npr--2020-02-20--Trusting Injection Drug Users With IV Antibiotics At Home: It Can Work

Trusting Injection Drug Users With IV Antibiotics At Home : It Can Work Two mornings a week , Arthur Jackson clears space on half of his cream-colored sofa .
He sets out a few rolls of tape and some gauze , then waits for a knock on his front door .
`` This is Brenda 's desk , '' Jackson says with a chuckle .
Brenda Mastricola is his visiting nurse .
After she arrives at Jackson 's home in Boston , she joins him on the couch and starts by taking his blood pressure .
Then she changes the @ @ @ @ @ @ @ His big toe was amputated at Brigham and Women 's Hospital in November .
A bacterial infection , osteomyelitis , had destroyed the bone .
Jackson is still taking intravenous penicillin to stop the infection .
He came home from the hospital wearing a small medication pump .
It delivers a steady dose of penicillin via a PICC line .
A PICC line ( for Peripherally Inserted or Percutaneous Indwelling Central Catheter ) looks sort of like a flexible IV tube , inserted into Jackson 's chest .
`` This all looks good @ @ @ @ @ @ @ to make sure the line is clean and in place .
`` You do n't need me . ''
When patients need weeks or months of IV antibiotic treatment , but otherwise do n't need to be hospitalized , the standard protocol is to discharge them with a PICC line , and allow them to finish the medication at home .
It saves money and is much more convenient for the patients .
But this arrangement is almost never offered to patients who have a history of addiction .
The fear is that @ @ @ @ @ @ @ the PICC line as a fast and easy way to inject drugs like heroin , cocaine or methamphetamine .
Jackson , who is 69 , was addicted to heroin for 40 years .
Although he 's been sober for years , most U.S. hospitals would force patients like Jackson to stay in the hospital , sometimes for eight weeks or more .
But Jackson 's hospital , Brigham and Women 's in Boston , along with just a few others in the U.S. , is challenging that protocol , allowing some patients to @ @ @ @ @ @ @ so boosts the chances these patients will stay on their antibiotics and beat the infection .
A small team of Brigham doctors and nurses started planning this very unusual option shortly after opening the Bridge Clinic , a walk-in clinic in Boston for patients who are seeking treatment for a substance use disorder .
Dr. Christin Price , one of the clinic 's directors , says virtually every patient who injects drugs develops some kind of infection .
It 's difficult to avoid injecting bacteria into the bloodstream when using drugs in an @ @ @ @ @ @ @ national opioid epidemic has led , in many cases , to a parallel increase in diseases related to injection drug use , such as HIV , hepatitis C and bacterial infections of the heart and bones .
A study of North Carolina hospitals found a 12-fold increase in cases of the heart infection endocarditis between 2010 and 2015 .
`` Every time someone uses injection drugs , they 're putting themselves at risk for a very complicated infection , '' Price says .
Treatment options for endocarditis patients with a history of drug @ @ @ @ @ @ @ facilities , home care agencies and antibiotic infusion companies wo n't work with these patients once they 're released from a hospital .
But Price says some of her patients are n't willing to remain in a hospital for weeks on end , just to finish a round of IV antibiotics .
`` They kind of get stir crazy , '' she says .
`` You can imagine it 's almost like being held captive for six weeks , especially when you 're feeling fine now because the infection is clearing .
A @ @ @ @ @ @ @ ca n't last — and so they leave before the six weeks are over . ''
Patients who do n't complete their course of antibiotics can end up with a recurring infection and a repeat trip to the hospital .
Doctors and nurses affiliated with the Bridge Clinic wondered if there was n't a way to send patients with a history of drug use home — safely .
They mapped out three requirements : First , patients would have be taking an addiction treatment medication such as buprenorphine , or be willing to @ @ @ @ @ @ @ have to check in weekly at the Bridge Clinic .
Third , patients would need to have stable housing , and live with a sober friend or loved one .
Price and colleagues began months of discussions with specialists in heart , bone and joint conditions , seeking buy-in from surgeons and nurses , so their patients could participate .
`` A lot of people did sort of look aghast , '' Price says .
`` It was just their policy that people with a history of injection drug use would not go @ @ @ @ @ @ @ encountered those looks , he says he 'd remind colleagues `` that the alternatives are n't that good either . ''
Holding patients for weeks in a hospital room is hard on both the patients and medical providers , he says .
And if patients want to use drugs they 'll find a way to do it , even in a hospital bed .
In the spring of 2018 , Price and Solomon and others enrolled a few of the first qualified patients , then a few more — intentionally cherry-picking those who @ @ @ @ @ @ @ had a sober , stable home .
Arthur Jackson says there should n't have been any question that he met the first and second requirements .
He 'd been on methadone for 10 years , used heroin again , then switched to Suboxone , a version of buprenorphine that he 's been taking for two years .
In fact , Jackson says he was insulted when one of the doctors presented the home treatment option to him , but said she was worried the PICC line might entice him to inject heroin .
@ @ @ @ @ @ @ recalls telling the nurse .
`` When it comes to my recovery , I 'm serious because I 've done so much to lick this this thing . ''
Not that Jackson did n't consider it .
`` First thing I thought was , 'Oh , I could inject heroin in here easily , ' `` Jackson says .
`` But I dismissed that thought because I 'm not going back '' — back to winters on the streets , and living from one heroin fix to the next .
Other Bridge patients @ @ @ @ @ @ @ .
`` Everyone makes such a big deal about this PICC line , '' says Stephen Connolly , 36 , who went home with the open port last year , while being treated for endocarditis .
`` If I want to get high , I know how to do it .
I 'm not going to mess around with a PICC . ''
Connolly says when he first came to Brigham and Women 's Hospital he was focused on his heart , ignoring his other disease : addiction .
Connolly says he was @ @ @ @ @ @ @ even his cardiologist , wanted to talk about addiction .
`` I 'm like , 'listen dude , my heart 's falling apart here , so let 's hold up with the drug talk , '' Connolly recalls .
He assured the cardiologist he had his addiction under control .
`` Obviously I did n't , but my mind tells me that .
It 's just crazy . ''
Connolly finished his antibiotic treatment while staying with family members in Abington , Mass .
Brigham doctors say the housing requirement eliminates many otherwise-eligible @ @ @ @ @ @ @ who have HIV or Hep C do take their antiviral medicines ; there are no equivalent robust studies on treating homeless patients who have bacterial infections .
Nevertheless , a few other hospitals are testing ways to continue outpatient treatment for patients who do n't have a stable home .
In Portland , Ore. , a medical center tried providing IV antibiotics inside addiction treatment programs .
A hospital in Kentucky combines addiction treatment , counseling and outpatient IV antibiotics .
In Vancouver , the Canadian national health program pays for small apartments @ @ @ @ @ @ @ a day , where patients can stay while they complete antibiotic treatment .
`` People who use drugs deserve the same standard of care , '' says Dr. Christy Sutherland , medical director at the Portland Hotel Society in Vancouver .
`` We ca n't change what we offer as clinicians — to give people subpar treatment with the excuse that they are IV drug users . ''
Arthur Jackson lives alone in his studio apartment , but he persuaded doctors he 'd be better off there than in the hospital , so @ @ @ @ @ @ @ , feed his tankful of tropical fish and his cat , and attend his regular Narcotics Anonymous meetings .
`` I guess the best way to put it is , I have a life and I need to get back to it , '' he says .
Jackson is one of 40 patients with a history of drug use the Brigham team has discharged from the hospital , to complete IV antibiotic treatment at home .
The team is paying particular attention to 21 patients within that group who , unlike Jackson , @ @ @ @ @ @ @ , these men and women have finished their antibiotic treatment via a PICC line with no complications .
One had to be readmitted because he had trouble administering the antibiotics .
Price says there were three patients who relapsed into drug use , but no one actually used the PICC line to inject illegal drugs .
`` I think we 've shown , through this pilot , that it is safe and feasible for certain patients , '' she says .
Brigham doctors have not yet published these initial results in a medical @ @ @ @ @ @ @ But already , Price says , the pilot program is helping to cut health care costs .
Taken as a group , the 21 high-risk patients who needed IV antibiotics spent 571 days at home rather than in a hospital or rehab facility — saving as much as $ 865,000 ( based on estimates of $ 1,500 per hospital day . )
That does n't include the cost of home care visits by a nurse .
This story is part of a reporting partnership that includes WBUR , NPR and Kaiser Health News @ @ @ @ @ @ @ on Twitter @ mbebinger .

