Close the bars. Open the schools.

Public health experts have been repeating this same refrain since the summer, when many states and cities reopened businesses like bars, restaurants, and gyms — all areas where the coronavirus is thought to spread readily — without a clear plan to reopen school buildings. And the call has only gotten louder in recent weeks as cases skyrocket in a third viral wave and officials close schools while keeping indoor dining open.

For example, New York City Mayor Bill de Blasio announced on November 18 that school buildings would close in the city in response to rising cases — but gyms and reduced-capacity indoor dining remain open, at least for now.

While there remains some debate, schools don’t appear to be major sources of viral spread in this pandemic. Restaurants, bars, and gyms, however — places where adults congregate, often in close quarters and often without masks — do seem to contribute to outbreaks. Indeed, many European countries that have locked down to mitigate their second waves have allowed schools to remain open while such businesses close. “It seems very clear to me that schools ought to be our priority,” Robin Lake, director of the Center on Reinventing Public Education, a research organization at the University of Washington, told Vox.

So why aren’t more places in the US closing the bars and keeping the schools open?

There are a lot of reasons, from agreements with teachers’ unions to pressure from restaurant and other lobbying groups to parents’ understandable fears of exposing their children — and potentially themselves — to a deadly virus. But one big reason for the seeming disconnect has gone somewhat overlooked: the lack of help from the federal government.

Money from the federal CARES Act kept many businesses afloat through shutdowns earlier this year, and expanded unemployment benefits and $1,200 stimulus checks kept many laid-off workers out of poverty. But with no more help on the horizon for businesses or ordinary people, shutdowns at the state and local level could have a steep cost, many say, leaving some local leaders hesitant to try them.

“I think we’re going to see a lot of layoffs again, and I think we’re going to see a lot of people go out of business,” Adam Ozimek, chief economist at the freelancing platform Upwork and the owner of two small businesses in Pennsylvania, told Vox.

Closing down schools, meanwhile, doesn’t have the same immediate economic impact, since teachers can still work and get paid while classes are remote. But shuttering school buildings does affect students’ learning, as well as parents’ ability to work, which will hamper any economic recovery in the future — as well as hurting kids and families today. In some ways, policymakers may be trading short-term economic damage for longer-term devastation, as an entire generation of working parents — the majority of them mothers — is forced to choose between getting a paycheck and caring for kids.

In general, the choice of restaurants over schools is yet another way the US government’s handling of the pandemic has caused needless pain, many say. “It’s not the Covid pandemic that has harmed so many businesses,” Ozimek said. “It’s our mismanagement of the Covid pandemic.”

Many places are leaving businesses open while schools are closed

While schools closed in all 50 states this spring as the first wave of the pandemic swept around the country, reopening in the fall has been a more uneven process: As of this summer, 49 percent of school districts planned for fully in-person classes, while 26 percent planned for a fully remote start and 12 percent planned on a hybrid model. Since then, some districts, especially in urban areas, have pushed back plans to return to in-person instruction as this fall’s surge in virus cases arrived.

But the evidence so far suggests that schools themselves have not been a major driver of outbreaks. In New York City, the largest district to try some in-person learning, the average test positivity rate in schools was just 0.17 percent as of last week, compared with close to 3 percent in the city as a whole. In Florida, meanwhile, reopening schools in the fall did not appear to lead to a surge in cases among children.

Some have argued that we don’t yet know enough about transmission within schools to say much about their safety, noting that little current research has focused specifically on Black and other students of color who come from communities that have been disproportionately affected by the virus.

Meanwhile, the risks to teachers — who, as adults, are more likely to become seriously ill from the virus — appear to be greater than the risks to students. And reopening of schools has often been driven more by politics than by science, with President Trump calling for schools around the country to reopen this summer in the face of rising caseloads, and without the financial assistance many said they needed to do so safely. Thanks in part to his pressure, schools are more likely to be open in more conservative areas of the country, which have tended to have fewer restrictions overall even as cases rise.

But in general, public health experts have not ranked schools among the most dangerous venues for Covid-19.

There’s a growing body of evidence, however, that restaurants, bars, and gyms are significant contributors to community transmission. A recent study using cellphone mobility data, for example, found that these venues were some of the biggest contributors to the spread of the virus in the spring, and that reducing capacity in them could be an effective way of reducing transmission in the future. In one CDC study, people who tested positive for Covid-19 were twice as likely to have eaten in a restaurant recently as those who tested negative, as Benjamin P. Linas wrote for Vox.

But even as states and cities reimpose restrictions to combat the fall surge, restaurants and gyms remain open in some places where most schools are closed or on the verge of closing — like Boston and New York City — even though closing eateries might do far more to curb spread. In other areas, such as San Francisco, indoor dining has closed only recently in response to new surges, while schools never opened in-person at all. Meanwhile, areas such as New York and New Jersey have instituted smaller restrictions like curfews on restaurants, even though some public health experts are skeptical of their efficacy.

Overall, while leaders are moving to impose restrictions as cases rise, the country is taking a slow and piecemeal approach in which schools can sometimes feel like an afterthought. And some of the reasons say a lot about the federal government’s failure to adequately respond to Covid-19.

Decisions about schools are reflective of larger pressures on cities and states

A lot of factors have gone into districts’ decisions to close or open schools. Teachers, for example, have been concerned about the risks to their health, especially in places where school buildings are old and poorly ventilated. When New York City reopened schools earlier this year, de Blasio announced that they would close if the citywide positivity rate hit 3 percent on a seven-day average, a threshold the teachers’ union urged the city to stick to as cases rose.

Some parents pushed back against the plan, arguing that schools should not shutter since they have not been major drivers of spread. “It seems like schools are the only thing being threatened with a shutdown,” said Daniela Jampel, a New York City parent who organized a petition to keep schools open, told Gothamist.

But other parents have concerns about keeping schools open. Some have chosen not to send their children back in person — in New York, for example, only 26 percent of students have attended class in person this year. And around the country, many Black and Latinx families, who often come from communities hard-hit by the virus, have been more wary than white parents about sending their kids back in person. In a poll conducted in the summer, about 67 percent of Black families said they supported keeping school remote, compared with just 32 percent of white families.

De Blasio announced on November 18 that schools in the city would close since the city’s positivity rate had hit the 3 percent threshold. Meanwhile, indoor dining, gyms, and other businesses remain open, although New York Gov. Andrew Cuomo said that closure of dining rooms in the city could be coming soon.

Overall, decisions about school are fraught because they involve children — and even though kids seem less vulnerable to the virus than adults, parents and policymakers are often leery of putting them in harm’s way.

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But there’s another big reason schools are closed while restaurants are open: money.

State and local authorities are in a tough position on ordering the closure of businesses like restaurants and bars. “It’s a really fragile time for small businesses,” Ozimek said, with many still taking in reduced revenue or losing money in the recession. “Then you add a several-month lockdown onto it, or even a several-week lockdown — that’s just a recipe for businesses who have made it this far not being able to go any further.”

And business closures or contractions will likely lead to layoffs. Some (though by no means all) of the millions of Americans laid off or furloughed in the spring have been rehired or gotten new jobs, Ozimek notes. But if more businesses fail, fall closures could be even more devastating — we could see “a lot of permanent layoffs as the businesses go under and people don’t have a job to go back to.”

For example, in hard-hit El Paso, Texas, 300 businesses have already shuttered due to the pandemic, according to the Washington Post. And 300 more, including restaurants, nail salons, and retail stores, don’t have enough cash on hand to survive for more than a month — and the city is already under a shutdown of nonessential businesses until December 1.

Around the country, “if we have more shutdowns, we are going to see unemployment rates spike again,” Lucy Dadayan, a senior research associate with the Urban-Brookings Tax Policy Center at the Urban Institute, told Vox.

Closing schools doesn’t have quite the same immediate economic effect, something local and state leaders are likely factoring into their decision-making — teachers can still work remotely and draw salaries, and public schools, at least, won’t shut down permanently due to virus-related closures.

Of course, closing schools still has economic effects — for example, a disproportionate share of women dropped out of the workforce in September, with the demands of child care and homeschooling likely a major factor. And then there’s the long-term impact of school closures on students. Research conducted in the spring found significant learning losses, with Black and Latinx students and those from low-income neighborhoods disproportionately affected.

Meanwhile, uncontrolled surges of the virus will likely also lead to layoffs and business closures, even without shutdowns, as fewer people go out and spend money. “Even if some businesses are still open and functioning despite the surge in cases, we are not functioning at full capacity,” Dadayan said. “The economy is not going to be back at the place where it was before the pandemic anytime soon.”

In a way, closing schools while leaving businesses open simply shifts the burden of the pandemic onto families with kids, where the impacts are no less severe, even if they’re less immediately visible. “Especially low-income families need their child to be in a supervised space so they can go to work, or even if they’re working from home,” Lake said. “Academically and economically, it’s a little bit crazy to prioritize bars over schools.”

