“Oh, my God, it smells so good!” Sierra, 39, said of the bounty she’d just picked up at a food pantry, pulling out a ready-made salad and a container of soup.

Sierra unpacked the donated food and planned lunch for Rachell and her siblings, ages 9 and 2, as a reporter watched through FaceTime. She said she doesn’t know what they’d do without the help.

The family lives in Bergen County, New Jersey, a dense grouping of 70 municipalities opposite Manhattan with about 950,000 people whose median household income ranks in the top 1% nationally. But Sierra and her husband, Aramon Morales, never earned a lot of money and are now out of work because of the pandemic.

The financial fallout of covid-19 has pushed child hunger to record levels. The need has been dire since the pandemic began and highlights the gaps in the nation’s safety net.

While every U.S. county has seen hunger rates rise, the steepest jumps have been in some of the wealthiest counties, where overall affluence obscures the tenuous finances of low-wage workers. Such sudden and unprecedented surges in hunger have overwhelmed many rich communities, which weren’t nearly as ready to cope as places that have long dealt with poverty and were already equipped with robust, organized charitable food networks.

Data from the anti-hunger advocacy group and the U.S. Census Bureau shows that counties seeing the largest estimated increases in child food insecurity in 2020 compared with 2018 generally have much higher median household incomes than counties with the smallest increases. In Bergen, where the median household income is $101,144, child hunger is estimated to have risen by 136%, compared with 47% nationally.

That doesn’t mean affluent counties have the greatest portion of hungry kids. An estimated 17% of children in Bergen face hunger, compared with a national average of around 25%.

But help is often harder to find in wealthier places. Missouri’s affluent St. Charles County, north of St. Louis, population 402,000, has seen child hunger rise by 69% and has 20 sites distributing food from the St. Louis Area Foodbank. The city of St. Louis, pop. 311,000, has seen child hunger rise by 36% and has 100 sites.

“There’s a huge variation in how different places are prepared or not prepared to deal with this and how they’ve struggled to address it,” said , assistant professor of public health nutrition at Harvard University. “The charitable food system has been very strained by this.”

Eleni Towns, associate director of the , said the pandemic “undid a decade’s worth of progress” on reducing food insecurity, which last year threatened at least 15 million kids.

And while President Joe Biden’s covid relief plan, which he signed into law March 11, promises to help with anti-poverty measures such as monthly payments to families of up to $300 per child this year, it’s unclear how far the recently passed legislation will go toward addressing hunger.

“It’s definitely a step in the right direction,” said , director of the Rudd Center for Food Policy and Obesity at the University of Connecticut. “But it’s hard to know what the impact is going to be.”

Need Grows in Places of Plenty

After the pandemic struck, the federal government boosted benefits from the Supplemental Nutrition Assistance Program and offered Pandemic Electronic Benefit Transfer cards to compensate for free or reduced-price school meals while children were schooled from home.

Sierra’s family saw their SNAP benefits of about $800 a month rise slightly and got two of those P-EBT payments, worth $434 each. But at the same time, they lost their main sources of income. Sierra had to leave her Amazon warehouse job when the kids’ school went remote, and Morales stopped driving for Uber when trips became scarce and he feared getting covid on top of his asthma.

Federal relief wasn’t enough for them and many others. So they flocked to food pantries.

In theory, pantries and the food banks that supply them are part of an emergency system designed for short-term crises, Schwartz said. “The problem is, they’ve actually become a standard source of food for a lot of people.”

In Bergen County, the Center for Food Action helped 40,500 households last year, up from 23,000 the year before. In Eagle County, Colorado, where the tony ski resort Vail is located, the Community Market food bank saw its client load nearly quadruple to 4,000. And outside Boston, in the affluent Massachusetts county of Norfolk — where Feeding America data shows child hunger jumped from an estimated 6% of kids to 16% — Dedham Food Pantry’s clients tripled to 1,800.

“This is just out of control compared to other times,” said Lynn Rogal, vice president of the Dedham pantry, which opened in 1990.

Pantry managers said a disproportionate number of clients are from minority groups. Many lost jobs in the eviscerated service sector that undergirds the wealthier parts of their counties. Julie Yurko, CEO of the , said up to half of her current clients have never sought help before.

“In early January, we had a white minivan pull up with three kids, 5 and younger. It ran out of gas sitting there,” Yurko said. “The mom was sobbing, and her beautiful children were sitting there watching her.”

Kelly Sirimoglu, spokesperson for New Jersey’s Center for Food Action, said the stigma around seeking help can be worse in wealthy areas. She said some people tell her, “I never thought I would be in line for food.”

Advocates said the reluctance to seek help means the need is likely even larger than it appears.

Katie Wilson of St. Charles, Missouri, said she heard about a food pantry run by the from a friend of a friend. She almost didn’t go. The single mom of two children, 11 and 9, lost her job as a hotel auditor in June and tried to squeak by without her income for two months.

“We found ourselves in a situation where it was a ‘heat or eat’ kind of thing,” said Wilson, 42, describing having to choose between heating her home or buying food. “It took me looking around and saying, ‘There is nothing to eat.’”

Struggling to Meet the Need

As hunger has become more visible, donations to food charities have risen. But they don’t address the core problem of an infrastructure that doesn’t match the new need. Some pantries are open just a few hours a week in church basements, a far cry from those that operate regularly and look like supermarkets. Many small pantries struggled to shift to outdoor food distribution during the pandemic or find new helpers when the few, often senior, volunteers felt unsafe doing the work.

“It definitely is harder in these places,” said Yurko, whose food bank distributes to Kendall County, Illinois, which has just three pantries for its population of 129,000. “The safety nets are not as robust.”

A strong safety net also requires pantries to cooperate with one another and the broader array of local social services. That’s been happening for years in Flint, Michigan, said Denise Diller, executive director of , which runs a pantry. Agencies and community leaders banded together in 2014 when lead poisoned the drinking water.

“When covid occurred, we were already kind of ready,” Diller said.

So was Atlanta. As in Flint, hunger was never hidden there; 15% of children in Fulton County, which includes Atlanta, faced hunger before the pandemic. After covid suspended volunteer shifts, the Atlanta Community Food Bank asked the Georgia National Guard to help sort, pack, warehouse and deliver food to help meet the needs of the estimated 22% of kids experiencing hunger. The food bank also partnered with seven school districts on more than 30 mobile pantries.

Such coordination and connections were lacking in Bergen County, where 80 pantries worked mostly in isolation when the pandemic hit, County Commissioner Tracy Zur said. “They weren’t collaborating. They were going along the same path they had for decades,” she said. “There was this need to break out of the old way of doing things and work together to be more impactful.”

Zur spearheaded the creation of a food security task force in July, reaching out to municipal and faith leaders. Goals include feeding people, connecting them to other services and turning some emergency food programs into full-fledged pantries. “Building an infrastructure is painstaking and ongoing,” she said.

Now, Zur said, pantries are starting to share with one another when one gets a large donation of perishable items such as eggs or milk.

With the need so widespread, residents do much the same.

During a recent pantry trip, Sierra, the New Jersey mom, opened the trunk of her 1999 Toyota and rummaged through the two big boxes volunteers had just placed there. She pointed to eggs, chicken, bread, butter, cheese and apples, observing, “I have more than I need.”

But she said it would never go to waste. Any extra would go to neighbors and their hungry children.

Midwest correspondent Cara Anthony and data editor Elizabeth Lucas contributed to this story.

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“We’re looking forward to having a season,” said the 18-year-old catcher for Dublin Coffman High School, outside Columbus, Ohio. “This game is something we really love.”

Kassis, whose team has started practices, is one of the millions of young people getting back onto ballfields, tennis courts and golf courses amid a decline in covid cases as spring approaches. But pandemic precautions portend a very different season this year, and some school districts still are delaying play — spurring spats among parents, coaches and public health experts across the nation.

Since fall, many parents have rallied for their kids to be allowed to play sports and objected to some safety policies, such as limits on spectators. Doctors, meanwhile, haven’t reached a consensus on whether contact sports are safe enough, especially indoors. While children are less likely than adults to become seriously ill from covid, they can still spread it, and those under 16 can’t be vaccinated yet.

Less was known about the virus early in the pandemic, so high school sports basically stopped last spring, starting up again in fits and spurts over the fall and winter in some places. Some kids turned to recreational leagues when their school teams weren’t an option.

But now, according to the , public high school sports are underway in every state, though not every district. Schedules in many places are being changed and condensed to allow as many sports as possible, including those not usually played in the spring, to make up for earlier cancellations.

Coaches and doctors agree that playing sports during a pandemic requires balancing the risk of covid with benefits such as improved cardiovascular fitness, strength and mental health. School sports can lead to college scholarships for the most elite student athletes, but even for those who end competitive athletics with high school, the rewards of playing can be extensive. Decisions about resuming sports, however, involve weighing the importance of academics against athletics, since adding covid risks from sports could jeopardize in-person learning during the pandemic.

Tim Saunders, executive director of the and coach at Dublin Coffman, said the pandemic has taken a significant mental and social toll on players. In a May survey of more than 3,000 teen athletes in Wisconsin, University of Wisconsin researchers found that about and the same portion reported symptoms of depression. Other studies have shown similar problems for students generally.

“You have to look at the kids and their depression,” Saunders said. “They need to be outside. They need to be with their friends.”

Before letting kids play sports, though, the Centers for Disease Control and Prevention said, coaches and school administrators should consider things like students’ underlying health conditions, the physical closeness of players in the specific sport and how widely covid is spreading locally.

Karissa Niehoff, executive director of the high school federation, that spring sports should be available to all students after last year’s cancellations. She said covid spread among student athletes — and the adults who live and work with them — is correlated to transmission rates in the community.

“Sports themselves are not spreaders when proper precautions are in place,” she said.

Still, outbreaks have occurred. A January report by CDC researchers pointed to a high school wrestling tournament in Florida after which . (Fewer than half were tested.) The report’s authors said outbreaks linked to youth sports suggest that close contact during practices, competitions and related social gatherings all raise the risk of the disease and “could jeopardize the safe operation of in-person education.”

Dr. , an infection control expert in Kentucky who runs the national patient safety group Health Watch USA, said contact sports are “very problematic,” especially those played indoors. He said heavy breathing during exertion could raise the risk of covid even if students wear cloth masks. Ideally, he said, indoor contact sports should not be played until after the pandemic.

“These are not professional athletes,” Kavanagh said. “They’re children.”

A released in January by University of Wisconsin researchers, who surveyed high school athletic directors representing more than 150,000 athletes nationally, bolsters the idea that indoor contact sports carry greater risks, finding a lower incidence of covid among athletes playing outdoor, non-contact sports such as golf and tennis.

Overall, “there’s not much evidence of transmission between players outdoors,” said Dr. Andrew Watson, lead author of the study, which he is submitting for peer-reviewed publication.

Dr. , a pediatrics professor at Washington University in St. Louis, said all sorts of youth sports, including indoor contact sports such as basketball, can be safe with the right prevention measures. He supported his daughter playing basketball while wearing a mask at her Kirkwood, Missouri, high school.

Doctors also pointed to other safety measures, such as forgoing locker rooms, keeping kids 6 feet apart when they’re not playing and requiring kids to bring their own water to games.

“The reality is, from a safety standpoint, sports can be played,” Newland said. “It’s the team dinner, the sleepover with the team — that’s where the issue shows up. It’s not the actual games.”

In Nevada’s Clark County School District, administrators said they’d restart sports only after students in grades 6-12 for in-person instruction as part of a hybrid model starting in late March. Cases in the county have in recent weeks, from a seven-day average of 1,924 cases a day on Jan. 10 to about 64 on March 3.

In early April, practices for spring sports such as track, swimming, golf and volleyball are scheduled to begin, with intramural fall sports held in April and May. No spectators will be allowed.

Parents who wanted sports to start much earlier created , one of many groups that popped up to protest the suspension of youth athletics. The Nevada group rallied late last month outside the Clark County school district’s offices shortly before the superintendent announced the reopening of schools to in-person learning.

Let Them Play Nevada organizer Dennis Goughnour said his son, Trey, a senior football player who also runs track, was “very, very distraught” this fall and winter about not playing.

With the reopening, he said, Trey will be able to run track, but the intramural football that will soon be allowed is “a joke,” essentially just practice with a scrimmage game.

“Basically, his senior year of football is a done deal. We are fighting for maybe one game, like a bowl game for the varsity squad at least,” he said. “They have done something, but too little, too late.”

Goughnour said Let Them Play is also fighting to have spectators at games. Limits on the numbers of spectators have riled parents across the nation, provoking “a ton of pushback,” said Niehoff, of the high school federation.

Parents have also objected to travel restrictions, quarantine rules and differing mask requirements. , Florida, hundreds of parents signed last fall against mandatory covid testing for football players.

Students, for their part, have quickly adjusted to pandemic requirements, including rules about masks, distancing and locker rooms, said , assistant executive director of the Illinois High School Association.

Kassis, the Ohio baseball player, said doing what’s required to stay safe is a small price to pay to get back in the game.

“We didn’t get to play at all last spring. I didn’t touch a baseball this summer,” he said. “It’s my senior year. I want to have a season and I’ll be devastated if we don’t.”

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The nominee to be Montana’s next health director faced an unwieldy disease outbreak and pushed Medicaid work requirements — two issues looming in Montana — when he held a similar job in Kentucky.

Montana senators will soon decide whether to confirm Adam Meier, Republican Gov. Greg Gianforte’s for director of the state Department of Public Health and Human Services. He would earn leading Montana’s , which oversees 13 divisions and is a leader in the state’s pandemic response.

Gianforte is confident Meier “will bring greater transparency, accountability, and efficiency to the department as it serves Montanans, especially the most vulnerable among us,” Brooke Stroyke, a governor’s office spokesperson, said in an emailed statement.

For many Montana officials and health care industry players, the focus is on Montana’s future, not Kentucky’s past. But it can be instructive to see how Meier handled similar issues in his prior role, which he held from May 2018 through December 2019.

Some have praised the job he did in Kentucky, including his spearheading of a program that would have created work requirements in the state’s Medicaid program. But others criticized those proposed changes as well as his handling of a large hepatitis A outbreak that spread through rural Appalachia starting in 2017, ultimately sickening more than 5,000 Kentuckians and killing 62. The details of the state’s response to the outbreak came to light after in 2019.

“The hep A response is probably one of the darkest or most concerning things he did when he was in Kentucky. He also didn’t perform well in my eyes on other issues,” said , an assistant professor at Pennsylvania State University who studies politics, health care and public policy. “He didn’t do so well in Kentucky, so I don’t know how well he’s going to do in Montana.”

Dr. , a retired Kentucky physician who runs the national watchdog group Health Watch USA, is among those who said Meier and his team needed to do more early on to curb the hepatitis outbreak as it made its way into Appalachia. Kavanagh said Meier’s handling of the outbreak provides a window into how he might handle the covid crisis in Montana.

“But it could be a learning opportunity if failed strategies are corrected,” Kavanagh said. “The biggest question is: What did he learn in Kentucky?”

