npr--2020-12-24--In Rural America, Fears About The Future Abound As Fewer Students Go To College

In Rural America , Fears About The Future Abound As Fewer Students Go To College Its roof frosted with a covering of the previous night 's snow , a yellow school bus chugs up to the front door of Bucksport High School in Maine , where Principal Josh Tripp greets the handful of late-arriving students as they drag themselves inside .
Tripp is just glad they 've shown up , in a year when school is half online , sports and clubs have been curtailed and the world can seem as cold and gray as a winter morning in this @ @ @ @ @ @ @ overall feeling toward education right now is that they 've just been beaten down , '' Tripp says .
`` Everything about this year has been harder .
Certainly being an election year and seeing so much negativity around forecasts of our future , regardless of what political side you 're on — there 's just a lot of dim and dreary outlooks . ''
In rural communities like this one , the isolation and uncertainty of the pandemic year is translating into more than teenage angst .
It 's driving a dramatic @ @ @ @ @ @ @ on to college , threatening the already precarious economies of rural areas and widening their socioeconomic drift from urban and suburban America .
The number of rural students filling out the federal application for financial aid , a sign of whether they 're even considering going to college , has plummeted by more than 18 % , the National College Attainment Network reports .
That 's worse than the also alarming nearly 16 % drop among urban students .
The numbers are down even more in largely rural states including West Virginia ( @ @ @ @ @ @ @ % ) , Mississippi ( 26 % ) , Alaska ( 24 % ) and Arkansas and Oklahoma ( 23 % ) .
Many universities and colleges in rural places already have seen big drops in enrollment this year .
In Idaho , for instance , which already has the lowest proportion in the country of high school graduates who go on to college ( tied with Alaska at 44 % ) , first-time undergraduate enrollment fell nearly 4 % at the University of Idaho , nearly 8 % at Idaho State University @ @ @ @ @ @ @ State University — with an even bigger slide among first-time in-state undergrads .
Those figures include huge declines among dual-enrollment students , who get a head start by taking college classes while they 're still in high school , suggesting that future numbers may be even worse .
`` One of my greatest fears is that they wo n't come back , '' Kevin Boys , president of Southern State Community College , says of the many students who have opted to forgo college in his service area of rural southwestern Ohio .
@ @ @ @ @ @ @ this semester , a spokeswoman said .
At the flagship campus of the University of Maine , the number of entering in-state students was down 11 % this fall , a spokeswoman said .
Maine is the nation 's most rural state , with more than 60 % of its population considered rural .
Until this year , there were indications that rural college-going was increasing .
The proportion of rural students going to college rose from 51 % in 2011 to 61 % in 2016 , according to the National Student Clearinghouse @ @ @ @ @ @ @ since then .
That 's the same proportion as urban students , if still fewer than the 67 % of suburban high school graduates who go to college .
Now there 's worry that this progress may reverse , thanks in large part to Covid-19 .
By far the biggest single barrier to college-going among students in rural schools is the price , according to a survey released in September by researchers at universities in Maine , Oregon , Georgia and Alaska .
Average household earnings in rural areas are nearly 20 % @ @ @ @ @ @ @ States Department of Agriculture ( USDA ) says .
This has also gotten worse as a result of the pandemic , which has shuttered businesses and cost jobs in rural communities already suffering from declines in agriculture and industry .
In Bucksport , the paper mill that was the town 's biggest employer closed abruptly just before Christmas in 2014 , taking more than 500 jobs with it .
Today , what 's left of the idle mill and its lone remaining smokestack loom over one end of Main Street , waiting to @ @ @ @ @ @ @ .
`` When you could go make $ 45,000 a year right out of high school working at the mill , there was n't that push to say you need to go spend $ 100,000 on a college education to do the same exact thing , '' says Tripp , wearing a facemask imprinted with the high school 's Golden Bucks logo .
Students do n't even feel like college is an option Then , he says `` cold turkey , [ people ] completely did n't have that choice .
You 've @ @ @ @ @ @ @ different communities across the state .
And those towns really have n't rebounded . ''
Thirty-seven percent of the students at Bucksport High School come from families with incomes low enough to qualify for free or reduced-price lunch , state figures show .
`` So a number of our students do n't even feel like [ college ] is an option for them , '' Tripp says .
Meanwhile , the prospect of having to pay for college only to remain online has fueled resistance among students who dislike the experience of remote @ @ @ @ @ @ @ vaccine will allow colleges to return to being fully in person , Ethan Lozier , a Bucksport High School senior , hears his classmates asking , `` Why do I want to go and have online classes like this and spend thousands of dollars ? ''
Lozier says he 's been wondering the same thing , although he plans to go to college next year .
Some rural students have stopped even coming to school .
In Maine , more than 4 % , or nearly 8,000 , have disappeared this year from @ @ @ @ @ @ @ .
Katy Hunter , a science teacher and college adviser at Bucksport High , grew close last year to a student with whom she ate lunch every day .
Now the student is n't showing up at all .
`` You feel helpless , ' Hunter says .
`` You know that this person is very capable , and a good person .
I do n't think they realize what this is going to do to their futures . ''
Sixty miles away , in the northern Maine community of Dover-Foxcroft , Amber @ @ @ @ @ @ @ `` Their drive is just gone .
The quarantine kind of just drained them and now they 're , like , 'Well , I do n't really want to now just go be in [ college ] . '
...
They just want a break . ''
Dover-Foxcroft spans the Piscataquis River , which once powered sawmills , tanneries , woolen companies , a piano factory and furniture makers ; it 's the seat of Piscataquis County , Maine 's poorest and least populated county , which is three times the size of @ @ @ @ @ @ @ people in it , or under five inhabitants per square mile .
In normal times locals would escape the winter darkness to watch basketball games at Foxcroft Academy , the nearly 200-year-old regional high school ; the team is still scheduled to play , but with strict limits on the number of people who can watch .
`` Friday nights here , not only do you have athletes on this floor , you 've got full stands '' of fans , says Kandi Martin , a college counselor at the school , gesturing @ @ @ @ @ @ @ hung with championship banners commemorating 11 state titles in the past 12 years .
It 's another example of how the isolation in rural America has been worsened by Covid-19 , making it hard for teachers to keep their students motivated , Martin says .
`` Living in Maine is tough , '' Martin says .
`` Living through a Maine winter is even more difficult .
Living through a Maine winter with Covid is crazy . ''
Even before now , rural students have doubted their prospects .
Though 81 % in @ @ @ @ @ @ @ degree , only 65 % said they expected they would actually get one .
Twenty percent said they were n't smart enough , 12 % did n't want to move away for college and 17 % said they had to go to work immediately after high school .
Sami Bitat intends to go to college when he graduates from Foxcroft Academy in the spring .
But he cites one of his friends when describing the way many of his other classmates feel about it : `` None of his family went to college @ @ @ @ @ @ @ So his idea is , like , 'Well , they did n't go to college and they 're doing fine .
I do n't see why I have to go to college . '
`` Meanwhile , the pandemic has put a stop to the usual class assemblies , meetings with college counselors and recruiters and raffles to encourage completing the financial aid forms .
`` This year there 's a lot less exposure to '' the idea of college , Bucksport High School senior Addie Morrison says .
`` So there 's @ @ @ @ @ @ @ High science teacher Katy Hunter stops to consider what life awaits some of her students who opt not to continue their educations .
`` I do n't know , '' she says .
`` I mean , McDonald 's ?
I have n't really thought about that .
I do n't really want to know what the end result is going to be .
Because it ca n't be good . ''
This story about rural students was produced by The Hechinger Report , a nonprofit , independent news organization focused on inequality @ @ @ @ @ @ @ with Maine Public Radio .
Additional reporting by Robbie Feinberg .

In Rural America, Fears About The Future Abound As Fewer Students Go To College
Enlarge this image toggle caption Molly Haley/The Hechinger Report Molly Haley/The Hechinger Report
A yellow school bus with snow on the roof chugs up to the front door of Bucksport High School in Maine, where Principal Josh Tripp greets the handful of late-arriving students as they drag themselves inside.
Tripp is just glad they've shown up in a year when school is half online, sports and clubs have been curtailed, and the world can seem as cold and gray as a winter morning in this sparsely populated coastal town.
"Their overall feeling toward education right now is that they've just been beaten down," Tripp says. "Everything about this year has been harder. Certainly being an election year and seeing so much negativity around forecasts of our future, regardless of what political side you're on — there's just a lot of dim and dreary outlooks."
In rural communities like this one, the isolation and uncertainty of the pandemic year are translating into more than teenage angst.
Their overall feeling toward education right now is that they've just been beaten down.
Big drops in enrollment
It's driving a dramatic drop in the proportion of students going on to college, threatening the already precarious economies of rural areas and widening their socioeconomic drift from urban and suburban America.
The number of rural students filling out the federal application for financial aid, a sign of whether they're even considering going to college, has plummeted by more than 18%, the National College Attainment Network reports. That's worse than the also alarming nearly 16% drop among urban students. The numbers are down even more in largely rural states including West Virginia (32%), Louisiana (30%), Mississippi (26%), Alaska (24%) and Arkansas and Oklahoma (23%).
Many universities and colleges in rural places already have seen big drops in enrollment this year. In Idaho, for instance, which already has the lowest proportion in the country of high school graduates who go on to college (tied with Alaska at 44%), first-time undergraduate enrollment fell nearly 4% at the University of Idaho, nearly 8% at Idaho State University and more than 5% at Boise State University — with an even bigger slide among first-time in-state undergrads.