To close businesses without economic devastation, states and cities need federal help

But when it comes to restrictions on businesses, authorities at the state and local level have been hamstrung, to some degree, by Washington’s inability to act.

“The federal government did not give them the tools and help they need to shut down those businesses without doing serious, long-term harm to their economies,” Ozimek said.

The biggest tool they need, many say, is stimulus money — funding, like that provided by the CARES Act, that could help keep businesses afloat and help ordinary people pay their bills if they’re not able to work. As Vox’s German Lopez reports, experts agree that such stimulus is necessary to help people and the economy weather the kinds of lockdowns that seem increasingly necessary as cases surge and winter approaches.

Many European nations like Britain and France have heeded this lesson and enacted furlough programs under which the government steps in to pay a portion of wages for companies affected by the pandemic. These programs have, so far, helped Europe avoid the huge layoffs that the US has faced: While unemployment here went from 3.5 percent to 14.7 percent between February and April, Europe saw a smaller rise from 6.5 percent in February to 7.4 percent in August, according to the Washington Post.

But so far, there’s little sign of another stimulus on the horizon, with Republicans in the Senate opposing both enhanced unemployment and a second round of checks to American taxpayers, which House Democrats made part of their proposal. President-elect Joe Biden has called for restart grants to help small businesses recover from the pandemic, as well as a government-funded workshare plan to help businesses bring back workers, but these, too, would likely need the support of Congress. Democrats face a steep challenge in winning control of the Senate in Georgia’s runoff elections in January.

He has also selected a team of experts to manage the Covid-19 response, including Céline Gounder, an infectious disease specialist who spoke to the New York Times this week of the importance of prioritizing schools over businesses like restaurants. “I would consider school an essential service,” she told the Times. “Those other things are not essential services.”

Ultimately, the country will need a plan for supporting both students and workers — who often have kids at home themselves. Unfortunately, such a plan doesn’t seem forthcoming under the current administration, and the country has to get through a fall and winter under Trump. Without a change in direction, we may continue to see states and cities prioritize businesses over schools — because the federal government has left them with only bad choices.

Naas CBS 3-14
St Brendan’s Killarney 2-15

Richard Commins reports at Croke Park

NAAS CBS BECAME the first Kildare school to lift the Hogan Cup after a high-quality encounter with four-time winners St Brendan’s Killarney in the Masita GAA All-Ireland Post Primary Schools Football Championship in Croke Park this afternoon.

Two goals from man-of-the-match Kevin Cummins and one from Fionn Cooke proved crucial as Naas saw a six-point half-time lead whittled down to a single point with three minutes remaining with the Kerry school valiantly trying to pull off a dramatic comeback win.

But in a riveting end-to-end encounter, one of the best matches played in Headquarters in recent years, Naas held their nerve, kicking some excellent scores into the Hill 16 end to keep ‘The Sem’ at bay before Cummins audaciously chipped the St Brendan’s goalkeeper Aaron O’Sullivan for the clinching third goal two minutes from the end of normal time.

57 nóim

Coláiste an Bhréanainn Cill Airne 1-15
Meánscoil Iognáid Rís, Nás na Ríogh 3-13

"Chomh dána de chríoch!"

Kevin Cummins with a fantastic goal for @CBSNaas 🤩@GAA_BEO @officialgaa
#GAABeo

BEO/LIVE AR @TG4TV pic.twitter.com/zXsjYbs8aI

— Spórt TG4 (@SportTG4) March 17, 2022

Sean Broderick’s point stretched the lead to five points before an injury time finish to the net from Sem substitute Mark O’Shea gave the Kerry side hope again. It wasn’t to be with Naas, the beaten finalists the last time this final was played in 2019, adding the Hogan Cup to three Leinster titles in the last four competitions.

It caps a remarkable few months for Kildare’s county town, with the local Naas GAA club having won Leinster and All-Ireland Intermediate hurling titles after the club’s senior teams completed a rare double of county titles.

Naas were the more dominant side in the early stages but failed to make it pay on the scoreboard, the more efficient St Brendan’s edging ahead three points to two with Cian Foley’s eighth minute point.

The Kildare side were boosted three minutes later though with impressive corner forward Cummins latching onto a long fist pass from Cian Boran and placing a superb shot across O’Sullivan and into the top right-hand corner of the net at the Canal End.

Five minutes before half-time intelligent centre-half forward Colm Dalton put Fionn Cooke through to confidently slot home a second goal with CBS going into the break six points clear (2-6 to 0-6).

The Sem came out fighting after the break and within two minutes of the restart a long ball from Killian O’Sullivan was only diverted into the path of William Shine by a Naas CBS defender and their best forward on the day found the same corner as Cummins had earlier.

The Killarney boys would rue shooting three successive wides after that and as an end-to-end feast of attacking football developed, Naas CBS were the more clinical. Three points in a row, however, from Cian McMahon (2) and Luke Crowley between the 52 nd and 54 th minutes had Naas nerves jangling with the gap down to a point (2-12 to 1-14).

Cummins settled the nerves though with a brilliant dummy and point and despite an equally impressive score from the classy Shine at the other end, a booming kick-out from David McPartlin found its way to Niall Dolan who put Cummins through for his vital late goal.

Scorers for NAAS CBS: Kevin Cummins 2-5 (2fs), Fionn Cooke 1-0, Gavin Thompson (1f) 0-3, Niall 0-2, Sean Broderick 0-2, Dara Crowley, Colm Dalton 0-1

Scorers for St Brendan’s Killarney: William Shine 1-5 (0-1f), Cian McMahon 0-4 (2fs), Mark O’Shea 1-0, Cian Foley, Luke Crowley 0-3 each.

NAAS CBS: David McPartlin (Raheens); Tim Ryan (Naas), Charlie Murphy (Naas), Cian Boran (Eadestown); Robert Fitzgerald (Naas), Fionn Tully (Raheens), Jack McKevitt (Naas); Dara Crowley (Raheens), Daire Guerin (Naas); Sean Broderick (Ballymore Eustace), Colm Dalton (Sallins), Fionn Cooke (Raheens); Niall Dolan (Raheens), Gavin Thompson (Raheens), Kevin Cummins (Naas).

Subs: Jack Taaffe (Naas) for Cooke 43, Elliot Beirne (Naas) for Thompson 60, Darragh Jameson (Eadestown) for Fitzgerald 61, Daniel Lenihan (Naas) for Broderick 63.

St Brendan’s Killarney: Aaron O’Sullivan (Legion); Cian Lynch (Glenflesk), Tomás Clifford (Firies), Harry Byrne (Dr. Crokes); Darragh Fleming (Legion), Dara O’Callaghan (Kilcummin), John Kelleher (Glenflesk); Liam Randles (Dr. Crokes), Killian O’Sullivan (Glenflesk); Mikey Moriarty (Beaufort), Cian Foley (Kilcummin), Luke Crowley (Glenflesk); Cian McMahon (Dr. Crokes), Alex Hannigan (Dr. Crokes), William Shine (Legion).

Subs: Charlie Keating (Dr. Croke’s) for Hennigan HT, Rian Colleran (Fossa) for Clifford HT, Mark O’Shea (Kilcummin) for Moriarty 37, Michael Mullane (Glenflesk) for
Randles 54, Aodhán O’Neill (Renard) for Foley 61.

Referee: Paul Faloon (Down)

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More than 100 disasters — many of which were climate- and weather-related — have affected more than 50 million people around the world since March, when the World Health Organization declared the coronavirus outbreak a pandemic. And though the money needed to protect against these disasters in the countries at risk exists, it’s not getting to those who need it most.

Those are the key findings of a new report from the Geneva-based International Federation of Red Cross and Red Crescent Societies (IFRC) released Tuesday. In it, the authors make clear that while global attention has been focused on the coronavirus pandemic — for good reason — the climate crisis and the resulting disasters facing communities around the world are just as catastrophic.

“It’s a very, very serious crisis the world is facing currently,” IFRC Secretary General Jagan Chapagain said of the Covid-19 pandemic, speaking at a virtual news conference on November 17. But he noted that while there is some good news regarding the possibility of a vaccine for Covid-19, “unfortunately, there is no vaccine for climate change.”

The IFRC report, titled “World Disasters Report 2020: Come Heat or High Water,” uses what’s known as “extreme event attribution” to show that over the past 10 years, climate- and weather-related disasters such as storms, floods, and heat waves have impacted 1.7 billion people. Over that same period, an additional 410,000 lives were lost, the majority of which were in lower- or middle-income countries.

Extreme event attribution is an emerging scientific field that has allowed scientists to study how human-induced climate change is connected to extreme weather events. As Vox’s Umair Irfan explains, in this field, “scientists construct models to evaluate the counterfactual of what would have happened in a certain event without climate change and compare it to observed results.”