During Meier’s confirmation hearing before Montana’s Senate Public Health, Wellness and Safety Committee, the nominee said one lesson he learned was to invest in public health infrastructure. Because hepatitis A was spreading in rural Kentucky mountains, he said, standard outreach to vulnerable populations in settings like homeless shelters didn’t work. Instead, health officials started vaccinating people at convenience stores.

“One of the things I’ve learned there is, you have to be creative about how you reach folks,” Meier said.

Kentucky’s outbreak first centered in Louisville, where a more than 200-person health department was able to administer tens of thousands of vaccines against the highly contagious liver infection caused by a virus. The Centers for Disease Control and Prevention .”

But in spring 2018, the disease began to spread in Appalachia, which had thinly staffed county health departments.

Dr. Robert Brawley, then the state’s chief of infectious diseases, sounded the alarm to his bosses. Brawley asked state officials to spend $10 million for vaccines and temporary health workers. Instead, the acting public health commissioner, Dr. Jeffrey Howard, sent $2.2 million in state funds to local health departments. Brawley called the response “too low and too slow.”

In the months that followed, the outbreak metastasized into the nation’s largest.

Howard’s decisions at the time and the agency’s response. In Meier’s Feb. 10 Montana hearing, he said Kentucky lacked the infrastructure to buy $10 million worth of vaccines, and they would have gone bad anyway because the state didn’t have the necessary storage. Brawley’s proposal had called for sending $6 million to health departments to buy vaccines, however, and $4 million for temporary health workers.

“The ‘too low and too slow’ response to the hepatitis A outbreak in Kentucky, reported in The Courier Journal, may be an albatross around his neck for a long time,” Brawley, who resigned in June 2018, said of Meier in an email.

Montana’s Democratic Party cited the hepatitis A outbreak when Meier was nominated for the Treasure State job in January, him as unsuitable.

The health department declined KHN’s request for an interview with Meier but provided letters from local Kentucky officials written in 2019. Allison Adams, public health director of Buffalo Trace District Health Department in Kentucky, defended the state’s actions in one February 2019 letter, arguing Kentucky’s leadership “made sound decisions regarding the support and known resources available.”

Meier has pitched himself as someone who works well with others, bolstered Kentucky’s family services and cut through the state’s bureaucracy.

Meier, an attorney, lived in Fort Thomas, Kentucky, near Cincinnati, with his wife and three children, where he served on the City Council just before being named deputy chief of staff for former Gov. Matt Bevin in 2015. After leaving Kentucky’s health Cabinet, he worked as a policy consultant with .

During Meier’s confirmation hearing before Montana lawmakers, Erica Johnston, operations services branch manager for the health department, said she was already impressed by his knowledge of the agency’s programs and ideas for changes. Past colleagues said he listened to those he oversaw. John Tilley, a former Democratic Kentucky representative who served as the state’s former head of Kentucky’s Justice and Public Safety Cabinet, called Meier a problem-solver.

“What I got in Adam was this refreshing take on government, this less than bureaucratic take,” Tilley testified.

While deputy chief of staff for Bevin, Meier oversaw the development of a Medicaid overhaul plan called Kentucky HEALTH, which would have required recipients who were ages 19-64 and without disabilities to work or do “engagement” activities such as job training or community service.

Bevin, a Republican who, like Gianforte, joined politics after making a fortune in business, described the effort as a way to ensure the long-term financial stability of Medicaid and prepare enrollees to transition to private insurance. In Meier’s Montana hearing, he said the goal was for Medicaid recipients to be linked to employment and training. Kentucky opponents said the program would have caused people to lose coverage and increase the state’s administrative burden.

That debate is familiar in Montana, where lawmakers approved work requirements for people who joined Medicaid under its expansion. The work rules are awaiting federal approval.

Kentucky’s requirements never took effect. They were authorized by a federal waiver but were tied up in legal challenges until the state’s current Democratic Gov. Andy Beshear rescinded the rules.

Still, Meier has said Medicaid’s enrollment dropped during his leadership and benefits remained steady for those who stayed on the rolls. That drop paralleled an in Medicaid enrollment that lasted through 2019.

Penn State’s Haeder, who observed Meier’s tenure, criticized Meier’s support for Medicaid work requirements, saying “excessive amounts of data show how detrimental they are to public health” because vulnerable people lose coverage.

, executive director for the Behavioral Health Alliance of Montana, said work restrictions aren’t a good model for Medicaid. But she said it isn’t surprising Meier has been in favor of those steps, given Montana’s recent efforts.

Even so, Windecker is optimistic when she talks about Meier’s confirmation. She said she’s thrilled he has experience with another state health agency.

“These are very complicated systems to run,” Windecker said. “If you understand health care, you stand a better shot at getting this.”

The Montana Senate has to take up Meier’s confirmation, which moved out of a committee Feb. 17.

While Meier awaits confirmation, he is already engaged in the state’s covid vaccine efforts and is working on the agency’s daily tasks, department spokesperson Jon Ebelt said in a statement. Meier is “focused on the job at hand,” Ebelt said.

Houghton, Montana correspondent, reported from Missoula. Ungar, Midwest editor and correspondent, reported from Louisville and formerly worked for The Courier Journal.

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But the coronavirus is spreading too quickly to open schools in Alameda County, based on the current state standards. And the local teachers union hasn’t agreed to go back — even after teachers have been vaccinated. So she expects her kids will be logging on to school from home for a while.

“The impediments to opening are just too great,” said Bacigalupi, who is lobbying California lawmakers to establish firm, statewide health metrics that, once met, would require schools to open. “In the end, it comes down to a lack of political will to get the kids back in the classroom.”

Parents across the country, many of whom relied on schools to care for their children while they worked, are frustrated and angry that remote instruction has gone on so long, even as grocery store clerks, city bus drivers and other essential workers have braved the risks of their workplaces. Lawmakers are increasingly joining their calls to get kids into classrooms, citing the loss of worker productivity and parents’ concerns about the social, emotional and academic effects on children.

President Joe Biden has to open most schools within his first 100 days in office if Congress provides funding, and if states and cities adopt safety steps.

But that will be a herculean task. Nearly one year into the pandemic, fewer than half of students are attending schools that are teaching in person every day, and the question of how and when to get kids back into classrooms often depends less on science than politics — including the strength of local teachers unions.

The Centers for Disease Control and Prevention concluded that schools can reopen safely if their communities have low levels of the virus and they adhere strictly to measures such as requiring everyone to stay 6 feet apart and wear masks.

But in numerous communities, those basic measures haven’t been followed, even before the vaccine rollout — and many teachers aren’t convinced they will be safe on campus.

With infection rates starting to decline nationally, many parents, superintendents, school boards and politicians insist this is the moment to stop striving for perfection and embrace the health measures necessary to get kids into classrooms safely. Some are even taking dramatic measures, such as the city of San Francisco, which Wednesday to force it to open.

The same day, CDC Director Dr. Rochelle Walensky that schools can safely reopen even if teachers aren’t yet vaccinated.

“If we wait for the perfect, we might as well just pack it up and just be honest with folks that we’re not going to open for in-person instruction in the school year,” Democratic California Gov. Gavin Newsom recently — breaking with the politically powerful California Teachers Association, which wants all teachers vaccinated before reopening.

Teachers Fear for Safety

In many states, teachers lobbied to be among the first to be vaccinated after health care workers and nursing home residents. But they also argue the vaccines alone are not enough to open schools. They want low levels of community spread. They want as many school staffers as possible vaccinated, which could take months. And they want assurances that schools won’t relax masking, physical distancing and other safety measures.

“We’ve had concerns about some districts being more lax even before the vaccine,” said , president of the Ohio Education Association, the state’s largest teachers union.

Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School, agreed that health measures must be enforced even after vaccination.

“It’s unfortunate that people think life goes back to normal, that once we get the vaccine, the masks come flying off,” he said. “Vaccination doesn’t take things back to normal.”

That’s because there are still unknowns about the vaccines: It’s unclear if vaccinated people can transmit the virus. Plus, not all adults can get a vaccine (for medical reasons), and about 5% of those who receive the Moderna or Pfizer-BioNTech versions might not be fully protected. Kids are another matter entirely: No covid vaccine has yet been approved for use in children younger than 16.

Teachers say they feel especially vulnerable when the virus is running rampant in a community, but health experts don’t agree on exactly what that means.

“We don’t know a definite threshold,” said Dr. , medical director of infection prevention and antimicrobial stewardship at Keck Medicine of the University of Southern California.

In Montgomery, Alabama, four educators died within 48 hours in January, spurring the city’s district to .

“We have educators who are dying from this. We know they’re taking it home,” said Theron Stokes, associate executive director of the teachers union.

The Politics of Reopening

As of late January, about 38% of K-12 public school students attended virtual-only schools, 38% attended in-person schools, and 24% attended hybrid schools that offered a mix of both, according to , a company tracking a representative sample of 1,200 school districts.

Decisions about returning to school have often been driven by ideology in the absence of firm scientific guidance about community spread.

Politics plays as big a role as health, said , practitioner-in-residence at the Center on Reinventing Education, a nonpartisan research center that has tracked 477 school districts since March. “Because the pandemic became so politicized, districts found themselves in political debates in their own communities.”

For instance, some politically motivated decisions to reopen schools were made despite dangerous surges in covid cases over the summer. In Texas, Republican Gov. Greg Abbott told schools in July they’d have to transition to in-person education after the state attorney general declared “” school closures unlawful. In Florida, Republican Gov. Ron DeSantis threatened to withhold state funding from schools that did not reopen in person.

In Democratic strongholds such as and , powerful unions have protested and delayed school reopenings.

Union opposition played a part in the Oakland school district’s decision to stick with remote-only learning in the fall, which boggled Bacigalupi’s mind because covid cases had dropped after the summer surge. At the time, restaurants, gyms and hair salons in her county were allowed to partially reopen, and some schools in neighboring counties had also opened.

“One of the reasons it’s so frustrating is that we can look at so many places and we see tens of thousands of kids back in school,” said Bacigalupi, whose children, ages 5 and 8, have been out of school for nearly a year. “I’m also just sad. And the sadness gets worse as you see what’s happening to your kid. It’s harming them.”

Bacigalupi said her second grader is like a different child — he’s quick to anger and struggles to regulate his emotions. He now gets counseling once a week.

Balancing Risks

Under pressure, more schools are reopening by the day. , city schools returned to a hybrid model of in-person and remote learning this month after a judge dismissed a teachers union lawsuit seeking to delay reopening.

Public health officials say districts must acknowledge that holding school in person is a calculated risk, and take concrete steps to minimize the danger for staff members and kids. These include separating desks in classrooms — even if that means holding class in a gymnasium — erecting plexiglass barriers where possible and limiting school sports.

“Implementing a combination of all of these layered approaches will make it a lot safer,” said , an assistant professor of environmental health sciences at the Yale School of Public Health, which last year issued to help schools determine when to reopen.

For example, the Los Angeles Unified School District, the second largest in the country, has taken a number of measures, including installing upgraded air filters, purchasing an ionized cleaning system to sanitize surfaces and rearranging furniture in classrooms, said , president of the school board.

But like the local and state teachers unions and the district superintendent, Gonez believes the rampant spread of covid in the region must be addressed first.

“Once the broader covid conditions are in a safer place in the community, I think we will be ready,” Gonez said. “We have the protocols in place to do this successfully.”

On Wednesday, the local American Academy of Pediatrics chapter that schools should reopen immediately because the social isolation, anxiety and lack of structure are “causing undue harm” to children.

“‘Safe’ is a relative term,” said Schleiss, the Minnesota professor. “Continuing to attend school with careful monitoring is reasonable. We don’t want the perfect to be the enemy of the good.”

This story was produced by , which publishes , an editorially independent service of the .

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“I’m concerned,” said Lebo, who teaches at Avon High School in the Indianapolis suburbs. “We’re not controlling the virus in our county. We’re not controlling it in our state. And we’re not controlling it in our schools.”

President Joe Biden’s covid response proposes $130 billion to improve school safety, offers federal guidance for making schools safer and improves workplace protections to safeguard teachers and other workers from covid.

This comes after many school districts and states holding in-person classes have ignored recommendations from public health officials or written their own questionable safety rules — creating a tinderbox where covid can sicken and kill.

A KHN analysis of federal and state Occupational Safety and Health Administration data found more than 780 covid-related complaints covering more than 2,000 public and private K-12 schools. But those pleas for help likely represent only a small portion of the problems, because a federal loophole prevents public school employees from lodging them in for local and state employees. Still, the complaints filed provide a window into the safety lapses: Employees reported sick children coming to school, maskless students and teachers less than 6 feet apart, and administrators minimizing the dangers of the virus and punishing teachers who spoke out.

KHN also found that practices contradicting safety experts’ advice are codified into the patchwork of covid rules put out by states and districts. For instance, about half of states don’t require masks for all students — including 11 that have exempted schoolchildren of various ages from mandatory masks, with New Hampshire excluding all K-12 students. Districts can craft stricter rules than their states but often don’t.

“The response to the virus has been politicized,” said Dr. , an expert in pediatric infectious diseases at the Indiana University School of Medicine. “There’s a willingness to ignore data and facts and go with whatever you’re hearing from the internet or from political leaders who don’t have any scientific knowledge.”

But even with Biden’s rollout of new school safety steps, struggles over balancing the need for education with covid safety are sure to continue, since it will be months before the nationwide vaccine rollout reaches all school staff members, and the shots haven’t yet been approved for kids.

Meanwhile, the scope of covid in schools remains unknown. Biden’s order calls for tracking it on the federal level, which wasn’t happening. States haven’t collected uniform data either. The , a project launched by volunteers and public health researchers, has counted more than 505,000 cases in K-12 schools — more than a quarter of them among staffers. Although kids are less likely than adults to become seriously ill, suggests they can spread the virus even if asymptomatic. The American Federation of Teachers estimates covid-19 has killed at least 325 school employees, though it’s unclear whether they caught it at school.

Among them was Susanne Michael, 47, a fourth grade teacher at Harrisburg Elementary School in northeastern Arkansas. As a cancer survivor with diabetes, she rarely went anywhere outside her home this past fall, according to her husband, Keith. She told him she worried about catching the coronavirus while teaching, but she “went and did it because she loved it.”

She tried her best to keep more than 20 students 6 feet apart, he said, but told him it was nearly impossible.

Though she always wore a mask, he doesn’t know if every student did. According to the district’s , masks are required in grades 4-12 “when social distancing is not feasible,” and “physical distancing will be practiced to the extent practical.” District leaders did not respond to requests for comment.

Michael wound up hospitalized on a ventilator. Doctors let her husband visit in protective gear because he, too, had the virus. He held her hand as she slipped away Oct. 1.

The loss hits him hardest at night. “For 27 years, I always had somebody there next to me,” he said. “It’s difficult and weighs on your mind and heart a lot when you’re laying there in an empty bed and your best friend’s gone.”

She left five children, ages 3 to 22, including a former student and her two siblings adopted in July.

A Litany of Lapses

Doctors said covid risks can be drastically reduced by following straightforward safety practices.

