learn from this year's experiences and find ways to make mail voting easier and more problem-free. She said there were many good examples of states educating their voters about the process and potential pitfalls. Hawaii, for one, sent a card to every voter letting them know that election officials would use their signatures to validate mail-in ballots and giving voters a chance to update the one on record. Other states extended ballot receipt deadlines and gave voters more time to cure their ballots, sometimes as the result of litigation.
But initial signs are not encouraging. Republican lawmakers in Pennsylvania, Wisconsin, Georgia, Arizona and elsewhere — citing Trump's baseless claims that mail-in voting leads to widespread fraud — are already talking about ways to restrict absentee voting. If only, they say, to restore voter confidence in the system.


npr--2020-12-31--U.S. Likely Will Miss Goal Of Vaccinating 20 Million By The New Year

U.S. Likely Will Miss Goal Of Vaccinating 20 Million By The New Year Snowstorms , holidays , and general inexperience in handling a pandemic response is to blame for a `` lag '' in the number of Americans so far vaccinated for the coronavirus , according to U.S. officials .
The federal government previously estimated 20 million Americans would receive the first dose of the Pfizer-BioNtech vaccine by the end of the year .
But as 2020 , a year defined by the coronavirus pandemic , comes to a close on Thursday , the government appears set to fall well @ @ @ @ @ @ @ General Gustave F. Perna , chief operating officer of Operation Warp Speed , and Dr. Moncef Slaoui , chief advisor to federal vaccine effort , said the U.S. has deployed around 14 million vaccine doses as of Wednesday , but only 2.1 million people had received shots .
Perna and Slaoui spoke on Wednesday during a news conference .
The vaccination process started on Dec. 14 with frontline health workers getting the shots first .
The number of people vaccinated as reported by Perna and Slaoui contrasts with data from the Centers for @ @ @ @ @ @ @ Thursday morning , the agency said that more than 12.4 million doses of Pfizer 's and Moderna 's two-dose vaccines had been distributed across the country .
The CDC reports just 2.7 million people have been vaccinated .
It has said , however , it is working with out of date data .
Perna said he is also working off of a 72- to 96-hour lag in vaccine reporting data , which he says will be adjusted as time goes on .
Regardless of the data used , Perna and Slaoui say the @ @ @ @ @ @ @ is far lower than what they would like .
`` We know it should be better and we are working hard to make it better , '' Slaoui said .
More than 338,000 Americans have died from the pandemic so far , according to Johns Hopkins University .
Health officials warn that January could be the deadliest month since the start of the pandemic , making a successful vaccine distribution all the more critical .
The vaccine rollout has been challenging , but officials expect that between Jan. 8 and Jan. 15 , @ @ @ @ @ @ @ Perna said .
Despite the early hiccups , Perna and Slaoui applauded the multi-pronged effort involving states and local governments , hospitals , pharmaceutical companies , and delivery companies to get the immunization program rolling .
President Trump criticized state officials for the lag in a tweet this week and urged states to , `` Get moving ! ''
News of the lag in vaccinations comes as reports of issues with state-level distribution processes trickle out .
Florida 's county-by-county plan to vaccinate the state 's elderly residents created a scramble earlier this @ @ @ @ @ @ @ Florida county encouraged anyone 65 and older and high-risk frontline health care workers to come to one of its seven vaccination sites — no appointment necessary .
Each location only had 300 doses , leading to overwhelmed health centers and residents camping out for several hours to get their shots .
In Wisconsin , a medical center employee intentionally left 57 vials of the Moderna vaccine out of its cold storage , leading health officials no choice but to destroy them .
The vials could 've provided around 500 doses .