And they have found that although global warming caused by fossil fuel emissions does not directly cause hurricanes or droughts, it is magnifying the risks and frequency of such events.

The authors of the IFRC report found that such catastrophes have been rising in number since the 1960s — and that a sharp increase of 35 percent has been recorded since the 1990s. The proportion of all disasters that can be attributed to climate change has also grown, from 76 percent in the 2000s to 83 percent in the 2010s.

Making matters worse, the report found that the world’s most vulnerable people aren’t getting the financial assistance they need to withstand such disasters, even though the funds they require exist.

The report’s authors argue that the speed at which governments and banks worldwide have developed economic stimulus packages is proof that funds can be assembled rapidly to meet existential threats. And they want to see governments mirror that energy when it comes to addressing the climate emergency.

A recent study, for instance, found that the money pledged globally for pandemic recovery thus far has surpassed $12 trillion. According to the IFRC, the stimulus model created during the pandemic would be a good model for governments to generate the $50 billion needed each year over the next 10 years to help 50 developing nations adjust to the worst impacts of climate change.

But they also warn that any money raised in the future can’t be distributed as aid has been to date: The report found that when it comes to receiving funding, the countries most vulnerable to the effects of climate change are being left behind.

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Why the countries most in need of climate change aid money aren’t getting it

Of the 20 countries considered most vulnerable to climate change and associated disasters, the IFRC found that none were in the top 20 countries receiving funding.

In climate science, vulnerability generally describes the likelihood that a country will experience negative impacts from storms and other extreme weather events. A community’s or country’s vulnerability can be measured in the long or short term, but it basically involves sensitivity to harm like natural disasters and the ability to adapt, or cope through processes like evacuation plans.

It’s also an issue of social protection. If homes are damaged, do people have funding available to make repairs? Do people have savings? Or do they need to rely on selling livestock and then have no means to make a living?

Somalia was ranked as the most vulnerable country in the IFRC’s report due to high levels of food insecurity and drought, but it only ranked 71st in per-person funding disbursements. None of the countries with the five highest disbursements had high or very high vulnerability scores, suggesting that more can be done to reach those most in need.

The main reason money isn’t flowing to where it is most needed is that, as IFRC’s senior analyst of humanitarian policy and project coordinator Kirsten Hagon told me, there is no framework for giving climate-related aid to countries that are seen as being unable to manage large influxes of capital.

Donor countries give aid mostly to governments. This means that to receive assistance, countries must have governments able and willing to meet criteria set by donors, such as putting forth funding proposals and showing financial capability. People living in some of the most affected countries often do not have governments that can meet these criteria, making it difficult for them to be eligible to get international help.

The result, as Hagon told me, is that “the vast majority [of donor countries] think they will invest in safe countries and someone else will in the ones that are trickier and nobody does. And so you see examples like the Central African Republic where nothing’s being invested there.”

Although the outlook for disaster preparedness looks bleak, there are ways to save lives

According to the report, a few things can be done immediately to help people prepare for the increasing frequency of extreme events and prevent the loss of lives.

One of the biggest is to focus on disaster preparedness plans at the local, rather than national, level — ensuring that communities have individually tailored plans that include designated signals to communicate when it is time to evacuate and transportation to shelters that can keep them safe.

Because, as Hagon told me, “without those basic things that have to happen at the community level, that have to be designed with and by the community, then you’re not going to save lives.”

Donors must also work together to identify which countries are being left behind and then find a way to fill the gaps. They should also consider more flexible criteria that different countries can meet and be able to apply for funding.

The IFRC has also called on organizations and governments to examine their own practices — and says it will begin with itself, in order to make sure its work is “climate smart,” taking climate change impacts like warmer temperatures and sea level rise into account when doing its work.

The coronavirus pandemic has shown how international solidarity can actually work to address global crises and how massive amounts of money can be generated to save lives and invest in solutions. Now, climate experts hope a similar effort can be applied in a global mission to save lives and prevent deaths from climate-related disasters in the most vulnerable communities.

“We have to scale up all of the things that we already know, but we have to take them to another level because this is a crisis like none that’s ever really faced humanity before,” Hagon said.

As confirmed coronavirus cases rise to their highest levels since the pandemic began, hospitals across the country are reporting critical staff shortages. And those shortages may only grow worse in the weeks to come, as thousands of the 1 million Americans diagnosed with Covid-19 in the past week begin to require hospitalization.

According to an NPR analysis of data released by the Department of Health and Human Services (HHS) this week, more than 1,000 hospitals across the country have been identified as “critically” short on staff as they face a dramatic third wave of Covid-19 infections.

That amounts to about 18 percent of all hospitals that report to HHS. In all, 21 percent of hospitals, representing 40 states and Puerto Rico, expect their staffing needs to increase in coming days. Seven states report shortages in 30 percent or more of their hospitals. North Dakota — which has one of the most severe coronavirus outbreaks in the US — is the worst hit, with 51 percent of hospitals reporting shortages.

Nebraska, Virginia, and Missouri report expecting the largest upticks they’ve faced during the pandemic in the next week.

According to NPR, the HHS data is incomplete because many hospitals do not share staffing numbers with HHS. The agency has been collecting this data since July, but this is the first time it has released it to the public.

These staff shortages translate to exhausted and overworked doctors, nurses, and other hospital employees, and also pose a risk that, as employees become sick themselves, there will be no one to cover for them.

Fear of overwhelming hospital systems was a large part of the “flatten the curve” messaging that accompanied the start of the outbreak in the United States in March. By keeping caseloads to reasonable numbers and admitting only the sickest patients to hospitals, medical experts explained, there was less risk of running out of bed space, ventilators, and other equipment central to the care of Covid-19 patients. It also meant that resources would be available for non-Covid patients as well.

With hospitalization and case rates at record highs, hospitals could soon be out of staff and space

Ultimately, the curve was flattened — but with cases worse than they have ever been, hospitals are again in danger of running out of space, and of health care professionals.

As of November 20, 82,178 people were hospitalized with Covid-19, according to the Covid Tracking Project — far more than the previous records of nearly 60,000 reached in the spring and summer. And on November 20, the US hit a record high of 192,805 confirmed coronavirus cases, breaking the record of the previous day: 182,832 confirmed cases.

As Vox’s Dylan Scott has explained, hospitalization is what is known as a lagging indicator. This means the number of people hospitalized rises after, rather than alongside, an increase in infections: It can take days, or longer, for an infected person to need hospitalization after receiving a positive test result.

This means already burdened hospitals will likely begin to see an increase in patients infected last week in the weeks to come, and providers struggling with those new patients could be overwhelmed in mid- to late December should cases increase sharply following Thanksgiving.

At the moment, hospitals are nearing capacity. HHS estimates that as of November 20, 73.66 percent of all US inpatient beds are full (counting both Covid-19 patients and those seeking treatment for other illnesses), and that 60.62 percent of all ICU beds are occupied.

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When the virus was more contained to several hot spots earlier in the year — in New York and New Jersey, for example — medical professionals from elsewhere, as well as from the US military, were also able to travel and provide short-term staffing support.

Now, with the virus so widespread, there are fewer health care providers able to leave one community and support another.

This has led to dramatic reports from local media across the country, as communities that previously saw few coronavirus cases begin to experience strain on their medical systems.

In North Dakota, where hospitals are at capacity, hospital workers have been told they may continue reporting to work even after testing positive for the coronavirus, so long as they are not exhibiting symptoms. (Covid-19 is contagious even in asymptomatic hosts.)

The University of Utah Hospital in Salt Lake City opened an overflow ICU two weeks ago, and officials there said it would be staffed by doctors and nurses working overtime. In Muskegon, Michigan, a recently-closed hospital has been reopened, and licensed nurses are being asked to come out of retirement to meet staffing and infrastructural demands.

And as the pandemic has begun surging in previously untouched parts of the country, rural hospitals, many of which lacked resources to begin with, have been especially hard-hit.

Rural hospitals reaching their capacity can have a ripple effect if nearby urban hospitals also become overwhelmed. As the Kansas City Star’s Jonathan Shorman, Sarah Ritter, and Matthew Kelly reported, Kansas City hospitals have “reached a tipping point where additional COVID admissions could trigger a crisis,” and may have to stop accepting patients from rural hospitals, leaving those patients with nowhere to go and without access to care.

Overwhelmed hospitals will almost certainly lead to more deaths. As Vox’s Julia Belluz has explained, medical professionals have become far better at treating Covid-19 patients than they once were, and the mortality rate has fallen:

Now, there’s strong evidence that common steroids like dexamethasone can reduce the risk of mortality in severely sick inpatients. Putting patients to rest on their stomachs instead of their backs (a practice known as proning) also seems to help.