“First and foremost, mask mandate, mask mandate, mask mandate,” said Dr. Jason Newland, a pediatrics and infectious diseases professor at Washington University in St. Louis.

But school employees across the nation complain such measures don’t exist or aren’t enforced.

“School officials openly scoff at covid-19 and believe it is a hoax. This attitude trickles down to staff, so hardly anyone has been wearing their mask or wearing it correctly,” an unidentified employee of Hart Public Schools, in rural western Michigan, wrote in an OSHA complaint in September. The complaint also described large crowds of students sitting too close in cafeterias. The employee alleges being terminated for whistleblowing.

Hart Superintendent Mark Platt said in an email that he won’t comment on personnel matters, but “takes seriously its health and safety protocols for students and staff.” The district’s covid requires staffers and older students to wear masks in classrooms, common areas and buses, while K-5 students must wear them everywhere except in their own classrooms with their own class.

At the public Avon Community School Corp. in Indiana, Lebo said, problems festered since the beginning of the fall semester in July, when an OSHA complaint was lodged. In addition to crowding in the halls and difficulty keeping students 6 feet apart in classrooms, Lebo said, the school’s many extracurricular activities — including football, wrestling and show choir — brought their own risks.

Avon schools spokesperson Kevin Carr wouldn’t comment except to say students and staff members have tried their best to abide by the district’s health and safety protocols.

Over the semester ending in December, Avon schools reported 346 covid cases among nearly 9,800 in-person students and staffers, a rate of 3.5% compared with 2.1% for 1,412 remote learners. The covid rate reached 5.5% at the high school, which went remote briefly in the fall after the number of people quarantining skyrocketed.

Like the vast majority of school OSHA complaints, the one about Avon was closed without an inspection. Across all industries, , just a small percentage of pandemic-related complaints have led to inspections or fines.

A Biden executive order on worker safety calls for OSHA to bolster enforcement and work with states and local governments to ensure workers, including those in the public sector, are protected from covid.

Without strong laws, “workers are facing big challenges: Do I speak up? Do I show up to work?” said Rebecca Reindel, director of occupational safety and health for the AFL-CIO. “They’re making a decision between needing a paycheck and risking bringing the virus home.”

Varied, Questionable Guidance

That decision gets even harder when potentially unsafe practices are written into official recommendations.

Missouri and Iowa, for example, advise that students exposed to covid don’t need to be quarantined as long as infected and exposed children are both wearing masks correctly — which goes against Centers for Disease Control and Prevention advice to quarantine anyone who has had close contact with a person who has the virus.

Some districts in South Carolina, Tennessee, Florida and Nebraska — with green lights from the Trump administration and their states — classified teachers as “critical infrastructure workers,” allowing them to keep working after exposure if they don’t develop symptoms.

A superintendent in Billings, Montana, told administrators in October to “disrupt the 15-minute timeline” required to be deemed a close contact “through movement, distancing or masking.” Following media reports, saying he hadn’t intended to “game the system” and no one should move students to avoid quarantines.

In many communities, mask rules are lax.

In Missouri, where there’s no statewide mask rule, Ozark School District requires them only “when social distancing is not an option,” according to its website, which describes spacing desks and using barriers to give people a “break” from masks.

Lakeland Joint School District in Idaho recommends masks when physical distancing isn’t possible. Dacia Chaffee, parent of an eighth grader and a high school freshman in the district, said “it’s almost like normal,” with few students wearing masks. Her kids don’t either, she said; they don’t want to stand out.

Public health experts said making schools safer will require clear, consistent data and guidance — and political will. They said governments also need to give public schools enough resources to keep more than 50 million students and 3.2 million teachers safe. A estimated that the cost of covid mitigation measures for the 2020-21 school year ranges from $55 per student for items such as masks, plexiglass barriers and face shields to $442 per student with added custodians and transportation, such as buses and drivers, to allow for better physical distancing.

And crucially, experts said, covid policies for schools must be rooted in science, not politics.

“Behaviors and attitudes flow from the top down,” said Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School. “We have to hold people accountable. This is a life-and-death situation.”

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Nowhere on the list of prioritized recipients are public officials’ spouses.

Yet the first ladies of Kentucky and West Virginia; Republican Vice President Mike Pence’s wife, Karen Pence; Democratic President-elect Joe Biden’s wife, Jill Biden; and Vice President-elect Kamala Harris’ husband, Doug Emhoff, were among the first Americans to get the potentially lifesaving shots.

Kentucky also vaccinated six former governors and four former first ladies, including current Democratic Gov. Andy Beshear’s parents.

The early vaccinations of political spouses spurred outrage on social media, with several Twitter users  they should not be able to “jump the line” ahead of doctors, nurses and older people.

In most of the 29 states that responded to KHN inquiries of all 50 governors’ offices, top elected officials said they — and their spouses — will be vaccinated but have chosen to wait their turn behind more vulnerable constituents. Some Congress members from both parties said much the same when they refused early doses offered in the name of keeping the government running. Those weren’t offered to their spouses.

Governors who got the shots along with their spouses, and the vice president’s office, said they wanted to set an example for residents, build trust, bridge ideological divides and show that the vaccine is safe and effective.

But that’s a rationale some critics don’t buy.

“It looks more like cutting in line than it does securing trust. The politicians can get the hospitals to give it to them under this illusion of building trust. But it’s a façade,” said , a bioethics professor and founding head of the medical ethics division at New York University Grossman School of Medicine. “People might say: ‘Yup, typical rich people. They can’t be trusted.’ This undermines what they set out to do.”

Besides, Caplan said, the public doesn’t trust politicians all that much anyway, so inoculating celebrities, religious leaders or sports figures would likely do more to boost confidence in the vaccine. Rock ’n’ roll king in 1956 to help win over those who were skeptical; the actions of governors’ wives from that period are less remembered.

Dr. José Romero, chairperson of the Centers for Disease Control and Prevention’s , said in an email to KHN that while his group provides an outline for distributing limited vaccine doses, “jurisdictions have the flexibility to do what’s appropriate for their population.” Kentucky and Texas officials pointed out that CDC Director Dr. encouraged governors to publicly get the vaccine.

No one mentioned medical reasons for their spouses to get vaccines; hospitals are generally not vaccinating the spouses of medical professionals who have gotten the shot. (It’s unclear whether vaccinated people can still spread the virus, so it’s possible that a vaccinated person could pass the virus to their spouse or have to quarantine if an unvaccinated spouse were to get covid.)

The office of West Virginia’s governor, Republican Jim Justice, released pictures of him, his wife, Cathy Justice, and other officials receiving shots. He also showed his own vaccination on .

Beshear’s office in Kentucky also released photos of him getting the vaccine in December on the same day as his wife, Britainy Beshear, and other state officials.

“There is no question that there is vaccine hesitancy out there,” Beshear said at a coronavirus briefing on Monday, the day former Kentucky governors and their spouses were vaccinated. He alluded to a future program involving faith leaders and others. “Validators are incredibly important to building that confidence.”

His father, Democratic former Gov. Steve Beshear, posted photos of his vaccination on , saying that he and his wife, Jane Beshear, along with other former Kentucky governors of both parties and their spouses, stepped up partly to show residents the vaccine is safe and encourage them to get it when it’s available to them.

Kentucky is currently in the first stage of vaccine distribution, which targets health care workers and residents of long-term care and assisted living facilities. Fewer than 15,000 of the 58,500 doses received for long-term care had been given out when the former governors and their spouses were vaccinated.

Tres Watson, a former communications director for the Republican Party of Kentucky who founded a political consulting firm, was skeptical about the intentions behind the event. He said it seemed to be a public relations effort created so the governor could vaccinate his parents.

“I understand the continuity of government, but first ladies have no part in the continuity of government,” he said. “You need to stick with the priorities. Once you start making exceptions, that’s when you run into problems.”

Officials representing the Biden-Harris transition team and three other states where governors got vaccinated — Republican-led West Virginia and Texas, and Democratic-led Kansas — either didn’t respond to KHN or didn’t answer questions about spouses. Alabama’s Republican governor, Kay Ivey, got the vaccine and is divorced.

Politicians in other states have taken the opposite tack.

In Arkansas, Republican Gov. Asa Hutchinson is focused on ensuring high-priority groups such as health care workers, long-term care staffers and residents are vaccinated, said spokesperson LaConda Watson. “He and his wife will receive the vaccination when it’s their turn,” she said.

In Missouri, Kelli Jones, communications director for Republican Gov. Mike Parson, said in an email that he and the first lady fully intend to get the vaccine. Like governors from Colorado, Nevada and elsewhere, they’ve both recovered from covid-19, Jones said, and will “wait until their age group is eligible” under the state plan. Doctors recommend vaccinations even for people who have already had covid.

Cissy Sanders, 52, an events manager who lives in Austin, Texas, said she understands why lawmakers would need to get the vaccine. Her own governor, Republican Greg Abbott, received it on live television to instill confidence, said his press secretary, Renae Eze, who wouldn’t address whether Abbott’s wife was vaccinated.

But Sanders said politicians’ spouses should not be vaccinated before nursing home residents like her 71-year-old mom. Sanders’ mother received the vaccine in late December — after some public officials’ spouses — but she said far too many nursing home residents across America are still waiting.

“Why is a non-high-risk group — i.e., these spouses — going before the most high-risk group? Who makes these decisions? Who thinks this is a good, responsible, safe decision to make?” she said. “Political spouses have not been at ground zero for the virus. Nursing home residents have been.”

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“She survived by the grace of God,” Fuhrman said of the illness that struck her oldest child in this central Missouri city almost five years ago. “She could’ve gone septic fast. Her condition was near critical.”

Pearl was fighting Clostridium difficile, or C. diff, a type of antibiotic-resistant bacteria known as a superbug. A growing body of research shows that overuse and misuse of antibiotics in children’s hospitals — which health experts and patients say should know better — helps fuel these dangerous bacteria that attack adults and, increasingly, children. Doctors worry that the covid pandemic will only lead to more overprescribing.

A study published in the journal in January found that 1 in 4 children given antibiotics in U.S. children’s hospitals are prescribed the drugs inappropriately — the wrong types, or for too long, or when they’re not necessary.

Dr. , a pediatrics professor at Washington University in St. Louis who co-authored the study, said that’s likely an underestimate because the research involved 32 children’s hospitals already working together on proper antibiotic use. Newland said the nation’s children’s hospitals need to do better.

“It’s irresponsible,” Fuhrman added. Coupled with parents begging for antibiotics in pediatricians’ offices, it’s “just creating a monster.”

Using antibiotics when they’re not needed is a long-standing problem, and the pandemic “has thrown a little bit of gas on the fire,” said Dr. , a pediatrics professor at the University of Minnesota Medical School.

Although fears of covid-19 mean fewer parents are taking their children to doctors’ offices and some have skipped routine visits for their kids, children are still getting antibiotics through telemedicine visits that don’t allow for in-person exams. And research shows children infected with the coronavirus were hospitalized between late May and late September. If symptoms point toward a bacterial infection on top of the coronavirus, Schleiss said, doctors sometimes prescribe antibiotics, which don’t work on viruses, until tests rule out bacteria.

At the same time, Newland said, the demands of caring for covid patients take time away from what are known as “stewardship” programs aimed at measuring and improving how antibiotics are prescribed. Often such efforts involve continuing education courses for health care professionals on how to use antibiotics safely, but the .

“There’s no doubt: We’ve seen some extra use of antibiotics,” Newland said. “The impact of the pandemic on antibiotic use will be significant.”

Habits Drive Superbug Growth

Antibiotic resistance occurs through random mutation and natural selection. Those bacteria most susceptible to an antibiotic die quickly, but , then spread. The process is driven by prescribing habits that lead to high levels of antibiotic use.

A in the journal Infection Control & Hospital Epidemiology found that the rates of antibiotic use on patients at 51 children’s hospitals ranged from 22% to 52%. Some of those medications treated actual bacterial infections, but others were given in hopes of preventing infections or when doctors didn’t know what was causing a problem.

“I hear a lot about antibiotic use for the ‘just in case’ scenarios,” said Dr. , director of the antimicrobial stewardship program at Nationwide Children’s Hospital in Ohio. “We underestimate the downsides.”

Newland said each specialty in medicine has its own culture around antibiotic use. Many surgeons, for example, routinely use antibiotics to prevent infection after operations.

Outside of hospitals, doctors have long been criticized for prescribing antibiotics too often for ailments such as ear infections, which can sometimes go away on their own or can be caused by viruses that antibiotics won’t counter.

Dr. an associate professor of pediatrics and microbiology at the University of Alabama at Birmingham, said not all doctors have been taught how to use antibiotics correctly.

“Many of us don’t realize we’re doing it,” she said of overuse. “It’s sort of not knowing what you’re doing until someone tells you.”

All this drives the growth of numerous superbugs in the very population served by these hospitals. Numerous studies, including in March, cite the rise among kids of C. diff, which causes gastrointestinal problems. A in the Journal of the Pediatric Infectious Diseases Society found that cases of a certain type of multidrug-resistant Enterobacteriaceae rose 700% in American children in just eight years. And a steady stream of research points to the stubborn prevalence in kids of the better-known MRSA, or methicillin-resistant Staphylococcus aureus.

Superbug infections can be extremely difficult — and sometimes impossible — to treat. Doctors often must turn to strong medicines with side effects or give drugs intravenously.

“It’s getting more and more worrisome,” Ross said. “We have had patients we have not been able to treat because we’ve had no antibiotics available” that could kill the germs.

Doctors say the world is nearing a “post-antibiotic era,” when antibiotics no longer work and common infections can kill.

A Monster Unleashed

Superbugs spawned by antibiotic overuse put everyone at risk.

Like her daughter, Fuhrman also suffered through a C. diff infection, getting sick after taking antibiotics following a root canal in 2012. While killing harmful germs, antibiotics can also . Fuhrman cycled in and out of the hospital for months. When she finally got better, she tried to avoid using antibiotics and never gave them to her daughter.

That’s because antibiotics affect your microbiome by wiping out bad germs and the good germs that protect your body against infections.

Pearl’s first symptoms of C. diff arose about three years later, at around 20 months old. Fuhrman noticed her daughter was having lots of bowel movements. The mom eventually found pus and blood in her daughter’s stools. One day, Pearl was so pale and weak that Fuhrman took her to the emergency room. She was discharged, then spiked a fever and returned to the hospital.

Doctors treated Pearl with Flagyl, a broad-spectrum antibiotic. But two days after the last dose, she went downhill. The infection had returned. She recovered only after going to the Mayo Clinic in Rochester, Minnesota, for a fecal microbiota transplantation, in which she received healthy donor stool from her dad through a colonoscopy.

Since her family’s ordeal, Fuhrman has been trying to raise awareness of superbugs and antibiotic overuse. She serves on the board of the , a C. diff education and advocacy organization, and has testified before a presidential advisory committee in Washington, D.C., about superbugs and antibiotic stewardship.

In March, the Centers for Medicare & Medicaid Services began requiring all hospitals to document that they have antibiotic stewardship programs.

One approach, Schleiss said, is to restrict antibiotics by “saving our most magic bullets for the most desperate situations.” Another is to stop antibiotics at, say, 72 hours, after reassessing whether patients need them. Meanwhile, doctors are calling for more research into antibiotic use in children.