Those figures include huge declines among dual-enrollment students, who get a head start by taking college classes while they're still in high school, suggesting that future numbers may be even worse.
"One of my greatest fears is that they won't come back," Kevin Boys, president of Southern State Community College, says of the many students who have opted to forgo college in his service area of rural southwestern Ohio. Enrollment at Southern State dropped 16% this semester, a spokeswoman said.
toggle caption Molly Haley/The Hechinger Report
Biggest barrier to college is price
At the flagship campus of the University of Maine, the number of entering in-state students was down 11% this fall, a spokeswoman said. Maine is the nation's most rural state, with more than 60% of its population considered rural.
Until this year, there were indications that rural college-going was increasing. The proportion of rural students going to college rose from 51% in 2011 to 61% in 2016, according to the National Student Clearinghouse Research Center, though it has stalled since then. That's the same proportion as urban students, if still fewer than the 67% of suburban high school graduates who go to college.
Now there's worry that this progress may reverse, in large part because of COVID-19.
By far the biggest single barrier to college among students in rural schools is the price, according to a survey released in September by researchers at universities in Maine, Oregon, Georgia and Alaska. Average household earnings in rural areas are nearly 20% lower than incomes elsewhere, the U.S. Department of Agriculture says. This has also gotten worse as a result of the pandemic, which has shuttered businesses and cost jobs in rural communities already suffering from declines in agriculture and industry.
In Bucksport, the paper mill that was the town's biggest employer closed abruptly just before Christmas in 2014, taking more than 500 jobs with it. Today, what's left of the idle mill and its lone remaining smokestack loom over one end of Main Street, waiting to be redeveloped into a promised salmon farm.
"When you could go make $45,000 a year right out of high school working at the mill, there wasn't that push to say you need to go spend $100,000 on a college education to do the same exact thing," says Tripp, wearing a facemask imprinted with the high school's Golden Bucks logo.
toggle caption Molly Haley/The Hechinger Report
Students don't even feel like college is an option
Then, "cold turkey, [people] completely didn't have that choice," he says. "You've seen that happen in a number of different communities across the state. And those towns really haven't rebounded."
Thirty-seven percent of the students at Bucksport High School come from families with incomes low enough to qualify for free or reduced-price lunch, state figures show. "So a number of our students don't even feel like [college] is an option for them," Tripp says.
Meanwhile, the prospect of having to pay for college, only to remain online, has fueled resistance among students who dislike the experience of remote education.
Even with prospects that a vaccine will allow colleges to return to being fully in person, Ethan Lozier, a Bucksport High School senior, hears his classmates asking, "Why do I want to go and have online classes like this and spend thousands of dollars?" Lozier says he's been wondering the same thing, although he plans to go to college next year.
Some rural students have stopped even coming to school. In Maine, more than 4%, or nearly 8,000, have disappeared this year from the public schools, state figures show.
Katy Hunter, a science teacher and college adviser at Bucksport High, grew close last year to a student with whom she ate lunch every day. Now the student isn't showing up at all. "You feel helpless," Hunter says. "You know that this person is very capable, and a good person. I don't think they realize what this is going to do to their futures."
Sixty miles away, in the northern Maine community of Dover-Foxcroft, Amber Richard says of her classmates: "Their drive is just gone. The quarantine kind of just drained them and now they're, like, 'Well, I don't really want to now just go be in [college].' ... They just want a break."
Dover-Foxcroft spans the Piscataquis River, which once powered sawmills, tanneries, woolen companies, a piano factory and furniture-makers; it's the seat of Piscataquis County, Maine's poorest and least populated county, which is three times the size of Rhode Island but has fewer than 18,000 people in it, or under five inhabitants per square mile.
toggle caption Molly Haley/The Hechinger Report
"Living in Maine is tough"
In normal times, locals would escape the winter darkness to watch basketball games at Foxcroft Academy, the nearly 200-year-old regional high school. The team is still scheduled to play, but with strict limits on the number of people who can watch.
"Friday nights here, not only do you have athletes on this floor, you've got full stands" of fans, says Kandi Martin, a college counselor at the school, gesturing around the empty gym, which is hung with championship banners commemorating 11 state titles in the past 12 years.
It's another example of how the isolation in rural America has been worsened by COVID-19, making it hard for teachers to keep their students motivated, Martin says.
"Living in Maine is tough," Martin says. "Living through a Maine winter is even more difficult. Living through a Maine winter with COVID is crazy."
Even before now, rural students have doubted their prospects. Though 81% in that survey said they want a college degree, only 65% said they expected they would actually get one. Twenty percent said they weren't smart enough, 12% didn't want to move away for college and 17% said they had to go to work immediately after high school.
Sami Bitat intends to go to college when he graduates from Foxcroft Academy in the spring. But he cites one of his friends when describing the way many of his classmates feel about it: "None of his family went to college, and they're doing fine. So his idea is, like, 'Well, they didn't go to college and they're doing fine. I don't see why I have to go to college.' "
Meanwhile, the pandemic has put a stop to the usual class assemblies, meetings with college counselors and recruiters, and raffles to encourage completing the financial aid forms. "This year there's a lot less exposure to" the idea of college, Bucksport High School senior Addie Morrison says. "So there's a lot less interest."
Bucksport High science teacher Katy Hunter stops to consider what life awaits some of her students who opt not to continue their educations.
"I don't know," she says. "I mean, McDonald's? I haven't really thought about that. I don't really want to know what the end result is going to be. Because it can't be good."
This story about rural students was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education, in collaboration with Maine Public Radio. Additional reporting by Robbie Feinberg.


npr--2020-12-24--The Federal Election Commission Can Finally Meet Again. And It Has A Big Backlog

The Federal Election Commission Can Finally Meet Again .
And It Has A Big Backlog The Federal Election Commission has not been able to operate since July , when a Republican commissioner resigned , leaving the FEC short of the four commissioners necessary to meet and unable fulfill its job of enforcing campaign finance law .
Following Senate action earlier in December , it now has a full compliment of six commissioners : three Democrats , two Republicans and one independent .
Still , former FEC associate counsel Adav Noti is not optimistic that even now the FEC will be @ @ @ @ @ @ @ , I would not say I 'm hopeful about the FCC performing any of its functions , '' Noti tells NPR .
`` I think the restoration of the quorum means that the agency will resolve matters .
But those resolutions are likely to be partisan deadlocks in all but the most trivial of cases . ''
Noti , now senior director for trial litigation and chief of staff at the Campaign Legal Center , says the commission is divided not so much by party , but ideology .
`` The usual situation @ @ @ @ @ @ @ have tried to enforce campaign finance law against both Democrats and Republicans , have tried to enforce it somewhat stringently , '' he says .
`` And the Republican commissioners have generally opposed enforcement of the law , regardless of whether the law-breaker was a Republican group or a Democratic group . ''
One of the highest-profile cases before the FEC was brought by the Campaign Legal Center against the Trump campaign and a related political action committee .
It charges the campaign `` disguised nearly $ 170 million of campaign spending by @ @ @ @ @ @ @ Trump 's recent campaign manager , Brad Parscale , and/or created by Trump 2 campaign lawyers . ''
The campaign has denied the charge .
Former FEC chairman Bradley Smith , a Republican , says the differences on the commission are usually over how campaign law should be interpreted .
`` I think this idea that the commission frequently deadlocks is probably vastly overstated , '' he says .
`` Most of the cases are pretty routine .
It does come up on questions of how aggressively I think at times to interpret @ @ @ @ @ @ @ it as something that should be interpreted narrowly or broadly in scope . ''
While the FEC was idled by lack of a quorum , it amassed a backlog of some 446 cases .
Smith says one issue he 'd like the commission to address is political contributions by nonprofits , like the Sierra Club or National Right to Life .
He says it 's unclear whether the names of donors to those groups — who may not have given for political reasons , but to support the cause — should be disclosed @ @ @ @ @ @ @ how much [ the groups ] need to disclose in terms of donors who may have given for totally different reasons .
And it 's not like a donor who gives to a campaign or donor gives to a political party or a PAC and expects it to be used on politics .
So this is a tough issue out there , '' he says .
Another big case pertains to Mike Bloomberg , according to Michael Beckel with the political reform group Issue One .
Beckel says the former New York City @ @ @ @ @ @ @ failed presidential bid this year to the Democratic Party .
`` Michael Bloomberg 's self-funded his presidential campaign , which made this $ 18 million transfer essentially an $ 18 million donation from him to the DNC , which far exceeded our campaign contribution limits .
So that 's a big high-profile case , '' he says .

The Federal Election Commission Can Finally Meet Again. And It Has A Big Backlog
Enlarge this image toggle caption Caroline Amenabar/NPR; 401(K) 2012/Flickr Caroline Amenabar/NPR; 401(K) 2012/Flickr
The Federal Election Commission has not been able to operate since July, when a Republican commissioner resigned, leaving the FEC short of the four commissioners necessary to meet and unable fulfill its job of enforcing campaign finance law.
Following Senate action earlier in December, it now has a full compliment of six commissioners: three Democrats, two Republicans and one independent.
Still, former FEC associate counsel Adav Noti is not optimistic that even now the FEC will be able to accomplish much.
"No, I would not say I'm hopeful about the FCC performing any of its functions," Noti tells NPR. "I think the restoration of the quorum means that the agency will resolve matters. But those resolutions are likely to be partisan deadlocks in all but the most trivial of cases."
Noti, now senior director for trial litigation and chief of staff at the Campaign Legal Center, says the commission is divided not so much by party, but ideology.