Though there’s still a lot of progress to be made, the treatment approach has become more standardized over time, said Jen Manne-Goehler, an infectious disease doctor at Brigham and Women’s and Massachusetts General hospitals. When she started treating Covid-19 patients in the spring, it felt like practice was changing every few days. Now it’s more streamlined — and that’s undoubtedly helping with survival, too.

But to receive those improved treatments, patients must have access to doctors. And increasingly, it appears that access may be severely — and perhaps dangerously — limited in the weeks to come. HHS has plans to coordinate between hospitals to make up for staff shortages, according to NPR. However, if hospitals are overwhelmed throughout the country, finding the staff needed to save lives may not be possible, for hospital systems or for the federal government.

Just last week, Pfizer and BioNTech revealed that their experimental Covid-19 vaccine, called BNT162b2, was at least 90 percent effective in an early analysis. On Wednesday, the pharmaceutical and biotech companies reported that their vaccine was even more effective after it cleared more clinical trial benchmarks for safety and efficacy. And on Friday, they said they are requesting an emergency use authorization (EUA) from the Food and Drug Administration.

If granted an EUA, the BNT162b2 vaccine could be administered to certain high-risk groups in the United States — most likely health workers — as soon as mid-December. Pfizer and BioNTech are filing for similar approvals in other countries as well.

“Filing for Emergency Use Authorization in the US is a critical step in making our vaccine candidate available to the global population as quickly as possible,” said Ugur Sahin, CEO and cofounder of BioNTech, in a statement.

The companies are confident in their vaccine after showing strong results from their phase 3 clinical trial: Out of 170 Covid-19 cases, eight people that received the vaccine got Covid-19 versus 162 in the placebo group, an efficacy of 95 percent. They also say there are no “serious safety concerns related to the vaccine.”

A competitor, the vaccine developer Moderna, also recently reported that its vaccine was 94.5 percent effective in an early analysis.

It’s worth pausing to reflect on where we are: At the one-year anniversary of the first detection in China of the SARS-CoV-2 virus, the pathogen that causes Covid-19, there are now two highly effective vaccine candidates developed at a record pace, both using mRNA, a new vaccine technology that has never before been approved for use in humans.

The announcements are a breathtaking feat of science, international collaboration, and public investment. “The study results mark an important step in this historic eight-month journey to bring forward a vaccine capable of helping to end this devastating pandemic,” said Albert Bourla, Pfizer chair and CEO, in a statement.

But there are concerns as well. Pfizer and BioNTech’s announcement of its efficacy results came, for the second time, in a press release instead of a peer-reviewed paper, although the companies revealed far more about the demographics of their clinical trial than in their first report. BNT162b2 also has some of the most stringent cold storage requirements of any vaccine, demanding temperatures of minus 70 degrees Celsius (minus 94 degrees Fahrenheit) or lower, which may make widespread distribution challenging. The vaccine is also administered in two doses spaced several weeks apart. That adds a huge logistical burden to rolling it out.

That the clinical trial racked up so many Covid-19 cases among its volunteers so quickly is also a grim reminder of just how fast the disease is spreading right now.

And it will likely take months before any Covid-19 vaccine gets full FDA approval, which would allow the general public to have access to it. Even then, immunizing millions of people in the US against Covid-19 would be an endeavor unprecedented in its speed and scale. So getting an EUA is just one step toward ending the pandemic.

Pfizer and BioNTech say their Covid-19 vaccine was safe and effective across a diverse pool of volunteers

Pfizer and BioNTech’s Covid-19 vaccine data so far is still preliminary, but it likely received validation from its Data Safety Monitoring Board (DSMB). This is an independent group of scientists that serves as an intermediary between the pharmaceutical companies and the clinical trial participants to ensure that there is no meddling in the trial. The DSMB meets with the companies at regular intervals to go over their observations of the trial. The fact that Pfizer and BioNTech were able to make this announcement likely means the committee reported this information to them during an analysis.

“To date, the Data Monitoring Committee for the study has not reported any serious safety concerns related to the vaccine,” the companies reported in their press release. In a separate trial of 8,000 participants, Pfizer and BioNTech reported that the only severe side effects they found that occurred in more than 2 percent of volunteers were fatigue, observed in 3.8 percent of participants, and headache, observed in 2 percent. Surprisingly, the companies found that older adults reported fewer and milder side effects.

The trial also recruited a diverse pool of volunteers to see how well the vaccine would work among different populations. About 30 percent of US trial participants came from diverse racial and ethnic backgrounds, and 45 percent were between the ages of 56 and 85. “Efficacy was consistent across age, gender, race and ethnicity demographics,” the companies reported.

What emergency use authorization means for a Covid-19 vaccine

During a public health crisis, the FDA can grant an EUA to allow unapproved medical products to treat or prevent serious diseases when there are no adequate alternatives on the market.

The benchmark for an EUA is lower than it is for full approval of licensure. In general, the treatment in question has to have a likely benefit, whereas approval demands evidence of a proven benefit.

However, it’s not just about efficacy. A vaccine has the additional hurdle of a much higher bar for safety than conventional drugs. Since a vaccine has to be distributed to millions of people, including those who are healthy and those who have preexisting conditions, the rate of complications has to be extremely low for both full approval and an EUA.

“The thing people need to keep in mind is the safety data. Do we have enough data on safety at this point that we can go forward with the EUA?” said Jose Romero, chair of the Advisory Committee on Immunization Practices (ACIP), an independent group of health experts that advises the Centers for Disease Control and Prevention on vaccines. “I think the FDA, ACIP, and all of the pharmaceutical companies have said over and over again that safety is paramount as they move forward with full licensure or an EUA for vaccines.”

The burden of approving a Covid-19 vaccine isn’t just on the companies. The FDA also has to be transparent about how it is making decisions. This is especially important given that public mistrust of a vaccine could be a major hurdle in the effort to contain the Covid-19 pandemic in the US.

Some experts are worried that the FDA damaged its credibility this year with its decisions to grant EUAs to treatments like hydroxychloroquine and convalescent plasma based on weak data, which may have been driven by political pressure from the White House. Some researchers have also criticized the FDA’s full approval of the antiviral drug remdesivir. These decisions have sown doubt about the FDA’s decision-making, and the agency will have to go out of its way to rebuild fragile trust with the public to roll out a vaccine.

How do we decide who gets a Covid-19 vaccine first?

Once an EUA is granted, the Covid-19 vaccine can start to be administered to people outside of the clinical trial. Health workers — doctors, nurses, first responders, medical cleaning staff — are the top priority. “They’re certainly high on the list,” Romero said.

Then the vaccine would be targeted at people who are likely to suffer severe complications from Covid-19, such as people over the age of 65 with other underlying health conditions.

However, there are 18 million health workers in the US alone. There are almost 50 million Americans over the age of 65. More than 10 million Americans are immunocompromised, and more than 100 million US adults have diabetes or prediabetes.

Pfizer and BioNTech said they only expect to have 50 million vaccine doses around the world by the end of the year. And remember, this is a two-dose vaccine, so 50 million doses will only protect 25 million people. That means there won’t be enough to go around, even for people at high risk. The companies do expect to have 1.3 billion doses ready in 2021.

ACIP is now putting together its recommendations for how to prioritize people for Covid-19 vaccination. But Romero explained they will also have to consider that there will likely be multiple vaccines on the market shortly. A dozen Covid-19 vaccine candidates are already in phase 3 trials, each with their own unique traits and caveats.

“It’s a little silly to think that all vaccines are going to be ranked the same, because they’ll have different characteristics,” Romero said. “Some vaccines may be better in younger populations; some may be better in older populations.”

The advisory committee will also have to weigh practicality, including the minus 70 degree Celsius storage requirements of the Pfizer-BioNTech vaccine. “Those are going to be very important and impact significantly the logistics of getting these vaccines out and into the arms of recipients,” Romero said. “It’s hard to imagine how you’re going to set up a system to deliver a vaccine that requires storage at minus 70 [Celsius] into the widespread community.”

It’s likely, then, that the BNT162b2 vaccine will be reserved at the outset for health workers who are already working in and around facilities that have the ultra-cold storage systems for this vaccine, or those who are near facilities that are equipped to distribute it. For those in far-flung regions or people who don’t have sophisticated $10,000 freezers nearby, a vaccine with easier storage requirements may be recommended. Moderna’s vaccine, for example, only needs long-term storage at minus 20 degrees Celsius (minus 4 degrees Fahrenheit) and is stable for 30 days between 2°C and 8°C (36°F to 46°F).

Pfizer and BioNTech say they do have a solution for getting their vaccine to places without ultra-cold freezers. “The companies have developed specially designed, temperature-controlled thermal shippers utilizing dry ice to maintain temperature conditions of -70°C±10°C,” according to their press release. “They can be used be as temporary storage units for 15 days by refilling with dry ice. Each shipper contains a GPS-enabled thermal sensor to track the location and temperature of each vaccine shipment across their pre-set routes leveraging Pfizer’s broad distribution network.”