U.S. Likely Will Miss Goal Of Vaccinating 20 Million By The New Year
Enlarge this image toggle caption Brendan Smialowski/AFP via Getty Images Brendan Smialowski/AFP via Getty Images
Snowstorms, holidays and general inexperience in handling a pandemic response is to blame for a "lag" in the number of Americans so far vaccinated for the coronavirus, according to U.S. officials.
The federal government previously estimated that 20 million Americans would receive the first dose of the Pfizer-BioNtech vaccine by the end of the year. But as 2020, a year defined by the coronavirus pandemic, comes to a close on Thursday, the government appears set to fall well short of that goal.
U.S. Army Gen. Gustave F. Perna, chief operating officer of Operation Warp Speed, and Moncef Slaoui, chief adviser to federal vaccine effort, said the U.S. has deployed around 14 million vaccine doses as of Wednesday, but only 2.1 million people had received shots. Perna and Slaoui spoke on Wednesday during a news conference.
The vaccination process started on Dec. 14 with frontline health workers getting the shots first.
The number of people vaccinated as reported by Perna and Slaoui contrasts with data from the Centers for Disease Control and Prevention. As of Thursday morning, the agency said that more than 12.4 million doses of Pfizer's and Moderna's two-dose vaccines had been distributed across the country. The CDC reports just 2.7 million people have been vaccinated. It has said, however, it is working with out-of-date data.
Perna said he is also working off of a 72- to 96-hour lag in vaccine reporting data, which he says will be adjusted as time goes on.
Regardless of the data used, Perna and Slaoui say the number of Americans vaccinated from the coronavirus is far lower than what they would like.
"We know it should be better, and we are working hard to make it better," Slaoui said.
More than 340,000 Americans have died from the pandemic, as of Thursday morning, according to Johns Hopkins University. Health officials warn that January could be the deadliest month since the start of the pandemic, making a successful vaccine distribution all the more critical.
The vaccine rollout has been challenging, but officials expect that between Jan. 8 and Jan. 15, access to vaccines will greatly increase, Perna said.
Despite the early hiccups, Perna and Slaoui applauded the multipronged effort involving states and local governments, hospitals, pharmaceutical companies and delivery companies to get the immunization program rolling.
President Trump criticized state officials for the lag in a tweet this week and urged states to, "Get moving!"
News of the lag in vaccinations comes as reports of problems with state-level distribution processes trickle out.
Florida's county-by-county plan to vaccinate the state's elderly residents created a scramble earlier this week. CNN reported that a southwest Florida county encouraged anyone 65 and older and high-risk frontline health care workers to come to one of its seven vaccination sites — no appointment necessary. Each location only had 300 doses, leading to overwhelmed health centers and residents camping out for several hours to get their shots.
In Wisconsin, a medical center employee intentionally left 57 vials of the Moderna vaccine out of its cold storage, leaving health officials with no choice but to destroy them. The vials could have provided around 500 doses.


npr--2020-12-31--Biden's Incoming Press Secretary: Briefings Won't Be A Platform For Right-Wing Spin

President-elect Joe Biden 's choice for White House press secretary says she will restore a tradition .
Unlike her immediate predecessors in the Trump administration , Jen Psaki plans to take questions from reporters each day .
Psaki has played similar roles before .
She was the spokesperson for the State Department when John Kerry was secretary of state , then President Barack Obama 's communications director , and she now speaks for Biden .
`` I think more than any point in history ... part of the job of the White House press secretary is to rebuild trust with @ @ @ @ @ @ @ in an interview with NPR 's Morning Edition .
President Trump 's first press secretary falsely claimed the biggest inauguration crowd in history .
His last made false claims about Trump 's election defeat .
Psaki promises to be `` as fact-based as I can be . ''
She says she wo n't limit right-wing media outlets ' access to White House briefings but adds that `` we 're not going to allow the briefing room to be a platform for propaganda . ''
Here are highlights of the interview , edited for @ @ @ @ @ @ @ a tension , of course , in this job , and it 's been highlighted in the last few years as to who you 're supposed to serve .
You 're , of course , working for a president , you 're getting out the message of the president .
But as reporters will be quick to point out , you 're on the public payroll and they see your job as working for them or really working for citizens , informing the public .