"The usual situation has been that the Democratic FEC commissioners have tried to enforce campaign finance law against both Democrats and Republicans, have tried to enforce it somewhat stringently," he says. "And the Republican commissioners have generally opposed enforcement of the law, regardless of whether the law-breaker was a Republican group or a Democratic group."
One of the highest-profile cases before the FEC was brought by the Campaign Legal Center against the Trump campaign and a related political action committee. It charges the campaign "disguised nearly $170 million of campaign spending by laundering the funds through firms headed by Trump's recent campaign manager, Brad Parscale, and/or created by Trump 2 campaign lawyers." The campaign has denied the charge.
Former FEC chairman Bradley Smith, a Republican, says the differences on the commission are usually over how campaign law should be interpreted.
"I think this idea that the commission frequently deadlocks is probably vastly overstated," he says. "Most of the cases are pretty routine. It does come up on questions of how aggressively I think at times to interpret the law and whether one one views it as something that should be interpreted narrowly or broadly in scope."
While the FEC was idled by lack of a quorum, it amassed a backlog of some 446 cases.
Smith says one issue he'd like the commission to address is political contributions by nonprofits, like the Sierra Club or National Right to Life. He says it's unclear whether the names of donors to those groups — who may not have given for political reasons, but to support the cause — should be disclosed.
"It's not quite clear how much [the groups] need to disclose in terms of donors who may have given for totally different reasons. And it's not like a donor who gives to a campaign or donor gives to a political party or a PAC and expects it to be used on politics. So this is a tough issue out there," he says.
Another big case pertains to Mike Bloomberg, according to Michael Beckel with the political reform group Issue One. Beckel says the former New York City mayor transferred $18 million from his failed presidential bid this year to the Democratic Party.
"Michael Bloomberg's self-funded his presidential campaign, which made this $18 million transfer essentially an $18 million donation from him to the DNC, which far exceeded our campaign contribution limits. So that's a big high-profile case," he says.


npr--2020-12-24--New Jersey EMTs In Early Epicenter Of Coronavirus Outbreak Brace For Surge

New Jersey EMTs In Early Epicenter Of Coronavirus Outbreak Brace For Surge When COVID-19 cases increased in New Jersey again this fall , a volunteer ambulance crew in the epicenter of the state 's spring outbreak held its breath , waiting for what they thought would be an inevitable spike in calls , too .
Even as the state 's hospitalizations have reached levels not seen since mid-May , the all-volunteer crew at the Teaneck Volunteer Ambulance Corps say they 're only getting a handful of COVID-19-related calls a week .
Back in the spring , the ambulance corps was @ @ @ @ @ @ @ — almost every single one COVID-19-related for patients in respiratory distress , cardiac arrest or already dead at home .
`` We 've definitely had more patients we 've transported who have tested positive or been around someone who was positive , '' said Chief Jacob Finklestein , 25 .
`` But we 're definitely not seeing the same type of grave medical conditions that we were seeing in March and April for the most part . ''
'Does n't mean that people are n't still getting sick' Hospital and EMT leaders say @ @ @ @ @ @ @ widespread , meaning people can find out they 're sick earlier — and seek medical treatment .
Doctors are also better at treating the virus and those sick in the second wave tend to be younger and do n't seem to be waiting as long to get medical help .
`` That does n't mean that people are n't still getting sick and it does n't mean that they do n't still need care , '' said Barbara Platt , president of the EMS Council of New Jersey .
`` They 're just @ @ @ @ @ @ @ Platt said `` it 's definitely not as chaotic '' but with another round of holidays around the corner and the projected peak of hospitalizations expected by mid-January , it 's impossible to predict what will happen .
The `` back to back to back lack of social distancing is probably going to further feed this , '' she said .
Teaneck , a North Jersey suburb of about 42,000 residents , was an early epicenter for the virus and its infection rate was slightly higher than New York City 's in the @ @ @ @ @ @ @ pandemic in April , volunteer EMTs were burning through personal protective equipment and relying on half the number of staff to respond to calls because many of them were out sick , on quarantine or did n't feel comfortable riding .
At the time , New Jersey was at its peak of 8,200 hospitalizations .
`` I was just like , is it going to stop ?
Is this going to end ?
Like , is it going to get better ? ''
said 22-year-old Joe Horowitz , a volunteer who responded to @ @ @ @ @ @ @ pandemic in March and April .
`` There was not for months , there was not a single easy call for me . ''
But then the COVID-19-related calls in Teaneck suddenly stopped .
There was one call in May and zero in June , July and August .
The reprieve helped the volunteers finally take some time to take care of themselves , mentally and physically , including losing the weight they gained from all the food donated by locals .
`` I started thinking about myself again , '' Horowitz , @ @ @ @ @ @ @ In September , coronavirus cases in the state began rising again and a handful of 911 COVID-19 calls started coming back in October but even then , patients were n't as sick .
`` I have not seen the severe low oxygen levels in the 50s and 60s , I have not seen that recently , '' said Amiel Rimberg , 22 , another volunteer .
`` I do n't think we will see anything like what we saw before .
We might see smaller waves . ''
Now , the crew wears @ @ @ @ @ @ @ N-95 masks for suspected COVID-19 cases .
`` We 've just been stocking up because we 're afraid if things become hard to get again , '' Finklestein said .
Finklestein said some gear like face shields and gowns became much easier to buy but N-95s are still hard to come by , especially for a small non-profit trying to bid against larger companies or school districts .
If things stay relatively quiet , Finklestein said he 'll have enough supplies for three months but if calls spike again , he 'll run @ @ @ @ @ @ @ recent night shift , there were no COVID-19 calls .
A woman who had chest pains was taken to the hospital where the Teaneck ambulance was the only one at the emergency room entrance .
`` On a normal day , even without COVID-19 , this whole area would be filled with ambulances but it 's empty now .
We are the only ones here , '' Finklestein said as he pulled up .
In the first wave of the pandemic , Finklestein said he 'd have to wait as long as 45 @ @ @ @ @ @ @ until a bed opened up .
The wait times and the refrigerated trucks for bodies are now gone .
Hospitalizations have reached 3,600 out of 21,000 total beds .
Hospitals remain at about 70 % capacity , which includes both COVID-19 and non-COVID-19 patients .
Days are a lot quieter for the Teaneck EMTs .
They 're back to responding to more normal calls , like car crashes and slip and falls .
But volunteer Leah Kahan said it 's still a risk .
`` It 's definitely scary , we know we @ @ @ @ @ @ @ have the PPE .
But you still never know , '' she said .

New Jersey EMTs In Early Epicenter Of Coronavirus Outbreak Brace For Surge
Enlarge this image toggle caption Karen Yi/WNYC Karen Yi/WNYC
When COVID-19 cases increased in New Jersey again this fall, a volunteer ambulance crew in the epicenter of the state's spring outbreak held its breath, waiting for what they thought would be an inevitable spike in calls, too.
They're still waiting.
Even as the state's hospitalizations have reached levels not seen since mid-May, the all-volunteer crew at the Teaneck Volunteer Ambulance Corps say they're only getting a handful of COVID-19-related calls a week. Back in the spring, the ambulance corps was slammed with twice the usual call volume — almost every single one COVID-19-related for patients in respiratory distress, cardiac arrest or already dead at home.
"We've definitely had more patients we've transported who have tested positive or been around someone who was positive," said Chief Jacob Finklestein, 25. "But we're definitely not seeing the same type of grave medical conditions that we were seeing in March and April for the most part."
'Doesn't mean that people aren't still getting sick'
Hospital and EMT leaders say that's partly because testing is more widespread, meaning people can find out they're sick earlier — and seek medical treatment. Doctors are also better at treating the virus and those sick in the second wave tend to be younger and don't seem to be waiting as long to get medical help.
"That doesn't mean that people aren't still getting sick and it doesn't mean that they don't still need care," said Barbara Platt, president of the EMS Council of New Jersey. "They're just not all necessarily calling 911."
Platt said "it's definitely not as chaotic" but with another round of holidays around the corner and the projected peak of hospitalizations expected by mid-January, it's impossible to predict what will happen. The "back to back to back lack of social distancing is probably going to further feed this," she said.
Teaneck, a North Jersey suburb of about 42,000 residents, was an early epicenter for the virus and its infection rate was slightly higher than New York City's in the spring. At the height of the pandemic in April, volunteer EMTs were burning through personal protective equipment and relying on half the number of staff to respond to calls because many of them were out sick, on quarantine or didn't feel comfortable riding.
At the time, New Jersey was at its peak of 8,200 hospitalizations.
"I was just like, is it going to stop? Is this going to end? Like, is it going to get better?" said 22-year-old Joe Horowitz, a volunteer who responded to calls daily throughout the worst of the pandemic in March and April. "There was not for months, there was not a single easy call for me."
COVID-19-related calls suddenly stopped
But then the COVID-19-related calls in Teaneck suddenly stopped. There was one call in May and zero in June, July and August. The reprieve helped the volunteers finally take some time to take care of themselves, mentally and physically, including losing the weight they gained from all the food donated by locals.
"I started thinking about myself again," Horowitz, a senior college student, said.
In September, coronavirus cases in the state began rising again and a handful of 911 COVID-19 calls started coming back in October but even then, patients weren't as sick.
Enlarge this image toggle caption Karen Yi/WNYC Karen Yi/WNYC
"I have not seen the severe low oxygen levels in the 50s and 60s, I have not seen that recently," said Amiel Rimberg, 22, another volunteer. "I don't think we will see anything like what we saw before. We might see smaller waves."