However, even with a green light from the FDA and assembly lines cranking out millions of vaccine vials, developers like Pfizer and BioNTech will still have to keep an eye on the people who received the vaccine to ensure there aren’t any super-rare complications that could arise. “I think it’s important for the public to understand that the process doesn’t end with approval,” Romero said.

For their part, Pfizer and BioNTech said they will continue monitoring their clinical trial participants for two years.

As these vaccines gradually roll out, people will still have to keep up measures to limit the spread of the virus: wearing masks, maintaining social distance, keeping up good hygiene. Until there is widespread vaccination, Covid-19 will remain dangerous and deadly, and the steps taken to mitigate it now will ensure a smoother and more effective campaign to halt the pandemic.

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THE TYRONE LADIES have appointed Seán O’Kane as the new manager ahead of their Division 2 relegation play-off against Clare in three weeks.

The previous manager, Kevin McCrystal, stepped down from the position on Sunday following a mixed start to their 2022 campaign.

Speaking to Gaelic Life about his exit, McCrystal explained that the players “decided they want to go down a different path and I have informed the executive of my decision to step aside.” He had been involved with the senior ladies and development squads for the last five years.

A statement released from Tyrone Ladies reads that O’Kane will take over the squad with immediate effect having previously enjoyed three successful terms with Tyrone.

“Formerly the north Tyrone man has had stints with Donegal, Antrim and Armagh while he also took Glenelly to an All-Ireland club final and most recently, Seán has been in charge of Jordanstown.

“With Tyrone, he won Ulster junior and senior titles, adding an All-Ireland junior crown over five years and three separate terms. Seán is set to finalise his backroom team over the next number of days, but plans to hit the ground running.

“Welcoming Seán back to his native county, Tyrone chairperson Donna McCrory wishes him and the team all the best for the rest of the year.”

Tyrone will meet Clare in their relegation play-off on Sunday, 3 April at Glennon Brothers Pearse Park in Longford.

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With two Covid-19 vaccine candidates expected to be approved for the US market in the coming weeks, a group of experts met Tuesday to advise on which Americans should be immunized first. In a 13-1 vote, they put health care personnel and staff and residents of long-term care facilities at the front of the line.

The Advisory Committee on Immunization Practices (ACIP), a panel of independent medical and public health experts, has been meeting for months to think through the question of whom to prioritize during a pandemic while vaccine supplies are still limited.

ACIP is highly influential in the US. It makes recommendations on vaccination policy to the Centers for Disease Control and Prevention, which overwhelmingly accepts the committee’s guidance. States aren’t obliged to follow it, however. It’s up to governors — and individual hospitals and vaccine sites — to make their own vaccine prioritization plans.

But with coronavirus hospitalizations and deaths rising exponentially, the meeting was another stark reminder that vaccine rationing will be a painful reality for months while supplies remain short.

“There is an average of one Covid death per minute right now,” said Dr. Beth Bell of the University of Washington, who chairs ACIP’s Work Groups, at the meeting’s opening. “In the time it takes us to have this ACIP meeting, 180 people will have died of Covid-19.”

And that’s one reason why, vaccine and public health experts told Vox, ACIP should have weighed in sooner. Major health groups like the World Health Organization (WHO) and the National Academies of Sciences, Engineering, and Medicine (NASEM) have published advice on how countries and other decision-making bodies can set their prioritization plans for Covid-19 vaccines.

“It would have been helpful to have this a week ago,” said Ruth Faden, the founder of the Johns Hopkins Berman Institute of Bioethics, since states, which have been waiting on the guidance, must place their first orders of Covid-19 vaccines with the government and share their initial distribution plans by Friday. “States were not caught completely unaware here,” Faden added — since ACIP had signaled in previous meetings the direction they were likely to go — but Tuesday’s guidance could have been more specific, particularly when it comes to how to immunize America’s health workforce.

The advice is not specific enough

ACIP’s primary task on Tuesday was to vote for phase 1a of the rollout for two priority groups: health care personnel and long-term care facility staff and residents, comprising about 24 million people.

According to CDC officials, there will only be 5 million to 10 million doses of the vaccines available per week for these groups once vaccines are approved, which should happen before the end of the year. The two manufacturers that are expected to have vaccines approved first, Moderna and Pfizer/BioNTech, will have enough doses to vaccinate only around 20 million people by the end of December.

Long-term care facility residents and staff are a top priority because they have accounted for 40 percent of US Covid-19 deaths, according to the committee. And it makes sense to prioritize health care workers — they’ve also been among the groups hardest hit by the virus, and we need them healthy and working to keep the health system functioning.

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But the gap between the priority groups and the expected supply is a problem ACIP should have addressed, experts say.

It’s not clear from the guidance who among the health workers should go first, said Jason Schwartz, assistant professor of public health at Yale School of Public Health. “This matters because states might have 20,000 or 100,000 doses and figuring out where to use them in a priority group is going to be a hard question.”

ACIP has only said that “individuals with direct patient contact,” personnel working in residential care and long-term care facilities, and workers without coronavirus infection in the last 90 days should go first.

“Direct patient care is often interpreted as physicians and nurses and clinicians,” said Saad Omer, director at the Yale Institute for Global Health, who is part of both the WHO and NASEM Covid-19 vaccine prioritization committees. “But you have to go beyond that to explicitly say that includes cleaning workers, others who are doing housekeeping, etc.”

These groups are potentially just as exposed to the coronavirus as ICU doctors or nurses since they’re working in the same high-risk spaces.

“There’s a huge difference between say a dermatologist that’s doing cosmetic surgery in a private office and somebody who’s in a Covid-19 ward in a large inner-city hospital,” Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, added. “It would be enormously helpful if there could be a greater stratification based upon risk of the health worker.”

What’s more, had ACIP been more specific about which health workers are high risk, “you leave open a strategy of prioritizing them then going to other high-risk groups rather than [immunizing] the entirety of the health system workforce,” said Faden — who also advises the WHO on vaccine prioritization.

The next challenge: How to prioritize the elderly

Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, said most states are planning to be able to immunize their entire health care workforce within three weeks of getting the first Covid-19 vaccine shipments. If that’s true, “issues here regarding sub-prioritization will be very short-lived and the need for more detailed guidance is reduced,” Schwartz said.

ACIP typically sets recommendations for vaccine policy based on specific vaccines, and they’ll reconvene and potentially shift their advice as soon as Covid-19 vaccines are approved by the Food and Drug Administration. They’ll also need to vote on which groups come after phase 1a of the rollout.

If ACIP follows through with what they’ve been telegraphing so far, the committee will prioritize essential workers (such as teachers, food and agriculture workers, police, and firefighters) in phase 1b, and adults 65 and older and with high-risk medical conditions in phase 1c.

ACIP would deviate from other international expert groups with this plan, Omer said. The WHO and NASEM vaccine frameworks have both prioritized older adults and adults with underlying health conditions alongside or immediately after health workers, instead of essential workers.

“The reason everyone is prioritizing the elderly — compared to people 18 to 29 years of age — is that even at ages 65 to 74, they have a 90 times higher risk of death,” Omer explained. “My hope is [ACIP] will revisit some of the assumptions that were driving the considerations for the trade-off between essential workers and older age populations.”

Joe Biden will become the US president during an extraordinary moment in history, one that could very well prove to be the calm before the storm, a brief prelude to dissolution and illiberalism. Trump’s bid to become a full-on authoritarian failed, but Democrats could easily lose the House in a 2022 backlash. Biden could face total congressional opposition, even impeachment — as the recent baseless “stolen election” narrative has shown, if Republicans don’t have any evidence, they’ll just make something up.

Or maybe Democrats will keep the House and take the Senate in 2022, and legislation will become possible! Who knows? (The Georgia Senate runoffs are another big question mark.) If there’s one thing I’ve learned over the past five years, it’s that I definitely don’t know what is going to happen next, and it doesn’t seem like anyone else does either.

What we do know is that Republicans will wage full-on war on Biden from the second he takes office. They will generate fake conspiracies and controversies through right-wing media and social media. Conservative voters will be told again and again that Biden and Kamala Harris are uniquely dangerous traitors engaged in all sorts of elaborate evil plots. The entire conservative movement, from top to bottom, will view limiting Biden to one term as its primary strategic objective. And the movement will engage in misinformation, norm violation, procedural fuckery, and outright lawbreaking, if necessary, to achieve that objective.

The right will be what it is, what it has been becoming for decades now; expecting anything else would be madness. The question is how the Biden administration should behave, knowing all this.

It would be foolish for anyone to claim to have all the answers, or any of the answers really, but in my mind the most pointed lesson about how to behave in a hopelessly partisan environment comes from Donald Trump himself.

Before getting to that (suspense!), it’s instructive to take a look back at some of the experiences of the administration for which Biden was vice president.