As you see it , who is your @ @ @ @ @ @ @ an honor to be speaking on behalf of the U.S. government , but my boss is really the American people and there are different entities who are kind of serving the American people .
Right ?
Of course , the president of the United States was elected by them .
But the media plays an essential role , too .
Right ?
And that may mean and it will mean , as you know — you 've been in that briefing room — on days we disagree , right , we 'll have @ @ @ @ @ @ @ are mishandled in the government .
But , you know , my view is , especially at this moment in history and in a moment where people do n't trust the information they 're getting from most sources , is to be as steady and as fact-based as I can be .
How do you think you will engage the right-wing media ecosystem , if I can call it that ?
I 'm thinking of networks like Fox , but also OANN and Newsmax that have larger and larger audiences .
And some @ @ @ @ @ @ @ , at least on a basic level , acknowledged that Joe Biden won the election .
Others are pushing completely discredited theories , but they 're all going to be there .
They 're all going to have an audience , and they 're all going to have questions for you .
That 's right .
And you know , Steve , again , just to go back to how valuable I find and how much I 'll rely on my experience at the State Department , there were many , many days @ @ @ @ @ @ @ air quoting that — who are from Russia or China , essentially arms of the government , you know , arms of the state-run media .
And we let them in the briefing room , and they ask questions , and sometimes I had a little fun with them , you know , about who they were asking the question on behalf of .
The first interview that I did after I was announced as White House press secretary was with Chris Wallace on Fox .
I do think there is a difference @ @ @ @ @ @ @ between some of the anchors and reporters at a network like Fox and some of the personalities .
I will not be doing an interview with Sean Hannity .
I think that would n't serve anybody , including the president-elect , who 's the most important factor there .
In terms of , you know , [ OANN ] and kind of other right-wing entities ?
I do n't think my job as the White House press secretary is to give them a bigger platform .
But at the same time , when @ @ @ @ @ @ @ 's COVID-safe and there is a full briefing room , I also do n't think it 's my job to keep people out .
There seemed to be different approaches at different times in the Obama administration to this question .
Of course , President Obama himself did interviews from time to time on Fox News , but the administration also grew frustrated with Fox , tried to shut them out from time to time , was criticized for that .
Do you feel that that question is resolved in the way that @ @ @ @ @ @ @ Steve , it 's a good question .
I do n't think it 's resolved , no .
And I will tell you , my resting place is to be steady and open and share information .
But I am no pushover either .
We 're not going to allow the briefing room to be a platform for propaganda , and we will shut that down as needed as well .
There was an astonishing amount of leaking to the media during the Trump administration .
And of course , if you 're @ @ @ @ @ @ @ argue that was mostly for the public good .
Thank goodness we found out what was going on in there might be your attitude .
But how do you mean to approach leaks in a Biden administration ?
I 've told some journalists this , anybody who covered only the Trump administration who 's looking for a continuation of the Game of Thrones-style personnel sniping , they will be sorely disappointed , I believe .
Our goal is for there to be a return to policy processes and policy briefings and policy experts @ @ @ @ @ @ @ explaining what a COVID package may look like or what we 're going to do about immigration .
And certainly there are leaks around that which may give me a headache for the day , but are not as damaging , I would say , as leaks that are around people 's lives or national security issues .
I 'm glad you mentioned national security , because as you know well , President Obama 's administration aggressively prosecuted leakers of classified information and that spilled over into investigating journalists , obtaining journalists ' @ @ @ @ @ @ @ goings from government agencies .
Does this administration mean to do the same ?
Obviously , there are different circumstances , as you well know , that came up during the Obama administration .
And a number of those were overseen by the Department of Justice at the time .
President-elect Biden has not even selected an attorney general yet .
Believe me , people want to know who it 's going to be .
But one of his priorities is returning that department to an independent department , one that does not @ @ @ @ @ @ @ , which will be quite a sea change from our current circumstance .
And I suspect those will be questions that future nominee for that role will be asked in a confirmation hearing .
Jeevika Verma , Jacob Conrad and Scott Saloway produced and edited the audio version of this story .
Avie Schneider produced for the Web .