The Case For Sending Drug Users Home From The Hospital With Open IV Lines
Enlarge this image toggle caption Jesse Costa/WBUR Jesse Costa/WBUR
Two mornings a week, Arthur Jackson clears space on half of his cream-colored sofa. He sets out a few rolls of tape and some gauze, then waits for a knock on his front door.
"This is Brenda's desk," Jackson says with a chuckle.
Brenda Mastricola is his visiting nurse. After she arrives at Jackson's home in Boston, she joins him on the couch and starts by taking his blood pressure. Then she changes the bandages on Jackson's right foot. His big toe was amputated at Brigham and Women's Hospital in November. A bacterial infection, osteomyelitis, had destroyed the bone.
Jackson is still taking intravenous penicillin to stop the infection. He came home from the hospital wearing a small medication pump. It delivers a steady dose of penicillin via a PICC line. A PICC line (for Peripherally Inserted or Percutaneous Indwelling Central Catheter) looks sort of like a flexible IV tube, inserted into Jackson's chest.
"This all looks good," Mastricola says, after checking to make sure the line is clean and in place. "You don't need me."
When patients need weeks or months of IV antibiotic treatment, but otherwise don't need to be hospitalized, the standard protocol is to discharge them with a PICC line, and allow them to finish the medication at home. It saves money and is much more convenient for the patients.
But this arrangement is almost never offered to patients who have a history of addiction. The fear is that such patients might be tempted to use the PICC line as a fast and easy way to inject drugs like heroin, cocaine or methamphetamine.
Jackson, who is 69, was addicted to heroin for 40 years. Although he's been sober for years, most U.S. hospitals would force patients like Jackson to stay in the hospital, sometimes for eight weeks or more. But Jackson's hospital, Brigham and Women's in Boston, along with just a few others in the U.S., is challenging that protocol, allowing some patients to go home anyway. They argue doing so boosts the chances these patients will stay on their antibiotics and beat the infection.
Mapping a path to safe at-home treatment
A small team of Brigham doctors and nurses started planning this very unusual option shortly after opening the Bridge Clinic, a walk-in clinic in Boston for patients who are seeking treatment for a substance use disorder.
Dr. Christin Price, one of the clinic's directors, says virtually every patient who injects drugs develops some kind of infection. It's difficult to avoid injecting bacteria into the bloodstream when using drugs in an alley or a public bathroom.
toggle caption Robin Lubbock/WBUR
The national opioid epidemic has led, in many cases, to a parallel increase in diseases related to injection drug use, such as HIV, hepatitis C and bacterial infections of the heart and bones. A study of North Carolina hospitals found a 12-fold increase in cases of the heart infection endocarditis between 2010 and 2015.
"Every time someone uses injection drugs, they're putting themselves at risk for a very complicated infection," Price says.
Treatment options for endocarditis patients with a history of drug use are limited. Some skilled nursing facilities, home care agencies and antibiotic infusion companies won't work with these patients once they're released from a hospital. But Price says some of her patients aren't willing to remain in a hospital for weeks on end, just to finish a round of IV antibiotics.
"They kind of get stir crazy," she says. "You can imagine it's almost like being held captive for six weeks, especially when you're feeling fine now because the infection is clearing. A huge problem is that some of them can't last — and so they leave before the six weeks are over."
Patients who don't complete their course of antibiotics can end up with a recurring infection and a repeat trip to the hospital.
Doctors and nurses affiliated with the Bridge Clinic wondered if there wasn't a way to send patients with a history of drug use home — safely. They mapped out three requirements: First, patients would have be taking an addiction treatment medication such as buprenorphine, or be willing to start one. Second, patients would have to check in weekly at the Bridge Clinic. Third, patients would need to have stable housing, and live with a sober friend or loved one.
Price and colleagues began months of discussions with specialists in heart, bone and joint conditions, seeking buy-in from surgeons and nurses, so their patients could participate.
"A lot of people did sort of look aghast," Price says. "It was just their policy that people with a history of injection drug use would not go home."
When Dr. Daniel Solomon encountered those looks, he says he'd remind colleagues "that the alternatives aren't that good either." Holding patients for weeks in a hospital room is hard on both the patients and medical providers, he says. And if patients want to use drugs they'll find a way to do it, even in a hospital bed.
In the spring of 2018, Price and Solomon and others enrolled a few of the first qualified patients, then a few more — intentionally cherry-picking those who wanted to be in treatment and who had a sober, stable home.
'I'm not going back'
Arthur Jackson says there shouldn't have been any question that he met the first and second requirements. He'd been on methadone for 10 years, used heroin again, then switched to Suboxone, a version of buprenorphine that he's been taking for two years. In fact, Jackson says he was insulted when one of the doctors presented the home treatment option to him, but said she was worried the PICC line might entice him to inject heroin.
"Stop right there," Jackson recalls telling the nurse. "When it comes to my recovery, I'm serious because I've done so much to lick this this thing."
Not that Jackson didn't consider it.
"First thing I thought was, 'Oh, I could inject heroin in here easily,' " Jackson says. "But I dismissed that thought because I'm not going back" — back to winters on the streets, and living from one heroin fix to the next.
Other Bridge patients scoff at those concerns about PICC lines.
"Everyone makes such a big deal about this PICC line," says Stephen Connolly, 36, who went home with the open port last year, while being treated for endocarditis. "If I want to get high, I know how to do it. I'm not going to mess around with a PICC."
toggle caption Robin Lubbock/WBUR
Connolly says when he first came to Brigham and Women's Hospital he was focused on his heart, ignoring his other disease: addiction. Connolly says he was surprised when every doctor he saw, even his cardiologist, wanted to talk about addiction.
"I'm like, 'listen dude, my heart's falling apart here, so let's hold up with the drug talk," Connolly recalls. He assured the cardiologist he had his addiction under control.
"Obviously I didn't, but my mind tells me that. It's just crazy."
Connolly finished his antibiotic treatment while staying with family members in Abington, Mass.
Brigham doctors say the housing requirement eliminates many otherwise-eligible patients. Recent research shows homeless patients who have HIV or Hep C do take their antiviral medicines; there are no equivalent robust studies on treating homeless patients who have bacterial infections.
Nevertheless, a few other hospitals are testing ways to continue outpatient treatment for patients who don't have a stable home. In Portland, Ore., a medical center tried providing IV antibiotics inside addiction treatment programs. A hospital in Kentucky combines addiction treatment, counseling and outpatient IV antibiotics. In Vancouver, the Canadian national health program pays for small apartments, staffed with a nurse 24 hours a day, where patients can stay while they complete antibiotic treatment.
"People who use drugs deserve the same standard of care," says Dr. Christy Sutherland, medical director at the Portland Hotel Society in Vancouver. "We can't change what we offer as clinicians — to give people subpar treatment with the excuse that they are IV drug users."
Promising early signs
Arthur Jackson lives alone in his studio apartment, but he persuaded doctors he'd be better off there than in the hospital, so he could visit his 93-year-old mother daily, feed his tankful of tropical fish and his cat, and attend his regular Narcotics Anonymous meetings.
"I guess the best way to put it is, I have a life and I need to get back to it," he says.
toggle caption Jesse Costa/WBUR
Jackson is one of 40 patients with a history of drug use the Brigham team has discharged from the hospital, to complete IV antibiotic treatment at home. The team is paying particular attention to 21 patients within that group who, unlike Jackson, are active drug users. So far, these men and women have finished their antibiotic treatment via a PICC line with no complications. One had to be readmitted because he had trouble administering the antibiotics. Price says there were three patients who relapsed into drug use, but no one actually used the PICC line to inject illegal drugs.
"I think we've shown, through this pilot, that it is safe and feasible for certain patients," she says.
Brigham doctors have not yet published these initial results in a medical journal, though they plan to. But already, Price says, the pilot program is helping to cut health care costs.
Taken as a group, the 21 high-risk patients who needed IV antibiotics spent 571 days at home rather than in a hospital or rehab facility — saving as much as $865,000 (based on estimates of $1,500 per hospital day.) That doesn't include the cost of home care visits by a nurse.
This story is part of a reporting partnership that includes WBUR, NPR and Kaiser Health News. Find health care reporter Martha Bebinger on Twitter @mbebinger.


npr--2020-02-20--6 Takeaways From The Nevada Democratic Debate

In Las Vegas — a city known for prize fights — the Democrats were gloves-off .
And there was a new entrant in the ring , who took a lot of incoming : Former New York Mayor Michael Bloomberg , who has spent more than $ 300 million of his own money on ads to raise his profile .
Bloomberg qualified for the debate just the day before , after an NPR/PBS NewsHour/Marist poll became the fourth national survey showing him with 10 % or more support in the race for the Democratic presidential nomination .
1 .
Bloomberg got @ @ @ @ @ @ @ performance All that money bought Bloomberg a raised profile – and a slot on the debate stage .
But he had a spotty debate .
Bloomberg had his good moments – talking about how to beat President Trump , why Vermont Sen. Bernie Sanders , in his view , would lose and defending capitalism against socialism .
`` What a wonderful country we have , '' Bloomberg said before taking aim at Sanders .
`` The best-known socialist in the country happens to be a millionaire with three houses .
What did I @ @ @ @ @ @ @ , has n't debated in 11 years , and it showed .
He was off balance now and again , and had a hard time defending himself , especially when it came to his past comments about women and non-disclosure agreements with some of his employees .
`` None of them accuse me of doing anything , '' Bloomberg said , `` other than maybe they did n't like a joke I told . ''
That , in response to a line of attack from Massachusetts Sen. Elizabeth Warren , was clearly out @ @ @ @ @ @ @ .
Bloomberg missed a lot of opportunities to take credit for his personal spending on political issues .
A more practiced candidate might have pivoted to talk about the $ 100 million he spent in 2018 trying to elect women candidates .
And he made no mention of the substantial sums he 's spent on promoting gun control .
Bloomberg may have become the most polarizing figure in the party with this debate performance , and that 's not what he wanted to accomplish .
2 .
Warren was the most aggressive she @ @ @ @ @ @ @ it 's not clear what that accomplished Elizabeth Warren torched everyone in her way .
There were those detailed arguments against Bloomberg on the allegations that he made disparaging remarks about women and fostered a discriminatory work environment at his company .
But she also said voting for Sanders was like `` gambling on a narrow vision '' and `` gambling on a revolution that wo n't bring along a majority of this country . ''
She accused former Vice President Joe Biden and Minnesota Sen. Amy Klobuchar of being too `` eager @ @ @ @ @ @ @ Leader Mitch McConnell ; and Warren alleged that former South Bend , Ind.
, Mayor Pete Buttigieg `` has been taking money from big donors and changing his positions . ''
Warren is in a tough position and perhaps has nothing to lose .
She sees the train to the nomination leaving the station , and she 's not on it .
But it 's not clear that Warren helped herself or that this version of Warren is one that can convince voters she can win in November .
Still , Warren has @ @ @ @ @ @ @ exceed expectations , starting in Nevada .
3 .
The centrists are not uniting It 's pretty clear that Klobuchar and Buttigieg either do n't like each other very much or at least get under each other 's skin .
Buttigieg had a strong debate , for the most part , except when going after Klobuchar for not remembering the name of Mexico 's president during a candidate forum .
It felt petty .
Klobuchar fired back : `` I wish everyone was as perfect as you , Pete . ''
Ouch .
@ @ @ @ @ @ @ .
Nevada very well may be something of a winnowing process for the two .
Buttigieg is the overall delegate leader after strong showings in Iowa and New Hampshire .
Klobuchar gained a lot of momentum pulling out a surprise third-place finish in New Hampshire .
Buttigieg needs Klobuchar to fade , so he can have a chance with her voters , and she needs him out of the way , so she can have a chance to continue her rise .
4 .
Biden tried to say he 's the most electable @ @ @ @ @ @ @ in Iowa and New Hampshire , respectively , Biden was insisting he was the best candidate to beat Trump .
So far , polls do continue to show him beating Trump by a wider margin than the other candidates , but , frankly , it 's been the case in this campaign that the idea of Biden has been better than the reality .
Biden had a strong moment when he went after Bloomberg on `` Stop and Frisk , '' the controversial New York City policing policy that disproportionately targeted young men @ @ @ @ @ @ @ there were n't many stand-out Biden moments .
In fact , in this debate , he spoke fifth-most out of six candidates .
Biden and Bloomberg are competing for the same voters .
The latest NPR/PBS NewsHour/Marist poll shows they pull equally from each other 's supporters ; they are the top second choices of the other 's backers .
So Nevada and , especially , South Carolina are critical for Biden to prove he should be the candidate moderates should coalesce around .
5 .
Sanders did n't do much to expand @ @ @ @ @ @ @ Since campaigning in Iowa and winning New Hampshire , Sanders ' demeanor has been subtly different than his usually fired-up persona .
Apparently sensing he could really be the nominee , Sanders has conducted himself largely composed and calm .
For so long , Sanders has been throwing stones from the outside , but suddenly , he 's the inside man , the one with the best chance at the nomination .
But in this debate , he reverted back to his irascible form .
That 's likely because he was on stage @ @ @ @ @ @ @ traditional system of campaigning and stands for a lot of things Sanders is diametrically opposed to .
Eventually , Sanders has to get back to a posture that does n't scare the rest of the party , but he 's got his base locked down , and the latest NPR/PBS NewsHour/Marist poll showed him expanding some .
With moderates still not coalescing around a single candidate , the chaos works to Sanders ' benefit .
He very well could wind up with a plurality of pledged delegates at the convention .
And that @ @ @ @ @ @ @ should be the nominee , even though the party 's rules require an absolute majority of delegates to secure the nomination .
6 .
The person all of this helps most is Trump Trump and his team likely could n't be happier seeing what they saw from this debate .
Arguments of capitalism versus socialism ; moderates unable to settle on one candidate ; and overall squabbling are music to the Make America Great Again crowd 's ears .
A long , drawn-out nomination contest — which everyone is now expecting — helps @ @ @ @ @ @ @ is in play , the longer it takes for Democrats to focus on Trump , build the needed infrastructure for a national campaign and raise the necessary money to win .
Trump got some good news out of the NPR/PBS NewsHour/Marist poll : 41 % say the country is headed in the right direction , which is the highest in eight years of the poll ; Trump has a 44 % approval among registered voters ; 54 % approve of his handling of the economy ; and 66 % say the economy is @ @ @ @ @ @ @ those improving numbers and Democratic infighting , Trump and his team are liking their chances .