Fuhrman said hospitals must do all they can to stop superbug infections. The stakes are enormous, she said, pointing toward Pearl, now a 7-year-old first grader who likes to wear a pink hair bow and paint her tiny fingernails a rainbow of pastel colors.

“Antibiotics are great, but they have to be used wisely,” Fuhrman said. “The problem of superbugs is here. It’s in our backyard now, and it’s just getting worse.”

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Chantee Mack, 44, died in May. More than 20 colleagues also caught the coronavirus, and some are suffering lasting problems.

Now, after a KHN and Associated Press story in July spurred an investigation, Prince George’s County officials say they have added an appeals process to their work-at-home policy and hired a consultant to identify “operational and management needs for improvement” in the department. Union officials say the county has also made personal protective equipment, such as masks and gloves, more available in recent months and put a greater emphasis on social distancing.

“We’re getting somewhere,” said Rhonda Wallace, leader of a local branch of the . “But we’re not there yet.”

In an email to KHN, health department spokesperson George Lettis said officials can’t release results of the county investigation because of personnel and medical information. But a shares the inquiry’s main conclusions: that the health department tried to get PPE in early March and advised employees about social distancing and proper hygiene via a newsletter.

“It must not be overlooked that this was a rapidly evolving situation,” said the letter from Dr. George Askew, deputy chief administrative officer for health, human services and education. “Best efforts were made to keep the community and Health Department employees safe and informed during this unprecedented time.” The letter does not acknowledge any lapses made by the county.

Some employees argue the investigation didn’t delve into the circumstances around Mack’s death and say the county should publicly acknowledge its role in what happened. At a news conference in July, County Executive Angela Alsobrooks said Mack’s death “deserves an investigation” and the county would “spare no time or expense.”

Mack, who worked in the department’s sexually transmitted diseases program, was denied permission to work from home in March even though she had health problems that put her at high risk for COVID-19 complications.

At least three other employees whose requests to work from home were denied around that time also got sick. Revonda Watts, a nurse and program manager, said she was allowed to work from home for one day before being called back to the office. Some of these employees worked face-to-face with the public at least part of the time.

A union document obtained by KHN detailed a conference call by department managers in which Diane Young, an associate director, laid out criteria for working from home, such as being 65 or older or having small children. She said decisions would be made case by case.

Meanwhile, protective masks, gowns and other safety equipment were in short supply nationally and at the health department, which distributed them only to certain workers. In early April, when Young asked Watts about PPE needs, Watts wrote in an email obtained by KHN: “N-95 masks are needed for all staff. We were given 1 mask to reuse. We have no face shields for the clinicians nor do we have gowns.”

Young responded that even though goggles were available, “face shields and gowns are in limited supply and will be used for those who are testing patients for COVID-19.”

Several employees described meetings and “morning huddles” in the office in March and April held without social distancing and during which few, if any, participants wore masks.

One employee after another got sick.

Watts, who is 58 and has asthma, developed bronchitis on top of COVID-19, then chest pain from spasms in her blood vessels. She spread the virus to her adult daughter.

Administrative aide Natania Bowen also spread the virus to her family, including her husband and 7-year-old daughter, who have since recovered. Bowen, a 47-year-old with asthma, experienced a bacterial lung infection along with COVID-19.

Receptionist Yolanda Potter, 53, had severe headaches for a month from her coronavirus infection. She developed a blood clot in her right leg and had to inject blood thinners into her stomach for 45 days to prevent it from breaking off and traveling to her lungs or brain. She and Carolyn Ferguson, an X-ray tech now on desk duty, suffer ongoing memory problems, while Bowen continues to have lung issues.

While Bowen now works from home, Watts, Potter and Ferguson are back at the office. As of mid-November, Lettis said, 141 health department employees were working fully on-site, 68 partly on-site and 196 at home.

Employees said they are pleased that social distancing is now the norm in the health department, that more places to sanitize hands exist and that PPE is easier to get. They’re also hopeful about the new policy on remote work.

The countywide rules include two levels of review for work-at-home requests: one by a supervisor and another by a higher-up boss who must give a reason if a worker’s request is denied. The employee can then ask the Office for Human Resource Management to review the denial.

Despite such measures, some employees still worry about contracting COVID-19 at work, especially as the state’s COVID dashboard puts the .

Several employees are seeking long-term disability leave or talking to lawyers about getting workers’ compensation. Watts said she is awaiting a workers’ comp hearing and has asked again for permission to work from home as she deals with crushing fatigue and numbness in her legs and hands. Since returning to the office, she said, she has had to bring her own mask from home.

“I get frustrated with not being able to just bounce back,” she said. The health department officials “really let us down and didn’t do their due diligence to make sure the staff was protected.”

This story is a collaboration between The Associated Press and KHN.

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Caine is one of several parents who followed Dr. to her new location on the outskirts of Minneapolis, an hour and a half away. Many couldn’t get appointments for months with swamped nearby doctors.

“I was kind of devastated that she was leaving because I don’t like switching providers, and my kids were used to her. She’s just an awesome doctor,” said Caine, a postal worker who recently piled the kids into her car for back-to-back appointments. “I just wish she didn’t have to go that far away.”

So does Decker, who had hoped to settle in the Sartell area. She recently bought her four-bedroom “dream home” there.

The HealthPartners Central Minnesota Clinic where Decker worked is part of a wave of COVID-related closures starting to wash across America, reducing access to care in areas already short on primary care doctors.

Although no one tracks medical closures, recent research suggests they number in the thousands. A by the estimated that 8% of all physician practices nationally — around 16,000 — have closed under the stress of the pandemic. That survey didn’t break them down by type, but another from the Virginia-based r and the found in late September that 7% of primary care practices were unsure they could stay open past December without financial assistance.

And many more teeter on the economic brink, experts say.

“The last few years have been difficult for primary care practices, especially independent ones,” said Dr. , co-director of the Center for Health Economics and Policy at Washington University in St. Louis. “Putting on top of that COVID, that’s in many cases the proverbial straw. These practices are not operating with huge margins. They’re just getting by.”

When offices close, experts said, the biggest losers are patients, who may skip preventive care or regular appointments that help keep chronic diseases such as diabetes under control.

“This is especially poignant in the rural areas. There aren’t any good choices. What happens is people end up getting care in the emergency room,” said Dr. , head of the family and community medicine department at the University of Missouri and a practicing physician in Columbia. “If anything, what this pandemic has done is put a big spotlight on what was already a big crack in our health care system.”

that 82 million Americans live in primary care “health professional shortage areas,” and the nation needed more than 15,000 more primary care practitioners even before the pandemic began.

Once the coronavirus struck, some practices buckled when patients stayed away in droves for fear of catching it, said Dr. , president of the Physicians Foundation, a nonprofit grant-making and research organization. Its survey, based on 3,513 responses from emails to half a million doctors, found that 4 in 10 practices saw patient volumes drop by more than a quarter.

On the West Coast, a released in October by the California Medical Association found that one-quarter of practices in that state saw revenues drop by at least half. One respondent wrote: “We are closing next month.”

Decker’s experience at HealthPartners is typical. Before the pandemic, she saw about 18 patients a day. That quickly dropped to six or eight, “if that,” she said. “There were no well checks, which is the bread-and-butter of pediatrics.”

In an emailed statement, officials at HealthPartners, which has more than 50 primary care clinics around the Twin Cities and western Wisconsin, said closing the one in Sartell “was not an easy decision,” but the pandemic caused an immediate, significant drop in revenue. While continuing to provide dental care in Sartell, northwest of Minneapolis, the company encouraged employees to apply for open positions elsewhere in the organization. Decker got one of them. Officials also posted for patients on where more than 20 clinicians were moving.

The pandemic’s financial ripples rocked practices of all sizes, said LeFevre, the Missouri doctor. Before the pandemic, he said, the 10 clinics in his group saw a total of 3,500 patients a week. COVID-19 temporarily cut that number in half.

“We had fiscal reserves to weather the storm. Small practices don’t often have that. But it’s not like we went unscathed,” he said. “All staff had a one-week furlough without pay. All providers took a 10% pay cut for three months.”

Federal figures show earn an average of $184,400 a year, and $201,400, making primary care doctors among the lowest-paid physicians.

As revenues dropped in medical practices, overhead costs stayed the same. And practices faced new costs such as personal protective equipment, which grew more expensive as demand exceeded supply, especially for small practices without the bulk buying power of large ones.

Doctors also lost money in other ways, said , co-director of the research group. For example, she said, pediatricians paid for vaccines upfront, “then when no one came in, they expired.”

Some doctors took out loans or applied for Provider Relief Fund money under the federal CARES Act. Dr. , who practices in Modesto, California, said his group of more than 300 physicians received $8.7 million in relief in the early days of the pandemic.

“We were about ready to go under,” he said. “That came in the nick of time.”

While the group’s patient loads have largely bounced back, it still had to permanently close three of 11 clinics.

“We’ve got to keep practice doors open so that we don’t lose access, especially now that people need it most,” said Dr. Ada Stewart, president of the .

Caine, the Minnesota mom, said her own health care has suffered because she also saw providers at the now-closed Sartell clinic. While searching for new ones, she’s had to seek treatment in urgent care offices and the emergency room.

“I’m fortunate because I’m able to make it. I’m able to improvise. But what about the families that don’t have transportation?” she said. “Older people and the more sickly people really need these services, and they’ve been stripped away.”

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“Me and a lot of other cats were seriously considering taking a year off and practicing at home,” lamented the 19-year-old jazz studies major from Gary, Indiana.

His worries evaporated when he arrived on campus and discovered that had invented a special mask with a hole and a protective flap to allow musicians to play while masked.

Students also got masks for the ends of their wind instruments, known as bell covers, allowing them to jam in person, albeit 6 feet apart.

“It’s amazing to play together,” Charleston said. “Music has always been my safe space. It’s what’s in your soul, and you’re sharing that with other people.”

Of course, the very act of making music powered by human breath involves blowing air — and possibly virus particles — across a room. One infamous choral practice in Washington state earlier this year led to confirmed diagnoses of COVID-19 in more than half of the 61 attendees. Two died.

So musicians around the country are taking it upon themselves to reduce the risk of COVID-19 without silencing the music. With pantyhose, air filters, magnets, bolts of fabric and a fusion of creativity, those who play wind instruments or sing are improvising masks to keep the band together.

A consortium of performing arts groups has commissioned research exploring ways for musicians to play safely. The group’s from July recommends instrumentalists wear masks with small slits, use bell covers, face the same direction while playing and stay 6 feet apart for most instruments — with a distance of 9 feet in front and back of trombonists. cotton bell covers on brass instruments reduced airborne particles by an average of 79% compared with playing without one.

Jelena Srebric, a University of Maryland engineering researcher involved in the consortium’s study, said it’s also best to play in a big space with good ventilation, and musicians should break after 30 minutes to allow the air to clear. These rudimentary solutions, she said, promise at least some protection against the virus.

“Nothing is 100%. Being alive is a dangerous business,” Srebric said. This “gives some way to engage with music, which is fantastic in this day and age of despair.”

, a National Institutes of Health research fellow at the University of Iowa Hospitals and Clinics, is a bassoonist who has . He said a combination of bell covers, social distancing and limited time playing together could be helpful, but the effectiveness of bell covers or masks for musicians to wear while playing is “completely unproven” at this point. Schwalje’s paper said it’s not possible to quantify the risk of playing wind instruments, which involves deep breathing, sometimes forceful exhalation and possible aerosolizing of the mucus in the mouth and nose.

Still, early results of research at the universities of Maryland and Colorado are helping to inspire improvisational mask-making and other safety measures, said Mark Spede, national president of the who is helping lead the commissioned research.

At Middle Tennessee State University, for example, tuba teacher Chris Combest said his students tie pillowcases over the bells of their instruments, and some wear masks that can be unbuttoned to play. At the wind players in small ensembles must use bell covers and masks, but they can pull them down when playing as long as they pull them up during rests. Heather Ainsworth-Dobbins said her students at Southern Virginia University use surgical masks with slits cut in them and bell covers made of pantyhose and MERV-13 air filters, similar to what is used on a furnace.

At Indiana, Walsh sought out whatever research he could find as he designed his tight-fitting cotton musical mask, reinforced with a layer of polypropylene and with adjustable ties in the back. A flap hangs over the hole, outfitted with two magnets that allow it to close over the instrument. The professor’s mom, Julie Walsh — who made his clothes when he was a kid — has sewn more than 80 of the musical masks for free. The opera program’s costume shop makes bell covers with a layer of fabric over a layer of stiff woven material known as interfacing fabric.

Bailey Cates, a freshman trumpet player, said the quality of the sound is about the same with these masks and they make her feel safer.

Flutes present unique challenges, partly because

target=”_blank” rel=”noopener noreferrer”>flutists blow air across

the mouthpiece. Alice Dade, an associate professor of flute at the University of Missouri, said she and her students clip on device called “wind guards” usually used outdoors, then sometimes fit surgical masks over them.

Indiana flute student Nathan Rakes uses a specially designed cloth mask with a slit and slips a silk sock on the instrument’s end. Rakes, a sophomore, said the fabric doesn’t affect the sound unless he’s playing a low B note, which he rarely plays.

Walsh is a stickler for finding big practice spaces, not playing together for more than half an hour and taking 20-minute breaks. All jazz ensemble musicians, for example, also must stay at least 10 feet apart.

“I carry a tape measure everywhere I go,” he said. “I feel responsible for our students.”

Some K-12 schools are trying similar strategies, said James Weaver, director of performing arts and sports for the National Federation of State High School Associations.

His son Cooper, a seventh grade sax player at Plainfield Community Middle School in Indiana, uses a surgical mask with a slit. It sometimes jerks to the side with the vibrations of playing, but Cooper said it “feels good as long as you have it in the right place.” Cooper also helped his dad make a bell cover with fabric and MERV-13 material.

While many groups use homemade bell covers, McCormick’s Group in Wheeling, Illinois, has transformed its 25-year-old business of making bell covers to display school colors and insignias into one that is making musicians safer with two-ply covers made of polyester/spandex fabric. CEO Alan Yefsky said his company started reinforcing the covers with the second layer this summer. Sales of the $20 covers have soared.

“It’s keeping people employed. We’re helping keep people safe,” Yefsky said. “All of a sudden, we got calls from nationally known symphony organizations.”

Other professional musicians take a different tack. Film and television soundtracks are often recorded in separate sessions; woodwinds and brass players in individual plexiglass cubicles and masked, with distanced string players recording elsewhere.

The U.S. Marine Band in Washington, D.C., practices in small, socially distanced groups, but string instrumentalists are the only ones wearing masks while playing.

For both professionals and students, the pandemic has virtually eliminated live audiences in favor of virtual performances. Many musicians say they miss traditional concerts but are not focusing on what they’ve lost.

“Creating that sense of community — an island to come together and play — is super important,” said Cates, the Indiana trumpet player. “Playing music feels like a mental release for a lot of us. When I’m playing, my mind is off of the pandemic.”