Biden's Incoming Press Secretary: Briefings Won't Be A Platform For Right-Wing Spin
Enlarge this image toggle caption Brendan Smialowski/AFP via Getty Images Brendan Smialowski/AFP via Getty Images
President-elect Joe Biden's choice for White House press secretary says she will restore a tradition. Unlike her immediate predecessors in the Trump administration, Jen Psaki plans to take questions from reporters each day.
Psaki has played similar roles before. She was the spokesperson for the State Department when John Kerry was secretary of state, then President Barack Obama's communications director, and she now speaks for Biden.
"I think more than any point in history ... part of the job of the White House press secretary is to rebuild trust with the American people," she says in an interview with NPR's Morning Edition.
President Trump's first press secretary falsely claimed the biggest inauguration crowd in history. His last made false claims about Trump's election defeat. Psaki promises to be "as fact-based as I can be." She says she won't limit right-wing media outlets' access to White House briefings but adds that "we're not going to allow the briefing room to be a platform for propaganda."
Here are highlights of the interview, edited for length and clarity:
Interview Highlights
There's always a tension, of course, in this job, and it's been highlighted in the last few years as to who you're supposed to serve. You're, of course, working for a president, you're getting out the message of the president. But as reporters will be quick to point out, you're on the public payroll and they see your job as working for them or really working for citizens, informing the public. As you see it, who is your boss?
Of course, it's an honor to be speaking on behalf of the U.S. government, but my boss is really the American people and there are different entities who are kind of serving the American people. Right? Of course, the president of the United States was elected by them. But the media plays an essential role, too. Right? And that may mean and it will mean, as you know — you've been in that briefing room — on days we disagree, right, we'll have failures or we'll have things that are mishandled in the government. But, you know, my view is, especially at this moment in history and in a moment where people don't trust the information they're getting from most sources, is to be as steady and as fact-based as I can be.
How do you think you will engage the right-wing media ecosystem, if I can call it that? I'm thinking of networks like Fox, but also OANN and Newsmax that have larger and larger audiences. And some of them, like Fox, have, at least on a basic level, acknowledged that Joe Biden won the election. Others are pushing completely discredited theories, but they're all going to be there. They're all going to have an audience, and they're all going to have questions for you.
That's right. And you know, Steve, again, just to go back to how valuable I find and how much I'll rely on my experience at the State Department, there were many, many days where there were journalists — I'm air quoting that — who are from Russia or China, essentially arms of the government, you know, arms of the state-run media. And we let them in the briefing room, and they ask questions, and sometimes I had a little fun with them, you know, about who they were asking the question on behalf of.
The first interview that I did after I was announced as White House press secretary was with Chris Wallace on Fox. I do think there is a difference, as I think everybody knows, between some of the anchors and reporters at a network like Fox and some of the personalities. I will not be doing an interview with Sean Hannity. I think that wouldn't serve anybody, including the president-elect, who's the most important factor there. In terms of, you know, [OANN] and kind of other right-wing entities? I don't think my job as the White House press secretary is to give them a bigger platform. But at the same time, when we're at a point when it's COVID-safe and there is a full briefing room, I also don't think it's my job to keep people out.
There seemed to be different approaches at different times in the Obama administration to this question. Of course, President Obama himself did interviews from time to time on Fox News, but the administration also grew frustrated with Fox, tried to shut them out from time to time, was criticized for that. Do you feel that that question is resolved in the way that you just said?
You know, Steve, it's a good question. I don't think it's resolved, no. And I will tell you, my resting place is to be steady and open and share information. But I am no pushover either. We're not going to allow the briefing room to be a platform for propaganda, and we will shut that down as needed as well.
There was an astonishing amount of leaking to the media during the Trump administration. And of course, if you're a critic of Trump, you would argue that was mostly for the public good. Thank goodness we found out what was going on in there might be your attitude. But how do you mean to approach leaks in a Biden administration?
I've told some journalists this, anybody who covered only the Trump administration who's looking for a continuation of the Game of Thrones-style personnel sniping, they will be sorely disappointed, I believe. Our goal is for there to be a return to policy processes and policy briefings and policy experts who are going to be out there explaining what a COVID package may look like or what we're going to do about immigration. And certainly there are leaks around that which may give me a headache for the day, but are not as damaging, I would say, as leaks that are around people's lives or national security issues.
I'm glad you mentioned national security, because as you know well, President Obama's administration aggressively prosecuted leakers of classified information and that spilled over into investigating journalists, obtaining journalists' phone records, tracking their comings and goings from government agencies. Does this administration mean to do the same?
Obviously, there are different circumstances, as you well know, that came up during the Obama administration. And a number of those were overseen by the Department of Justice at the time. President-elect Biden has not even selected an attorney general yet. Believe me, people want to know who it's going to be. But one of his priorities is returning that department to an independent department, one that does not have political influence from the White House, which will be quite a sea change from our current circumstance. And I suspect those will be questions that future nominee for that role will be asked in a confirmation hearing.
Jeevika Verma, Jacob Conrad and Scott Saloway produced and edited the audio version of this story. Avie Schneider produced for the Web.