Obama’s efforts to collect and spend “political capital” were mostly for naught

When Barack Obama took office in 2009 in a deepening recession, he expected to receive some Republican help bailing out the economy. It’s easy today to look back on that expectation as naive, but at the time it wasn’t unreasonable. The economy was on the brink of disaster, the need was clear, and the depth of conservative backlash was not yet as evident as it would become later.

What happened instead was a wall of opposition from Republicans, built on bad-faith objections about deficit spending and government waste. With so little room to maneuver, Democrats were forced to negotiate with the tiny handful of moderate Republicans and the large handful of conservative Democrats in the Senate, holding the stimulus bill down to their arbitrary spending caps. In the end, the stimulus bill passed with zero Republican votes in the House and just three in the Senate. The result was an inadequate economic boost and a sluggish recovery that hobbled the rest of Obama’s presidency.

Since it was widely agreed that “political capital” was limited and Democrats could only take on one fight at a time, the question then became what to tackle next. The answer proved to be health care reform, perceived as a policy better developed and more widely supported in the Democratic caucus.

In July 2009, Democrats in the House introduced a health care plan based on a system that had been road-tested by Mitt Romney in his recent tenure as governor in Massachusetts. Many Democrats thought the process would take a few months, and then Congress could move on to climate change. Instead, again and again, Republicans lured Democrats into extended negotiations, only to withdraw support at the last minute over some new bad-faith objection (see: “death panels”). That left Democrats negotiating with their most conservative members, who did much the same thing (Joe Lieberman, may his name live in infamy).

In the end, talks dragged on until March 2010, when Obama finally signed the Affordable Care Act. It got no Republican votes, in the Senate or the House.

Then it was finally time for climate change, and the strategy there was yet more clever sequencing. Obama told Republicans that if they didn’t cooperate on climate change legislation, he would regulate greenhouse gases via the Environmental Protection Agency, which would offer less flexibility and less ability to compensate hard-hit communities. The idea was that the threat of EPA regulations — made inevitable by the Supreme Court’s 2007 Massachusetts v. EPA judgment that carbon dioxide is a pollutant subject to the Clean Air Act — would frighten Republicans to the legislative table, where they could better defend their interests.

Instead, Republicans vowed implacable opposition to all of it. They would fight furiously against legislation when it was on the table and then fight regulations just as furiously when they came up.

To a cool Vulcan mind like Obama’s, it seemed entirely irrational, against Republicans’ own best interests. At that point, he had not fully internalized the extent to which the conservative movement has become unleashed id, driven more by right-wing media than by Republican politicians, fueled by resentment and organized purely to defeat the libs.

In June 2009, when the climate bill passed the House, it got eight Republican votes. By mid-2010, it was dead in the water, with no hope of any Republican votes in the Senate. Democrats no longer had their filibuster-proof 60 seats, and there was nothing like the same support in the caucus that health care reform generated, so it never came to a Senate vote. It ended with a whimper, not a bang.

As promised, Obama’s EPA began slowly rolling out regulations, one at a time. It wasn’t until late in his first term that auto mileage standards were finalized and into his second term before EPA got to power plants. Republicans were able to keep Obama’s Clean Power Plan tied up in court through the end of his second term. Then Trump took power and began a simultaneous all-fronts assault on Obama’s regulations, unrolling them so fast it was difficult to even keep track.

Two-party partisan politics really is a zero-sum game

The theme of these stories is that Democrats relied on clever sequencing over and over again, imagining some amount of political capital (“credibility”) that they could husband and spend strategically to get assistance across the aisle, at every juncture underestimating the ferocity and unanimity of Republican opposition. They kept behaving as though they would find good-faith negotiating partners, as though they were still in the postwar American era of relatively low (or at least manageable) polarization.

What too few of them realized was that they were already in a new era of near-total polarization, with the population sorted into like-minded enclaves, a bifurcated media ecosystem nurturing stacked (and diametrically opposed) “mega-identities,” and voters motivated primarily by “negative partisanship,” which is to say, hatred of the other side.

A fully polarized two-party system really is a zero-sum game. Any victories or gains by one side come at the other side’s expense, even if the victory secures shared goals. The rational course for the party out of power is to fight with full intensity against everything, always, and that’s what Republicans did under Obama. With scarcely any exceptions, from 2010 through 2020, they pushed in every case for maximal partisan advantage, no matter the stakes or possible cost.

The GOP has failed to repeal the Affordable Care Act, despite a few close calls, but otherwise, its unprincipled pursuit of raw power has paid off handsomely. The party captured state legislatures in 2010 and was able to gerrymander itself minority rule in several states. It practically shut down Congress as a legislative body for six years of Obama’s term. It blocked Merrick Garland’s nomination to the Supreme Court and for its efforts got Neil Gorsuch. It ignored Ruth Bader Ginsburg’s dying wishes and for its efforts got a 6-3 conservative Court majority that could last for generations.

Republicans blocked so many Democratic judicial nominations that Senate leader Harry Reid had to get rid of the judicial filibuster to keep the courts staffed. Then, when the GOP took control of the presidency and Senate, it used the absence of the filibuster to pack the federal courts full of hyper-ideological, young, often woefully unqualified judges.

Rather than paying any price for total partisan warfare, Republicans were rewarded in 2016 with the presidency and both houses of Congress. After carrying the country to the brink of authoritarian crisis, it has now lost the House and the presidency. But Joe Biden has been left to tackle a virtually uncontrolled pandemic and millions of people out of work and on the verge of homelessness or food insecurity.

The GOP will likely retain control of the Senate, which means there will be no adequate economic recovery package and none of Biden’s ambitious campaign plans will come to fruition. It has kept control of key state legislatures, so it will be able to gerrymander itself an advantage for another decade.

The elections of 2022 will be another partisan brawl, and the odds are stacked against Democrats; the president’s party has lost seats in every first-term midterm in the past 100 years, save three. If Republicans gain full control of Congress, impeachment becomes a real possibility, even if conviction is very unlikely.

It’s a grim situation, and Biden is starting out behind the eight-ball. How should he proceed?

Biden should run a blitz

Here we return to the lesson that Trump has to teach Biden about life in hyperpolarized politics.

To wit: blitz. Do everything at once.

No matter what the Biden administration does, it will be accused of socialism and corruption by the right. And the past several years have richly demonstrated that conservative parts of the country, particularly rural areas and low-density suburbs, are almost completely captured by right-wing media, from Fox on the TV to AM conservative radio to Sinclair-owned local news to the profusion of shady Facebook sources and groups, where misinformation is rapid and rampant.

Democrats badly need to address this media asymmetry. Despite what conservatives have convinced themselves, mainstream media outlets like CNN are not analogous to Fox, and Democrats have no comparable radio, local TV, or social media operations to carry their messages and narratives straight to voters where they live.

But that is long-term work, and 2022 is right around the corner.

The only thing Biden will have real control over is his administration and what it does. And his North Star, his organizing principle, should be doing as much good on as many fronts as fast as possible. Blitz.

By constantly blundering forward, Trump has helped chart which US institutions and norms provide real resistance and which don’t. The courts have tangibly restrained Trump; they have been the primary bulwark against him. But the chattering of the media and the political classes? Moral outrage? Precedent and tradition? Civil protest?

All of these have proven gossamer. Trump charged right through them like they were cotton candy. By constantly acting, being on the offensive, generating new stories and controversies, he simply overwhelmed the ability of the system to fasten on any one thing.

Biden should learn the lesson. All that matters is what gets done, put on paper and into law. The rest is vapor.

The administration should staff up as rapidly as possible with ambitious young progressives and tell every single civil servant that the next two years are going to be a full sprint. Start immediately rewriting and reimplementing the environmental, public health, and worker safety regulations Trump has weakened. Reverse his immigration policies. Drop his lawsuits.

Reassess the social cost of carbon. Replace Trump’s weak Affordable Clean Energy rule with more stringent carbon rules for the power sector. Ditch EPA’s “secret science” rule and restock scientific advisory boards with actual scientists. Put a moratorium on new oil and gas drilling leases on public land. Pledge the purchasing power of the federal government — around $500 billion a year — toward clean energy technology.

Through the Office of Management and Budget (OMB), direct federal financing toward carbon reduction and clean energy across agencies. Use the Office of Information and Regulatory Affairs (OIRA) to reject regulations from any agency that do not include both a climate and equity “screen” to ensure that they reduce emissions and help the most vulnerable. Use the powers conferred by the Dodd-Frank financial reform bill to integrate climate risks into the financial system.

I’ve written more about what Biden can do on climate change without Congress. Vox’s Dylan Matthews took a wider policy view with 10 big things Biden can do with executive powers, from forgiving student loan debt to reigning in factory farming. More ideas can be found here, here, here, and here, among other places. There’s no shortage of ways for Biden to deploy the powers of the presidency, and he should maximize every one of them.

