Jan Dyer

In early January, Ohio not only set a state record for COVID-19 hospitalizations—it had the fourth highest rate in the country, with 6,747 hospitalized coronavirus patients on January 10, a 40% increase over the previous 21 days. Most were unvaccinated. To help overwhelmed hospitals cope, Ohio Gov. Mike DeWine turned to the National Guard. Unfortunately, nearly half of the Ohio National Guard also were unvaccinated.

By US Department of Defense (DoD) directive, National Guard members must have a COVID-19 vaccination to be deployed on hospital missions. Thus, in COVID hotspots across the nation, governors are on the horns of a dilemma. They want and need to deploy the National Guard to give medical and nonclinical support but aren’t sure whether they will be able to or, indeed, whether they should.

So far, vaccinated teams are already on the ground in a number of states. In Indiana, where hospitalizations jumped 50% over 2 weeks in December, the National Guard sent 6-person teams, all fully vaccinated. In New Hampshire, 70 guards are being deployed to help hospitals with food service, clerical work, and other nonmedical functions. New York Governor Kathy Hochul has deployed guard members for help to ease the strain on nursing homes. Massachusetts Governor Charlie Baker has activated up to 500 guard members; some will be supporting 55 acute care hospital and 12 ambulance services. In Maine, where cases have peaked, Governor Janet Mills activated guard members to support nursing facilities and administer monoclonal antibodies. The Louisiana National Guard has administered more than 542,000 COVID-19 tests and 206,300 vaccines. As many as 1,000 Maryland Air and Army National Guardsmen are being activated to help with testing and other missions.

However, as in Ohio, other states are facing problematic scenarios. For instance, about 40% of the more than 20,000 Texas National Guard are refusing to get vaccinated, challenging the Biden Administration vaccine requirement for all military.

And a court showdown over federal vaccine mandates, started by Governor Kevin Stitt of Oklahoma and joined by the Republican governors of Wyoming, Iowa, Alaska, Nebraska, and Mississippi, came to a head in December. Last November, Stitt asked Defense Secretary Lloyd Austin to exempt Oklahoma’s National Guard from the vaccine mandate. He claimed the requirement violated the personal freedoms of many Oklahomans and could cause them to “potentially sacrifice their personal beliefs.” But in a memo to the Joint Chiefs chairmen, the service secretaries and the head of the National Guard Bureau, Austin wrote that Pentagon funds could not be used to pay for duties performed under Title 32 for members of the Guard who do not comply with the military’s vaccine requirement. (Title 32 refers to Guard operations under state orders.) Austin also said National Guard members must be vaccinated to participate in drills, training, and other duty conducted under Title 32.

Stitt, maintaining that he is commander in chief of the Oklahoma National Guard as long as it operates under Title 32 orders, put out his own memo stipulating that no Guard member was required to get vaccinated. He also ordered Brig. Gen. Thomas Mancino, newly appointed commander of the Oklahoma National Guard, to not enforce the mandate. Subsequently, Mancino issued a statement pointing out that current state law is limited in protecting troops who opt out of the shot. Moreover, if the Guard were called up under federal orders, he said, he would enforce the mandate. Training events, schools, and mobilizations were going to “eventually force you out of that safe harbor,” he wrote, “…This is reality.”

In late December, a federal judge denied Oklahoma’s motion to enjoin the mandate. The Oklahoma Attorney General’s office responded, “We will not be surprised if the President’s vaccine mandate actually reduces the nation’s military readiness instead of promoting it.”

In a press briefing, Pentagon press secretary John Kirby said, “The Secretary has the authorities he needs to require this vaccine across the force, including the National Guard. …[E]ven when they’re in a Title 32 status.” He added, “It is a lawful order for National Guardsmen to receive the COVID vaccine. It’s a lawful order, and refusing to do that, absent of an improved exemption, puts them in the same potential [position] as active-duty members who refuse the vaccine.” That could mean, for instance, loss of pay and membership in the National Guard.