npr--2020-12-31--DOJ National Security Boss Is Moving On — But Cyber, China Threats Aren't

DOJ National Security Boss Is Moving On — But Cyber , China Threats Aren't When John Demers came in to lead the Justice Department 's national security division , the United States was grappling with the fallout from Russia 's cyberattack on the 2016 election .
Now , as he and the Trump administration prepare to leave office , the U.S. is dealing with another massive hack that American officials have again pinned on Moscow .
`` Well , there is a certain symmetry to all of this , '' Demers said in an interview with NPR as his time @ @ @ @ @ @ @ close .
Those bookends illustrate how the threats the U.S. is facing have shifted since his last stint at the department , during the George W. Bush administration .
`` A big difference in my time here , the first time and the second time , is the rise of a nation state threat actors and in particular , their use of cyber to protect their nation state interests and their power , '' Demers said .
`` So it 's fitting , I think , that we began with a significant election @ @ @ @ @ @ @ are at the end dealing with a different kind of cyber activity . ''
This year a number of U.S. government agencies , including the State Department and the Pentagon , have been compromised by another vast intrusion .
Demers said he agrees with Secretary of State Mike Pompeo 's statement that Russia appears to be behind the breach .
The government is still scrambling to understand the breadth of the damage , Demers said , but so far it appears to be limited to the unclassified systems .
`` A lot still @ @ @ @ @ @ @ the scope and depth of this hack , '' he said .
`` But as you know , there 's a lot of confidential and sensitive information that is transmitted and stored on unclassified systems , a lot of information that would be of interest to a foreign state who was trying to learn about our intentions and our planning . ''
An adversary not only can snoop on what a government agency is doing that 's not classified but also not public .
It also can pair what it learns with what @ @ @ @ @ @ @ including related to secret information or from human spies .
From what he 's seen so far , Demers said the hack appears to be different from Russia 's cyberattack and social media campaign against the 2016 U.S. election , when the Kremlin wanted to sow chaos and undermine American democracy .
`` This looks more like what a nation state would traditionally try to do through human means , through spies , but trying to do it through technical means and cyber intrusions , '' he said .
While Russia has grabbed @ @ @ @ @ @ @ , Demers spent a lot of his time and energy on another foreign adversary — China .
Trump administration officials have tagged China as the primary long-term threat to the United States .
U.S. officials have accused China of waging a relentless campaign to steal American intellectual property , government secrets and academic information to try to supplant the U.S as the world 's preeminent power .
To try to counter that threat , the department launched what it calls the China Initiative .
Demers has led that effort , and from that @ @ @ @ @ @ @ alone in its plundering of American corporate secrets .
`` We do see some other countries engaging episodically in economic espionage , but none of them on the scale and sophistication and persistence of the Chinese government , '' he said .
Russia , for example , also has tried to steal sophisticated technology that is used in military equipment , and the Justice Department has charged such cases .
China 's economic theft , in contrast , is much broader than that , and targets everything from biotechnology to engineering and aerospace @ @ @ @ @ @ @ to develop the Chinese economy and Chinese companies under this rubric of rob , replicate and replace , '' he said .
It 's an accusation that Demers and other U.S. officials have made before -- allegations that China denies .
U.S. officials say the Chinese steal the technology , replicate the product and then aim to replace the American or European company first in China 's market and then on the global market .
The scale of the problem is reflected in the Justice Department 's workload .
Eighty percent of the @ @ @ @ @ @ @ Chinese government , while two-thirds of its trade theft cases involve a Chinese company , Demers said .
In the past few years alone , the Justice Department has unsealed one indictment after another related to China .
Prosecutors have charged American and Chinese researchers and business people for allegedly stealing everything from high-tech wireless design to turbine technology .
The government also has brought cases against U.S. academics for failing to disclose ties to the Chinese government .
The prime example of that is an indictment against the chair of Harvard University @ @ @ @ @ @ @ And then there are the cases of political espionage .
At least three former U.S. intelligence officers have been convicted of spying for China , while a fourth is facing charges of doing so .
The department 's crackdown has n't brought an end to China 's efforts , and it wo n't .
But that does n't mean it is n't having an effect , Demers said .
`` These prosecutors are not silver bullets that are going to make the problem go away , '' he said .
`` The Chinese @ @ @ @ @ @ @ and the resourcing is there .
But we 're going to call attention to and we 're going to shine a light on it and we 're going to make their job harder and harder . ''
The indictments do so , he says , by disrupting China 's activities .
He pointed to the case of a Chinese intelligence officer who was extradited to the U.S. from Belgium in 2018 for allegedly trying to steal jet fan blade designs from GE Aviation .
`` The significance of that was n't just a @ @ @ @ @ @ @ , '' Demers said .
`` The other significance was making the Chinese think twice — and more than twice — about using Europe as a safe place to meet Americans who they were trying to co-opt . ''
Chinese intelligence officers do n't like coming to the U.S. for clandestine work because of the chance of arrest , while Americans considering providing sensitive information to the Chinese often are reluctant to travel to China early on in their relationships with handlers , Demers said .
For that reason , Europe often served @ @ @ @ @ @ @ to meet .
Demers said the arrest and extradition from Belgium sent a signal to the Chinese intelligence services that Europe was no longer a safe place for such operations , which was `` very important in terms of disrupting their tradecraft . ''
As Demers ' time winds down at the DOJ with the looming change in administration , he said he expects his successor will build on what he 's done much as Demers built off of his predecessors .
There are two areas — both related to China — that @ @ @ @ @ @ @ sticking around .
One is finding a way to better protect Chinese students at U.S. universities from what he calls `` surveillance and intimidation by their own government . ''
`` I think that 's an issue we need to look at .
I know that 's an issue that a number of universities have paid careful attention to , '' he said .
The other , he said , is on China 's foreign influence efforts , which are focused on swaying U.S. policy makers to allow China to pursue its interests @ @ @ @ @ @ @ silencing criticism of Beijing 's actions in Hong Kong or Tibet .
`` We see them less sort of broadly thinking that they need to undermine democracy and more specifically , focusing on issues that are near and dear to their hearts and not tolerating any criticism of their behavior . ''