Now, the crew wears surgical masks on every call, reserving N-95 masks for suspected COVID-19 cases.
"We've just been stocking up because we're afraid if things become hard to get again," Finklestein said.
Finklestein said some gear like face shields and gowns became much easier to buy but N-95s are still hard to come by, especially for a small non-profit trying to bid against larger companies or school districts. If things stay relatively quiet, Finklestein said he'll have enough supplies for three months but if calls spike again, he'll run out in two weeks.
Days are a lot quieter
On a recent night shift, there were no COVID-19 calls. A woman who had chest pains was taken to the hospital where the Teaneck ambulance was the only one at the emergency room entrance.
"On a normal day, even without COVID-19, this whole area would be filled with ambulances but it's empty now. We are the only ones here," Finklestein said as he pulled up. In the first wave of the pandemic, Finklestein said he'd have to wait as long as 45 minutes with a patient in his ambulance until a bed opened up. The wait times and the refrigerated trucks for bodies are now gone.
Hospitalizations have reached 3,600 out of 21,000 total beds. Hospitals remain at about 70% capacity, which includes both COVID-19 and non-COVID-19 patients.
Days are a lot quieter for the Teaneck EMTs. They're back to responding to more normal calls, like car crashes and slip and falls. But volunteer Leah Kahan said it's still a risk.
"It's definitely scary, we know we have the protections, we know we have the PPE. But you still never know," she said.


npr--2020-12-24--The Tragedy Of 'St Joe's'

The Tragedy Of 'St Joe's'

The people in the yellow hazmat suits arrived at St. Joseph 's Senior Home in Woodbridge , N.J. , on a crisp morning in late March , emerging from blue and white ambulance buses all suited up , like astronauts descending from a lunar rover .
For the 78 residents whom they had come to evacuate on March 25th , however , this all felt more like an alien abduction .
As the hazmats approached , some residents shouted and furiously clawed at the air ; others begged not to be taken away , clutching the nuns ' sleeves , @ @ @ @ @ @ @ ran St. Joseph 's told the residents ' families later that they 'd never seen anything like it .
`` People were loaded up like cattle , '' said one person who saw the events unfold .
`` It was horrible ...
When I close my eyes , even today , I still see it . ''
That day St. Joseph 's — most people call it `` St. Joe 's '' — became the only long-term care facility in New Jersey to be entirely evacuated during the pandemic , and no other @ @ @ @ @ @ @ cleared out in the same way since .
A months-long NPR Investigation involving three dozen interviews with former and current New Jersey Department of Health officials , family members , experts on the elderly , and people who witnessed the events as they unfolded found that the State 's decision to evacuate St. Joe 's was both rushed and flawed .
The reporting makes clear that the state failed to sufficiently take into account the fragility of the evacuees , possible alternatives to the move , and how complicated it would be to @ @ @ @ @ @ @ 45 minutes away .
The consequences of the decision are stark : nearly half the people loaded on the ambulance buses that morning died a short time later , some within days .
Experts on aging say the stress of the evacuation was undoubtedly a contributing factor .
According to people close to St. Joe 's and families who were monitoring the facility at the time , when the evacuation order came , the nuns who ran St. Joe 's were not presiding over an uncontrollable outbreak .
NPR saw contemporaneous emails that @ @ @ @ @ @ @ the residents had confirmed positive for the virus shortly before the state decided to evacuate .
The New Jersey Department of Health , through a spokesperson , claimed there were twice that many .
In a written statement , the department said residents in the facility were showing signs of illness , but they stopped short of saying they had tested positive for the virus .
`` The impact of COVID-19 on St. Joseph 's was severe , '' a spokesperson wrote .
It appears that the real problem at St. Joe 's @ @ @ @ @ @ @ among residents as it was an acute shortage of staff — something at least half the states in the U.S. are struggling with now in this latest winter surge .
Nurses , certified nursing assistants , and caregivers at St. Joe 's who had contact with residents who had tested positive for COVID-19 had to be quarantined to make sure they would n't contribute to the spread .
Some of the facility 's outside staff — concerned they would catch the mysterious virus that few understood at the time — stopped showing up @ @ @ @ @ @ @ needed help .
Before the coronavirus , a typical shift at St. Joe 's included some 50 people with direct access to the patients .
In the days just before the evacuation , that number had fallen to about twenty .
That 's why the nuns at St. Joe 's started calling around for reinforcements .
A DOH spokesperson said the agency spent two days looking for temporary staff for St. Joe 's .
They sent over some people from New Jersey 's largest nursing home chain , CareOne .
A handful of @ @ @ @ @ @ @ .
Annette Kociolek , 93 , a bubbly , devout Catholic who was known in her family for her love of broaches , beads and barrettes , had been sitting up in bed , watching TV , and talking on the phone with her daughters just days before the evacuation .
So she was surprised to find herself strapped to a gurney and loaded onto an ambulance bus the morning of March 25th .
Her daughters say she was one of St. Joe 's reluctant evacuees , fighting off the hazmat suits when @ @ @ @ @ @ @ nuns to tell them she wanted to stay .
`` When I try to imagine what that would have felt like , seeing people in hazmat suits , me being wheeled out of the place that I know is my home , away from the caretakers , having no family around to comfort or explain what was going on , '' her daughter Angie Kociolek told me .
`` It had to be traumatic . ''
Christopher Neuwirth was part of the New Jersey Health Department 's Emergency Preparedness and Response at the @ @ @ @ @ @ @ had helped with floods and fires and yet , when it came to the evacuation of St. Joe 's , he 'd never seen the state weigh in like this .
`` It was obvious from the get-go that everything that happened with St. Joe 's was odd , '' he told NPR .
`` The State does n't get involved with local evacuations .
Even at the time everyone in my office was saying , wait , why are we in the middle of this ? ''
Neuwirth no longer works for @ @ @ @ @ @ @ fired earlier this year because he filed an ethics complaint against a high ranking official .
He has since filed a whistleblower complaint and the suit is pending .
The State has denied his allegations .
St. Joseph 's Senior Home is a four-star , 101-bed facility run by The Little Servant Sisters to the Immaculate Conception , a Polish order established in the 1850s with the mission to `` nurture the mind , body , and soul ... by serving the residents with the same love as if serving Christ Himself .
@ @ @ @ @ @ @ , health care facilities , and senior homes in New Jersey since 1926 .
For 93-year-old Annette Kociolek — her friends called her `` Toni '' — the family atmosphere and the religiosity of the place appealed .
`` My mom was Polish Catholic and St. Joe 's was run by Polish sisters , '' the eldest of her three daughters , Bernadette Sohler explained .
`` They had masses daily and the nuns spoke Polish to her , '' which Annette Kociolek loved .
It is important to remember that in early @ @ @ @ @ @ @ pandemic seemed a distant threat , like a light on a far off field .
The first big coronavirus outbreak on the east coast , in New Rochelle , N.Y. , had yet to make the headlines and family members were still allowed to visit nursing homes and bring in food .
Ten days before the evacuation , on March 15 , Kociolek was in her room at St. Joe 's eating Polish donuts with her daughter and Sohler said visits to her mother were riotous affairs .
`` She 'd always say @ @ @ @ @ @ @ big deal , and 'this is my daughter ' to all the workers there , '' her daughter recalled .
`` Little did we know , you know , less than two weeks later , everything would change . ''
The first inkling that something was wrong came on March 16th , when the nuns called Sohler to report that a couple of the residents `` had the sniffles . ''
Just to be safe , the nuns told her , they had confined everyone to their rooms .
St. Joe 's phoned @ @ @ @ @ @ @ that the facility appeared to have its first positive COVID case .
A day after that , Sohler found out that the St. Joe resident who had tested positive was her mother 's roommate .
`` I remember calling my sister saying , you know , hopefully we have nothing to worry about , '' Sohler said .
`` My mother is very , very resilient .
She had been hospitalized three times last year , she bounces back all the time .
I talked to her that day and I asked her @ @ @ @ @ @ @ goes , ' I got these little sniffles . '
She was more concerned about what they were giving her for lunch than about any virus . ''
After that , however , everything seemed to pick up speed .
The staff at St. Joe 's began quarantining ; caregivers were n't showing up to work .
The COVID numbers inside the facility began ticking up .
By March 21st , seven residents had tested positive for the virus and Toni Kociolek was among them .
`` It happened so , so very @ @ @ @ @ @ @ when you know , one person had it , then seven people had it , '' Sohler said .
`` They had suspended social activity for the residents , and Sister Monika told me they had contacted the state for additional nursing support . ''
Sohler found out four days later that the state had ordered that all the residents be transferred to another facility .
The decision came so fast , Sohler said later , the nuns did n't have time to inform all the families .
Viral outbreaks have rocked New @ @ @ @ @ @ @ 2018 , in what had become an infamous case , a strain of adenovirus raged through a pediatric ward of medically frail children in northern New Jersey .
The virus , common in communal living facilities , rarely results in serious illness , but it can be fatal to those with compromised immune systems , which is exactly what these children had .
Dozens fell ill , 11 died .
In response , New Jersey Gov .
Phil Murphy signed a law requiring that nearly all of the state 's more than 840 @ @ @ @ @ @ @ plans .
Among other things , facilities needed to work out how they would isolate and separate the sick from at-risk residents who are healthy .
The homes had 180 days to come up with a list of protocols and many had to submit their plans to the state by February 11 , 2020 — just weeks before the coronavirus arrived in earnest in New Jersey .