A core rationale for the mandate, according to Secretary Austin, is the need for military readiness—meaning Guard members must be healthy and fit for duty. And that extends to being healthy and fit for missions like transporting at-risk patients. Ohio National Guard Adjutant General Major General John Harris Jr. said, “I would never put a soldier or airman in harm’s way without the best protection we could put on them—body armor, helmets. And this medical readiness is the exact same thing. We’re putting folks into harm’s way.” He has moved the deadline from the Pentagon’s June 30 date to March 31—a move that boosted the vaccination rate from 53% to 56% in one week.

Ohio Governor DeWine has expressed frustration that almost half of the Ohio Army National Guard personnel can’t be deployed on this mission because they’re unvaccinated. “In some of our testing places, 40 to 50% of the people are testing positive,” he said. “So this is a high-risk operation. You need to be protected. The best way for you to be protected is to get the vaccination.”

As of December 2021, according to the National Guard Bureau, the National Guard as a whole was 66% fully vaccinated. The percentages vary according to service; for instance, nearly 90% of airmen have been vaccinated, compared with only 40% of Army Guardsmen. Among the states challenging the mandate, the vaccinated rates have been moving upward: In Alaska, about 92% of the Air National Guard have been vaccinated—leaving roughly 11,000 troops who had not met the December 2 deadline. In Iowa, as of Nov. 30, 91% of Air National Guard and 80% of Army National Guard members had been vaccinated, but about 9,000 soldiers had been directed to get the vaccination or risk disciplinary action. Almost 2,200 of the more than 2,800-strong Wyoming National Guard (77%) have received at least 1 dose. Nebraska Air National Guard’s force of 1,000 was 94% fully vaccinated as of December 1. (Maj Scott Ingalsbe, public affairs officer, said, “Vaccinations are tied to individual medical readiness. They provide service members with the best protection available so they can perform missions across the globe.”).

In most states, Army National Guard members have until June 30, 2022, to comply. “Our soldiers …have until [the DoD’s deadline], and some of them are just going to wait close to the deadline,” John Goheen of the National Guard Association of the United States said in a discussion on NPR. “That’s human nature.”

Earlier this month, Texas Governor Greg Abbott told National Guard members they can ignore the Pentagon’s COVID-19 vaccine mandate: “President Biden is not your commander-in-chief.” He has also sued the Biden administration over the requirement.

In the meantime, the hospitals at breaking point must hope for the best and take as much help as they can get. 

In early January, Ohio not only set a state record for COVID-19 hospitalizations—it had the fourth highest rate in the country, with 6,747 hospitalized coronavirus patients on January 10, a 40% increase over the previous 21 days. Most were unvaccinated. To help overwhelmed hospitals cope, Ohio Gov. Mike DeWine turned to the National Guard. Unfortunately, nearly half of the Ohio National Guard also were unvaccinated.

By US Department of Defense (DoD) directive, National Guard members must have a COVID-19 vaccination to be deployed on hospital missions. Thus, in COVID hotspots across the nation, governors are on the horns of a dilemma. They want and need to deploy the National Guard to give medical and nonclinical support but aren’t sure whether they will be able to or, indeed, whether they should.

So far, vaccinated teams are already on the ground in a number of states. In Indiana, where hospitalizations jumped 50% over 2 weeks in December, the National Guard sent 6-person teams, all fully vaccinated. In New Hampshire, 70 guards are being deployed to help hospitals with food service, clerical work, and other nonmedical functions. New York Governor Kathy Hochul has deployed guard members for help to ease the strain on nursing homes. Massachusetts Governor Charlie Baker has activated up to 500 guard members; some will be supporting 55 acute care hospital and 12 ambulance services. In Maine, where cases have peaked, Governor Janet Mills activated guard members to support nursing facilities and administer monoclonal antibodies. The Louisiana National Guard has administered more than 542,000 COVID-19 tests and 206,300 vaccines. As many as 1,000 Maryland Air and Army National Guardsmen are being activated to help with testing and other missions.