DOJ National Security Boss Is Moving On — But Cyber, China Threats Aren't
Enlarge this image toggle caption Sarah Silbiger/AP Sarah Silbiger/AP
When John Demers came in to lead the Justice Department's national security division, the United States was grappling with the fallout from Russia's cyberattack on the 2016 election.
Now, as he and the Trump administration prepare to leave office, the U.S. is dealing with another massive hack that American officials have again pinned on Moscow.
"Well, there is a certain symmetry to all of this," Demers said in an interview with NPR as his time at the Justice Department draws to a close.
Those bookends illustrate how the threats the U.S. is facing have shifted since his last stint at the department, during the George W. Bush administration.
"A big difference in my time here, the first time and the second time, is the rise of a nation state threat actors and in particular, their use of cyber to protect their nation state interests and their power," Demers said. "So it's fitting, I think, that we began with a significant election interference hack ... and then here we are at the end dealing with a different kind of cyber activity."
This year a number of U.S. government agencies, including the State Department and the Pentagon, have been compromised by another vast intrusion. Demers said he agrees with Secretary of State Mike Pompeo's statement that Russia appears to be behind the breach.
The government is still scrambling to understand the breadth of the damage, Demers said, but so far it appears to be limited to the unclassified systems.
"A lot still to be analyzed in terms of both the scope and depth of this hack," he said. "But as you know, there's a lot of confidential and sensitive information that is transmitted and stored on unclassified systems, a lot of information that would be of interest to a foreign state who was trying to learn about our intentions and our planning."
An adversary not only can snoop on what a government agency is doing that's not classified but also not public. It also can pair what it learns with what it's gleaning from other sources, including related to secret information or from human spies.
From what he's seen so far, Demers said the hack appears to be different from Russia's cyberattack and social media campaign against the 2016 U.S. election, when the Kremlin wanted to sow chaos and undermine American democracy.
"This looks more like what a nation state would traditionally try to do through human means, through spies, but trying to do it through technical means and cyber intrusions," he said.
China, China, China
While Russia has grabbed headlines for much of the Trump administration, Demers spent a lot of his time and energy on another foreign adversary — China.
Trump administration officials have tagged China as the primary long-term threat to the United States. U.S. officials have accused China of waging a relentless campaign to steal American intellectual property, government secrets and academic information to try to supplant the U.S as the world's preeminent power.
To try to counter that threat, the department launched what it calls the China Initiative. Demers has led that effort, and from that depth of knowledge he says China stands alone in its plundering of American corporate secrets.
"We do see some other countries engaging episodically in economic espionage, but none of them on the scale and sophistication and persistence of the Chinese government," he said.
Russia, for example, also has tried to steal sophisticated technology that is used in military equipment, and the Justice Department has charged such cases.
China's economic theft, in contrast, is much broader than that, and targets everything from biotechnology to engineering and aerospace.
"It really is an effort to develop the Chinese economy and Chinese companies under this rubric of rob, replicate and replace," he said.
It's an accusation that Demers and other U.S. officials have made before --allegations that China denies.
U.S. officials say the Chinese steal the technology, replicate the product and then aim to replace the American or European company first in China's market and then on the global market.
The scale of the problem is reflected in the Justice Department's workload.
Eighty percent of the department's industrial espionage cases involve the Chinese government, while two-thirds of its trade theft cases involve a Chinese company, Demers said.
In the past few years alone, the Justice Department has unsealed one indictment after another related to China.
Prosecutors have charged American and Chinese researchers and business people for allegedly stealing everything from high-tech wireless design to turbine technology.
The government also has brought cases against U.S. academics for failing to disclose ties to the Chinese government. The prime example of that is an indictment against the chair of Harvard University's chemistry and chemical Biology Department.
And then there are the cases of political espionage. At least three former U.S. intelligence officers have been convicted of spying for China, while a fourth is facing charges of doing so.
The department's crackdown hasn't brought an end to China's efforts, and it won't. But that doesn't mean it isn't having an effect, Demers said.
"These prosecutors are not silver bullets that are going to make the problem go away," he said. "The Chinese are persistent. The will is there and the resourcing is there. But we're going to call attention to and we're going to shine a light on it and we're going to make their job harder and harder."
Disrupting tradecraft
The indictments do so, he says, by disrupting China's activities. He pointed to the case of a Chinese intelligence officer who was extradited to the U.S. from Belgium in 2018 for allegedly trying to steal jet fan blade designs from GE Aviation.
"The significance of that wasn't just a disruption of that avenue of economic espionage," Demers said. "The other significance was making the Chinese think twice — and more than twice — about using Europe as a safe place to meet Americans who they were trying to co-opt."
Chinese intelligence officers don't like coming to the U.S. for clandestine work because of the chance of arrest, while Americans considering providing sensitive information to the Chinese often are reluctant to travel to China early on in their relationships with handlers, Demers said. For that reason, Europe often served as a mutually acceptable place for them to meet.
Demers said the arrest and extradition from Belgium sent a signal to the Chinese intelligence services that Europe was no longer a safe place for such operations, which was "very important in terms of disrupting their tradecraft."
As Demers' time winds down at the DOJ with the looming change in administration, he said he expects his successor will build on what he's done much as Demers built off of his predecessors.
There are two areas — both related to China — that he'd focus on if he were sticking around.
One is finding a way to better protect Chinese students at U.S. universities from what he calls "surveillance and intimidation by their own government."
"I think that's an issue we need to look at. I know that's an issue that a number of universities have paid careful attention to," he said.
The other, he said, is on China's foreign influence efforts, which are focused on swaying U.S. policy makers to allow China to pursue its interests at home and abroad, such as silencing criticism of Beijing's actions in Hong Kong or Tibet.
"We see them less sort of broadly thinking that they need to undermine democracy and more specifically, focusing on issues that are near and dear to their hearts and not tolerating any criticism of their behavior."