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“Oh, my God, it smells so good!” Sierra, 39, said of the bounty she’d just picked up at a food pantry, pulling out a ready-made salad and a container of soup.

Sierra unpacked the donated food and planned lunch for Rachell and her siblings, ages 9 and 2, as a reporter watched through FaceTime. She said she doesn’t know what they’d do without the help.

The family lives in Bergen County, New Jersey, a dense grouping of 70 municipalities opposite Manhattan with about 950,000 people whose median household income ranks in the top 1% nationally. But Sierra and her husband, Aramon Morales, never earned a lot of money and are now out of work because of the pandemic.

The financial fallout of covid-19 has pushed child hunger to record levels. The need has been dire since the pandemic began and highlights the gaps in the nation’s safety net.

While every U.S. county has seen hunger rates rise, the steepest jumps have been in some of the wealthiest counties, where overall affluence obscures the tenuous finances of low-wage workers. Such sudden and unprecedented surges in hunger have overwhelmed many rich communities, which weren’t nearly as ready to cope as places that have long dealt with poverty and were already equipped with robust, organized charitable food networks.

Data from the anti-hunger advocacy group and the U.S. Census Bureau shows that counties seeing the largest estimated increases in child food insecurity in 2020 compared with 2018 generally have much higher median household incomes than counties with the smallest increases. In Bergen, where the median household income is $101,144, child hunger is estimated to have risen by 136%, compared with 47% nationally.

That doesn’t mean affluent counties have the greatest portion of hungry kids. An estimated 17% of children in Bergen face hunger, compared with a national average of around 25%.

But help is often harder to find in wealthier places. Missouri’s affluent St. Charles County, north of St. Louis, population 402,000, has seen child hunger rise by 69% and has 20 sites distributing food from the St. Louis Area Foodbank. The city of St. Louis, pop. 311,000, has seen child hunger rise by 36% and has 100 sites.

“There’s a huge variation in how different places are prepared or not prepared to deal with this and how they’ve struggled to address it,” said , assistant professor of public health nutrition at Harvard University. “The charitable food system has been very strained by this.”

Eleni Towns, associate director of the , said the pandemic “undid a decade’s worth of progress” on reducing food insecurity, which last year threatened at least 15 million kids.

And while President Joe Biden’s covid relief plan, which he signed into law March 11, promises to help with anti-poverty measures such as monthly payments to families of up to $300 per child this year, it’s unclear how far the recently passed legislation will go toward addressing hunger.

“It’s definitely a step in the right direction,” said , director of the Rudd Center for Food Policy and Obesity at the University of Connecticut. “But it’s hard to know what the impact is going to be.”

Need Grows in Places of Plenty

After the pandemic struck, the federal government boosted benefits from the Supplemental Nutrition Assistance Program and offered Pandemic Electronic Benefit Transfer cards to compensate for free or reduced-price school meals while children were schooled from home.

Sierra’s family saw their SNAP benefits of about $800 a month rise slightly and got two of those P-EBT payments, worth $434 each. But at the same time, they lost their main sources of income. Sierra had to leave her Amazon warehouse job when the kids’ school went remote, and Morales stopped driving for Uber when trips became scarce and he feared getting covid on top of his asthma.

Federal relief wasn’t enough for them and many others. So they flocked to food pantries.

In theory, pantries and the food banks that supply them are part of an emergency system designed for short-term crises, Schwartz said. “The problem is, they’ve actually become a standard source of food for a lot of people.”

In Bergen County, the Center for Food Action helped 40,500 households last year, up from 23,000 the year before. In Eagle County, Colorado, where the tony ski resort Vail is located, the Community Market food bank saw its client load nearly quadruple to 4,000. And outside Boston, in the affluent Massachusetts county of Norfolk — where Feeding America data shows child hunger jumped from an estimated 6% of kids to 16% — Dedham Food Pantry’s clients tripled to 1,800.

“This is just out of control compared to other times,” said Lynn Rogal, vice president of the Dedham pantry, which opened in 1990.

Pantry managers said a disproportionate number of clients are from minority groups. Many lost jobs in the eviscerated service sector that undergirds the wealthier parts of their counties. Julie Yurko, CEO of the , said up to half of her current clients have never sought help before.

“In early January, we had a white minivan pull up with three kids, 5 and younger. It ran out of gas sitting there,” Yurko said. “The mom was sobbing, and her beautiful children were sitting there watching her.”

Kelly Sirimoglu, spokesperson for New Jersey’s Center for Food Action, said the stigma around seeking help can be worse in wealthy areas. She said some people tell her, “I never thought I would be in line for food.”

Advocates said the reluctance to seek help means the need is likely even larger than it appears.

Katie Wilson of St. Charles, Missouri, said she heard about a food pantry run by the from a friend of a friend. She almost didn’t go. The single mom of two children, 11 and 9, lost her job as a hotel auditor in June and tried to squeak by without her income for two months.

“We found ourselves in a situation where it was a ‘heat or eat’ kind of thing,” said Wilson, 42, describing having to choose between heating her home or buying food. “It took me looking around and saying, ‘There is nothing to eat.’”

Struggling to Meet the Need

As hunger has become more visible, donations to food charities have risen. But they don’t address the core problem of an infrastructure that doesn’t match the new need. Some pantries are open just a few hours a week in church basements, a far cry from those that operate regularly and look like supermarkets. Many small pantries struggled to shift to outdoor food distribution during the pandemic or find new helpers when the few, often senior, volunteers felt unsafe doing the work.

“It definitely is harder in these places,” said Yurko, whose food bank distributes to Kendall County, Illinois, which has just three pantries for its population of 129,000. “The safety nets are not as robust.”

A strong safety net also requires pantries to cooperate with one another and the broader array of local social services. That’s been happening for years in Flint, Michigan, said Denise Diller, executive director of , which runs a pantry. Agencies and community leaders banded together in 2014 when lead poisoned the drinking water.

“When covid occurred, we were already kind of ready,” Diller said.

So was Atlanta. As in Flint, hunger was never hidden there; 15% of children in Fulton County, which includes Atlanta, faced hunger before the pandemic. After covid suspended volunteer shifts, the Atlanta Community Food Bank asked the Georgia National Guard to help sort, pack, warehouse and deliver food to help meet the needs of the estimated 22% of kids experiencing hunger. The food bank also partnered with seven school districts on more than 30 mobile pantries.

Such coordination and connections were lacking in Bergen County, where 80 pantries worked mostly in isolation when the pandemic hit, County Commissioner Tracy Zur said. “They weren’t collaborating. They were going along the same path they had for decades,” she said. “There was this need to break out of the old way of doing things and work together to be more impactful.”

Zur spearheaded the creation of a food security task force in July, reaching out to municipal and faith leaders. Goals include feeding people, connecting them to other services and turning some emergency food programs into full-fledged pantries. “Building an infrastructure is painstaking and ongoing,” she said.

Now, Zur said, pantries are starting to share with one another when one gets a large donation of perishable items such as eggs or milk.

With the need so widespread, residents do much the same.

During a recent pantry trip, Sierra, the New Jersey mom, opened the trunk of her 1999 Toyota and rummaged through the two big boxes volunteers had just placed there. She pointed to eggs, chicken, bread, butter, cheese and apples, observing, “I have more than I need.”

But she said it would never go to waste. Any extra would go to neighbors and their hungry children.

Midwest correspondent Cara Anthony and data editor Elizabeth Lucas contributed to this story.

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“We’re looking forward to having a season,” said the 18-year-old catcher for Dublin Coffman High School, outside Columbus, Ohio. “This game is something we really love.”

Kassis, whose team has started practices, is one of the millions of young people getting back onto ballfields, tennis courts and golf courses amid a decline in covid cases as spring approaches. But pandemic precautions portend a very different season this year, and some school districts still are delaying play — spurring spats among parents, coaches and public health experts across the nation.

Since fall, many parents have rallied for their kids to be allowed to play sports and objected to some safety policies, such as limits on spectators. Doctors, meanwhile, haven’t reached a consensus on whether contact sports are safe enough, especially indoors. While children are less likely than adults to become seriously ill from covid, they can still spread it, and those under 16 can’t be vaccinated yet.

Less was known about the virus early in the pandemic, so high school sports basically stopped last spring, starting up again in fits and spurts over the fall and winter in some places. Some kids turned to recreational leagues when their school teams weren’t an option.

But now, according to the , public high school sports are underway in every state, though not every district. Schedules in many places are being changed and condensed to allow as many sports as possible, including those not usually played in the spring, to make up for earlier cancellations.

Coaches and doctors agree that playing sports during a pandemic requires balancing the risk of covid with benefits such as improved cardiovascular fitness, strength and mental health. School sports can lead to college scholarships for the most elite student athletes, but even for those who end competitive athletics with high school, the rewards of playing can be extensive. Decisions about resuming sports, however, involve weighing the importance of academics against athletics, since adding covid risks from sports could jeopardize in-person learning during the pandemic.

Tim Saunders, executive director of the and coach at Dublin Coffman, said the pandemic has taken a significant mental and social toll on players. In a May survey of more than 3,000 teen athletes in Wisconsin, University of Wisconsin researchers found that about and the same portion reported symptoms of depression. Other studies have shown similar problems for students generally.

“You have to look at the kids and their depression,” Saunders said. “They need to be outside. They need to be with their friends.”

Before letting kids play sports, though, the Centers for Disease Control and Prevention said, coaches and school administrators should consider things like students’ underlying health conditions, the physical closeness of players in the specific sport and how widely covid is spreading locally.

Karissa Niehoff, executive director of the high school federation, that spring sports should be available to all students after last year’s cancellations. She said covid spread among student athletes — and the adults who live and work with them — is correlated to transmission rates in the community.

“Sports themselves are not spreaders when proper precautions are in place,” she said.

Still, outbreaks have occurred. A January report by CDC researchers pointed to a high school wrestling tournament in Florida after which . (Fewer than half were tested.) The report’s authors said outbreaks linked to youth sports suggest that close contact during practices, competitions and related social gatherings all raise the risk of the disease and “could jeopardize the safe operation of in-person education.”

Dr. , an infection control expert in Kentucky who runs the national patient safety group Health Watch USA, said contact sports are “very problematic,” especially those played indoors. He said heavy breathing during exertion could raise the risk of covid even if students wear cloth masks. Ideally, he said, indoor contact sports should not be played until after the pandemic.

“These are not professional athletes,” Kavanagh said. “They’re children.”

A released in January by University of Wisconsin researchers, who surveyed high school athletic directors representing more than 150,000 athletes nationally, bolsters the idea that indoor contact sports carry greater risks, finding a lower incidence of covid among athletes playing outdoor, non-contact sports such as golf and tennis.

Overall, “there’s not much evidence of transmission between players outdoors,” said Dr. Andrew Watson, lead author of the study, which he is submitting for peer-reviewed publication.

Dr. , a pediatrics professor at Washington University in St. Louis, said all sorts of youth sports, including indoor contact sports such as basketball, can be safe with the right prevention measures. He supported his daughter playing basketball while wearing a mask at her Kirkwood, Missouri, high school.

Doctors also pointed to other safety measures, such as forgoing locker rooms, keeping kids 6 feet apart when they’re not playing and requiring kids to bring their own water to games.

“The reality is, from a safety standpoint, sports can be played,” Newland said. “It’s the team dinner, the sleepover with the team — that’s where the issue shows up. It’s not the actual games.”

In Nevada’s Clark County School District, administrators said they’d restart sports only after students in grades 6-12 for in-person instruction as part of a hybrid model starting in late March. Cases in the county have in recent weeks, from a seven-day average of 1,924 cases a day on Jan. 10 to about 64 on March 3.

In early April, practices for spring sports such as track, swimming, golf and volleyball are scheduled to begin, with intramural fall sports held in April and May. No spectators will be allowed.

Parents who wanted sports to start much earlier created , one of many groups that popped up to protest the suspension of youth athletics. The Nevada group rallied late last month outside the Clark County school district’s offices shortly before the superintendent announced the reopening of schools to in-person learning.

Let Them Play Nevada organizer Dennis Goughnour said his son, Trey, a senior football player who also runs track, was “very, very distraught” this fall and winter about not playing.

With the reopening, he said, Trey will be able to run track, but the intramural football that will soon be allowed is “a joke,” essentially just practice with a scrimmage game.

“Basically, his senior year of football is a done deal. We are fighting for maybe one game, like a bowl game for the varsity squad at least,” he said. “They have done something, but too little, too late.”

Goughnour said Let Them Play is also fighting to have spectators at games. Limits on the numbers of spectators have riled parents across the nation, provoking “a ton of pushback,” said Niehoff, of the high school federation.

Parents have also objected to travel restrictions, quarantine rules and differing mask requirements. , Florida, hundreds of parents signed last fall against mandatory covid testing for football players.

Students, for their part, have quickly adjusted to pandemic requirements, including rules about masks, distancing and locker rooms, said , assistant executive director of the Illinois High School Association.

Kassis, the Ohio baseball player, said doing what’s required to stay safe is a small price to pay to get back in the game.

“We didn’t get to play at all last spring. I didn’t touch a baseball this summer,” he said. “It’s my senior year. I want to have a season and I’ll be devastated if we don’t.”

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The nominee to be Montana’s next health director faced an unwieldy disease outbreak and pushed Medicaid work requirements — two issues looming in Montana — when he held a similar job in Kentucky.

Montana senators will soon decide whether to confirm Adam Meier, Republican Gov. Greg Gianforte’s for director of the state Department of Public Health and Human Services. He would earn leading Montana’s , which oversees 13 divisions and is a leader in the state’s pandemic response.

Gianforte is confident Meier “will bring greater transparency, accountability, and efficiency to the department as it serves Montanans, especially the most vulnerable among us,” Brooke Stroyke, a governor’s office spokesperson, said in an emailed statement.

For many Montana officials and health care industry players, the focus is on Montana’s future, not Kentucky’s past. But it can be instructive to see how Meier handled similar issues in his prior role, which he held from May 2018 through December 2019.

Some have praised the job he did in Kentucky, including his spearheading of a program that would have created work requirements in the state’s Medicaid program. But others criticized those proposed changes as well as his handling of a large hepatitis A outbreak that spread through rural Appalachia starting in 2017, ultimately sickening more than 5,000 Kentuckians and killing 62. The details of the state’s response to the outbreak came to light after in 2019.

“The hep A response is probably one of the darkest or most concerning things he did when he was in Kentucky. He also didn’t perform well in my eyes on other issues,” said , an assistant professor at Pennsylvania State University who studies politics, health care and public policy. “He didn’t do so well in Kentucky, so I don’t know how well he’s going to do in Montana.”

Dr. , a retired Kentucky physician who runs the national watchdog group Health Watch USA, is among those who said Meier and his team needed to do more early on to curb the hepatitis outbreak as it made its way into Appalachia. Kavanagh said Meier’s handling of the outbreak provides a window into how he might handle the covid crisis in Montana.

“But it could be a learning opportunity if failed strategies are corrected,” Kavanagh said. “The biggest question is: What did he learn in Kentucky?”