6 Takeaways From The Nevada Democratic Debate
Enlarge this image toggle caption Mario Tama/Getty Images Mario Tama/Getty Images
In Las Vegas — a city known for prize fights — the Democrats were gloves off.
And a new entrant in the ring took a lot of incoming: former New York City Mayor Michael Bloomberg, who has spent more than $300 million of his own money on ads to raise his profile.
Bloomberg qualified for the debate just the day before, after an NPR/PBS NewsHour/Marist poll became the fourth national survey showing him with 10% or more support in the race for the Democratic presidential nomination.
Herewith, six takeaways from a rollicking night.
Media no longer available
1. Bloomberg got onstage but had an uneven performance.
All that money bought Bloomberg a raised profile — and a slot on the debate stage. But he had a spotty debate.
Bloomberg had his good moments, talking about how to beat President Trump and why Vermont Sen. Bernie Sanders, in his view, would lose, and defending capitalism against socialism.
"What a wonderful country we have," Bloomberg said before taking aim at Sanders. "The best-known socialist in the country happens to be a millionaire with three houses. What did I miss here?
But Bloomberg, 78, hasn't debated in 11 years, and it showed. He was off balance now and again and had a hard time defending himself, especially when it came to his past comments about women and nondisclosure agreements with some of his employees.
"None of them accuse me of doing anything," Bloomberg said, "other than maybe they didn't like a joke I told."
That, in response to a line of attack from Massachusetts Sen. Elizabeth Warren, was clearly out of step with today's Democratic Party.
Bloomberg missed a lot of opportunities to take credit for his personal spending on political issues. A more practiced candidate might have pivoted to talk about the $100 million he spent in 2018 trying to elect women candidates. And he made no mention of the substantial sums he has spent on promoting gun control.
Bloomberg may have become the most polarizing figure in the party with this debate performance, and that's not what he wanted to accomplish.
Enlarge this image toggle caption John Locher/AP John Locher/AP
2. Warren was the most aggressive she has been during the campaign, but it's not clear what that accomplished.
Warren torched everyone in her way. There were those detailed arguments against Bloomberg on the allegations that he made disparaging remarks about women and fostered a discriminatory work environment at his company. But she also said voting for Sanders is like "gambling on a narrow vision" and "gambling on a revolution that won't bring along a majority of this country."
She accused former Vice President Joe Biden and Minnesota Sen. Amy Klobuchar of being too "eager to be liked" by Senate Majority Leader Mitch McConnell; and Warren alleged that former South Bend, Ind., Mayor Pete Buttigieg "has been taking money from big donors and changing his positions."
Warren is in a tough position and perhaps has nothing to lose. She sees the train to the nomination leaving the station, and she's not on it. But it's not clear that Warren helped herself or that this version of Warren is one that can convince voters she can win in November. Still, Warren has a strong organization and a chance to exceed expectations, starting in Nevada.
3. The centrists are not uniting.
It's pretty clear that Klobuchar and Buttigieg either don't like each other very much or at least get under each other's skin. Buttigieg had a strong debate, for the most part, except when going after Klobuchar for not remembering the name of Mexico's president during a candidate forum.
It felt petty. Klobuchar fired back: "I wish everyone was as perfect as you, Pete." Ouch.
Each sees the other as a threat. Nevada very well may be something of a winnowing process for the two. Buttigieg is the overall delegate leader after strong showings in Iowa and New Hampshire. Klobuchar gained a lot of momentum pulling out a surprise third-place finish in New Hampshire.
Buttigieg needs Klobuchar to fade so he can have a chance with her voters, and she needs him out of the way so she can have a chance to continue her rise.
Enlarge this image toggle caption John Locher/AP John Locher/AP
4. Biden tried to say he's the most electable, really.
Despite finishing fourth and fifth in Iowa and New Hampshire, respectively, Biden was insisting that he is the best candidate to beat Trump. So far, polls do continue to show him beating Trump by a wider margin than the other candidates, but frankly, it has been the case in this campaign that the idea of Biden has been better than the reality.
Biden had a strong moment when he went after Bloomberg on "stop and frisk," the controversial New York City policing policy that disproportionately targeted young men of color. But beyond that, there weren't many standout Biden moments. In fact, in this debate, he spoke fifth most out of the six candidates.
Biden and Bloomberg are competing for the same voters. The latest NPR/PBS NewsHour/Marist poll shows that they pull equally from each other's supporters; each is the top second choice of the other's backers. So Nevada and, especially, South Carolina are critical for Biden to prove he should be the candidate whom moderates should coalesce around.
Enlarge this image toggle caption John Locher/AP John Locher/AP
5. Sanders didn't do much to expand his base, but the chaos helps.
Since campaigning in Iowa and winning New Hampshire, Sanders has had a demeanor that has been subtly different from his usually fired-up persona.
Apparently sensing he could really be the nominee, Sanders has conducted himself largely composed and calm. For so long, Sanders has been throwing stones from the outside, but suddenly, he's the inside man, the one with the best chance at the nomination.
But in this debate, he reverted back to his irascible form. That's likely because he was onstage with a billionaire who has bypassed the traditional system of campaigning and stands for a lot of things Sanders is diametrically opposed to. Eventually, Sanders has to get back to a posture that doesn't scare the rest of the party, but he has his base locked down and the latest NPR/PBS NewsHour/Marist poll showed him expanding some.
With moderates still not coalescing around a single candidate, the chaos works to Sanders' benefit. He very well could wind up with a plurality of pledged delegates at the convention. And that explains his position that the pledged-delegate leader should be the nominee, even though the party's rules require an absolute majority of delegates to secure the nomination.
6. The person all of this helps the most is Trump.
Trump and his team likely couldn't be happier seeing what they saw from this debate. Arguments about capitalism versus socialism, moderates unable to settle on one candidate and overall squabbling are music to the Make America Great Again crowd's ears.
A long, drawn-out nomination contest — which everyone is now expecting — helps the president. The longer the prize is in play, the longer it takes for Democrats to focus on Trump, build the needed infrastructure for a national campaign and raise the necessary money to win.
Trump got some good news out of the NPR/PBS NewsHour/Marist poll: 41% say the country is headed in the right direction, which is the highest in eight years of the poll; Trump has a 44% approval rating among registered voters; 54% approve of his handling of the economy; and 66% say the economy is working well for them personally.
With those improving numbers and Democratic infighting, Trump and his team are liking their chances.


npr--2020-02-19--Centuries-Old Law Against Cursing In Public Repealed By Virginia Legislators

Centuries-Old Law Against Cursing In Public Repealed By Virginia Legislators In Virginia , letting an F-bomb fly in public could get you slapped with a misdemeanor and up to a $ 250 fine .
`` Profane swearing '' has been illegal in the commonwealth since 1792 , when the fine was 83 cents .
Just what bleepin ' words are banned ?
Well , the state code does n't say .
But on Wednesday , legislators said to hell with the anti-swearing law : The Virginia Senate voted to repeal it , just weeks after the House did the same @ @ @ @ @ @ @ Northam 's signature .
Northam spokesperson Alena Yarmosky tells NPR the governor will review the bill when it gets to his desk , adding , `` It 's past time we swore off the antiquated policies of the past . ''
If he signs the bill , Virginians will legally be able to curse to their heart 's content starting July 1 .
Though , the current law does n't seem to be stopping many people from doing just that .
Statewide enforcement numbers are hard to pin down , but according to @ @ @ @ @ @ @ Northern Virginia only charged three people with cursing over two years .
Other communities have been more proactive .
The Oceanfront area of Virginia Beach has long had no-cursing signs on its boardwalk — you can even buy replica versions at tchotchke gift shops .
The signs were put up by the visitor 's bureau to `` encourage courteous language '' in a family-friendly area , the Virginian-Pilot reported .
The effort to repeal the anti-swearing law appeared to be cursed in previous legislative sessions , failing every year since it was first @ @ @ @ @ @ @ Michael Webert — a cattle farmer from Fauquier County — has sponsored the bill every year .
`` When you 're working with cows and a 1,400-pound animal does n't do what you want it to , or steps on your feet , every once in a while something colorful comes out of your mouth , '' Webert told The Washington Post in 2017 .
So why did the bill finally pass in 2020 ?
Webert tells NPR it 's because of the new makeup of the statehouse after Democrats took over both @ @ @ @ @ @ @ bipartisanship .
`` Every time we brought it , it failed , '' Webert says .
`` And this year , we put it in and then [ Democratic Del .
Dawn Adams ] put it in as well .
...
It was a good match . ''
He says he and his Democratic colleagues agree that the current code violates free speech and is unconstitutional .
`` We do n't necessarily see everything eye to eye , but on certain issues like this , when you have somebody that feels the same @ @ @ @ @ @ @ ... that makes it much easier to get things through . ''
Opposition to the bill was also bipartisan : Two Democratic and five Republican senators voted against it .
Democratic legislators in Virginia are also working to remove outdated racist and discriminatory laws from the books .
On Wednesday , state lawmakers also voted to repeal the law against fornication , defined as `` voluntary sexual intercourse by an unmarried person . ''
But they voted to keep the ban on spitting , with one lawmaker calling it `` yucky . ''
@ @ @ @ @ @ @ curse in public in Mississippi where it could cost you $ 100 or 30 days in jail .
And according to a Georgia law , using `` obscene and vulgar or profane language '' is considered disorderly conduct , but only if you 're in the presence of someone under the age of 14 .