However, as in Ohio, other states are facing problematic scenarios. For instance, about 40% of the more than 20,000 Texas National Guard are refusing to get vaccinated, challenging the Biden Administration vaccine requirement for all military.

And a court showdown over federal vaccine mandates, started by Governor Kevin Stitt of Oklahoma and joined by the Republican governors of Wyoming, Iowa, Alaska, Nebraska, and Mississippi, came to a head in December. Last November, Stitt asked Defense Secretary Lloyd Austin to exempt Oklahoma’s National Guard from the vaccine mandate. He claimed the requirement violated the personal freedoms of many Oklahomans and could cause them to “potentially sacrifice their personal beliefs.” But in a memo to the Joint Chiefs chairmen, the service secretaries and the head of the National Guard Bureau, Austin wrote that Pentagon funds could not be used to pay for duties performed under Title 32 for members of the Guard who do not comply with the military’s vaccine requirement. (Title 32 refers to Guard operations under state orders.) Austin also said National Guard members must be vaccinated to participate in drills, training, and other duty conducted under Title 32.

Stitt, maintaining that he is commander in chief of the Oklahoma National Guard as long as it operates under Title 32 orders, put out his own memo stipulating that no Guard member was required to get vaccinated. He also ordered Brig. Gen. Thomas Mancino, newly appointed commander of the Oklahoma National Guard, to not enforce the mandate. Subsequently, Mancino issued a statement pointing out that current state law is limited in protecting troops who opt out of the shot. Moreover, if the Guard were called up under federal orders, he said, he would enforce the mandate. Training events, schools, and mobilizations were going to “eventually force you out of that safe harbor,” he wrote, “…This is reality.”

In late December, a federal judge denied Oklahoma’s motion to enjoin the mandate. The Oklahoma Attorney General’s office responded, “We will not be surprised if the President’s vaccine mandate actually reduces the nation’s military readiness instead of promoting it.”

In a press briefing, Pentagon press secretary John Kirby said, “The Secretary has the authorities he needs to require this vaccine across the force, including the National Guard. …[E]ven when they’re in a Title 32 status.” He added, “It is a lawful order for National Guardsmen to receive the COVID vaccine. It’s a lawful order, and refusing to do that, absent of an improved exemption, puts them in the same potential [position] as active-duty members who refuse the vaccine.” That could mean, for instance, loss of pay and membership in the National Guard.

A core rationale for the mandate, according to Secretary Austin, is the need for military readiness—meaning Guard members must be healthy and fit for duty. And that extends to being healthy and fit for missions like transporting at-risk patients. Ohio National Guard Adjutant General Major General John Harris Jr. said, “I would never put a soldier or airman in harm’s way without the best protection we could put on them—body armor, helmets. And this medical readiness is the exact same thing. We’re putting folks into harm’s way.” He has moved the deadline from the Pentagon’s June 30 date to March 31—a move that boosted the vaccination rate from 53% to 56% in one week.

Ohio Governor DeWine has expressed frustration that almost half of the Ohio Army National Guard personnel can’t be deployed on this mission because they’re unvaccinated. “In some of our testing places, 40 to 50% of the people are testing positive,” he said. “So this is a high-risk operation. You need to be protected. The best way for you to be protected is to get the vaccination.”

As of December 2021, according to the National Guard Bureau, the National Guard as a whole was 66% fully vaccinated. The percentages vary according to service; for instance, nearly 90% of airmen have been vaccinated, compared with only 40% of Army Guardsmen. Among the states challenging the mandate, the vaccinated rates have been moving upward: In Alaska, about 92% of the Air National Guard have been vaccinated—leaving roughly 11,000 troops who had not met the December 2 deadline. In Iowa, as of Nov. 30, 91% of Air National Guard and 80% of Army National Guard members had been vaccinated, but about 9,000 soldiers had been directed to get the vaccination or risk disciplinary action. Almost 2,200 of the more than 2,800-strong Wyoming National Guard (77%) have received at least 1 dose. Nebraska Air National Guard’s force of 1,000 was 94% fully vaccinated as of December 1. (Maj Scott Ingalsbe, public affairs officer, said, “Vaccinations are tied to individual medical readiness. They provide service members with the best protection available so they can perform missions across the globe.”).