During Meier’s confirmation hearing before Montana’s Senate Public Health, Wellness and Safety Committee, the nominee said one lesson he learned was to invest in public health infrastructure. Because hepatitis A was spreading in rural Kentucky mountains, he said, standard outreach to vulnerable populations in settings like homeless shelters didn’t work. Instead, health officials started vaccinating people at convenience stores.

“One of the things I’ve learned there is, you have to be creative about how you reach folks,” Meier said.

Kentucky’s outbreak first centered in Louisville, where a more than 200-person health department was able to administer tens of thousands of vaccines against the highly contagious liver infection caused by a virus. The Centers for Disease Control and Prevention .”

But in spring 2018, the disease began to spread in Appalachia, which had thinly staffed county health departments.

Dr. Robert Brawley, then the state’s chief of infectious diseases, sounded the alarm to his bosses. Brawley asked state officials to spend $10 million for vaccines and temporary health workers. Instead, the acting public health commissioner, Dr. Jeffrey Howard, sent $2.2 million in state funds to local health departments. Brawley called the response “too low and too slow.”

In the months that followed, the outbreak metastasized into the nation’s largest.

Howard’s decisions at the time and the agency’s response. In Meier’s Feb. 10 Montana hearing, he said Kentucky lacked the infrastructure to buy $10 million worth of vaccines, and they would have gone bad anyway because the state didn’t have the necessary storage. Brawley’s proposal had called for sending $6 million to health departments to buy vaccines, however, and $4 million for temporary health workers.

“The ‘too low and too slow’ response to the hepatitis A outbreak in Kentucky, reported in The Courier Journal, may be an albatross around his neck for a long time,” Brawley, who resigned in June 2018, said of Meier in an email.

Montana’s Democratic Party cited the hepatitis A outbreak when Meier was nominated for the Treasure State job in January, him as unsuitable.

The health department declined KHN’s request for an interview with Meier but provided letters from local Kentucky officials written in 2019. Allison Adams, public health director of Buffalo Trace District Health Department in Kentucky, defended the state’s actions in one February 2019 letter, arguing Kentucky’s leadership “made sound decisions regarding the support and known resources available.”

Meier has pitched himself as someone who works well with others, bolstered Kentucky’s family services and cut through the state’s bureaucracy.

Meier, an attorney, lived in Fort Thomas, Kentucky, near Cincinnati, with his wife and three children, where he served on the City Council just before being named deputy chief of staff for former Gov. Matt Bevin in 2015. After leaving Kentucky’s health Cabinet, he worked as a policy consultant with .

During Meier’s confirmation hearing before Montana lawmakers, Erica Johnston, operations services branch manager for the health department, said she was already impressed by his knowledge of the agency’s programs and ideas for changes. Past colleagues said he listened to those he oversaw. John Tilley, a former Democratic Kentucky representative who served as the state’s former head of Kentucky’s Justice and Public Safety Cabinet, called Meier a problem-solver.

“What I got in Adam was this refreshing take on government, this less than bureaucratic take,” Tilley testified.

While deputy chief of staff for Bevin, Meier oversaw the development of a Medicaid overhaul plan called Kentucky HEALTH, which would have required recipients who were ages 19-64 and without disabilities to work or do “engagement” activities such as job training or community service.

Bevin, a Republican who, like Gianforte, joined politics after making a fortune in business, described the effort as a way to ensure the long-term financial stability of Medicaid and prepare enrollees to transition to private insurance. In Meier’s Montana hearing, he said the goal was for Medicaid recipients to be linked to employment and training. Kentucky opponents said the program would have caused people to lose coverage and increase the state’s administrative burden.

That debate is familiar in Montana, where lawmakers approved work requirements for people who joined Medicaid under its expansion. The work rules are awaiting federal approval.

Kentucky’s requirements never took effect. They were authorized by a federal waiver but were tied up in legal challenges until the state’s current Democratic Gov. Andy Beshear rescinded the rules.

Still, Meier has said Medicaid’s enrollment dropped during his leadership and benefits remained steady for those who stayed on the rolls. That drop paralleled an in Medicaid enrollment that lasted through 2019.

Penn State’s Haeder, who observed Meier’s tenure, criticized Meier’s support for Medicaid work requirements, saying “excessive amounts of data show how detrimental they are to public health” because vulnerable people lose coverage.

, executive director for the Behavioral Health Alliance of Montana, said work restrictions aren’t a good model for Medicaid. But she said it isn’t surprising Meier has been in favor of those steps, given Montana’s recent efforts.

Even so, Windecker is optimistic when she talks about Meier’s confirmation. She said she’s thrilled he has experience with another state health agency.

“These are very complicated systems to run,” Windecker said. “If you understand health care, you stand a better shot at getting this.”

The Montana Senate has to take up Meier’s confirmation, which moved out of a committee Feb. 17.

While Meier awaits confirmation, he is already engaged in the state’s covid vaccine efforts and is working on the agency’s daily tasks, department spokesperson Jon Ebelt said in a statement. Meier is “focused on the job at hand,” Ebelt said.

Houghton, Montana correspondent, reported from Missoula. Ungar, Midwest editor and correspondent, reported from Louisville and formerly worked for The Courier Journal.

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But the coronavirus is spreading too quickly to open schools in Alameda County, based on the current state standards. And the local teachers union hasn’t agreed to go back — even after teachers have been vaccinated. So she expects her kids will be logging on to school from home for a while.

“The impediments to opening are just too great,” said Bacigalupi, who is lobbying California lawmakers to establish firm, statewide health metrics that, once met, would require schools to open. “In the end, it comes down to a lack of political will to get the kids back in the classroom.”

Parents across the country, many of whom relied on schools to care for their children while they worked, are frustrated and angry that remote instruction has gone on so long, even as grocery store clerks, city bus drivers and other essential workers have braved the risks of their workplaces. Lawmakers are increasingly joining their calls to get kids into classrooms, citing the loss of worker productivity and parents’ concerns about the social, emotional and academic effects on children.

President Joe Biden has to open most schools within his first 100 days in office if Congress provides funding, and if states and cities adopt safety steps.

But that will be a herculean task. Nearly one year into the pandemic, fewer than half of students are attending schools that are teaching in person every day, and the question of how and when to get kids back into classrooms often depends less on science than politics — including the strength of local teachers unions.

The Centers for Disease Control and Prevention concluded that schools can reopen safely if their communities have low levels of the virus and they adhere strictly to measures such as requiring everyone to stay 6 feet apart and wear masks.

But in numerous communities, those basic measures haven’t been followed, even before the vaccine rollout — and many teachers aren’t convinced they will be safe on campus.

With infection rates starting to decline nationally, many parents, superintendents, school boards and politicians insist this is the moment to stop striving for perfection and embrace the health measures necessary to get kids into classrooms safely. Some are even taking dramatic measures, such as the city of San Francisco, which Wednesday to force it to open.

The same day, CDC Director Dr. Rochelle Walensky that schools can safely reopen even if teachers aren’t yet vaccinated.

“If we wait for the perfect, we might as well just pack it up and just be honest with folks that we’re not going to open for in-person instruction in the school year,” Democratic California Gov. Gavin Newsom recently — breaking with the politically powerful California Teachers Association, which wants all teachers vaccinated before reopening.

Teachers Fear for Safety

In many states, teachers lobbied to be among the first to be vaccinated after health care workers and nursing home residents. But they also argue the vaccines alone are not enough to open schools. They want low levels of community spread. They want as many school staffers as possible vaccinated, which could take months. And they want assurances that schools won’t relax masking, physical distancing and other safety measures.

“We’ve had concerns about some districts being more lax even before the vaccine,” said , president of the Ohio Education Association, the state’s largest teachers union.

Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School, agreed that health measures must be enforced even after vaccination.

“It’s unfortunate that people think life goes back to normal, that once we get the vaccine, the masks come flying off,” he said. “Vaccination doesn’t take things back to normal.”

That’s because there are still unknowns about the vaccines: It’s unclear if vaccinated people can transmit the virus. Plus, not all adults can get a vaccine (for medical reasons), and about 5% of those who receive the Moderna or Pfizer-BioNTech versions might not be fully protected. Kids are another matter entirely: No covid vaccine has yet been approved for use in children younger than 16.

Teachers say they feel especially vulnerable when the virus is running rampant in a community, but health experts don’t agree on exactly what that means.

“We don’t know a definite threshold,” said Dr. , medical director of infection prevention and antimicrobial stewardship at Keck Medicine of the University of Southern California.

In Montgomery, Alabama, four educators died within 48 hours in January, spurring the city’s district to .

“We have educators who are dying from this. We know they’re taking it home,” said Theron Stokes, associate executive director of the teachers union.

The Politics of Reopening

As of late January, about 38% of K-12 public school students attended virtual-only schools, 38% attended in-person schools, and 24% attended hybrid schools that offered a mix of both, according to , a company tracking a representative sample of 1,200 school districts.

Decisions about returning to school have often been driven by ideology in the absence of firm scientific guidance about community spread.

Politics plays as big a role as health, said , practitioner-in-residence at the Center on Reinventing Education, a nonpartisan research center that has tracked 477 school districts since March. “Because the pandemic became so politicized, districts found themselves in political debates in their own communities.”

For instance, some politically motivated decisions to reopen schools were made despite dangerous surges in covid cases over the summer. In Texas, Republican Gov. Greg Abbott told schools in July they’d have to transition to in-person education after the state attorney general declared “” school closures unlawful. In Florida, Republican Gov. Ron DeSantis threatened to withhold state funding from schools that did not reopen in person.

In Democratic strongholds such as and , powerful unions have protested and delayed school reopenings.

Union opposition played a part in the Oakland school district’s decision to stick with remote-only learning in the fall, which boggled Bacigalupi’s mind because covid cases had dropped after the summer surge. At the time, restaurants, gyms and hair salons in her county were allowed to partially reopen, and some schools in neighboring counties had also opened.

“One of the reasons it’s so frustrating is that we can look at so many places and we see tens of thousands of kids back in school,” said Bacigalupi, whose children, ages 5 and 8, have been out of school for nearly a year. “I’m also just sad. And the sadness gets worse as you see what’s happening to your kid. It’s harming them.”

Bacigalupi said her second grader is like a different child — he’s quick to anger and struggles to regulate his emotions. He now gets counseling once a week.

Balancing Risks

Under pressure, more schools are reopening by the day. , city schools returned to a hybrid model of in-person and remote learning this month after a judge dismissed a teachers union lawsuit seeking to delay reopening.

Public health officials say districts must acknowledge that holding school in person is a calculated risk, and take concrete steps to minimize the danger for staff members and kids. These include separating desks in classrooms — even if that means holding class in a gymnasium — erecting plexiglass barriers where possible and limiting school sports.

“Implementing a combination of all of these layered approaches will make it a lot safer,” said , an assistant professor of environmental health sciences at the Yale School of Public Health, which last year issued to help schools determine when to reopen.

For example, the Los Angeles Unified School District, the second largest in the country, has taken a number of measures, including installing upgraded air filters, purchasing an ionized cleaning system to sanitize surfaces and rearranging furniture in classrooms, said , president of the school board.

But like the local and state teachers unions and the district superintendent, Gonez believes the rampant spread of covid in the region must be addressed first.

“Once the broader covid conditions are in a safer place in the community, I think we will be ready,” Gonez said. “We have the protocols in place to do this successfully.”

On Wednesday, the local American Academy of Pediatrics chapter that schools should reopen immediately because the social isolation, anxiety and lack of structure are “causing undue harm” to children.

“‘Safe’ is a relative term,” said Schleiss, the Minnesota professor. “Continuing to attend school with careful monitoring is reasonable. We don’t want the perfect to be the enemy of the good.”

This story was produced by , which publishes , an editorially independent service of the .

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“I’m concerned,” said Lebo, who teaches at Avon High School in the Indianapolis suburbs. “We’re not controlling the virus in our county. We’re not controlling it in our state. And we’re not controlling it in our schools.”

President Joe Biden’s covid response proposes $130 billion to improve school safety, offers federal guidance for making schools safer and improves workplace protections to safeguard teachers and other workers from covid.

This comes after many school districts and states holding in-person classes have ignored recommendations from public health officials or written their own questionable safety rules — creating a tinderbox where covid can sicken and kill.

A KHN analysis of federal and state Occupational Safety and Health Administration data found more than 780 covid-related complaints covering more than 2,000 public and private K-12 schools. But those pleas for help likely represent only a small portion of the problems, because a federal loophole prevents public school employees from lodging them in for local and state employees. Still, the complaints filed provide a window into the safety lapses: Employees reported sick children coming to school, maskless students and teachers less than 6 feet apart, and administrators minimizing the dangers of the virus and punishing teachers who spoke out.

KHN also found that practices contradicting safety experts’ advice are codified into the patchwork of covid rules put out by states and districts. For instance, about half of states don’t require masks for all students — including 11 that have exempted schoolchildren of various ages from mandatory masks, with New Hampshire excluding all K-12 students. Districts can craft stricter rules than their states but often don’t.

“The response to the virus has been politicized,” said Dr. , an expert in pediatric infectious diseases at the Indiana University School of Medicine. “There’s a willingness to ignore data and facts and go with whatever you’re hearing from the internet or from political leaders who don’t have any scientific knowledge.”

But even with Biden’s rollout of new school safety steps, struggles over balancing the need for education with covid safety are sure to continue, since it will be months before the nationwide vaccine rollout reaches all school staff members, and the shots haven’t yet been approved for kids.

Meanwhile, the scope of covid in schools remains unknown. Biden’s order calls for tracking it on the federal level, which wasn’t happening. States haven’t collected uniform data either. The , a project launched by volunteers and public health researchers, has counted more than 505,000 cases in K-12 schools — more than a quarter of them among staffers. Although kids are less likely than adults to become seriously ill, suggests they can spread the virus even if asymptomatic. The American Federation of Teachers estimates covid-19 has killed at least 325 school employees, though it’s unclear whether they caught it at school.

Among them was Susanne Michael, 47, a fourth grade teacher at Harrisburg Elementary School in northeastern Arkansas. As a cancer survivor with diabetes, she rarely went anywhere outside her home this past fall, according to her husband, Keith. She told him she worried about catching the coronavirus while teaching, but she “went and did it because she loved it.”

She tried her best to keep more than 20 students 6 feet apart, he said, but told him it was nearly impossible.

Though she always wore a mask, he doesn’t know if every student did. According to the district’s , masks are required in grades 4-12 “when social distancing is not feasible,” and “physical distancing will be practiced to the extent practical.” District leaders did not respond to requests for comment.

Michael wound up hospitalized on a ventilator. Doctors let her husband visit in protective gear because he, too, had the virus. He held her hand as she slipped away Oct. 1.

The loss hits him hardest at night. “For 27 years, I always had somebody there next to me,” he said. “It’s difficult and weighs on your mind and heart a lot when you’re laying there in an empty bed and your best friend’s gone.”

She left five children, ages 3 to 22, including a former student and her two siblings adopted in July.

A Litany of Lapses

Doctors said covid risks can be drastically reduced by following straightforward safety practices.