Centuries-Old Law Against Cursing In Public Repealed By Virginia Legislators
In Virginia, letting an F-bomb fly in public could get you slapped with a misdemeanor and up to a $250 fine.
"Profane swearing" has been illegal in the commonwealth since 1792, when the fine was 83 cents. Just what bleepin' words are banned? Well, the state code doesn't say.
But on Wednesday, legislators said to hell with the anti-swearing law: The Virginia Senate voted to repeal it, just weeks after the House did the same.
It now awaits Gov. Ralph Northam's signature. Northam spokesperson Alena Yarmosky tells NPR the governor will review the bill when it gets to his desk, adding, "It's past time we swore off the antiquated policies of the past."
If he signs the bill, Virginians will legally be able to curse to their heart's content starting July 1.
Though, the current law doesn't seem to be stopping many people from doing just that. Statewide enforcement numbers are hard to pin down, but according to The Washington Post, Arlington County in Northern Virginia only charged three people with cursing over two years.
Other communities have been more proactive. The Oceanfront area of Virginia Beach long had no-cursing signs on its boardwalk — you can even buy replica versions at tchotchke gift shops. The signs were put up by the visitor's bureau to "encourage courteous language" in a family-friendly area, the Virginian-Pilot reported.
The effort to repeal the anti-swearing law appeared to be cursed in previous legislative sessions, failing every year since it was first introduced in 2016.
Republican Del. Michael Webert — a cattle farmer from Fauquier County — has sponsored the bill every year.
"When you're working with cows and a 1,400-pound animal doesn't do what you want it to, or steps on your feet, every once in a while something colorful comes out of your mouth," Webert told The Washington Post in 2017.
So why did the bill finally pass in 2020? Webert tells NPR it's because of the new makeup of the statehouse after Democrats took over both chambers in November. He also cited bipartisanship.
"Every time we brought it, it failed," Webert says. "And this year, we put it in and then [Democratic Del. Dawn Adams] put it in as well. ... It was a good match."
He says he and his Democratic colleagues agree that the current code violates free speech and is unconstitutional.
"We don't necessarily see everything eye to eye, but on certain issues like this, when you have somebody that feels the same way in regards to first amendment rights... that makes it much easier to get things through."
Opposition to the bill was also bipartisan: Two Democratic and five Republican senators voted against it.
Democratic legislators in Virginia are also working to remove outdated racist and discriminatory laws from the books.
On Wednesday, state lawmakers also voted to repeal the law against fornication, defined as "voluntary sexual intercourse by an unmarried person."
But they voted to keep the ban on spitting, with one lawmaker calling it "yucky."
Meanwhile, it's still illegal to curse in public in Mississippi where it could cost you $100 or 30 days in jail. And according to a Georgia law, using "obscene and vulgar or profane language" is considered disorderly conduct, but only if you're in the presence of someone under the age of 14.


npr--2020-02-19--Musician Plays Her Violin During Brain Surgery

As doctors in London performed surgery on Dagmar Turner 's brain , the sound of a violin filled the operating room .
The music came from the patient on the operating table .
In a video from the surgery , the violinist moves her bow up and down as surgeons behind a plastic sheet work to remove her brain tumor .
The King 's College Hospital surgeons woke her up in the middle of the operation in order to ensure they did not compromise parts of the brain necessary for playing the violin , such as parts that control precise @ @ @ @ @ @ @ knew how important the violin is to Dagmar , so it was vital that we preserved function in the delicate areas of her brain that allowed her to play , '' Keyoumars Ashkan , a neurosurgeon at King 's College Hospital , said in a press release .
Turner , 53 , learned that she had a slow-growing tumor in 2013 .
Late last year , doctors found that it had become more aggressive and the violinist decided to have surgery to remove it .
In an interview with ITV News , Turner @ @ @ @ @ @ @ tumor is on the right-hand side , so it will not affect your right-hand side , it will affect your left-hand side . ''
`` And I 'm just like , 'Oh , hang on , this is my most important part .
My job these days is playing the violin , ' `` she said , making a motion of pushing down violin strings with her left hand .
Ashkan , an accomplished pianist , and his colleagues came up with a plan to keep the hand 's functions intact .
`` @ @ @ @ @ @ @ two hours carefully mapping her brain to identify areas that were active when she played the violin and those responsible for controlling language and movement , '' the hospital statement said .
Waking her up during surgery then allowed doctors to monitor whether those parts were sustaining damage .
`` The violin is my passion ; I 've been playing since I was 10 years old , '' Turner said in the hospital press release .
`` The thought of losing my ability to play was heart-breaking but , being a musician himself @ @ @ @ @ @ @ '' The surgery was a success , Ashkan said : `` We managed to remove over 90 percent of the tumour , including all areas suspicious of aggressive activity , while retaining full function of her left hand . ''
While it 's rare for a patient to play their instrument during brain surgery , there have been other cases .
For example , in July 2016 a team of scientists removed a tumor from a music teacher 's brain as he played the saxophone .
Brad Mahon , a cognitive neuroscientist at @ @ @ @ @ @ @ the scientists who mapped the music teacher 's brain .
Mahon said that surgery was particularly intense because it was in an area of the brain that `` can actually lead to loss of the knowledge of how to conduct music , how to understand music . ''
Ultimately , that surgery was successful too .
Mahon said the basic features of an `` awake craniotomy '' — the type of brain surgery where patients are awake in order to avoid damage to critical brain areas — have remained largely unchanged for decades @ @ @ @ @ @ @ used simple tests such as asking a patient to name what they 're seeing in pictures to make sure language ability is preserved .
But he said that doctors are now able to map the patient 's brain activity in great detail before the surgery using an imaging technique called functional MRI .
That means surgeons are coming into the operating room with far more information about a specific patient 's brain .
That kind of information helps doctors tailor tests to a patient 's particular needs .
According to Mahon , an @ @ @ @ @ @ @ surgery to make sure those abilities remained intact .
Brain mapping also can help determine what kinds of functions are at risk during a brain surgery .
Having a `` personalized brain map , '' Mahon said , matters a lot when surgeons are making `` millimeter by millimeter decisions '' that could determine whether a person can even communicate after an operation , let alone follow their passions .

Musician Plays Her Violin During Brain Surgery
As doctors in London performed surgery on Dagmar Turner's brain, the sound of a violin filled the operating room.
The music came from the patient on the operating table. In a video from the surgery, the violinist moves her bow up and down as surgeons behind a plastic sheet work to remove her brain tumor.
The King's College Hospital surgeons woke her up in the middle of the operation in order to ensure they did not compromise parts of the brain necessary for playing the violin, such as parts that control precise hand movements and coordination.
"We knew how important the violin is to Dagmar, so it was vital that we preserved function in the delicate areas of her brain that allowed her to play," Keyoumars Ashkan, a neurosurgeon at King's College Hospital, said in a press release.
Turner, 53, learned that she had a slow-growing tumor in 2013. Late last year, doctors found that it had become more aggressive and the violinist decided to have surgery to remove it.
King's College Hospital NHS Foundation Trust YouTube
In an interview with ITV News, Turner recalled doctors telling her, "Your tumor is on the right-hand side, so it will not affect your right-hand side, it will affect your left-hand side."
"And I'm just like, 'Oh, hang on, this is my most important part. My job these days is playing the violin,' " she said, making a motion of pushing down violin strings with her left hand.
Ashkan, an accomplished pianist, and his colleagues came up with a plan to keep the hand's functions intact.
"Prior to Dagmar's operation they spent two hours carefully mapping her brain to identify areas that were active when she played the violin and those responsible for controlling language and movement," the hospital statement said. Waking her up during surgery then allowed doctors to monitor whether those parts were sustaining damage.
"The violin is my passion; I've been playing since I was 10 years old," Turner said in the hospital press release. "The thought of losing my ability to play was heart-breaking but, being a musician himself, Prof. Ashkan understood my concerns."
The surgery was a success, Ashkan said: "We managed to remove over 90 percent of the tumour, including all areas suspicious of aggressive activity, while retaining full function of her left hand."
While it's rare for a patient to play their instrument during brain surgery, there have been other cases. For example, in July 2016 a team of scientists removed a tumor from a music teacher's brain as he played the saxophone.
Brad Mahon, a cognitive neuroscientist at Carnegie Mellon University, was one of the scientists who mapped the music teacher's brain. Mahon said that surgery was particularly intense because it was in an area of the brain that "can actually lead to loss of the knowledge of how to conduct music, how to understand music." Ultimately, that surgery was successful too.
Mahon said the basic features of an "awake craniotomy" — the type of brain surgery where patients are awake in order to avoid damage to critical brain areas — have remained largely unchanged for decades. For example, doctors have long used simple tests such as asking a patient to name what they're seeing in pictures to make sure language ability is preserved.
But he said that doctors are now able to map the patient's brain activity in great detail before the surgery using an imaging technique called functional MRI. That means surgeons are coming into the operating room with far more information about a specific patient's brain.
That kind of information helps doctors tailor tests to a patient's particular needs. According to Mahon, an accountant once completed math problems during his surgery to make sure those abilities remained intact.
Brain mapping also can help determine what kinds of functions are at risk during a brain surgery. Having a "personalized brain map," Mahon said, matters a lot when surgeons are making "millimeter by millimeter decisions" that could determine whether a person can even communicate after an operation, let alone follow their passions.