In most states, Army National Guard members have until June 30, 2022, to comply. “Our soldiers …have until [the DoD’s deadline], and some of them are just going to wait close to the deadline,” John Goheen of the National Guard Association of the United States said in a discussion on NPR. “That’s human nature.”

Earlier this month, Texas Governor Greg Abbott told National Guard members they can ignore the Pentagon’s COVID-19 vaccine mandate: “President Biden is not your commander-in-chief.” He has also sued the Biden administration over the requirement.

In the meantime, the hospitals at breaking point must hope for the best and take as much help as they can get. 

In early January, Ohio not only set a state record for COVID-19 hospitalizations—it had the fourth highest rate in the country, with 6,747 hospitalized coronavirus patients on January 10, a 40% increase over the previous 21 days. Most were unvaccinated. To help overwhelmed hospitals cope, Ohio Gov. Mike DeWine turned to the National Guard. Unfortunately, nearly half of the Ohio National Guard also were unvaccinated.

By US Department of Defense (DoD) directive, National Guard members must have a COVID-19 vaccination to be deployed on hospital missions. Thus, in COVID hotspots across the nation, governors are on the horns of a dilemma. They want and need to deploy the National Guard to give medical and nonclinical support but aren’t sure whether they will be able to or, indeed, whether they should.

So far, vaccinated teams are already on the ground in a number of states. In Indiana, where hospitalizations jumped 50% over 2 weeks in December, the National Guard sent 6-person teams, all fully vaccinated. In New Hampshire, 70 guards are being deployed to help hospitals with food service, clerical work, and other nonmedical functions. New York Governor Kathy Hochul has deployed guard members for help to ease the strain on nursing homes. Massachusetts Governor Charlie Baker has activated up to 500 guard members; some will be supporting 55 acute care hospital and 12 ambulance services. In Maine, where cases have peaked, Governor Janet Mills activated guard members to support nursing facilities and administer monoclonal antibodies. The Louisiana National Guard has administered more than 542,000 COVID-19 tests and 206,300 vaccines. As many as 1,000 Maryland Air and Army National Guardsmen are being activated to help with testing and other missions.

However, as in Ohio, other states are facing problematic scenarios. For instance, about 40% of the more than 20,000 Texas National Guard are refusing to get vaccinated, challenging the Biden Administration vaccine requirement for all military.

And a court showdown over federal vaccine mandates, started by Governor Kevin Stitt of Oklahoma and joined by the Republican governors of Wyoming, Iowa, Alaska, Nebraska, and Mississippi, came to a head in December. Last November, Stitt asked Defense Secretary Lloyd Austin to exempt Oklahoma’s National Guard from the vaccine mandate. He claimed the requirement violated the personal freedoms of many Oklahomans and could cause them to “potentially sacrifice their personal beliefs.” But in a memo to the Joint Chiefs chairmen, the service secretaries and the head of the National Guard Bureau, Austin wrote that Pentagon funds could not be used to pay for duties performed under Title 32 for members of the Guard who do not comply with the military’s vaccine requirement. (Title 32 refers to Guard operations under state orders.) Austin also said National Guard members must be vaccinated to participate in drills, training, and other duty conducted under Title 32.

Stitt, maintaining that he is commander in chief of the Oklahoma National Guard as long as it operates under Title 32 orders, put out his own memo stipulating that no Guard member was required to get vaccinated. He also ordered Brig. Gen. Thomas Mancino, newly appointed commander of the Oklahoma National Guard, to not enforce the mandate. Subsequently, Mancino issued a statement pointing out that current state law is limited in protecting troops who opt out of the shot. Moreover, if the Guard were called up under federal orders, he said, he would enforce the mandate. Training events, schools, and mobilizations were going to “eventually force you out of that safe harbor,” he wrote, “…This is reality.”