“First and foremost, mask mandate, mask mandate, mask mandate,” said Dr. Jason Newland, a pediatrics and infectious diseases professor at Washington University in St. Louis.

But school employees across the nation complain such measures don’t exist or aren’t enforced.

“School officials openly scoff at covid-19 and believe it is a hoax. This attitude trickles down to staff, so hardly anyone has been wearing their mask or wearing it correctly,” an unidentified employee of Hart Public Schools, in rural western Michigan, wrote in an OSHA complaint in September. The complaint also described large crowds of students sitting too close in cafeterias. The employee alleges being terminated for whistleblowing.

Hart Superintendent Mark Platt said in an email that he won’t comment on personnel matters, but “takes seriously its health and safety protocols for students and staff.” The district’s covid requires staffers and older students to wear masks in classrooms, common areas and buses, while K-5 students must wear them everywhere except in their own classrooms with their own class.

At the public Avon Community School Corp. in Indiana, Lebo said, problems festered since the beginning of the fall semester in July, when an OSHA complaint was lodged. In addition to crowding in the halls and difficulty keeping students 6 feet apart in classrooms, Lebo said, the school’s many extracurricular activities — including football, wrestling and show choir — brought their own risks.

Avon schools spokesperson Kevin Carr wouldn’t comment except to say students and staff members have tried their best to abide by the district’s health and safety protocols.

Over the semester ending in December, Avon schools reported 346 covid cases among nearly 9,800 in-person students and staffers, a rate of 3.5% compared with 2.1% for 1,412 remote learners. The covid rate reached 5.5% at the high school, which went remote briefly in the fall after the number of people quarantining skyrocketed.

Like the vast majority of school OSHA complaints, the one about Avon was closed without an inspection. Across all industries, , just a small percentage of pandemic-related complaints have led to inspections or fines.

A Biden executive order on worker safety calls for OSHA to bolster enforcement and work with states and local governments to ensure workers, including those in the public sector, are protected from covid.

Without strong laws, “workers are facing big challenges: Do I speak up? Do I show up to work?” said Rebecca Reindel, director of occupational safety and health for the AFL-CIO. “They’re making a decision between needing a paycheck and risking bringing the virus home.”

Varied, Questionable Guidance

That decision gets even harder when potentially unsafe practices are written into official recommendations.

Missouri and Iowa, for example, advise that students exposed to covid don’t need to be quarantined as long as infected and exposed children are both wearing masks correctly — which goes against Centers for Disease Control and Prevention advice to quarantine anyone who has had close contact with a person who has the virus.

Some districts in South Carolina, Tennessee, Florida and Nebraska — with green lights from the Trump administration and their states — classified teachers as “critical infrastructure workers,” allowing them to keep working after exposure if they don’t develop symptoms.

A superintendent in Billings, Montana, told administrators in October to “disrupt the 15-minute timeline” required to be deemed a close contact “through movement, distancing or masking.” Following media reports, saying he hadn’t intended to “game the system” and no one should move students to avoid quarantines.

In many communities, mask rules are lax.

In Missouri, where there’s no statewide mask rule, Ozark School District requires them only “when social distancing is not an option,” according to its website, which describes spacing desks and using barriers to give people a “break” from masks.

Lakeland Joint School District in Idaho recommends masks when physical distancing isn’t possible. Dacia Chaffee, parent of an eighth grader and a high school freshman in the district, said “it’s almost like normal,” with few students wearing masks. Her kids don’t either, she said; they don’t want to stand out.

Public health experts said making schools safer will require clear, consistent data and guidance — and political will. They said governments also need to give public schools enough resources to keep more than 50 million students and 3.2 million teachers safe. A estimated that the cost of covid mitigation measures for the 2020-21 school year ranges from $55 per student for items such as masks, plexiglass barriers and face shields to $442 per student with added custodians and transportation, such as buses and drivers, to allow for better physical distancing.

And crucially, experts said, covid policies for schools must be rooted in science, not politics.

“Behaviors and attitudes flow from the top down,” said Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School. “We have to hold people accountable. This is a life-and-death situation.”

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Nowhere on the list of prioritized recipients are public officials’ spouses.

Yet the first ladies of Kentucky and West Virginia; Republican Vice President Mike Pence’s wife, Karen Pence; Democratic President-elect Joe Biden’s wife, Jill Biden; and Vice President-elect Kamala Harris’ husband, Doug Emhoff, were among the first Americans to get the potentially lifesaving shots.

Kentucky also vaccinated six former governors and four former first ladies, including current Democratic Gov. Andy Beshear’s parents.

The early vaccinations of political spouses spurred outrage on social media, with several Twitter users  they should not be able to “jump the line” ahead of doctors, nurses and older people.

In most of the 29 states that responded to KHN inquiries of all 50 governors’ offices, top elected officials said they — and their spouses — will be vaccinated but have chosen to wait their turn behind more vulnerable constituents. Some Congress members from both parties said much the same when they refused early doses offered in the name of keeping the government running. Those weren’t offered to their spouses.

Governors who got the shots along with their spouses, and the vice president’s office, said they wanted to set an example for residents, build trust, bridge ideological divides and show that the vaccine is safe and effective.

But that’s a rationale some critics don’t buy.

“It looks more like cutting in line than it does securing trust. The politicians can get the hospitals to give it to them under this illusion of building trust. But it’s a façade,” said , a bioethics professor and founding head of the medical ethics division at New York University Grossman School of Medicine. “People might say: ‘Yup, typical rich people. They can’t be trusted.’ This undermines what they set out to do.”

Besides, Caplan said, the public doesn’t trust politicians all that much anyway, so inoculating celebrities, religious leaders or sports figures would likely do more to boost confidence in the vaccine. Rock ’n’ roll king in 1956 to help win over those who were skeptical; the actions of governors’ wives from that period are less remembered.

Dr. José Romero, chairperson of the Centers for Disease Control and Prevention’s , said in an email to KHN that while his group provides an outline for distributing limited vaccine doses, “jurisdictions have the flexibility to do what’s appropriate for their population.” Kentucky and Texas officials pointed out that CDC Director Dr. encouraged governors to publicly get the vaccine.

No one mentioned medical reasons for their spouses to get vaccines; hospitals are generally not vaccinating the spouses of medical professionals who have gotten the shot. (It’s unclear whether vaccinated people can still spread the virus, so it’s possible that a vaccinated person could pass the virus to their spouse or have to quarantine if an unvaccinated spouse were to get covid.)

The office of West Virginia’s governor, Republican Jim Justice, released pictures of him, his wife, Cathy Justice, and other officials receiving shots. He also showed his own vaccination on .

Beshear’s office in Kentucky also released photos of him getting the vaccine in December on the same day as his wife, Britainy Beshear, and other state officials.

“There is no question that there is vaccine hesitancy out there,” Beshear said at a coronavirus briefing on Monday, the day former Kentucky governors and their spouses were vaccinated. He alluded to a future program involving faith leaders and others. “Validators are incredibly important to building that confidence.”

His father, Democratic former Gov. Steve Beshear, posted photos of his vaccination on , saying that he and his wife, Jane Beshear, along with other former Kentucky governors of both parties and their spouses, stepped up partly to show residents the vaccine is safe and encourage them to get it when it’s available to them.

Kentucky is currently in the first stage of vaccine distribution, which targets health care workers and residents of long-term care and assisted living facilities. Fewer than 15,000 of the 58,500 doses received for long-term care had been given out when the former governors and their spouses were vaccinated.

Tres Watson, a former communications director for the Republican Party of Kentucky who founded a political consulting firm, was skeptical about the intentions behind the event. He said it seemed to be a public relations effort created so the governor could vaccinate his parents.

“I understand the continuity of government, but first ladies have no part in the continuity of government,” he said. “You need to stick with the priorities. Once you start making exceptions, that’s when you run into problems.”

Officials representing the Biden-Harris transition team and three other states where governors got vaccinated — Republican-led West Virginia and Texas, and Democratic-led Kansas — either didn’t respond to KHN or didn’t answer questions about spouses. Alabama’s Republican governor, Kay Ivey, got the vaccine and is divorced.

Politicians in other states have taken the opposite tack.

In Arkansas, Republican Gov. Asa Hutchinson is focused on ensuring high-priority groups such as health care workers, long-term care staffers and residents are vaccinated, said spokesperson LaConda Watson. “He and his wife will receive the vaccination when it’s their turn,” she said.

In Missouri, Kelli Jones, communications director for Republican Gov. Mike Parson, said in an email that he and the first lady fully intend to get the vaccine. Like governors from Colorado, Nevada and elsewhere, they’ve both recovered from covid-19, Jones said, and will “wait until their age group is eligible” under the state plan. Doctors recommend vaccinations even for people who have already had covid.

Cissy Sanders, 52, an events manager who lives in Austin, Texas, said she understands why lawmakers would need to get the vaccine. Her own governor, Republican Greg Abbott, received it on live television to instill confidence, said his press secretary, Renae Eze, who wouldn’t address whether Abbott’s wife was vaccinated.

But Sanders said politicians’ spouses should not be vaccinated before nursing home residents like her 71-year-old mom. Sanders’ mother received the vaccine in late December — after some public officials’ spouses — but she said far too many nursing home residents across America are still waiting.

“Why is a non-high-risk group — i.e., these spouses — going before the most high-risk group? Who makes these decisions? Who thinks this is a good, responsible, safe decision to make?” she said. “Political spouses have not been at ground zero for the virus. Nursing home residents have been.”

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“She survived by the grace of God,” Fuhrman said of the illness that struck her oldest child in this central Missouri city almost five years ago. “She could’ve gone septic fast. Her condition was near critical.”

Pearl was fighting Clostridium difficile, or C. diff, a type of antibiotic-resistant bacteria known as a superbug. A growing body of research shows that overuse and misuse of antibiotics in children’s hospitals — which health experts and patients say should know better — helps fuel these dangerous bacteria that attack adults and, increasingly, children. Doctors worry that the covid pandemic will only lead to more overprescribing.

A study published in the journal in January found that 1 in 4 children given antibiotics in U.S. children’s hospitals are prescribed the drugs inappropriately — the wrong types, or for too long, or when they’re not necessary.

Dr. , a pediatrics professor at Washington University in St. Louis who co-authored the study, said that’s likely an underestimate because the research involved 32 children’s hospitals already working together on proper antibiotic use. Newland said the nation’s children’s hospitals need to do better.

“It’s irresponsible,” Fuhrman added. Coupled with parents begging for antibiotics in pediatricians’ offices, it’s “just creating a monster.”

Using antibiotics when they’re not needed is a long-standing problem, and the pandemic “has thrown a little bit of gas on the fire,” said Dr. , a pediatrics professor at the University of Minnesota Medical School.

Although fears of covid-19 mean fewer parents are taking their children to doctors’ offices and some have skipped routine visits for their kids, children are still getting antibiotics through telemedicine visits that don’t allow for in-person exams. And research shows children infected with the coronavirus were hospitalized between late May and late September. If symptoms point toward a bacterial infection on top of the coronavirus, Schleiss said, doctors sometimes prescribe antibiotics, which don’t work on viruses, until tests rule out bacteria.

At the same time, Newland said, the demands of caring for covid patients take time away from what are known as “stewardship” programs aimed at measuring and improving how antibiotics are prescribed. Often such efforts involve continuing education courses for health care professionals on how to use antibiotics safely, but the .

“There’s no doubt: We’ve seen some extra use of antibiotics,” Newland said. “The impact of the pandemic on antibiotic use will be significant.”

Habits Drive Superbug Growth

Antibiotic resistance occurs through random mutation and natural selection. Those bacteria most susceptible to an antibiotic die quickly, but , then spread. The process is driven by prescribing habits that lead to high levels of antibiotic use.

A in the journal Infection Control & Hospital Epidemiology found that the rates of antibiotic use on patients at 51 children’s hospitals ranged from 22% to 52%. Some of those medications treated actual bacterial infections, but others were given in hopes of preventing infections or when doctors didn’t know what was causing a problem.

“I hear a lot about antibiotic use for the ‘just in case’ scenarios,” said Dr. , director of the antimicrobial stewardship program at Nationwide Children’s Hospital in Ohio. “We underestimate the downsides.”

Newland said each specialty in medicine has its own culture around antibiotic use. Many surgeons, for example, routinely use antibiotics to prevent infection after operations.

Outside of hospitals, doctors have long been criticized for prescribing antibiotics too often for ailments such as ear infections, which can sometimes go away on their own or can be caused by viruses that antibiotics won’t counter.

Dr. an associate professor of pediatrics and microbiology at the University of Alabama at Birmingham, said not all doctors have been taught how to use antibiotics correctly.

“Many of us don’t realize we’re doing it,” she said of overuse. “It’s sort of not knowing what you’re doing until someone tells you.”

All this drives the growth of numerous superbugs in the very population served by these hospitals. Numerous studies, including in March, cite the rise among kids of C. diff, which causes gastrointestinal problems. A in the Journal of the Pediatric Infectious Diseases Society found that cases of a certain type of multidrug-resistant Enterobacteriaceae rose 700% in American children in just eight years. And a steady stream of research points to the stubborn prevalence in kids of the better-known MRSA, or methicillin-resistant Staphylococcus aureus.

Superbug infections can be extremely difficult — and sometimes impossible — to treat. Doctors often must turn to strong medicines with side effects or give drugs intravenously.

“It’s getting more and more worrisome,” Ross said. “We have had patients we have not been able to treat because we’ve had no antibiotics available” that could kill the germs.

Doctors say the world is nearing a “post-antibiotic era,” when antibiotics no longer work and common infections can kill.

A Monster Unleashed

Superbugs spawned by antibiotic overuse put everyone at risk.

Like her daughter, Fuhrman also suffered through a C. diff infection, getting sick after taking antibiotics following a root canal in 2012. While killing harmful germs, antibiotics can also . Fuhrman cycled in and out of the hospital for months. When she finally got better, she tried to avoid using antibiotics and never gave them to her daughter.

That’s because antibiotics affect your microbiome by wiping out bad germs and the good germs that protect your body against infections.

Pearl’s first symptoms of C. diff arose about three years later, at around 20 months old. Fuhrman noticed her daughter was having lots of bowel movements. The mom eventually found pus and blood in her daughter’s stools. One day, Pearl was so pale and weak that Fuhrman took her to the emergency room. She was discharged, then spiked a fever and returned to the hospital.

Doctors treated Pearl with Flagyl, a broad-spectrum antibiotic. But two days after the last dose, she went downhill. The infection had returned. She recovered only after going to the Mayo Clinic in Rochester, Minnesota, for a fecal microbiota transplantation, in which she received healthy donor stool from her dad through a colonoscopy.

Since her family’s ordeal, Fuhrman has been trying to raise awareness of superbugs and antibiotic overuse. She serves on the board of the , a C. diff education and advocacy organization, and has testified before a presidential advisory committee in Washington, D.C., about superbugs and antibiotic stewardship.

In March, the Centers for Medicare & Medicaid Services began requiring all hospitals to document that they have antibiotic stewardship programs.

One approach, Schleiss said, is to restrict antibiotics by “saving our most magic bullets for the most desperate situations.” Another is to stop antibiotics at, say, 72 hours, after reassessing whether patients need them. Meanwhile, doctors are calling for more research into antibiotic use in children.