St. Joe 's does not appear to have created a plan , but they were n't alone .
As COVID raged , the uneven , panicked @ @ @ @ @ @ @ , according to Laurie Facciarossa Brewer , an ombudsman for New Jersey 's Long-term Care system .
`` It 's pretty clear that most long-term care facilities did not have those plans in place when they were required to be done by the second week of February , '' she said .
One way to minimize outbreaks in communal living situations is something called cohorting — essentially it involves isolating those who have the disease or virus from those who do n't .
St Joe 's began doing that when its residents first @ @ @ @ @ @ @ '' That may be why the nuns seemed to be able to keep the total number of positive cases among the residents so low .
The evacuation team , when it first arrived the morning of March 25th , attempted to keep all of St. Joe 's COVID positive patients together , relegating them to their own buses .
But by the end of a long day , with nearly everyone loaded and ready , the team started to put the remaining residents wherever they could find room , according to medical officials @ @ @ @ @ @ @ who heard about the evacuation later .
A DOH official said later that they just assumed everyone at St. Joe 's had been exposed to the virus .
`` Well , that 's kind of crazy , '' said Melissa O'Connor , an expert in nursing care for older adults at Villanova University 's M. Louise Fitzpatrick College of Nursing in Pennsylvania .
`` Buses do n't have filtration systems like airplanes , they were all breathing the same air '' and probably contracting the virus in the process .
O'Connor and others @ @ @ @ @ @ @ about the community spread of the coronavirus , those residents who did n't have COVID when they left St. Joe 's on March 25th , may well have caught it during their transfer .
Even if they were masked , the danger was there as they waited in the buses for the other residents to load and then drove , all together , the 45 minutes to the new facility .
Dr. Pamela Cacchione , who studies older adult care at University of Pennsylvania School of Nursing , said she does n't understand @ @ @ @ @ @ @ St. Joe 's a COVID facility and leave all the residents there — isolating the sick — instead of transferring them somewhere else .
That would have been easier on everyone involved , particularly given that CareOne in Hanover did n't actually have vacant beds waiting for the residents of St. Joe 's .
To accommodate them , CareOne had to move dozens of their own residents to three other CareOne homes in the area .
CareOne declined to comment for this story .
Neuwirth , the former DOH assistant commissioner for emergency @ @ @ @ @ @ @ other things , New Jersey officials seemed to have fixed on the wrong protocol when they decided to empty out St. Joe 's .
`` This was n't a flood or a fire but they responded like this was a natural disaster and they needed to rush to higher ground , '' he said .
`` That does n't work when you 're dealing with a pandemic disease .
It follows you , wherever you go . ''
Around the same time the nuns were having their staffing problems at St. Joe 's @ @ @ @ @ @ @ outbreak at the New Jersey Veterans Home at Paramus , a state-run facility for former military veterans about 40 minutes from St. Joe 's in Woodbridge .
By late March , almost every resident at the Paramus facility — 98 percent — had contracted the coronavirus .
Some 60 percent of their staff was out sick in what quickly evolved into one of the biggest coronavirus outbreaks in the country .
U.S. Rep. Josh Gottheimer , who has Paramus in his district , weighed in and arranged for nurses and the National Guard @ @ @ @ @ @ @ have an answer as to why the same was n't done for St. Joe 's , though officials who were there at the time , and spoke on the condition of anonymity out of concern they would lose their jobs , said it seemed once Health Department officials decided to evacuate , momentum to finish the job continued to build .
Donna Leusner , director of communications for the New Jersey Department of Health , denied this in response to questions from NPR .
She said the state tried to help the sisters @ @ @ @ @ @ @ DOH spent two days looking for reinforcements .
At some point , a nun named Sister Patricia Codey began talking to state officials about the staffing issues at St. Joe 's .
`` Sister Pat , '' as she 's called , is president of The Catholic HealthCare Partnership of New Jersey , and few people in the state 's health care circles are as connected as she .
Her brother , Richard , used to be governor .
Codey declined to be interviewed for this story .
But three officials familiar with @ @ @ @ @ @ @ to name because they fear retaliation for revealing internal deliberations , said she brought the problems at St. Joe 's to the attention of health department officials , and to one in particular , Deputy Commissioner of Health Systems , Marcela Maziarz , who oversees nursing homes in the state .
`` Maziarz was quite open about asking people in meetings to help her find a place to put people from St. Joe 's , '' said one Department of Health official , who was part of the discussions in mid-March and still @ @ @ @ @ @ @ to be first in line for a move . ''
According to three officials who attended meetings with Maziarz in March and April , the deputy commissioner told colleagues in meetings that she thought the best thing to do would be move them to CareOne Hanover .
As the largest nursing home chain in the state , CareOne had the beds , the ability to isolate COVID-19 patients , and a willingness to help .
Maziarz had been working with people at CareOne on various licensing agreements for months so the transfer was @ @ @ @ @ @ @ officials close to the discussions say it started as a verbal agreement — CareOne would take St. Joe 's residents — and the precise terms , everyone agreed , would be worked out later .
DOH 's Leusner told NPR `` emergent discussions came before executing '' the agreement because it was `` very time sensitive . ''
NPR filed an Open Public Records Act request to look at any contracts and agreements between CareOne and DOH , and the request was denied .
DOH declined to make Maziarz available for comment .
@ @ @ @ @ @ @ .
`` I 'm not surprised that a company like CareOne would be a place where you would look to try to do something quickly , '' said Brewer , the long-term care ombudsman .
`` A lot of other long-term care facilities were really struggling at that point and would not have been able to do it . ''
Brewer said she could n't say why state officials did n't just supplement St. Joe 's staff instead .
`` I think the model is to move people out when there 's a @ @ @ @ @ @ @ Historically that has been the way to solve a problem in a facility , usually it is a physical plant problem '' like a flood , not a virus .
Two DOH officials confirmed that someone in the deputy commissioner 's office , it is unclear if it was Maziarz herself , asked CareOne to send people over to St. Joe 's to assess the situation .
They were nurses and managers from various CareOne facilities and , according to DOH , they reported what they saw at St. Joe 's to state @ @ @ @ @ @ @ CareOne had sent staff into the facility to assist , they were able to provide the Department with information to determine the best way to provide care '' for the residents of St. Joe 's , Leusner said in a written statement .
Their recommendation was to move them all to CareOne .
There was never an independent assessment before the evacuation .
University of Pennsylvania 's Cacchione , the elder care specialist , said having CareOne do that assessment was `` very concerning '' because of the obvious conflict of interest .
@ @ @ @ @ @ @ the henhouse , '' she said .
NPR filed numerous Open Public Records Act requests to DOH asking for a copy of that assessment of St. Joe 's .
Several DOH divisions said they had no documents that would be responsive to the request .
One division said it would keep looking .
The report CareOne sent to the state , according to two officials familiar with it , characterized the situation inside St. Joe 's as chaotic .
CareOne officials claimed there were only a handful of nuns taking care of the @ @ @ @ @ @ @ Joe 's say that when the CareOne officials showed up on March 22nd — three days before everyone at St. Joe 's was evacuated — there were nearly two dozen caregivers , nurses , nurses assistants and visiting nuns in the facility caring for the residents .
Little Servant Sisters ' other locations in New Jersey had pitched in to help .
Shortly after CareOne provided its report to the State , New Jersey Department of Health Commissioner Judy Persichilli told reporters , at a March 24 press conference , that DOH was @ @ @ @ @ @ @ evacuation .
`` This may result , unfortunately and ultimately , in the closure of that facility , '' she said , `` a facility that has cared for the most vulnerable population in Woodbridge and the surrounding area for decades . ''
Standard operating procedure when moving older patients is to look for available beds close by , where people can live temporarily and their families can still have some sort of access .
Typically , there are a couple beds here , and a few others there .
Last March , @ @ @ @ @ @ @ , the state 's long-term care ombudsman Brewer said , those spare beds were hard to find .
`` To me , the part of the St. Joe 's evacuation that was really unusual was that they all went from one place to another place , '' she said .
`` But then , everything was unprecedented at that time .
The rules that we had all abided by all these years seem to be falling by the wayside . ''
One of those rules is that moving the elderly is a last @ @ @ @ @ @ @ Cacchione was doing her research on long-term care , she had worked with the elderly during a natural disaster .
A mini tornado had knocked out the power to a long-term care facility that she was studying .
Everyone had to be evacuated for five days .
She said the move traumatized those who were evacuated .
`` Over 50 percent of the participants in the study became delirious or developed acute confusion , which is potentially fatal in itself , '' she said .
`` To think that [ St. Joe 's @ @ @ @ @ @ @ from one facility to another is hard to fathom .
The literature shows that these acute evacuations are very dangerous for older adults . ''
Even if older evacuees weather the physical transfer , Cacchione said , under the best of circumstances they have to endure mix-ups at the receiving facility .
Just think how complicated it is to check someone into the hospital , she said , now multiply that by 78 all arriving at once .
`` Just the medication errors that would occur from a transition like that are just @ @ @ @ @ @ @ Getting the appropriate diet , preparing them for appropriate roommate situations , when they often had their own rooms prior to this .
That 's a real significant challenge to an older adult . ''
It appeared to be a challenge for Annette Kociolek .
`` My gut reaction was that [ my mom ] was going to get lost in the mix , '' Kociolek 's middle daughter , Dorothy Cassaro told me , as she tracked her mother 's progress from St. Joe 's to CareOne .
`` Up until the @ @ @ @ @ @ @ still sitting up , watching TV , and she was still verbal '' but the new facility would n't know that , she said .