In late December, a federal judge denied Oklahoma’s motion to enjoin the mandate. The Oklahoma Attorney General’s office responded, “We will not be surprised if the President’s vaccine mandate actually reduces the nation’s military readiness instead of promoting it.”

In a press briefing, Pentagon press secretary John Kirby said, “The Secretary has the authorities he needs to require this vaccine across the force, including the National Guard. …[E]ven when they’re in a Title 32 status.” He added, “It is a lawful order for National Guardsmen to receive the COVID vaccine. It’s a lawful order, and refusing to do that, absent of an improved exemption, puts them in the same potential [position] as active-duty members who refuse the vaccine.” That could mean, for instance, loss of pay and membership in the National Guard.

A core rationale for the mandate, according to Secretary Austin, is the need for military readiness—meaning Guard members must be healthy and fit for duty. And that extends to being healthy and fit for missions like transporting at-risk patients. Ohio National Guard Adjutant General Major General John Harris Jr. said, “I would never put a soldier or airman in harm’s way without the best protection we could put on them—body armor, helmets. And this medical readiness is the exact same thing. We’re putting folks into harm’s way.” He has moved the deadline from the Pentagon’s June 30 date to March 31—a move that boosted the vaccination rate from 53% to 56% in one week.

Ohio Governor DeWine has expressed frustration that almost half of the Ohio Army National Guard personnel can’t be deployed on this mission because they’re unvaccinated. “In some of our testing places, 40 to 50% of the people are testing positive,” he said. “So this is a high-risk operation. You need to be protected. The best way for you to be protected is to get the vaccination.”

As of December 2021, according to the National Guard Bureau, the National Guard as a whole was 66% fully vaccinated. The percentages vary according to service; for instance, nearly 90% of airmen have been vaccinated, compared with only 40% of Army Guardsmen. Among the states challenging the mandate, the vaccinated rates have been moving upward: In Alaska, about 92% of the Air National Guard have been vaccinated—leaving roughly 11,000 troops who had not met the December 2 deadline. In Iowa, as of Nov. 30, 91% of Air National Guard and 80% of Army National Guard members had been vaccinated, but about 9,000 soldiers had been directed to get the vaccination or risk disciplinary action. Almost 2,200 of the more than 2,800-strong Wyoming National Guard (77%) have received at least 1 dose. Nebraska Air National Guard’s force of 1,000 was 94% fully vaccinated as of December 1. (Maj Scott Ingalsbe, public affairs officer, said, “Vaccinations are tied to individual medical readiness. They provide service members with the best protection available so they can perform missions across the globe.”).

In most states, Army National Guard members have until June 30, 2022, to comply. “Our soldiers …have until [the DoD’s deadline], and some of them are just going to wait close to the deadline,” John Goheen of the National Guard Association of the United States said in a discussion on NPR. “That’s human nature.”

Earlier this month, Texas Governor Greg Abbott told National Guard members they can ignore the Pentagon’s COVID-19 vaccine mandate: “President Biden is not your commander-in-chief.” He has also sued the Biden administration over the requirement.

In the meantime, the hospitals at breaking point must hope for the best and take as much help as they can get. 

Thousands of health care professionals who separate from active duty each year now have a route to stay in federal health care jobs, including open positions in US Department of Veterans Affairs (VA) hospitals. President Biden signed the Hire Veteran Health Heroes Act of 2021 into law on November 30, saying, “This new program will build upon existing efforts to create a pipeline for former military health professionals….to allow those professionals to continue their service to each other and to our nation.”

Senators Mike Braun (R, Indiana) and Maggie Hassan (D, New Hampshire) introduced the bill last March; Representatives Robert Latta (Ohio-05) and Kathleen Rice (New York-04) introduced companion legislation in the House.