Fuhrman said hospitals must do all they can to stop superbug infections. The stakes are enormous, she said, pointing toward Pearl, now a 7-year-old first grader who likes to wear a pink hair bow and paint her tiny fingernails a rainbow of pastel colors.

“Antibiotics are great, but they have to be used wisely,” Fuhrman said. “The problem of superbugs is here. It’s in our backyard now, and it’s just getting worse.”

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Chantee Mack, 44, died in May. More than 20 colleagues also caught the coronavirus, and some are suffering lasting problems.

Now, after a KHN and Associated Press story in July spurred an investigation, Prince George’s County officials say they have added an appeals process to their work-at-home policy and hired a consultant to identify “operational and management needs for improvement” in the department. Union officials say the county has also made personal protective equipment, such as masks and gloves, more available in recent months and put a greater emphasis on social distancing.

“We’re getting somewhere,” said Rhonda Wallace, leader of a local branch of the . “But we’re not there yet.”

In an email to KHN, health department spokesperson George Lettis said officials can’t release results of the county investigation because of personnel and medical information. But a shares the inquiry’s main conclusions: that the health department tried to get PPE in early March and advised employees about social distancing and proper hygiene via a newsletter.

“It must not be overlooked that this was a rapidly evolving situation,” said the letter from Dr. George Askew, deputy chief administrative officer for health, human services and education. “Best efforts were made to keep the community and Health Department employees safe and informed during this unprecedented time.” The letter does not acknowledge any lapses made by the county.

Some employees argue the investigation didn’t delve into the circumstances around Mack’s death and say the county should publicly acknowledge its role in what happened. At a news conference in July, County Executive Angela Alsobrooks said Mack’s death “deserves an investigation” and the county would “spare no time or expense.”

Mack, who worked in the department’s sexually transmitted diseases program, was denied permission to work from home in March even though she had health problems that put her at high risk for COVID-19 complications.

At least three other employees whose requests to work from home were denied around that time also got sick. Revonda Watts, a nurse and program manager, said she was allowed to work from home for one day before being called back to the office. Some of these employees worked face-to-face with the public at least part of the time.

A union document obtained by KHN detailed a conference call by department managers in which Diane Young, an associate director, laid out criteria for working from home, such as being 65 or older or having small children. She said decisions would be made case by case.

Meanwhile, protective masks, gowns and other safety equipment were in short supply nationally and at the health department, which distributed them only to certain workers. In early April, when Young asked Watts about PPE needs, Watts wrote in an email obtained by KHN: “N-95 masks are needed for all staff. We were given 1 mask to reuse. We have no face shields for the clinicians nor do we have gowns.”

Young responded that even though goggles were available, “face shields and gowns are in limited supply and will be used for those who are testing patients for COVID-19.”

Several employees described meetings and “morning huddles” in the office in March and April held without social distancing and during which few, if any, participants wore masks.

One employee after another got sick.

Watts, who is 58 and has asthma, developed bronchitis on top of COVID-19, then chest pain from spasms in her blood vessels. She spread the virus to her adult daughter.

Administrative aide Natania Bowen also spread the virus to her family, including her husband and 7-year-old daughter, who have since recovered. Bowen, a 47-year-old with asthma, experienced a bacterial lung infection along with COVID-19.

Receptionist Yolanda Potter, 53, had severe headaches for a month from her coronavirus infection. She developed a blood clot in her right leg and had to inject blood thinners into her stomach for 45 days to prevent it from breaking off and traveling to her lungs or brain. She and Carolyn Ferguson, an X-ray tech now on desk duty, suffer ongoing memory problems, while Bowen continues to have lung issues.

While Bowen now works from home, Watts, Potter and Ferguson are back at the office. As of mid-November, Lettis said, 141 health department employees were working fully on-site, 68 partly on-site and 196 at home.

Employees said they are pleased that social distancing is now the norm in the health department, that more places to sanitize hands exist and that PPE is easier to get. They’re also hopeful about the new policy on remote work.

The countywide rules include two levels of review for work-at-home requests: one by a supervisor and another by a higher-up boss who must give a reason if a worker’s request is denied. The employee can then ask the Office for Human Resource Management to review the denial.

Despite such measures, some employees still worry about contracting COVID-19 at work, especially as the state’s COVID dashboard puts the .

Several employees are seeking long-term disability leave or talking to lawyers about getting workers’ compensation. Watts said she is awaiting a workers’ comp hearing and has asked again for permission to work from home as she deals with crushing fatigue and numbness in her legs and hands. Since returning to the office, she said, she has had to bring her own mask from home.

“I get frustrated with not being able to just bounce back,” she said. The health department officials “really let us down and didn’t do their due diligence to make sure the staff was protected.”

This story is a collaboration between The Associated Press and KHN.

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Caine is one of several parents who followed Dr. to her new location on the outskirts of Minneapolis, an hour and a half away. Many couldn’t get appointments for months with swamped nearby doctors.

“I was kind of devastated that she was leaving because I don’t like switching providers, and my kids were used to her. She’s just an awesome doctor,” said Caine, a postal worker who recently piled the kids into her car for back-to-back appointments. “I just wish she didn’t have to go that far away.”

So does Decker, who had hoped to settle in the Sartell area. She recently bought her four-bedroom “dream home” there.

The HealthPartners Central Minnesota Clinic where Decker worked is part of a wave of COVID-related closures starting to wash across America, reducing access to care in areas already short on primary care doctors.

Although no one tracks medical closures, recent research suggests they number in the thousands. A by the estimated that 8% of all physician practices nationally — around 16,000 — have closed under the stress of the pandemic. That survey didn’t break them down by type, but another from the Virginia-based r and the found in late September that 7% of primary care practices were unsure they could stay open past December without financial assistance.

And many more teeter on the economic brink, experts say.

“The last few years have been difficult for primary care practices, especially independent ones,” said Dr. , co-director of the Center for Health Economics and Policy at Washington University in St. Louis. “Putting on top of that COVID, that’s in many cases the proverbial straw. These practices are not operating with huge margins. They’re just getting by.”

When offices close, experts said, the biggest losers are patients, who may skip preventive care or regular appointments that help keep chronic diseases such as diabetes under control.

“This is especially poignant in the rural areas. There aren’t any good choices. What happens is people end up getting care in the emergency room,” said Dr. , head of the family and community medicine department at the University of Missouri and a practicing physician in Columbia. “If anything, what this pandemic has done is put a big spotlight on what was already a big crack in our health care system.”

that 82 million Americans live in primary care “health professional shortage areas,” and the nation needed more than 15,000 more primary care practitioners even before the pandemic began.

Once the coronavirus struck, some practices buckled when patients stayed away in droves for fear of catching it, said Dr. , president of the Physicians Foundation, a nonprofit grant-making and research organization. Its survey, based on 3,513 responses from emails to half a million doctors, found that 4 in 10 practices saw patient volumes drop by more than a quarter.

On the West Coast, a released in October by the California Medical Association found that one-quarter of practices in that state saw revenues drop by at least half. One respondent wrote: “We are closing next month.”

Decker’s experience at HealthPartners is typical. Before the pandemic, she saw about 18 patients a day. That quickly dropped to six or eight, “if that,” she said. “There were no well checks, which is the bread-and-butter of pediatrics.”

In an emailed statement, officials at HealthPartners, which has more than 50 primary care clinics around the Twin Cities and western Wisconsin, said closing the one in Sartell “was not an easy decision,” but the pandemic caused an immediate, significant drop in revenue. While continuing to provide dental care in Sartell, northwest of Minneapolis, the company encouraged employees to apply for open positions elsewhere in the organization. Decker got one of them. Officials also posted for patients on where more than 20 clinicians were moving.

The pandemic’s financial ripples rocked practices of all sizes, said LeFevre, the Missouri doctor. Before the pandemic, he said, the 10 clinics in his group saw a total of 3,500 patients a week. COVID-19 temporarily cut that number in half.

“We had fiscal reserves to weather the storm. Small practices don’t often have that. But it’s not like we went unscathed,” he said. “All staff had a one-week furlough without pay. All providers took a 10% pay cut for three months.”

Federal figures show earn an average of $184,400 a year, and $201,400, making primary care doctors among the lowest-paid physicians.

As revenues dropped in medical practices, overhead costs stayed the same. And practices faced new costs such as personal protective equipment, which grew more expensive as demand exceeded supply, especially for small practices without the bulk buying power of large ones.

Doctors also lost money in other ways, said , co-director of the research group. For example, she said, pediatricians paid for vaccines upfront, “then when no one came in, they expired.”

Some doctors took out loans or applied for Provider Relief Fund money under the federal CARES Act. Dr. , who practices in Modesto, California, said his group of more than 300 physicians received $8.7 million in relief in the early days of the pandemic.

“We were about ready to go under,” he said. “That came in the nick of time.”

While the group’s patient loads have largely bounced back, it still had to permanently close three of 11 clinics.

“We’ve got to keep practice doors open so that we don’t lose access, especially now that people need it most,” said Dr. Ada Stewart, president of the .

Caine, the Minnesota mom, said her own health care has suffered because she also saw providers at the now-closed Sartell clinic. While searching for new ones, she’s had to seek treatment in urgent care offices and the emergency room.

“I’m fortunate because I’m able to make it. I’m able to improvise. But what about the families that don’t have transportation?” she said. “Older people and the more sickly people really need these services, and they’ve been stripped away.”

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“Me and a lot of other cats were seriously considering taking a year off and practicing at home,” lamented the 19-year-old jazz studies major from Gary, Indiana.

His worries evaporated when he arrived on campus and discovered that had invented a special mask with a hole and a protective flap to allow musicians to play while masked.

Students also got masks for the ends of their wind instruments, known as bell covers, allowing them to jam in person, albeit 6 feet apart.

“It’s amazing to play together,” Charleston said. “Music has always been my safe space. It’s what’s in your soul, and you’re sharing that with other people.”

Of course, the very act of making music powered by human breath involves blowing air — and possibly virus particles — across a room. One infamous choral practice in Washington state earlier this year led to confirmed diagnoses of COVID-19 in more than half of the 61 attendees. Two died.

So musicians around the country are taking it upon themselves to reduce the risk of COVID-19 without silencing the music. With pantyhose, air filters, magnets, bolts of fabric and a fusion of creativity, those who play wind instruments or sing are improvising masks to keep the band together.

A consortium of performing arts groups has commissioned research exploring ways for musicians to play safely. The group’s from July recommends instrumentalists wear masks with small slits, use bell covers, face the same direction while playing and stay 6 feet apart for most instruments — with a distance of 9 feet in front and back of trombonists. cotton bell covers on brass instruments reduced airborne particles by an average of 79% compared with playing without one.

Jelena Srebric, a University of Maryland engineering researcher involved in the consortium’s study, said it’s also best to play in a big space with good ventilation, and musicians should break after 30 minutes to allow the air to clear. These rudimentary solutions, she said, promise at least some protection against the virus.

“Nothing is 100%. Being alive is a dangerous business,” Srebric said. This “gives some way to engage with music, which is fantastic in this day and age of despair.”

, a National Institutes of Health research fellow at the University of Iowa Hospitals and Clinics, is a bassoonist who has . He said a combination of bell covers, social distancing and limited time playing together could be helpful, but the effectiveness of bell covers or masks for musicians to wear while playing is “completely unproven” at this point. Schwalje’s paper said it’s not possible to quantify the risk of playing wind instruments, which involves deep breathing, sometimes forceful exhalation and possible aerosolizing of the mucus in the mouth and nose.

Still, early results of research at the universities of Maryland and Colorado are helping to inspire improvisational mask-making and other safety measures, said Mark Spede, national president of the who is helping lead the commissioned research.

At Middle Tennessee State University, for example, tuba teacher Chris Combest said his students tie pillowcases over the bells of their instruments, and some wear masks that can be unbuttoned to play. At the wind players in small ensembles must use bell covers and masks, but they can pull them down when playing as long as they pull them up during rests. Heather Ainsworth-Dobbins said her students at Southern Virginia University use surgical masks with slits cut in them and bell covers made of pantyhose and MERV-13 air filters, similar to what is used on a furnace.

At Indiana, Walsh sought out whatever research he could find as he designed his tight-fitting cotton musical mask, reinforced with a layer of polypropylene and with adjustable ties in the back. A flap hangs over the hole, outfitted with two magnets that allow it to close over the instrument. The professor’s mom, Julie Walsh — who made his clothes when he was a kid — has sewn more than 80 of the musical masks for free. The opera program’s costume shop makes bell covers with a layer of fabric over a layer of stiff woven material known as interfacing fabric.

Bailey Cates, a freshman trumpet player, said the quality of the sound is about the same with these masks and they make her feel safer.

Flutes present unique challenges, partly because

target=”_blank” rel=”noopener noreferrer”>flutists blow air across

the mouthpiece. Alice Dade, an associate professor of flute at the University of Missouri, said she and her students clip on device called “wind guards” usually used outdoors, then sometimes fit surgical masks over them.

Indiana flute student Nathan Rakes uses a specially designed cloth mask with a slit and slips a silk sock on the instrument’s end. Rakes, a sophomore, said the fabric doesn’t affect the sound unless he’s playing a low B note, which he rarely plays.

Walsh is a stickler for finding big practice spaces, not playing together for more than half an hour and taking 20-minute breaks. All jazz ensemble musicians, for example, also must stay at least 10 feet apart.

“I carry a tape measure everywhere I go,” he said. “I feel responsible for our students.”

Some K-12 schools are trying similar strategies, said James Weaver, director of performing arts and sports for the National Federation of State High School Associations.

His son Cooper, a seventh grade sax player at Plainfield Community Middle School in Indiana, uses a surgical mask with a slit. It sometimes jerks to the side with the vibrations of playing, but Cooper said it “feels good as long as you have it in the right place.” Cooper also helped his dad make a bell cover with fabric and MERV-13 material.

While many groups use homemade bell covers, McCormick’s Group in Wheeling, Illinois, has transformed its 25-year-old business of making bell covers to display school colors and insignias into one that is making musicians safer with two-ply covers made of polyester/spandex fabric. CEO Alan Yefsky said his company started reinforcing the covers with the second layer this summer. Sales of the $20 covers have soared.

“It’s keeping people employed. We’re helping keep people safe,” Yefsky said. “All of a sudden, we got calls from nationally known symphony organizations.”

Other professional musicians take a different tack. Film and television soundtracks are often recorded in separate sessions; woodwinds and brass players in individual plexiglass cubicles and masked, with distanced string players recording elsewhere.

The U.S. Marine Band in Washington, D.C., practices in small, socially distanced groups, but string instrumentalists are the only ones wearing masks while playing.

For both professionals and students, the pandemic has virtually eliminated live audiences in favor of virtual performances. Many musicians say they miss traditional concerts but are not focusing on what they’ve lost.

“Creating that sense of community — an island to come together and play — is super important,” said Cates, the Indiana trumpet player. “Playing music feels like a mental release for a lot of us. When I’m playing, my mind is off of the pandemic.”

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