npr--2020-02-19--Israel Is Eager To Annex West Bank Lands, But U.S. Says To Wait

Israel Is Eager To Annex West Bank Lands , But U.S. Says To Wait President Trump 's Mideast peace plan was expected to help Israeli Prime Minister Benjamin Netanyahu instantly fulfill a campaign promise to annex occupied land that Israelis and Palestinians have fought over for more than half a century .
But it did n't go as Netanyahu had hoped .
Trump 's plan , announced on Jan. 28 , would eventually give major swaths of the West Bank to Israel , but the administration offered a mixed message about the timing .
Trump seemed to suggest annexation could @ @ @ @ @ @ @ advised Israel not to annex any land before Israeli elections on March 2 .
Now , Netanyahu is lobbying the White House for a compromise , according to the leader of Israel 's movement of hundreds of thousands of West Bank settlers .
David Alhayani , chairman of the Yesha Council , the top settler leadership organization , tells NPR that the prime minister is seeking the Trump administration 's blessing for Israel to claim at least one settlement or area before Israelis go to the polls .
`` Something .
One step @ @ @ @ @ @ @ regularly with Netanyahu and supports his right-wing Likud party .
`` If not , I 'm afraid we will lose the election . ''
The White House had no comment .
Netanyahu 's office would not confirm any such lobbying efforts .
`` It 's too soon to tell what the final outcome and timeline will be '' of Trump 's peace plan , says Evan Gary Cohen , the prime minister 's international media adviser .
Hundreds of thousands of Jewish settlers live on land Israel captured in 1967 .
Palestinian leaders @ @ @ @ @ @ @ .
Last November , the Trump administration reversed decades of U.S. policy announcing it no longer considered Israeli settlements in the West Bank a violation of international law .
The Jordan Valley , where Alhayani lives and works , would be a strategic spot for Israel , near the border with Jordan and filled with chalky desert mountains and palm trees full of medjool dates .
Annexing this land would be an explosive move that Palestinians see as killing off their quest for a state of their own .
The Trump Mideast plan @ @ @ @ @ @ @ Bank — including all Israeli settlements and the Jordan Valley — becoming part of Israel .
Israel also would get to keep most of east Jerusalem , which the Palestinians demand for their future capital .
It also proposes a Palestinian state comprising a disjointed patchwork of lands connected by roads , bridges and tunnels .
The plan drew a strong rebuke from Palestinians .
A recent poll said 94 % of Palestinians reject the Trump plan .
Though the plan tilts heavily in Israel 's favor , and Netanyahu has enthusiastically endorsed @ @ @ @ @ @ @ reactions by Netanyahu 's supporters in Israel .
Some Israelis have even called for him to ditch it .
The day before Trump presented the initiative , Netanyahu huddled with Israeli settler leaders at the U.S. presidential guest house across from the White House .
He had just met with Trump earlier that day , and sought to rally the settlers ' support for Trump 's plan .
Netanyahu said Trump would allow Israel to declare immediate sovereignty over large parts of the West Bank .
( Israeli and U.S. officials avoid calling @ @ @ @ @ @ @ describe it as recognizing Israel 's `` sovereignty '' over areas it captured in 1967 . )
`` I never saw him so excited , '' says Alhayani , who was at the meeting .
`` I told him , 'Prime Minister , when it will be ? '
He said to me , 'David , maybe tomorrow .
Maybe tomorrow . '
`` The other half of the plan was harder for them to swallow : the eventual formation of a Palestinian state , even if Israel would get security and border @ @ @ @ @ @ @ 's own party and political supporters oppose any kind of Palestinian state .
Alhayani says such a state would leave Israel exposed to attacks and threaten its existence .
`` We ca n't take any more risks because we [ endured ] the Holocaust , '' Alhayani says .
`` I told him , 'Prime Minister Netanyahu , a plan that will bring a Palestinian state — you have to take the plan and throw it in the garbage . '
'' The following day at the White House , standing beside Netanyahu @ @ @ @ @ @ @ would map out the areas Israel would annex so the U.S. could recognize it `` immediately . ''
U.S .
Ambassador to Israel David Friedman said Israel did not need to wait , and Netanyahu 's spokesman tweeted that annexation would be brought to a vote quickly in the Israeli Cabinet .
Then the spokesman deleted the tweet , as presidential adviser Jared Kushner said in an interview with analyst Ian Bremmer that Israel would be expected to wait until the mapping process is complete and a new Israeli government is in place @ @ @ @ @ @ @ tweeted : `` Any unilateral action in advance of the completion of the committee process endangers the Plan & American recognition . ''
Kushner , in charge of developing the Mideast peace plan , may have sensed an immediate annexation would jeopardize his efforts to rally Arab states ' support for the initiative and their help bringing Palestinian leaders to the negotiating table .
`` [ Kushner ] understands that an immediate move by Israel to annex these territories will pretty much strangle those efforts to recruit Arab support in the crib , @ @ @ @ @ @ @ Israel Dan Shapiro .
`` That left Netanyahu a little bit hung out to dry , but he had to make an adjustment to this now more definitive U.S .
position . ''
Another calculation : Israeli domestic politics .
Israel had two inconclusive elections in the past year .
Netanyahu is neck and neck with a centrist rival , former army general Benny Gantz — who says he does not want to rush into annexation .
`` Trump would not have rolled this plan out when he did if he did n't @ @ @ @ @ @ @ Netanyahu .
But it was also clear ... that he ca n't be sure Netanyahu is actually going to remain prime minister , '' Shapiro says .
`` Do n't take a knife and put it in the back of Netanyahu .
Maybe Netanyahu will lose the election because of that , '' says Alhayani .
Annexation is Netanyahu 's central election pledge to his right-wing and settler supporters .
Now many settlers fear it may never happen .
Last week , hundreds of young religious Jewish settlers rallied outside the prime minister @ @ @ @ @ @ @ , '' and demanding he ignore the White House and declare Israeli sovereignty over the West Bank immediately .
Even as they insisted on urgency , the demonstrators took the long view on their quest to cement their grip over the disputed West Bank .
They sang a favorite religious chant in Hebrew : `` The eternal people are n't afraid — are n't afraid of a long road . ''

Israel Is Eager To Annex West Bank Lands, But U.S. Says To Wait
Enlarge this image toggle caption Menahem Kahana/AFP via Getty Images Menahem Kahana/AFP via Getty Images
President Trump's Mideast peace plan was expected to help Israeli Prime Minister Benjamin Netanyahu instantly fulfill a campaign promise to annex occupied land that Israelis and Palestinians have fought over for more than half a century.
But it didn't go as Netanyahu had hoped.
Trump's plan, announced on Jan. 28, would eventually give major swaths of the West Bank to Israel, but the administration offered a mixed message about the timing. Trump seemed to suggest annexation could happen immediately, while U.S. officials later advised Israel not to annex any land before Israeli elections on March 2.
Now, Netanyahu is lobbying the White House for a compromise, according to the leader of Israel's movement of hundreds of thousands of West Bank settlers.
David Alhayani, chairman of the Yesha Council, the top settler leadership organization, tells NPR that the prime minister is seeking the Trump administration's blessing for Israel to claim at least one settlement or area before Israelis go to the polls.
Enlarge this image toggle caption Daniel Estrin/NPR Daniel Estrin/NPR
"Something. One step," says Alhayani, who meets regularly with Netanyahu and supports his right-wing Likud party. "If not, I'm afraid we will lose the election."
The White House had no comment. Netanyahu's office would not confirm any such lobbying efforts. "It's too soon to tell what the final outcome and timeline will be" of Trump's peace plan, says Evan Gary Cohen, the prime minister's international media adviser.
Hundreds of thousands of Jewish settlers live on land Israel captured in 1967. Palestinian leaders and most countries consider the settlements illegal. Last November, the Trump administration reversed decades of U.S. policy announcing it no longer considered Israeli settlements in the West Bank a violation of international law.
The Jordan Valley, where Alhayani lives and works, would be a strategic spot for Israel, near the border with Jordan and filled with chalky desert mountains and palm trees full of medjool dates. Annexing this land would be an explosive move that Palestinians see as killing off their quest for a state of their own.
Middle East Netanyahu Vows To Annex Part Of West Bank If He Is Reelected Netanyahu Vows To Annex Part Of West Bank If He Is Reelected Listen · 3:31 3:31
The Trump Mideast plan envisions about 30% of the West Bank — including all Israeli settlements and the Jordan Valley — becoming part of Israel. Israel also would get to keep most of east Jerusalem, which the Palestinians demand for their future capital. It also proposes a Palestinian state comprising a disjointed patchwork of lands connected by roads, bridges and tunnels. The plan drew a strong rebuke from Palestinians. A recent poll said 94% of Palestinians reject the Trump plan.
Enlarge this image toggle caption Daniel Estrin/NPR Daniel Estrin/NPR
Though the plan tilts heavily in Israel's favor, and Netanyahu has enthusiastically endorsed it, it has met with mixed reactions by Netanyahu's supporters in Israel. Some Israelis have even called for him to ditch it.
Immediate recognition?
The day before Trump presented the initiative, Netanyahu huddled with Israeli settler leaders at the U.S. presidential guest house across from the White House. He had just met with Trump earlier that day, and sought to rally the settlers' support for Trump's plan.
Netanyahu said Trump would allow Israel to declare immediate sovereignty over large parts of the West Bank. (Israeli and U.S. officials avoid calling it "annexation"; instead they describe it as recognizing Israel's "sovereignty" over areas it captured in 1967.)
"I never saw him so excited," says Alhayani, who was at the meeting. "I told him, 'Prime Minister, when it will be?' He said to me, 'David, maybe tomorrow. Maybe tomorrow.' "
Enlarge this image toggle caption Daniel Estrin/NPR Daniel Estrin/NPR
The other half of the plan was harder for them to swallow: the eventual formation of a Palestinian state, even if Israel would get security and border control over it. Most of Netanyahu's own party and political supporters oppose any kind of Palestinian state. Alhayani says such a state would leave Israel exposed to attacks and threaten its existence.
"We can't take any more risks because we [endured] the Holocaust," Alhayani says. "I told him, 'Prime Minister Netanyahu, a plan that will bring a Palestinian state — you have to take the plan and throw it in the garbage.'"
The following day at the White House, standing beside Netanyahu, Trump said U.S. and Israeli officials would map out the areas Israel would annex so the U.S. could recognize it "immediately." U.S. Ambassador to Israel David Friedman said Israel did not need to wait, and Netanyahu's spokesman tweeted that annexation would be brought to a vote quickly in the Israeli Cabinet.
Then the spokesman deleted the tweet, as presidential adviser Jared Kushner said in an interview with analyst Ian Bremmer that Israel would be expected to wait until the mapping process is complete and a new Israeli government is in place following March elections.
Ambassador Friedman recently tweeted: "Any unilateral action in advance of the completion of the committee process endangers the Plan & American recognition."
Risky move
Kushner, in charge of developing the Mideast peace plan, may have sensed an immediate annexation would jeopardize his efforts to rally Arab states' support for the initiative and their help bringing Palestinian leaders to the negotiating table.
"[Kushner] understands that an immediate move by Israel to annex these territories will pretty much strangle those efforts to recruit Arab support in the crib," says former U.S. Ambassador to Israel Dan Shapiro. "That left Netanyahu a little bit hung out to dry, but he had to make an adjustment to this now more definitive U.S. position."
Another calculation: Israeli domestic politics. Israel had two inconclusive elections in the past year. Netanyahu is neck and neck with a centrist rival, former army general Benny Gantz — who says he does not want to rush into annexation.
"Trump would not have rolled this plan out when he did if he didn't think it would provide some benefit to Netanyahu. But it was also clear ... that he can't be sure Netanyahu is actually going to remain prime minister," Shapiro says.
Settler leader Alhayani accuses Kushner of sabotage for holding back annexation moves.
"Don't take a knife and put it in the back of Netanyahu. Maybe Netanyahu will lose the election because of that," says Alhayani.
Annexation is Netanyahu's central election pledge to his right-wing and settler supporters. Now many settlers fear it may never happen.
Last week, hundreds of young religious Jewish settlers rallied outside the prime minister's residence, chanting "sovereignty now," and demanding he ignore the White House and declare Israeli sovereignty over the West Bank immediately.
Even as they insisted on urgency, the demonstrators took the long view on their quest to cement their grip over the disputed West Bank. They sang a favorite religious chant in Hebrew: "The eternal people aren't afraid — aren't afraid of a long road."