She was sure her mother would seem weaker than she was .
`` She was going to be presented on a stretcher , she 's going to look weak and feeble , and I guess I felt that would impact judgments , '' she said .
Cassaro 's inclination proved to be prescient .
When her mother arrived at CareOne , the doctor there immediately recommended that she @ @ @ @ @ @ @ of compassionate care for people in the last stages of life .
`` We were a little stubborn about signing the papers , '' said Cassaro , saying they were trying to slow walk the decision , hoping her mother would rally .
`` She was admitted on a Wednesday or Thursday and I believe it was Saturday that she went into hospice . ''
Cassaro kept calling , asking for updates .
The nurse offered to set up a FaceTime call as soon as her mother arrived on her floor .
Nine @ @ @ @ @ @ @ .
Ten thirty came and went .
`` You 're in a weird situation , right , because you 're a family member , but you do n't want to be that family member . ''
The kind of family member whose calls nurses try to avoid .
Finally at noon Cassaro called back .
The nurse told her to stay on the line while she went to her mother 's floor .
The call dropped in the elevator .
Cassaro called back and she and the nurse began talking about end-of-life visits @ @ @ @ @ @ @ she can give me my mother 's vital signs only because I felt like if I heard the vital signs , I would know how close she was , '' Cassaro said .
But doing something as simple as checking her vitals seemed like more than the nursing station could handle at the time .
`` They seemed really busy , '' Cassaro said , so she told the nurse that a FaceTime call with her mom would do and the nurse could `` catch me up on the vitals afterwards . ''
@ @ @ @ @ @ @ the hospice room and started talking to Cassaro 's mother , telling her her daughter was on the line .
`` I 'm like , Hey , Ma , how are you doing ? ''
Cassaro said .
`` I said you do n't look any worse for wear today , or something to her . ''
Cassaro could only see her mother from the nose up .
She asked the nurse to move the camera down and then she gasped .
What Cassaro saw was what she called a `` death gape @ @ @ @ @ @ @ taken aback , '' she said , `` and I take a screenshot and another nurse walks in off camera and she goes , oh , your mother has passed . ''
Then , Cassaro said , the nurse turned the camera on herself and told her , `` I 'm sorry for your loss . ''
Then the line went dead .
CareOne told NPR that it `` unequivocally denies the allegation .
The family did n't FaceTime immediately in advance of their loved one 's passing . ''
Cassaro shared that @ @ @ @ @ @ @ a timestamp coinciding with Cassaro 's version of events .
Annette Kociolek , 93 , who loved broaches , beads and barrettes , died March 30 , 2020 , five days after the buses came to take her away from St. Joe 's .
The cause , according to her death certificate : complications from COVID-19 .
But there is an odd thing about that , too .
The New Jersey Department of Health Long-Term Care Facility list of recorded COVID-19 deaths indicated that Annette Kociolek and the 35 other St. Joe 's @ @ @ @ @ @ @ did n't die at CareOne .
Instead the list suggests they died at St. Joe 's .
Annette Kociolek 's family found that galling .
Their mother was moved against her will , and now it appeared that the nuns at St. Joe 's had presided over her death when they had n't .
`` No one she knew was holding her hand , '' said Cassaro .
`` My mom died among strangers . ''
The keeper of the COVID-19 list , Dr. Tina Tan , who is the state 's epidemiologist @ @ @ @ @ @ @ NPR 's repeated requests for an interview .
But DOH said in a statement that during outbreaks `` deaths are counted based on the association with an outbreak facility , not the actual location of the individual 's death . ''
DOH said there were 36 confirmed COVID-19 deaths among the residents of St. Joe 's , and three or four additional deaths that were thought to be COVID-19 related but were n't confirmed — the patients had n't been tested .
But that 's odd too .
St. Joe 's claims it @ @ @ @ @ @ @ cases among the residents before the evacuation .
The state maintains it was twice that many , but again , it has not produced any documents corroborating that figure .
Yet all 36 of the evacuees who died at CareOne in the ensuing weeks showed up as part of the tally of dead associated with St. Joe 's .
Kociolek 's youngest daughter , Angie Krza-Kociolek , has been trying to get that changed for months .
She needs that , she said , for closure .
`` Even though my mother had @ @ @ @ @ @ @ least we could do is honor the deaths that occurred by reporting the deaths accurately , '' she said .
Since July , the New Jersey DOH has changed the way it compiles the list , reporting only active outbreaks in long-term care facilities , telling NPR it made the change `` to more accurately represent the current situation in facilities .
Cases or deaths from an outbreak that ended are not included in the list . ''
An outbreak is considered over in a facility if there has n't been a new @ @ @ @ @ @ @ 320,000 deaths attributed to the coronavirus in the United States , some 116,000 of them are linked to long-term care facilities — almost 40 percent of the nation 's COVID-19 deaths .
At St. Joes , the numbers are equally stark — 78 people evacuated , 36 of whom died .
There 's little question that New Jersey officials would handle St. Joe 's differently if the outbreak happened today , if only because no outbreak has been handled like it since .
St. Joe 's is still the only long-term care facility @ @ @ @ @ @ @ out in that way .
Shortly after it took in the residents of St. Joe 's , CareOne was given a license agreement to provide more than 700 beds at five of its facilities to care for COVID-19 patients being discharged from hospitals , according to DOH .
According to an investigation by ProPublica published in August , in the early days of the pandemic CareOne would go on to have the highest rate of COVID-19-related deaths among large long-term care companies in New Jersey .
As for St. Joe 's ?
Three @ @ @ @ @ @ @ of New Jersey moved 38 surviving evacuees back .
As of December 21st , records show that St. Joe 's had one resident and four staff testing positive for COVID-19 .

The Tragedy Of 'St. Joe's'
Enlarge this image toggle caption Seth Wenig/AP Seth Wenig/AP
The people in the yellow hazmat suits arrived at St. Joseph's Senior Home in Woodbridge, N.J., on a crisp morning in late March, emerging from blue and white ambulance buses all suited up, like astronauts descending from a lunar rover.
For the 78 residents whom they had come to evacuate on March 25, however, this all felt more like an alien abduction. As the hazmats approached, some residents shouted and furiously clawed at the air; others begged not to be taken away, clutching the nuns' sleeves, dissolving into tears.
The sisters who ran St. Joseph's told the residents' families later they'd never seen anything like it. "People were loaded up like cattle," said one person who saw the events unfold. "It was horrible. ... When I close my eyes, even today, I still see it."
That day St. Joseph's — most people call it "St. Joe's" — became the only long-term care facility in New Jersey to be entirely evacuated during the pandemic, and no other long-term facilities in the state have been cleared out in the same way since.
A months-long NPR investigation involving three dozen interviews with former and current New Jersey Department of Health officials, family members, experts on the elderly, and people who witnessed the events as they unfolded found that the state's decision to evacuate St. Joe's was both rushed and flawed.
toggle caption Dorothy Cassaro
The reporting makes clear the state failed to take into account the fragility of the evacuees sufficiently, possible alternatives to the move, and how complicated it would be to transfer 78 older adults to a facility 45 minutes away. The consequences of the decision are stark: Nearly half the people loaded on the ambulance buses that morning died a short time later, some within days. Experts on aging say the stress of the evacuation was undoubtedly a contributing factor.
According to people close to St. Joe's and families who were monitoring the facility at the time, when the evacuation order came, the nuns who ran St. Joe's were not presiding over an uncontrollable outbreak.
NPR saw contemporaneous emails that indicated that fewer than a dozen of the residents had been confirmed positive for the virus shortly before the state decided to evacuate. The New Jersey Department of Health, through a spokesperson, claimed that by the time of the evacuation there were twice that many.
In a written statement, the department said residents in the facility were initially showing signs of illness, but they stopped short of saying they had tested positive for the virus. Nonetheless, "the impact of COVID-19 on St. Joseph's was severe," a spokesperson wrote.
It appears that the real problem at St. Joe's was not so much a coronavirus outbreak among residents as it was an acute shortage of staff — something at least half the states in the U.S. are struggling with now in this latest winter surge.
Nurses, certified nursing assistants and caregivers at St. Joe's who had contact with residents who had tested positive for the coronavirus had to be quarantined to make sure they wouldn't contribute to the spread. Some of the facility's outside staff — concerned they would catch the mysterious virus that few understood at the time — stopped showing up for work. So St. Joe's needed help.
Before the coronavirus, a typical shift at St. Joe's included some 50 people with direct access to the patients. In the days just before the evacuation, that number had fallen to about 20.
That's why the nuns at St. Joe's started calling around for reinforcements. A Department of Health spokesperson said the agency spent two days looking for temporary staff for St. Joe's. They sent over some people from New Jersey's largest nursing home chain, CareOne. A handful of their nurses and managers covered three shifts.
Enlarge this image toggle caption Janie Osborne for NPR Janie Osborne for NPR
Annette Kociolek, 93, a bubbly, devout Catholic who was known in her family for her love of brooches, beads and barrettes, had been sitting up in bed, watching TV and talking on the phone with her daughters just days before the evacuation.
So she was surprised to find herself strapped to a gurney and loaded onto an ambulance bus the morning of March 25. Her daughters said she was one of St. Joe's reluctant evacuees, fighting off the hazmat suits when they came for her, asking the nuns to tell them she wanted to stay.
"When I try to imagine what that would have felt like, seeing people in hazmat suits, me being wheeled out of the place that I know is my home, away from the caretakers, having no family around to comfort or explain what was going on," her daughter Angie Kociolek told me, "it had to be traumatic."