npr--2020-12-31--COMIC: How The Census Turns Into Political Power (And What Trump Wants To Change)

COMIC : How The Census Turns Into Political Power ( And What Trump Wants To Change ) Edited by Acacia @ @ @ @ @ with copy-editing by Preeti Aroon

Why Your State May Win Or Lose A Seat In Congress After The Census A little-known process determines your state's representation in Congress and the Electoral College. Trump wants to try to change it by excluding unauthorized immigrants for the first time in history.


npr--2020-12-31--'Last Little Hurrah' Thwarts Tribe's Effort To Keep COVID-19 Off Reservation

'Last Little Hurrah ' Thwarts Tribe 's Effort To Keep COVID-19 Off Reservation Gary Carden sits on the reclining chair in front of the tavern he 's owned and managed for two and half decades in the north central Washington town of Nespelem , on the Colville Reservation .
The 63-year-old is on the concrete porch with his two dogs , Sissy and Harold .
`` She 's the older dog , '' he says , `` and that 's probably the best thing that happened to her is finding her a small buddy , 'cause he 's so active @ @ @ @ @ @ @ 's normally active too , not just running the tavern but riding horses and motorcycles .
But , one day this past June , he felt out of breath and exhausted .
`` And my sister came walking in , '' Carden recalls .
`` And she says , 'God , brother , you do n't look good .
Do you want me to call the ambulance ? '
`` He replied , `` Yeah , I think you better .
There 's something wrong . ''
Carden thought he had heat exhaustion @ @ @ @ @ @ @ was transferred to a hospital about 100 miles away , in the city of Wenatchee , Wash .
He spent a month there — a week of that time on a ventilator .
`` It 's tough , '' Carden remembers .
`` It was tough .
I was even ready to give up . ''
The Colville Tribal Council has been doing its best to insulate its community from the pandemic .
In mid-March , the council closed the reservation to non-essential travel .
And , when members tested positive for the @ @ @ @ @ @ @ by providing portable toilets , mobile homes and even hotel rooms as needed .
But COVID-19 cases are hitting record highs throughout the state .
And the reservation 's borders are fluid , so even the tribe 's extensive precautions have n't been enough to fully protect Colville members .
About 300 people on the Colville Reservation have tested positive for the coronavirus .
That 's a big hit for a small community of 5,000 people .
The infection rate on the reservation is twice that of Washington state 's most populous county @ @ @ @ @ @ @ , '' says Larry Smith , a doctor on the reservation who runs two of its four clinics .
Smith says it was scary to see so many COVID-19 patients .
`` Probably 80 % of the people that I see have some risk factors — whether it 's hypertension , diabetes , or autoimmune disease , '' he says .
To Smith , the numbers have been overwhelming .
`` For six weeks , we were seeing four to five cases every single day , '' he says .
Vice-chair of the @ @ @ @ @ @ @ are up in neighboring communities , it 's difficult hard to keep the virus out .
`` When you do go off-reservation , there 's communities that almost pride themselves on not wearing masks , and it 's a serious danger , '' he says .
Boyd says the most serious outbreaks came from tribal members going off-reservation .
The current outbreak started when a group of about 10 people from the Colville Reservation went to a nearby town in mid-November , before Washington state 's governor closed indoor dining again .
`` @ @ @ @ @ @ @ hurrah , I guess you would call it , '' Boyd says .
`` And unfortunately , that was all it took for us to get a nice little outbreak . ''
Many people on the reservation live in large , multi-generational households , so the virus spreads rapidly within families .
To try to contain the reservation 's current outbreak , the tribal council took a new step : It imposed a curfew to try to keep people from gathering after work .
`` A lot of people that have got it @ @ @ @ @ @ @ about , you know , how they got it and that they 're sorry for spreading it , '' Boyd says .
`` And I 'm thankful that they 're sharing that to prevent it from happening again . ''
Boyd says people telling their stories about how they got infected is an important way to spread the word on the reservation about need to take precautions .
Tavern owner Gary Carden says he often shares the story of how he almost died so others on the reservation can learn from what happened @ @ @ @ @ @ @ his time in the hospital , `` I even told them doctors , you know , 'Hey , I quit .
Pull these tubes out . '
`` A young intern sat down at his bedside and gave him a pep talk .
`` He says , 'Gary , do n't give up , ' `` Carden recalls.
`` 'You 've made it through the hard part .
You 've got 20-plus years still to go .
Hang in there .
You 've almost got it licked . '
``