npr--2020-02-19--What's A 'Super-Spreading Event'? And Has It Happened With COVID-19?

What 's A 'Super-Spreading Event ' ?
And Has It Happened With COVID-19 ?
Last month , a British man went to a conference in Singapore , then on a ski trip to the French Alps .
What he did n't know when he arrived in the Alps was that he was infected with the virus behind the COVID-19 outbreak .
During his stay at a ski village , it appears he infected 11 other people , who subsequently traveled on to the U.K. and Spain , the World Health Organization says .
Early estimates for the new coronavirus suggest @ @ @ @ @ @ @ disease to two to three other people .
But this man 's ski trip caused a cluster of cases .
Some have described this cluster as a `` super-spreading event '' — in which an individual infects an unusually high number of people .
Dr. Mike Ryan , WHO 's executive director for health emergencies , said last week that it 's way `` too early '' to call it that — and that officials believe they caught the situation before it ignited a chain that could have spread COVID-19 throughout Europe .
@ @ @ @ @ @ @ term `` super-spreader '' because it stigmatizes individuals .
These types of cases are a concern to global health researchers because they echo a pattern seen in past epidemics .
Super-spreading has triggered explosive chains of transmission in other outbreaks such as SARS , MERS and Ebola .
`` The poster child for a super-spreading event happened during the SARS outbreak , where a huge proportion of cases was traced back to the Metropole Hotel , '' says Jessica Metcalf , a demographer at Princeton University .
SARS is the acronym for severe @ @ @ @ @ @ @ caused by a coronavirus .
Back in 2003 , a doctor who had treated SARS patients checked into a room on the 9th floor of the Hong Kong hotel .
At least 13 other people on his floor got sick , and when his floormates left the country , they spread the disease to Canada , Vietnam and Singapore .
A woman returning to Canada then infected her son , leading to more than 100 new cases in the Toronto hospital where he was treated .
In a 2015 outbreak of Middle East @ @ @ @ @ @ @ two-thirds of the transmission came from just two super-spreading events in hospitals , which fast-tracked the spread of the virus , says Adam Kucharski , who researches the dynamics of infectious disease at the London School of Hygiene and Tropical Medicine .
`` In that situation , if you [ could have ] avoid [ ed ] those two events happening , you 've got rid of most of your outbreak , '' he says .
In diseases driven by super-spreading , a rule of thumb is the `` 20/80 rule '' — @ @ @ @ @ @ @ for at least 80 % of the infections , though the actual numbers vary by disease , Metcalf says .
But a pattern in which outbreaks are driven by relatively few cases holds across several diseases , including HIV , tuberculosis and typhoid , according to researchers who study disease patterns .
There 's a lot that 's still unknown about what causes super-spreading .
Researchers who study it say it 's a combination of factors that are hard to disentangle .
Max Lau models infectious disease dynamics at Emory University .
From @ @ @ @ @ @ @ 2014-2015 epidemic in West Africa , he thinks that social behavior plays a big part .
Lau found that super-spreading events tended to happen more around people under 15 or over 45 .
That could be because `` the younger ones or the older ones tend to get more people to visit and care for them when they get sick , '' he says .
He also thinks biology plays a role .
Individuals are more likely to infect others when they 're carrying and shedding a lot of virus .
New infections @ @ @ @ @ @ @ hospitals , where people go because they 're really sick .
Their immune systems are weakened , and they can carry a greater volume of the virus than other patients might , making them more infectious .
They 're also getting hospital procedures that might expose others to their blood or lung fluids .
Both biological and behavioral factors contributed to a 2014 Ebola super-spreading event at a funeral in Sierra Leone .
A popular healer treated Ebola patients from an outbreak in neighboring Guinea , contracted the disease and died .
Hundreds @ @ @ @ @ @ @ burial .
Bodies of people who recently died can still shed the Ebola virus , says Lau .
And in many cultures , including Sierra Leone 's , it 's traditional for mourners to wash , dress and have direct contact with the body .
More than 300 Ebola cases were traced to the healer 's funeral , which soon exploded into an outbreak that overwhelmed hospitals in southeastern Sierra Leone .
Another contributor to high transmission events is the local environment , such as stale air in enclosed spaces or a lot @ @ @ @ @ @ @ The number of people infected in any situation depends on how the risk factors line up , says David Heymann , an epidemiologist at the London School of Hygiene and Tropical Medicine .
It 's how infectious a person is , what setting they 're in , how they behave around others — and whether the people they 're interacting with , including health workers , wash their hands frequently and take other measures to protect themselves from infection .
Super-spreading events may be happening with the new coronavirus but do n't seem @ @ @ @ @ @ @ did in the early days of SARS , says Jamie Lloyd-Smith , who studies how diseases spread at the University of California , Los Angeles .
But why ?
`` Is it a biological difference between the two viruses ? ''
he says , `` Or [ have ] we actually learned some things about how to deal with these viruses and infection control ? ''
It 's a question that China 's Center for Disease Control and Prevention is pondering , based on early conclusions from a new report from this week @ @ @ @ @ @ @ no evidence of a super-spreader event occurring in any of the Chinese health facilities serving COVID-19 patients , '' the report states .
`` However , we do not know whether this is due to the nature of the virus itself or whether these events have been successfully prevented . ''
To try to stop super-spreading events , public health officials say it 's important to try to find cases early to figure out who else was exposed and to keep sick people away from those who are n't .
These are strategies @ @ @ @ @ @ @ but they have worked to contain past epidemics , including SARS in 2004 , says WHO .
These common-sense strategies are the best way they know to stop a new disease from spreading .