Christopher Neuwirth was part of the New Jersey Department of Health's Emergency Preparedness and Response at the time. As an assistant commissioner, he had helped with floods and fires, and yet when it came to the evacuation of St. Joe's, he'd never seen the state weigh in like this.
"It was obvious from the get-go that everything that happened with St. Joe's was odd," he told NPR. "The state doesn't get involved with local evacuations. Even at the time everyone in my office was saying, wait, why are we in the middle of this?"
Neuwirth no longer works for the state. He said he was fired earlier this year because he filed an ethics complaint against a high-ranking official. He has since filed a whistleblower complaint, and the suit is pending. The state has denied his allegations.
Little Servant Sisters
St. Joseph's Senior Home is a four-star, 101-bed facility run by the Little Servant Sisters of the Immaculate Conception, a Polish order established in the 1850s with the mission to "nurture the mind, body, and soul ... by serving the residents with the same love as if serving Christ Himself." The nuns have been operating schools, health care facilities and senior homes in New Jersey since 1926.
For Annette Kociolek — her friends called her "Toni" — the family atmosphere and the religiosity of the place appealed.
"My mom was Polish Catholic and St. Joe's was run by Polish sisters," explained the eldest of her three daughters, Bernadette Sohler. "They had Masses daily and the nuns spoke Polish to her," which Annette Kociolek loved.
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It is important to remember that in early March, the mere idea of a pandemic seemed a distant threat, like a light on a far-off field. The first big coronavirus outbreak on the East Coast, in New Rochelle, N.Y., had yet to make the headlines, and family members were still allowed to visit nursing homes and bring in food.
On Feb. 29, Kociolek was at St. Joe's eating Polish doughnuts with her daughter, Bernadette Sohler. Sohler said visits to her mother were riotous affairs. "She'd always say, 'Bernie!' And make a big deal, and 'This is my daughter' to all the workers there," her daughter recalled. "Little did we know, you know, about two weeks later, everything would change."
The first inkling that something was wrong came on March 16, when the nuns called Sohler to report that a couple of the residents "had the sniffles." Just to be safe, the nuns told her, they had confined everyone to their rooms.
St. Joe's phoned Sohler again the next day to say that the facility appeared to have its first positive coronavirus case. A day afterward, Sohler found out the St. Joe resident who had tested positive was her mother's roommate.
"I remember calling my sister saying, you know, hopefully we have nothing to worry about," Sohler said. "My mother is very, very resilient. She had been hospitalized three times last year; she bounces back all the time. I talked to her that day and I asked her how she was doing, and she goes, 'I got these little sniffles.' She was more concerned about what they were giving her for lunch than about any virus."
After that, however, everything seemed to pick up speed.
The staff at St. Joe's began quarantining; caregivers weren't showing up to work. The COVID-19 numbers inside the facility began ticking up. By March 21, seven residents had tested positive for the virus, and Kociolek was among them.
Enlarge this image toggle caption Dorothy Cassaro Dorothy Cassaro
"It happened so, so very fast from when there were sniffles to when you know, one person had it, then seven people had it," Sohler said. "They had suspended social activity for the residents, and Sister Monika told me they had contacted the state for additional nursing support."
Sohler found out four days later that the state had ordered all the residents be transferred to another facility. The decision came so fast, Sohler said later, the nuns didn't have time to inform all the families.
A bus ride with the virus
Viral outbreaks have rocked New Jersey long-term care facilities before. In 2018, in what had become an infamous case, a strain of adenovirus raged through a pediatric ward of medically frail children in northern New Jersey.
The virus, common in communal living facilities, rarely results in serious illness, but it can be fatal to those with compromised immune systems, which is exactly what these children had. Dozens fell ill; 11 died.
In response, New Jersey Gov. Phil Murphy signed a law requiring that nearly all of the state's more than 840 long-term care facilities draw up outbreak response plans. Among other things, facilities needed to work out how they would isolate and separate the sick from at-risk residents who are healthy.
Enlarge this image toggle caption Julio Cortez/AP Julio Cortez/AP
The homes had 180 days to come up with a list of protocols and many had to submit their plans to the state by Feb. 11, 2020 — just weeks before the coronavirus arrived in earnest in New Jersey. St. Joe's does not appear to have created a plan, but it wasn't alone.
As COVID-19 raged, the uneven, panicked responses made plain that many had not, according to Laurie Facciarossa Brewer, an ombudsman for New Jersey's long-term care system. "It's pretty clear that most long-term care facilities did not have those plans in place when they were required to be done by the second week of February," she said.
One way to minimize outbreaks in communal living situations is something called cohorting — essentially it involves isolating those who have the disease or virus from those who don't. St. Joe's began doing that when its residents first began to "have the sniffles." That may be why the nuns seemed to be able to keep the total number of positive cases among the residents so low.
The evacuation team, when it first arrived the morning of March 25, attempted to keep all of St. Joe's coronavirus-positive patients together, relegating them to their own buses.
But by the end of a long day, with nearly everyone loaded and ready, the team started to put the remaining residents wherever they could find room, according to medical officials who received the patients and family members who heard about the evacuation later.
A Department of Health official said later that they just assumed everyone at St. Joe's had been exposed to the virus.
"Well, that's kind of crazy," said Melissa O'Connor, an expert in nursing care for older adults at Villanova University's M. Louise Fitzpatrick College of Nursing in Pennsylvania. "Buses don't have filtration systems like airplanes; they were all breathing the same air" and probably contracting the virus in the process.
O'Connor and others said that given what we now know about the community spread of the coronavirus, those residents who didn't have COVID-19 when they left St. Joe's on March 25, may well have caught it during their transfer. Even if they were masked, the danger was there as they waited in the buses for the other residents to load and then drove, all together, the 45 minutes to the new facility.
Enlarge this image toggle caption Seth Wenig/AP Seth Wenig/AP
Dr. Pamela Cacchione, who studies older adult care at the University of Pennsylvania School of Nursing, said she doesn't understand why the state didn't just designate St. Joe's a COVID-19 facility and leave all the residents there — isolating the sick — instead of transferring them somewhere else.
That would have been easier on everyone involved, particularly given that CareOne at Hanover didn't actually have vacant beds waiting for the residents of St. Joe's. To accommodate them, CareOne had to move dozens of their own residents to three other CareOne homes in the area.
CareOne declined to comment for this story.
Neuwirth, the former Department of Health assistant commissioner for emergency preparedness, told NPR that, among other things, New Jersey officials seemed to have fixed on the wrong protocol when they decided to empty out St. Joe's.
"This wasn't a flood or a fire, but they responded like this was a natural disaster, and they needed to rush to higher ground," he said. "That doesn't work when you're dealing with a pandemic disease. It follows you, wherever you go."
Behind the scenes
Around the same time the nuns were having their staffing problems at St. Joe's, there was a much worse coronavirus outbreak at the New Jersey Veterans Home at Paramus, a state-run facility for former military veterans about 40 minutes from St. Joe's in Woodbridge.
By late March, almost every resident at the Paramus facility — 98% — had contracted the coronavirus. Some 60% of the staff was out sick in what quickly evolved into one of the biggest coronavirus outbreaks in the country.
U.S. Rep. Josh Gottheimer, who has Paramus in his district, weighed in and arranged for nurses and the National Guard to help.
No one seems to have an answer as to why the same wasn't done for St. Joe's, though officials who were there at the time, and spoke on the condition of anonymity out of concern they would lose their jobs, said it seemed once Department of Health officials decided to evacuate, momentum to finish the job continued to build.
Donna Leusner, director of communications for the New Jersey Department of Health, denied this in response to questions from NPR.
She said the state tried to help the sisters find staff and, she said, the Department of Health spent two days looking for reinforcements.
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At some point, a nun named Sister Patricia Codey began talking to state officials about the staffing issues at St. Joe's. "Sister Pat," as she's called, is president of the Catholic HealthCare Partnership of New Jersey, and few people in the state's health care circles are as connected as her. Her brother, Richard, used to be governor.
Codey declined to be interviewed for this story. But three officials familiar with the discussions, whom NPR agreed not to name because they fear retaliation for revealing internal deliberations, said she brought the problems at St. Joe's to the attention of health department officials, and to one in particular, deputy commissioner of health systems, Marcela Maziarz, who oversees nursing homes in the state.
A focus on evacuation
"Maziarz was quite open about asking people in meetings to help her find a place to put people from St. Joe's," said one Department of Health official, who was part of the discussions in mid-March and still works there. "She wanted them to be first in line for a move."
According to three officials who attended meetings with Maziarz in March and April, the deputy commissioner told colleagues in meetings that she thought the best thing to do would be move them to CareOne at Hanover. As the largest nursing home chain in the state, CareOne had the beds, the ability to isolate COVID-19 patients and a willingness to help.
Maziarz had been working with people at CareOne on various licensing agreements for months so the transfer was relatively simple to arrange.
Three Department of Health officials close to the discussions said it started as a verbal agreement — CareOne would take St. Joe's residents — and the precise terms, everyone agreed, would be worked out later.
The Department of Health's Leusner told NPR that "emergent discussions came before executing" the agreement because it was "very time sensitive."
NPR filed an Open Public Records Act request to look at any contracts and agreements between CareOne and the Department of Health, and the request was denied.
The Department of Health declined to make Maziarz available for comment. Care One declined to comment as well.