The new rule of partisan politics is to act, not react

All of these moves will elicit howls of outrage and court challenges from the right. Many will also infuriate the left, since they will inevitably fall short of Biden’s grand campaign promises.

Biden can’t control any of that. Doing less, negotiating more, relying on clever sequencing, chasing after receding promises of cooperation — none of that will solve anything, any more than it did for Obama. He can reach across the aisle, make it clear his door is open, but he shouldn’t wait around for anyone to walk in.

Biden’s best chance is to try to overwhelm the system the way Trump did, by doing so much that it’s impossible to make any one thing into a lasting story. He should launch so many simultaneous reforms that there’s no time for right-wing media to make up lies about all of them or for the Supreme Court to hear them all. He should ignore bad-faith attacks and stay relentlessly on message about what’s gotten done and what’s getting done next. He should, at every juncture, get caught trying to make government work better for ordinary people.

To succeed, all this must happen alongside Democratic Party efforts to improve messaging and media, get persistent party infrastructure on the ground in communities the party has neglected, and innovate on voter outreach and persuasion. (Aaron Strauss has some good ideas on that front.)

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But Biden has something the rest of the party at the federal level does not have: the power to improve Americans’ lives in a visible way. More than anything else, cynicism about government’s ability to do that is corroding US politics. The best thing Biden can do, morally and politically, is act, as much and as fast as possible, and then talk about it, and do more of it, and talk about it more. (And he should be clear about exactly who stands in the way of bigger, better changes, and why his name is Mitch McConnell.)

The rest of it, he should ignore: the Washington chatter about the latest Republican accusations or catty infighting among Democratic factions, the cable news story or Twitter drama of the day, the latest offensive thing Trump or some Trump surrogate said, all of it. Bulldoze through it.

The president has limited ability to control political discourse and drama, but he has an enormous capacity to change policy and direct resources. Biden should use that power while he has it, without hesitation or apology.

When the Covid-19 pandemic forced much of the US to lock down in the spring of 2020, officials and experts worried the necessary social distancing measures would make another public health crisis — the opioid epidemic — worse. Addiction treatment is traditionally done in person, and restrictions on gatherings and closed businesses would make it much less accessible.

So the federal government responded by easing rules for getting into treatment virtually — making it easier for treatment providers to retain patients and attract new ones. Even before the pandemic, experts had been calling for making treatment easier to get in the US, and the new rules were a big step forward.

But with vaccines for the coronavirus moving through clinical trials and the end of the pandemic in sight, advocates are worried that the old rules will snap back into place — making it harder, once again, to get people into addiction treatment.

Officials relaxed federal rules in several ways. They allowed doctors to prescribe buprenorphine, an evidence-based medication for opioid addiction, over video or audio calls without requiring an in-person evaluation. They also made it easier to prescribe the medication across state lines, which previously required prescribers to be licensed in both states. And they eased rules for take-home doses of methadone, another proven opioid addiction medication, which traditionally is administered daily to patients at an in-person clinic.

State and federal officials also made it possible for public health insurance programs, like Medicare and Medicaid, to pay for telemedicine addiction treatment services. And some places received permission to go further — for example, delivering methadone to patients rather than requiring they pick it up in person.

Providers say the changes really helped. Many of them had to go virtual almost overnight, as the threat of the coronavirus became clear to much of the country. But they had feared they wouldn’t be able to prescribe necessary medications at all, given the arduous rules on such drugs, possibly putting their patients at risk of relapse, overdose, and death.

Things haven’t gone perfectly, but the relaxed rules, providers and experts say, have helped avoid the worst of it.

“It was incredibly challenging [for us], as it was for all providers,” Alexis Geier-Horan, vice president of government relations at the addiction treatment provider CleanSlate, told me. “Thankfully, we really didn’t lose many patients. … That was only possible because of what the federal government did in response to public health emergencies.”

Addiction treatment has long been difficult to access in the US. According to federal data, only 1 in 10 people with a drug use disorder get specialty treatment. Multiple problems play into that treatment gap, including a lack of local providers, high costs, and poor insurance coverage. Much of the treatment provided lacks evidence, or even rejects evidence-based modalities, and can even be downright fraudulent — leaving potential patients resistant to getting care in a broken system.

That’s why, even before the Covid-19 pandemic, activists and providers were calling for making it easier to prescribe addiction medications. Pandemic or not, some patients have always struggled with transportation, or lived in underserved areas that would require a lengthy trip to get treatment. For these patients, getting prescriptions by telemedicine or phone, or simply having to go to a clinic less often for medication, would help.

On the flip side, the patients who now rely on these services to get treatment, regardless of the pandemic, could stand to lose if the relaxed regulations expire. That’s what those in the field are now worried about: If those patients lose their means to treatment, they might give up on it altogether.

That would come at a particularly calamitous time for the opioid epidemic. Even before the pandemic, drug overdose deaths were trending up. But with the pandemic and continuing spread of the potent opioid fentanyl, overdose deaths have skyrocketed this year: On April 2020 (the latest month of data), there were nearly 78,000 drug overdose deaths, based on preliminary federal data — a 13 percent increase from the same time last year, setting up 2020 to be the worst year for overdose deaths ever.

That’s not, advocates and experts say, a sign that the measures easing access to addiction treatment failed, but rather that the measures didn’t and couldn’t go far enough to address a rapidly worsening overdose crisis. While the measures likely helped ease some of the pain brought on by Covid-19, they couldn’t resolve all the hurdles to treatment in America. That’s a case for building on the relaxed rules, not taking them away when the pandemic subsides.

“The stakes are life and death,” Kelly Clark, president of the advocacy group Addiction Crisis Solutions, told me. “We know, absolutely, that people who are taking their maintenance medications like buprenorphine for opioid addiction have a decreased chance of dying prematurely because of their addiction compared to those who aren’t on medications. This is very clear.”

Providers now worry the lax rules could go away soon

Two of the three federally approved medications for opioid addiction, methadone and buprenorphine, are among the most regulated drugs in the country. Methadone is only administered at specialized clinics — requiring patients to go to a clinic as often as daily to get it, and only letting them earn the ability to take some doses home over time. Buprenorphine can be prescribed by a doctor and picked up at a pharmacy, like other medications, but it still requires the prescriber to go through a special certification, and starting a patient required an in-person medical evaluation.

Then the Covid-19 pandemic came, almost immediately making these requirements unfeasible for patients and providers who now had to get and do treatment virtually.

So federal agencies took advantage of the federal public health emergency declared to combat Covid-19 to ease the rules — making telemedicine, including video and audio calls, more feasible for buprenorphine, and easing rules for methadone take-home doses. Local and state agencies followed suit.

But the changes are only in effect until the public health emergency expires. That’s left advocates and providers worried, and they’re increasingly sounding the alarm — as early as possible — to get Congress or other officials to act. They’ve called on federal lawmakers to pass the TREATS Act, which would make many of the rule changes permanent, as soon as possible.

“Speaking for [the American Society of Addiction Medicine], ASAM would love to see the TREATS Act passed with any kind of legislation that goes through during this lame-duck [period], so that we don’t have to face this other unknown coming into the year,” Clark, former president of ASAM and vice chair of the group’s Covid-19 task force, told me.

The typical argument for keeping the old rules comes down to fears of diversion: that the medications will be diverted to a black market for recreational uses. Buprenorphine and methadone are opioids, and, though they’re very effective for treating addiction, they can be misused. So loosening access to either too much, the argument goes, could lead to the drugs ending up in the wrong hands.

As the Drug Enforcement Administration put it, “Under normal circumstances, DEA would not consider the initiation of treatment with a controlled substance based on a mere phone call to be consistent with the framework of the [Controlled Substance Act] given that doing so creates a high risk of diversion.”

Providers take these concerns very seriously, and have adopted a range of practices, such as regular urine screenings, to make sure people are actually taking their medications and not relapsing. Many providers are concerned that loosening the rules too much, and simply doing treatment virtually, could make it harder to prevent diversion.

At the same time, some experts argue that concerns about diversion are overblown. For one, some research suggests that diversion is a result of people not being able to legally obtain buprenorphine or other treatment, forcing them to resort to illegal means of getting the medication. So the stricter regulations could be causing more diversion, not preventing it.

That indicates a balancing act is needed. If it turns out, in the pandemic, that expanding telemedicine for buprenorphine increases access without much more, if any, diversion, then maybe the right balance is more toward a laxer regime than the longstanding laws and rules suggest.

“These agencies are trying to balance the public safety side of making these changes with the public health side,” Geier-Horan, who previously worked on addiction treatment under the Obama administration, said. “From a CleanSlate perspective, the benefit of these things far outweighs those [diversion] concerns.”

Some researchers are working to find out if that’s the case, studying how virtual treatment has worked throughout the pandemic. A JAMA Psychiatry article noted there’s a dearth of research on the role of telemedicine in addiction treatment, including whether it improves access and can be done without significantly increasing diversion.