What's A 'Super-Spreading Event'? And Has It Happened With COVID-19?
Enlarge this image toggle caption K.Y. Cheng/South China Morning Post via Getty Images K.Y. Cheng/South China Morning Post via Getty Images
Updated Feb. 21, 11:46 a.m. ET
Last month, a British man went to a conference in Singapore, then on a ski trip to the French Alps.
What he didn't know when he arrived in the Alps was that he was infected with the virus behind the COVID-19 outbreak.
During his stay at a ski village, it appears he infected 11 other people, who subsequently traveled on to the U.K. and Spain, the World Health Organization says.
Early estimates for the new coronavirus suggest that the average infected person spreads the disease to two to three other people. But this man's ski trip caused a cluster of cases.
Some have described this cluster as a "super-spreading event" — in which an individual infects an unusually high number of people. Dr. Mike Ryan, WHO's executive director for health emergencies, said last week that it's way "too early" to call it that — and that officials believe they caught the situation before it ignited a chain that could have spread COVID-19 throughout Europe.
WHO doesn't want to use the term "super-spreader" because it stigmatizes individuals.
These types of cases are a concern to global health researchers because they echo a pattern seen in past epidemics. Super-spreading has triggered explosive chains of transmission in other outbreaks such as SARS, MERS and Ebola.
"The poster child for a super-spreading event happened during the SARS outbreak, where a huge proportion of cases was traced back to the Metropole Hotel," says Jessica Metcalf, a demographer at Princeton University. SARS is the acronym for severe acute respiratory syndrome, a disease also caused by a coronavirus.
Back in 2003, a doctor who had treated SARS patients checked into a room on the 9th floor of the Hong Kong hotel. At least 13 other people on his floor got sick, and when his floormates left the country, they spread the disease to Canada, Vietnam and Singapore. A woman returning to Canada then infected her son, leading to more than 100 new cases in the Toronto hospital where he was treated.
In a 2015 outbreak of Middle East respiratory syndrome in South Korea, about two-thirds of the transmission came from just two super-spreading events in hospitals, which fast-tracked the spread of the virus, says Adam Kucharski, who researches the dynamics of infectious disease at the London School of Hygiene and Tropical Medicine.
"In that situation, if you [could have] avoid[ed] those two events happening, you've got rid of most of your outbreak," he says.
In diseases driven by super-spreading, a rule of thumb is the "20/80 rule" — around 20% of individuals are responsible for at least 80% of the infections, though the actual numbers vary by disease, Metcalf says. But a pattern in which outbreaks are driven by relatively few cases holds across several diseases, including HIV, tuberculosis and typhoid, according to researchers who study disease patterns.
There's a lot that's still unknown about what causes super-spreading. Researchers who study it say it's a combination of factors that are hard to disentangle.
Max Lau models infectious disease dynamics at Emory University. From his work on Ebola transmission during the 2014-2015 epidemic in West Africa, he thinks that social behavior plays a big part.
Lau found that super-spreading events tended to happen more around people under 15 or over 45. That could be because "the younger ones or the older ones tend to get more people to visit and care for them when they get sick," he says.
He also thinks biology plays a role. Individuals are more likely to infect others when they're carrying and shedding a lot of virus.
New infections among patients and staff often happen in hospitals, where people go because they're really sick. Their immune systems are weakened, and they can carry a greater volume of the virus than other patients might, making them more infectious. They're also getting hospital procedures that might expose others to their blood or lung fluids.
Both biological and behavioral factors contributed to a 2014 Ebola super-spreading event at a funeral in Sierra Leone. A popular healer treated Ebola patients from an outbreak in neighboring Guinea, contracted the disease and died. Hundreds of mourners came to her funeral and burial.
Bodies of people who recently died can still shed the Ebola virus, says Lau. And in many cultures, including Sierra Leone's, it's traditional for mourners to wash, dress and have direct contact with the body. More than 300 Ebola cases were traced to the healer's funeral, which soon exploded into an outbreak that overwhelmed hospitals in southeastern Sierra Leone.
Another contributor to high transmission events is the local environment, such as stale air in enclosed spaces or a lot of people sharing the same space.
The number of people infected in any situation depends on how the risk factors line up, says David Heymann, an epidemiologist at the London School of Hygiene and Tropical Medicine. It's how infectious a person is, what setting they're in, how they behave around others — and whether the people they're interacting with, including health workers, wash their hands frequently and take other measures to protect themselves from infection.
With COVID-19, there have been fewer reports of super-spreading events so far compared with the early days of SARS, says Jamie Lloyd-Smith of the University of California, Los Angeles who studies how diseases spread. But why? "Is it a biological difference between the two viruses?" he says, "Or [have] we actually learned some things about how to deal with these viruses and infection control?"
It's a question that China's Center for Disease Control and Prevention is pondering, based on early conclusions from a new report from this week: "To date, there is no evidence of a super-spreader event occurring in any of the Chinese health facilities serving COVID-19 patients," the report states. "However, we do not know whether this is due to the nature of the virus itself or whether these events have been successfully prevented."
To try to stop super-spreading events, public health officials say it's important to try to find cases early to figure out who else was exposed and to keep sick people away from those who aren't.
These are strategies that date back to the 1800s, but they have worked to contain past epidemics, including SARS in 2004, says WHO. These common-sense strategies are the best way they know to stop a new disease from spreading.


npr--2020-02-19--Pop Smoke, Rising New York Rapper, Dead At 20

Bashar Jackson , better known as the rapper Pop Smoke , has died .
He was 20 years old .
The news was confirmed to NPR in a statement from Republic Records , a label Jackson had worked with .
Jackson 's cause of death was not confirmed , though in a press conference today , LAPD Captain Steve Lurie said that `` at 4:55 this morning , '' LAPD officers received a phone call `` from back east '' that a house in the Hollywood Hills had been broken into , and that when officers arrived on the scene @ @ @ @ @ @ @ victim was then transported to Cedars-Sinai Hospital , where they were pronounced dead .
`` We are devastated by the unexpected and tragic loss of Pop Smoke , '' Republic Records ' statement reads .
`` Our prayers and thoughts go out to his family , friends and fans , as we mourn this loss together . ''
Jackson was raised in Canarsie , Brooklyn , growing up in a neighborhood and moment defined by cultural exchange .
He was raised in a Panamanian household , he lived around West Indians , he @ @ @ @ @ @ @ first love as a recording artist was a beat from a U.K. producer who goes by 808Melo .
That beat turned into Jackson 's first song , `` MPR , '' which he released in December 2018 .
Even in that early work , you could hear what millions more would gravitate towards over the next year : Jackson had a voice — billowing and ghoulish , scorched and scarily effortless .
And his ear for beats was unlike any other in the nascent New York drill scene , a regional bubble of @ @ @ @ @ @ @ gritty street talk .
Jackson dared to rap with a thick Brooklyn accent over grime-inflected beats with bass lines that sounded like transmissions from another planet .
The lodestar for a New York drill hit may forever be Jackson 's `` Welcome To The Party . ''
The city typically has its own song of the summer every year , and `` Welcome To The Party '' was the runaway favorite in 2019 .
A bludgeoning ode to excess , the single — which received remixes from Nicki Minaj , ASAP Ferg , @ @ @ @ @ @ @ into the upper echelon of the city 's rap talent .
A deal with Republic Records followed soon after , as did his debut mixtape , Meet The Woo , and his second national hit , `` Dior . ''
With Jackson 's rapid success came increased attention from the NYPD .
The rapper had a history of crime , but he and others from the New York drill scene were trying to come clean as they entered the spotlight .
Still , during 2019 's Rolling Loud NYC , the first time @ @ @ @ @ @ @ 's birthplace , the NYPD removed Jackson , Sheff G , 22Gz and two more of the drill scene 's rising rappers from the lineup .
As drill continues to rise in popularity , Jackson may be remembered as the face of the scene 's ongoing battle with the NYPD .
The situation at Rolling Loud did n't slow him down ; if anything , it seemed to put a battery in his back .
Meet The Woo 2 , released just weeks ago on Feb. 7 , was a thrilling update to @ @ @ @ @ @ @ at No .
7 on the Billboard 200 albums chart .
It 's easy to say that it sounds like a rapper mastering his form but the truth is that Pop Smoke 's music was distinctly his own , defying pat categorization or classification .

Pop Smoke, Rising New York Rapper, Dead At 20
Enlarge this image toggle caption Pascal Le Segretain/Getty Images Pascal Le Segretain/Getty Images
Bashar Jackson, better known as the Brooklyn rapper Pop Smoke, died Wednesday morning in Los Angeles during what appeared to be a home invasion. He was 20 years old.
While the Los Angeles Police Department would not identify Jackson by name as the victim in Wednesday morning's shooting, NPR confirmed his death through his record label, Republic Records.
In a press conference on Wednesday, LAPD captain Steve Lurie said that officers received a phone call at 4:55 a.m. claiming that a house in the Hollywood Hills neighborhood had been broken into. When officers arrived on the scene, they discovered a shooting victim, as well as several witnesses. The victim was transported to Cedars-Sinai Medical Center, where he was pronounced dead.
"We are devastated by the unexpected and tragic loss of Pop Smoke," Republic Records' statement reads. "Our prayers and thoughts go out to his family, friends and fans, as we mourn this loss together."
Jackson skyrocketed to fame last summer as a 19 year old thanks to the success of his single, "Welcome to the Party," and had just released his second mixtape earlier this month.
Jackson was raised in Canarsie, Brooklyn, growing up in a neighborhood and moment defined by cultural exchange. He was raised in a Panamanian household, he lived around West Indians, he played African drums in church and his first love as a recording artist was a beat from a U.K. producer who goes by 808Melo. That beat turned into Jackson's first song, "MPR," which he released in December 2018. Even in that early work, you could hear what millions more would gravitate towards over the next year: Jackson had a voice — billowing and ghoulish, scorched and scarily effortless. And his ear for beats was unlike any other in the nascent New York drill scene, a regional bubble of rappers taking on propulsive drum patterns with gritty street talk. Jackson dared to rap with a thick Brooklyn accent over grime-inflected beats with bass lines that sounded like transmissions from another planet.
YouTube
The lodestar for a New York drill hit may forever be "Welcome to the Party." The city typically has its own song of the summer every year, and "Welcome to the Party" was the runaway favorite in 2019. A bludgeoning ode to excess, the single — which received remix appearances from Nicki Minaj, ASAP Ferg, Meek Mill and more — catapulted Jackson into the upper echelon of the city's rap talent. A deal with Republic Records followed soon after, as did his debut mixtape, Meet The Woo, and his second national hit, "Dior."
With Jackson's rapid success came increased attention from the NYPD. The rapper had a history of legal problems, but he and others from the New York drill scene were trying to come clean as they entered the spotlight. Still, during 2019's Rolling Loud NYC, the first time the rap-focused festival landed in the genre's birthplace, the NYPD removed Jackson, Sheff G, 22Gz and two more of the drill scene's rising rappers from the lineup.
As drill continues to rise in popularity, Jackson may be remembered as the face of the scene's ongoing battle with the NYPD.
The situation at Rolling Loud didn't slow him down; if anything, it seemed to put a battery in his back. Meet The Woo 2, released just weeks ago on Feb. 7, was a thrilling update to the first tape's sound, debuting at No. 7 on the Billboard 200 albums chart. It's easy to say that it sounds like a rapper mastering his form but the truth is that Pop Smoke's music was distinctly his own, defying pat categorization or classification.
Additional reporting by Andrew Flanagan.


npr--2020-02-19--Coronavirus Update: Diamond Princess Passengers Leave Ship As Expert Slams Quarantine