'Last Little Hurrah' Thwarts Tribe's Effort To Keep COVID-19 Off Reservation
Enlarge this image toggle caption Eilis O'Neill/Eilis O'Neill Eilis O'Neill/Eilis O'Neill
Gary Carden sits on the reclining chair in front of the tavern he's owned and managed for two and half decades in the north central Washington town of Nespelem, on the Colville Reservation. The 63-year-old is on the concrete porch with his two dogs, Sissy and Harold.
"She's the older dog," he says, "and that's probably the best thing that happened to her is finding her a small buddy, 'cause he's so active and keeps her active."
Carden's normally active too, not just running the tavern but riding horses and motorcycles. But, one day this past June, he felt out of breath and exhausted.
"And my sister came walking in," Carden recalls. "And she says, 'God, brother, you don't look good. Do you want me to call the ambulance?' " He replied, "Yeah, I think you better. There's something wrong."
Carden thought he had heat exhaustion. But it was COVID-19. He was transferred to a hospital about 100 miles away, in the city of Wenatchee, Wash.
He spent a month there — a week of that time on a ventilator.
"It's tough," Carden remembers. "It was tough. I was even ready to give up."
The Colville Tribal Council has been doing its best to insulate its community from the pandemic.
In mid-March, the council closed the reservation to non-essential travel. And, when members tested positive for the coronavirus, the council helped them isolate by providing portable toilets, mobile homes and even hotel rooms as needed.
But COVID-19 cases are hitting record highs throughout the state. And the reservation's borders are fluid, so even the tribe's extensive precautions haven't been enough to fully protect Colville members. About 300 people on the Colville Reservation have tested positive for the coronavirus.
That's a big hit for a small community of 5,000 people. The infection rate on the reservation is twice that of Washington state's most populous county.
"We got hit so hard," says Larry Smith, a doctor on the reservation who runs two of its four clinics.
Smith says it was scary to see so many COVID-19 patients.
"Probably 80% of the people that I see have some risk factors — whether it's hypertension, diabetes, or autoimmune disease," he says.
To Smith, the numbers have been overwhelming.
"For six weeks, we were seeing four to five cases every single day," he says.
Vice-chair of the tribal council Joel Boyd says when cases are up in neighboring communities, it's difficult hard to keep the virus out.
"When you do go off-reservation, there's communities that almost pride themselves on not wearing masks, and it's a serious danger," he says.
Boyd says the most serious outbreaks came from tribal members going off-reservation.
The current outbreak started when a group of about 10 people from the Colville Reservation went to a nearby town in mid-November, before Washington state's governor closed indoor dining again.
"Everyone was getting in their last little hurrah, I guess you would call it," Boyd says. "And unfortunately, that was all it took for us to get a nice little outbreak."
Many people on the reservation live in large, multi-generational households, so the virus spreads rapidly within families.
To try to contain the reservation's current outbreak, the tribal council took a new step: It imposed a curfew to try to keep people from gathering after work.
"A lot of people that have got it recently — they're being pretty vocal about, you know, how they got it and that they're sorry for spreading it," Boyd says. "And I'm thankful that they're sharing that to prevent it from happening again."
Boyd says people telling their stories about how they got infected is an important way to spread the word on the reservation about need to take precautions.
Tavern owner Gary Carden says he often shares the story of how he almost died so others on the reservation can learn from what happened to him.
Carden says that during his time in the hospital, "I even told them doctors, you know, 'Hey, I quit. Pull these tubes out.' "
A young intern sat down at his bedside and gave him a pep talk.
"He says, 'Gary, don't give up,' " Carden recalls. " 'You've made it through the hard part. You've got 20-plus years still to go. Hang in there. You've almost got it licked.' "