“That could be really helpful in getting people on board,” Allison Lin, lead author of the JAMA Psychiatry article and an addiction psychiatrist and researcher at the University of Michigan and the VA Center for Clinical Management Research, told me. “We do need more research to provide that data. We don’t have those kinds of answers just yet.”

Short of that, providers are sharing their own experiences, arguing that they’ve been able to maintain a level of care, and even gain some patients, throughout the pandemic despite the obvious disruptions Covid-19 has brought on. But they also worry that losing the new tools they have now could lead to the opposite result once the pandemic is over, fueling a drug overdose crisis that’s already getting worse.

Effective addiction treatment is inaccessible to many Americans

Although the Covid-19 pandemic has in some ways overshadowed it, America’s opioid epidemic is still in full force. It’s in fact gotten worse this year, based on the data we have. The widespread sense of isolation and despair that many people have felt this year, coupled with greater difficulty finding help for such problems as many places close down, has contributed to more drug overdose deaths. Paired with that, the powerful synthetic opioid fentanyl has continued to supplant heroin in more of the illicit market — and in part because it’s so potent, it’s more likely to cause overdoses and deaths.

“While our attention has gone to Covid, and rightly so, our overdose deaths have skyrocketed,” Clark said. “We have to keep overdose deaths on the map.”

One of the key contributors to this crisis all along has been lack of access to evidence-based treatment. Good treatment remains very difficult to get in the US — it can cost tens of thousands of dollars out of pocket, and despite those high costs, it’s still frequently of bad to mediocre quality. One family I spoke to last year told me that they spent $200,000 on treatment before they found something that worked. That’s an extreme example, but it’s not rare, based on the thousands of responses to Vox’s survey about the issue, for people to spend an exorbitant amount on treatment and end up with little to nothing to show for it.

That’s not because evidence-based treatment doesn’t exist. For opioid addiction, the medications are truly proven to work well. Studies show buprenorphine and methadone reduce all-cause mortality among opioid addiction patients by half or more, and they do a far better job of keeping people in treatment than non-medication approaches. There are all sorts of other good treatment modalities for other kinds of addiction, including medications and paying people to stay in treatment (known as contingency management).

But these evidence-based approaches are dramatically underutilized. According to federal data, only 42 percent of the nearly 15,000 facilities tracked by the Substance Abuse and Mental Health Services Administration (SAMHSA) provide any type of medication for opioid addiction. This is largely driven by stigma — the faulty notion that medications replace one drug for another, even though the medications are proven to improve outcomes compared to continuing to use illicit drugs.

So there’s a dearth of providers for evidence-based treatment. When those providers are available, they might not be covered by insurance, and cost thousands out of pocket. If someone has gone to a treatment facility before and ended up with a bad experience due to shoddy, evidence-less care, they also might be skeptical that there’s good help out there at all. That all makes treatment less accessible, and people less receptive to it.

That’s why much of the work to combat the opioid epidemic, from legislation passed by Congress to state efforts to more localized approaches to lawsuits, has gone to expanding access to treatment: If truly effective treatment exists, then it’s just a matter of making sure it’s available to the public.

Along those lines, activists had pushed for more access to telemedicine for years. Of particular concern were underserved areas with few providers — like rural West Virginia, which has a massive overdose crisis and not enough addiction treatment providers to handle demand from patients. Telemedicine can make it easier for existing providers to serve other areas in the state, or even people in other states entirely.

It’s also about expanding the spectrum of care. Every person dealing with addiction is different. Some people are fine with being on medications; some people aren’t. Some will like treatment through Zoom or phone; some won’t. Some have a car; some have no reliable transportation. By offering a variety of options for what care is delivered and how, the hope is fewer people won’t get into treatment because there’s not an option for them.

“It’s not to say everybody should get telehealth, or everybody should get in-person [treatment],” Lin said. “It was just that, before, everybody was in person because that was the only option available.”

Covid-19 has made a lot of things worse, including the opioid crisis. A silver lining to all of this is it’s also given us a big, ongoing experiment to see if a telemedicine model can work for addiction care.

Some providers are now hoping that the eventual end of the pandemic isn’t the end of that experiment — given that it may be helping stave off what’s already the worst drug overdose crisis in American history.

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THE GPA HAVE released a detailed statement this evening as the dispute with the GAA over player expenses continues.

Written by Wexford hurler and GPA National Executive Committee Co-Chair Matthew O’Hanlon, the GPA chief insists it is false to suggest that the group would be happy to allow over training continue.

The statement also questions whether the GAA pursued an honest way to negotiate over the recent charter and that if the GAA allows unlimited training, the players would be financially penalised.

The statement, in full, reads:

“I, like many players, read what GAA Director General Tom Ryan had to say to county boards this week with interest. I have read the reaction to what he had to say and what GPA CEO Tom Parsons has had to say this week too, and I find some of it hard to fathom. So, I want to make some points for clarity.

“Last weekend players took a stand that we would not engage in match day media activity around games. It was a small gesture to highlight player frustration over the ongoing issues around squad charters. It had minimal impact on fans, if any. The GAA’s response was to unilaterally, without the agreement of players, try to impose a squad charter on their terms.

“The GAA have designed this charter, by their account, with player welfare in mind. Again, let’s be clear on this. Last December through to March the GAA came to the negotiating table wanting to retain the cost saving measures players had agreed to during the Covid crisis. Now however, language around player welfare had been conveniently added in.

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“At the time the GAA negotiating team put forward a case that 50 cent per mile for 3 sessions a week and a cap of 32 players was all they could afford. Two months later they posted a profit for 2021 of €13.5 million. Was that an honest way to negotiate?

“That brings me specifically to player welfare. The GAA are now willing to cover 4 sessions per week at 65c. That came about because last week the GPA let them know we would be communicating with all players. 3 sessions were then moved to 4 over the course of 24 hours. Surely if player welfare was the concern here such a move, adding 33% to a training load, would be unthinkable.

“Following on from that, the GAA now want to enforce a charter where 4 sessions are agreed at 65c per mile and then anything above that will need to be negotiated locally by players with county boards. In other words, county boards can allow as many sessions as they want – the GAA would be openly allowing unlimited training, but players would be financially penalised because the GAA accept a reduced mileage rate for sessions above 4.

“This is what some commentators are accusing the GPA of wanting. It’s hard to believe that when Tom Parsons refers to training once or ten times a week to emphasise a point, it is being portrayed that the GPA would be happy to allow such over training. It’s spreading and creating a false picture – deliberately.

“To put an end to that I’ll say this. Back as far as January, separate to the charter negotiations, the GPA’s Player Welfare Manager Colm Begley discussed a working document with the GAA’s Sports Science Group looking at the area of contact hours. In it, recommendations are made on the required number of sessions a player would train at each stage of the season. Colm will be presenting to the GAA group on March 30th on this matter, an arrangement again made back in January. This is with a view to getting expert scientific and medical input to add to that already gathered by the GPA.

“This policy concept was proposed to the GAA charter negotiating team on December 16th via a memo as a means of using sports science to identify the required number of sessions per week as it varies from pre-season to in-season and from Rookie to late career players. It would not just be done by picking an arbitrary number like 3 out of the air and then moving that to 4 at a whim last week.

Statement on behalf of Matthew O'Hanlon, GPA National Executive Co-Chair and Wexford hurler, on Player Charter situation with GAA.https://t.co/HxODXDC6Fp

— GPA (@gaelicplayers) March 16, 2022

“For clarity, the working document outlines situations where 5 sessions a week might be needed in pre-season. During the playing season and a de-load week for example, sports science indicates 3 sessions a week is adequate for performance.

“As part of the negotiations with the GAA, the GPA proposed that this is the policy that should be used as the means of regulating sessions, rooted in sports science and with player welfare actually to the fore. It’s our view that all parties, players, managers and county boards, should then sign off on a Contact Hours Policy that indicates the optimum number of sessions allowable for all players on the squad. The mileage rate and claimable expenses by players cannot be the mechanism to do this; it’s a point of principle.

“Players are not looking to be paid expenses for unlimited sessions; they are just looking for all squad members (not just the 32) to be reimbursed for all the sessions they take part in at the same rate of 65c. Players, through the GPA, have proposed how to properly regulate sessions using scientific expertise. That should be signed off by all and policed by the GAA to ensure County Boards and managers are adhering to it.

“Players are still open and willing to go back to the negotiating table based on the above. It would be fair, based on expertise and would likely not cost the GAA anything more than what they are trying to impose.

“The key difference – players would not be used by the GAA as a cost control measure. If they actually have player welfare in mind, then it’s a no-brainer to use a Contact Hours Policy.

“Revert to the 2019 charter and let’s sort this out with a Contact Hours Policy initiative as proposed by the players body in December of 2021.”