Roughly 600 passengers left the Diamond Princess cruise ship in Yokohama , Japan , on Wednesday , as a controversial shipwide coronavirus quarantine finally began to wind down .
All of those passengers had been tested for the COVID-19 disease by the Japanese health ministry , according to cruise operator Princess Cruises .
As they left , they were met in the terminal by the cruise line 's president , Jan Swartz .
Several hundred other passengers who are n't taking repatriation flights to their home countries are expected to leave the ship on Thursday .
The quarantine has been @ @ @ @ @ @ @ spread of the COVID-19 among passengers and crew .
Even as hundreds of people disembarked , Japanese officials announced 79 more confirmed cases aboard the ship .
And in at least one case , a family was informed of a positive test result just hours before they were scheduled to disembark .
A total of 621 people from the cruise ship have now been confirmed to have the newly identified coronavirus — or about 20 % of the 3,011 people who had been tested as of Wednesday .
Some of the sharpest criticism @ @ @ @ @ @ @ cruise ship came from Kentaro Iwata , an infectious disease specialist at Kobe University who posted a video about his visit to the Diamond Princess on Tuesday .
After getting a look around the ship 's interior , Iwata said , it `` turned out that the cruise ship was completely inadequate in terms of the infection control . ''
`` There was no distinction between the green zone , which is free of infection , and the red zone , which is potentially contaminated by virus , '' he added .
Iwata @ @ @ @ @ @ @ .
In response to questions about red and green zones on the ship , Health Minister Katsunobu Kato insisted that sections of the ship have been `` properly managed , '' The Japan Times reports .
It adds that another government official said the crew had taken `` thorough measures '' to stop infections from spreading .
In the YouTube video , Iwata called the ship 's environment `` completely chaotic , '' saying that `` people could come and go '' regardless of whether they were wearing personal protective equipment such as @ @ @ @ @ @ @ .
He added that one medical officer had seemingly given up protecting herself and others , believing she was likely already infected .
`` I dealt with lots of infections — more than 20 years , '' Iwata said .
`` I was in Africa dealing with the Ebola outbreak .
I was in other countries dealing with the cholera outbreak .
I was in China in 2003 to deal with SARS . ''
In those outbreaks , Iwata said , `` I never had fear of getting infections myself ... because I @ @ @ @ @ @ @ to protect others . ''
`` But inside Princess Diamond , I was so scared , '' he added .
`` I was so scared of getting COVID-19 because there was no way to tell where the virus is . ''
Criticizing a lack of carefulness on the ship , Iwata said there was also no clear leadership role by medical experts .
`` There was no single professional infection control person inside the ship , and there was nobody in charge of infection prevention as a professional .
The bureaucrats were in @ @ @ @ @ @ @ .
When he raised those concerns with a senior officer of Japan 's health ministry , Iwata added , the official was `` very unhappy '' with his suggestions for improving protections on the ship .
In his video , Iwata also noted that Japan , unlike the U.S. and other countries , does not have an agency with the specific task of combating disease and infections , such as the U.S. Centers for Disease Control and Prevention and similar agencies in other countries .
The Wall Street Journal reported that the health @ @ @ @ @ @ @ that Iwata had violated the terms under which he boarded the Diamond Princess and had been ordered to leave .
Roughly 3,700 passengers and crew were aboard the Diamond Princess when it pulled into the Yokohama terminal south of Tokyo .
People who have tested positive for the virus have been taken off the ship and sent to local hospitals — and their traveling partners and close contacts put under a fresh 14-day quarantine order .
Those passengers who have been declared free of the virus and are leaving the ship for the @ @ @ @ @ @ @ confusing array of circumstances .
Many will be forced to undergo a 14-day quarantine upon their return home — reflecting a lack of trust in the effectiveness of the ship 's quarantine .
Others can remain in Japan under their own recognizance but are still barred from returning home for two weeks .
The family of passenger Aun Na Tan of Australia was hit with an eleventh-hour setback when her daughter , Kaitlyn , tested positive for COVID-19 .
They got the news after stacking their luggage near the front door , awaiting @ @ @ @ @ @ @ `` It was n't a pretty sight for me and Kaitlyn , '' Tan wrote , describing the impact of the bad news .
`` The boys were calmer .
We have bounced back now . ''
The good news , she added , is that her daughter has n't developed symptoms of the respiratory illness .
And Tan said she and her husband and son planned to stay with her daughter .
`` We decided not to be separated , '' Tan said on Instagram .
`` They are trying to find @ @ @ @ @ @ @ of us . ''
The embassies of Canada , Australia and Hong Kong are arranging for their citizens to travel home via charter flights this week , Princess Cruises said Wednesday .
All of those governments and the U.S. are requiring a second quarantine , the cruise line says .
The U.S. government brought more than 300 American passengers back stateside on chartered repatriation flights early this week .
Those passengers are now quarantined at military bases in California and Texas — and 14 of them who tested positive for COVID-19 are in @ @ @ @ @ @ @ on temporary no-fly list Some 61 U.S. citizens were not flown home and remained on board the Diamond Princess .
The Department of Homeland Security has temporarily put those Americans on a federal no-fly list to bar them from traveling to the U.S. , the CDC says .
`` This action has been taken because you are reasonably suspected of having had an exposure to novel coronavirus ( COVID-19 ) while onboard the Diamond Princess cruise ship , '' the CDC said in a letter to the passengers .
Anyone who tries to @ @ @ @ @ @ @ to Mexico or Canada `` will be stopped by U.S. Customs and Border Protection officials , '' the CDC adds .

Coronavirus Update: Diamond Princess Passengers Leave Ship As Expert Slams Quarantine
Enlarge this image toggle caption Clare Hedger/via Reuters Clare Hedger/via Reuters
Updated at 4 p.m. ET
Roughly 600 passengers left the Diamond Princess cruise ship in Yokohama, Japan, on Wednesday, as a controversial shipwide coronavirus quarantine finally began to wind down.
All of those passengers had been tested for the COVID-19 disease by the Japanese health ministry, according to cruise operator Princess Cruises. As they left, they were met in the terminal by the cruise line's president, Jan Swartz.
Several hundred other passengers who aren't taking repatriation flights to their home countries are expected to leave the ship on Thursday.
The quarantine has been heavily criticized for failing to prevent the spread of the COVID-19 among passengers and crew. Even as hundreds of people disembarked, Japanese officials announced 79 more confirmed cases aboard the ship. And in at least one case, a family was informed of a positive test result just hours before they were scheduled to disembark.
A total of 621 people from the cruise ship have now been confirmed to have the newly identified coronavirus — or about 20% of the 3,011 people who had been tested as of Wednesday.
Japanese expert criticizes cruise ship protocols
Some of the sharpest criticism of Japan's handling of the stricken cruise ship came from Kentaro Iwata, an infectious disease specialist at Kobe University who posted a video about his visit to the Diamond Princess on Tuesday.
After getting a look around the ship's interior, Iwata said, it "turned out that the cruise ship was completely inadequate in terms of the infection control."
"There was no distinction between the green zone, which is free of infection, and the red zone, which is potentially contaminated by virus," he added.
Iwata's comments quickly drew attention in Japan. In response to questions about red and green zones on the ship, Health Minister Katsunobu Kato insisted that sections of the ship have been "properly managed," The Japan Times reports. It adds that another government official said the crew had taken "thorough measures" to stop infections from spreading.
YouTube
In the YouTube video, Iwata called the ship's environment "completely chaotic," saying that "people could come and go" regardless of whether they were wearing personal protective equipment such as gloves, face masks and other gear. He added that one medical officer had seemingly given up protecting herself and others, believing she was likely already infected.
"I dealt with lots of infections — more than 20 years," Iwata said. "I was in Africa dealing with the Ebola outbreak. I was in other countries dealing with the cholera outbreak. I was in China in 2003 to deal with SARS."
In those outbreaks, Iwata said, "I never had fear of getting infections myself ... because I know how to protect myself and how to protect others."
"But inside Princess Diamond, I was so scared," he added. "I was so scared of getting COVID-19 because there was no way to tell where the virus is."
Criticizing a lack of carefulness on the ship, Iwata said there was also no clear leadership role by medical experts.
"There was no single professional infection control person inside the ship, and there was nobody in charge of infection prevention as a professional. The bureaucrats were in charge of everything," he said.
When he raised those concerns with a senior officer of Japan's health ministry, Iwata added, the official was "very unhappy" with his suggestions for improving protections on the ship.
In his video, Iwata also noted that Japan, unlike the U.S. and other countries, does not have an agency with the specific task of combating disease and infections, such as the U.S. Centers for Disease Control and Prevention and similar agencies in other countries.
The Wall Street Journal reported that the health minister told a news conference late Wednesday that Iwata had violated the terms under which he boarded the Diamond Princess and had been ordered to leave.
Passengers face new quarantines and restrictions
Roughly 3,700 passengers and crew were aboard the Diamond Princess when it pulled into the Yokohama terminal south of Tokyo.
People who have tested positive for the virus have been taken off the ship and sent to local hospitals — and their traveling partners and close contacts put under a fresh 14-day quarantine order.
Those passengers who have been declared free of the virus and are leaving the ship for the first time in two weeks face a confusing array of circumstances. Many will be forced to undergo a 14-day quarantine upon their return home — reflecting a lack of trust in the effectiveness of the ship's quarantine. Others can remain in Japan under their own recognizance but are still barred from returning home for two weeks.
The family of passenger Aun Na Tan of Australia was hit with an eleventh-hour setback when her daughter, Kaitlyn, tested positive for COVID-19. They got the news after stacking their luggage near the front door, awaiting their turn to leave the ship.
"It wasn't a pretty sight for me and Kaitlyn," Tan wrote, describing the impact of the bad news. "The boys were calmer. We have bounced back now."
The good news, she added, is that her daughter hasn't developed symptoms of the respiratory illness. And Tan said she and her husband and son planned to stay with her daughter.
"We decided not to be separated," Tan said on Instagram. "They are trying to find a hospital which will take all 4 of us."
The embassies of Canada, Australia and Hong Kong are arranging for their citizens to travel home via charter flights this week, Princess Cruises said Wednesday. All of those governments and the U.S. are requiring a second quarantine, the cruise line says.
The U.S. government brought more than 300 American passengers back stateside on chartered repatriation flights early this week. Those passengers are now quarantined at military bases in California and Texas — and 14 of them who tested positive for COVID-19 are in hospitals.
Americans who stayed aboard are on temporary no-fly list
Some 61 U.S. citizens were not flown home and remained on board the Diamond Princess. The Department of Homeland Security has temporarily put those Americans on a federal no-fly list to bar them from traveling to the U.S., the CDC says.
"This action has been taken because you are reasonably suspected of having had an exposure to novel coronavirus (COVID-19) while onboard the Diamond Princess cruise ship," the CDC said in a letter to the passengers.
Anyone who tries to subvert the travel ban by flying first to Mexico or Canada "will be stopped by U.S. Customs and Border Protection officials," the CDC adds.