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"I'm not surprised that a company like CareOne would be a place where you would look to try to do something quickly," said Brewer, the long-term care ombudsman. "A lot of other long-term care facilities were really struggling at that point and would not have been able to do it."
Brewer said she couldn't say why state officials didn't just supplement St. Joe's staff instead. "I think the model is to move people out when there's a crisis," she said. "Historically that has been the way to solve a problem in a facility; usually it is a physical plant problem" such as a flood, not a virus.
Two Department of Health officials confirmed that someone in the deputy commissioner's office — it is unclear if it was Maziarz — asked CareOne to send people over to St. Joe's to assess the situation. They were nurses and managers from various CareOne facilities, and, according to the Department of Health, they reported what they saw at St. Joe's to state officials the same day.
"Because CareOne had sent staff into the facility to assist, they were able to provide the Department with information to determine the best way to provide care" for the residents of St. Joe's, Leusner said in a written statement.
Their recommendation was to move them all to CareOne. There was never an independent assessment before the evacuation. The University of Pennsylvania's Cacchione, the elder care specialist, said having CareOne do that assessment was "very concerning" because of the obvious conflict of interest. "It's like the fox guarding the henhouse," she said.
NPR filed numerous Open Public Records Act requests to the Department of Health asking for a copy of that assessment of St. Joe's. Several Department of Health divisions said they had no documents that would be responsive to the request. One division said it would keep looking.
The report CareOne sent to the state, according to two officials familiar with it, characterized the situation inside St. Joe's as chaotic. CareOne officials claimed there were only a handful of nuns taking care of the residents there.
Officials close to St. Joe's said that when the CareOne officials showed up on March 22 — three days before everyone at St. Joe's was evacuated — there were nearly two dozen caregivers, nurses, nurses' assistants and visiting nuns in the facility caring for the residents. Little Servant Sisters' other locations in New Jersey had pitched in to help.
Shortly after CareOne provided its report to the State, New Jersey Department of Health Commissioner Judy Persichilli told reporters, at a March 24 press conference, that the department was working with St. Joe's on an evacuation.
"This may result, unfortunately and ultimately, in the closure of that facility," she said, "a facility that has cared for the most vulnerable population in Woodbridge and the surrounding area for decades."
Twelve hours later, the ambulance buses arrived.
Care transition
Enlarge this image toggle caption Seth Wenig/AP Seth Wenig/AP
Standard operating procedure when moving older patients is to look for available beds close by, where people can live temporarily and their families can still have some sort of access. Typically, there are a couple of beds here, and a few others there. In March, as the pandemic was starting to rage, the state's long-term care ombudsman Brewer said, those spare beds were hard to find.
"To me, the part of the St. Joe's evacuation that was really unusual was that they all went from one place to another place," she said. "But then, everything was unprecedented at that time. The rules that we had all abided by all these years seem to be falling by the wayside."
One of those rules is that moving older adults is a last resort.
When the University of Pennsylvania's Cacchione was doing her research on long-term care, she had worked with older adults during a natural disaster. A mini-tornado had knocked out the power to a long-term care facility that she was studying. Everyone had to be evacuated for five days. She said the move traumatized those who were evacuated.
"Over 50% of the participants in the study became delirious or developed acute confusion, which is potentially fatal in itself," she said. "To think that [St. Joe's] had to transition 78 older adults from one facility to another is hard to fathom. The literature shows that these acute evacuations are very dangerous for older adults."
Even if older evacuees weather the physical transfer, Cacchione said, under the best of circumstances they have to endure mix-ups at the receiving facility. Just think how complicated it is to check someone into the hospital, she said, now multiply that by 78 all arriving at once.
"Just the medication errors that would occur from a transition like that are just tremendous," she said. "Getting the appropriate diet, preparing them for appropriate roommate situations, when they often had their own rooms prior to this. That's a real significant challenge to an older adult."
A FaceTime goodbye
It appeared to be a challenge for Annette Kociolek.
"My gut reaction was that [my mom] was going to get lost in the mix," Kociolek's middle daughter, Dorothy Cassaro, told me, as she tracked her mother's progress from St. Joe's to CareOne. "Up until the time of the evacuation my mother was still sitting up, watching TV, and she was still verbal," but the new facility wouldn't know that, she said. She was sure her mother would seem weaker than she was.
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"She was going to be presented on a stretcher, she's going to look weak and feeble, and I guess I felt that would impact judgments," she said.
Cassaro's inclination proved to be prescient. When her mother arrived at CareOne, the doctor there immediately recommended she be put into hospice, a kind of compassionate care for people in the last stages of life.
"We were a little stubborn about signing the papers," Cassaro said, adding they were trying to slow walk the decision, hoping her mother would rally. "She was admitted on a Wednesday or Thursday, and I believe it was Saturday that she went into hospice."
Cassaro kept calling, asking for updates. The nurse offered to set up a FaceTime call as soon as her mother arrived on her floor. First 9:30 came and went without a call. Then 10:30 came and went. "You're in a weird situation, right, because you're a family member, but you don't want to be that family member" — the kind of family member whose calls nurses try to avoid.
Finally at noon Cassaro called back. The nurse told her to stay on the line while she went to her mother's floor. The call dropped in the elevator.
Cassaro called back, and she and the nurse began talking about end-of-life visits. "I was asking her if she can give me my mother's vital signs only because I felt like if I heard the vital signs, I would know how close she was," Cassaro said.
But doing something as simple as checking her vitals seemed like more than the nursing station could handle at the time. "They seemed really busy," Cassaro said, so she told the nurse that a FaceTime call with her mom would do and the nurse could "catch me up on the vitals afterwards."
Cassaro listened as the nurse walked into the hospice room and started talking to Cassaro's mother, telling her that her daughter was on the line. "I'm like, Hey, Ma, how are you doing?" Cassaro said. "I said you don't look any worse for wear today, or something to her."
Cassaro could only see her mother from the nose up. She asked the nurse to move the camera down and then she gasped. What Cassaro saw was what she called a "death gape."
"I was kind of taken aback," she said, "and I take a screenshot and another nurse walks in off camera and she goes, 'Oh, your mother has passed.' " Then, Cassaro said, the nurse turned the camera on herself and told her, "I'm sorry for your loss."
Then the line went dead.
CareOne told NPR that it "unequivocally denies the allegation. The family didn't FaceTime immediately in advance of their loved one's passing." Cassaro shared that last screenshot with NPR, which had a time stamp coinciding with Cassaro's version of events.
The list
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Annette Kociolek, 93, who loved brooches, beads and barrettes, died March 30, five days after the buses came to take her away from St. Joe's. The cause, according to her death certificate: complications from COVID-19.
But there is an odd thing about that, too. The New Jersey Department of Health Long-Term Care Facility list of recorded COVID-19 deaths indicated that Kociolek and the 35 other St. Joe's evacuees who died days after the move didn't die at CareOne.
Instead the list suggests they died at St. Joe's. Kociolek's family found that galling. Their mother was moved against her will, and now it appeared the nuns at St. Joe's had presided over her death when they hadn't. "No one she knew was holding her hand," Cassaro said. "My mom died among strangers."
The keeper of the COVID-19 list, Dr. Tina Tan, who is the state's epidemiologist at the Department of Health, declined NPR's repeated requests for an interview.
But the Department of Health said in a statement that during outbreaks "deaths are counted based on the association with an outbreak facility, not the actual location of the individual's death."
The Department of Health said there were 36 confirmed COVID-19 deaths among the residents of St. Joe's, and three or four additional deaths that were thought to be related to COVID-19 but weren't confirmed — the patients hadn't been tested.
But that's odd, too. St. Joe's claims it only had about a dozen confirmed COVID-19 cases among the residents before the evacuation. The state maintains it was twice that many, but again, it has not produced any documents corroborating that figure.
Yet all 36 of the evacuees who died at CareOne in the ensuing weeks showed up as part of the tally of dead associated with St. Joe's.
Enlarge this image toggle caption Janie Osborne for NPR Janie Osborne for NPR
Kociolek's youngest daughter, Angie Kociolek, has been trying to get that changed for months. She needs that, she said, for closure. "Even though my mother had already died, I felt like the least we could do is honor the deaths that occurred by reporting the deaths accurately," she said.
Since July, the New Jersey Department of Health has changed the way it compiles the list, reporting only active outbreaks in long-term care facilities, telling NPR it made the change "to more accurately represent the current situation in facilities. Cases or deaths from an outbreak that ended are not included in the list."
An outbreak is considered over in a facility if there hasn't been a new case in 28 days.
Of the 320,000 deaths attributed to the coronavirus in the United States, some 116,000 of them are linked to long-term care facilities — almost 40% of the nation's COVID-19 deaths.
At St. Joe's, the numbers are equally stark — 78 people evacuated, 36 of whom died.
There's little question that New Jersey officials would handle St. Joe's differently if the outbreak happened today, if only because no outbreak has been handled like it since. St. Joe's is still the only long-term care facility in the state to have been emptied out in that way.
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Shortly after it took in the residents of St. Joe's, CareOne was given a license agreement to provide more than 700 beds at five of its facilities to care for COVID-19 patients being discharged from hospitals, according to the Department of Health.
According to an investigation by ProPublica published in August, in the early days of the pandemic, CareOne would go on to have the highest rate of deaths related to COVID-19 among large long-term care companies in New Jersey.
As for St. Joe's? Three weeks after the evacuation, the state of New Jersey moved 38 surviving evacuees back. As of Dec. 21, records show that St. Joe's had one resident and four staff testing positive for the coronavirus.
NPR's Monika Evstatieva contributed to this report.