The Act serves multiple purposes, including to retain the critical experience of doctors, nurses, pharmacists, technicians, and physical therapists who understand the challenges service members face; to give those professionals continued employment; and to fill empty staff positions. Two years ago, the VA Inspector General said staff shortages are a root cause of many of the problems in veterans’ care.

 The bill directs the VA to create a program to recruit military medical personnel who are within 1 year of completing their military service. On average, 13,000 active-duty medical department members separate from the military each year at the end of enlistments or contracts, or through retirement. But until now, there has been no formal program to actively recruit them to stay.

The Act requires VA leaders to work with US Department of Defense officials to identify, refer, and transition service members who have critically needed skills. Moreover, the bill specifically mandates that if a member of the Armed Forces expresses an interest in working in a health care occupation within the VA, the VA Secretary “shall refer the member to a recruiter of the Department for consideration of open positions in the specialty and geography of interest to the member.”

Senator Hassan, in an official statement, said, “[W]e must always ensure that veterans have the support and resources that they need to succeed, and a critical way to do that is by expanding employment opportunities for our nation’s heroes and strengthening their health care.”

In his remarks, President Biden said, “For both our veterans and our military medical personnel, service isn’t just what they do, it’s who they are.”

Thousands of health care professionals who separate from active duty each year now have a route to stay in federal health care jobs, including open positions in US Department of Veterans Affairs (VA) hospitals. President Biden signed the Hire Veteran Health Heroes Act of 2021 into law on November 30, saying, “This new program will build upon existing efforts to create a pipeline for former military health professionals….to allow those professionals to continue their service to each other and to our nation.”

Senators Mike Braun (R, Indiana) and Maggie Hassan (D, New Hampshire) introduced the bill last March; Representatives Robert Latta (Ohio-05) and Kathleen Rice (New York-04) introduced companion legislation in the House.

The Act serves multiple purposes, including to retain the critical experience of doctors, nurses, pharmacists, technicians, and physical therapists who understand the challenges service members face; to give those professionals continued employment; and to fill empty staff positions. Two years ago, the VA Inspector General said staff shortages are a root cause of many of the problems in veterans’ care.

 The bill directs the VA to create a program to recruit military medical personnel who are within 1 year of completing their military service. On average, 13,000 active-duty medical department members separate from the military each year at the end of enlistments or contracts, or through retirement. But until now, there has been no formal program to actively recruit them to stay.

The Act requires VA leaders to work with US Department of Defense officials to identify, refer, and transition service members who have critically needed skills. Moreover, the bill specifically mandates that if a member of the Armed Forces expresses an interest in working in a health care occupation within the VA, the VA Secretary “shall refer the member to a recruiter of the Department for consideration of open positions in the specialty and geography of interest to the member.”

Senator Hassan, in an official statement, said, “[W]e must always ensure that veterans have the support and resources that they need to succeed, and a critical way to do that is by expanding employment opportunities for our nation’s heroes and strengthening their health care.”

In his remarks, President Biden said, “For both our veterans and our military medical personnel, service isn’t just what they do, it’s who they are.”

Thousands of health care professionals who separate from active duty each year now have a route to stay in federal health care jobs, including open positions in US Department of Veterans Affairs (VA) hospitals. President Biden signed the Hire Veteran Health Heroes Act of 2021 into law on November 30, saying, “This new program will build upon existing efforts to create a pipeline for former military health professionals….to allow those professionals to continue their service to each other and to our nation.”

Senators Mike Braun (R, Indiana) and Maggie Hassan (D, New Hampshire) introduced the bill last March; Representatives Robert Latta (Ohio-05) and Kathleen Rice (New York-04) introduced companion legislation in the House.

The Act serves multiple purposes, including to retain the critical experience of doctors, nurses, pharmacists, technicians, and physical therapists who understand the challenges service members face; to give those professionals continued employment; and to fill empty staff positions. Two years ago, the VA Inspector General said staff shortages are a root cause of many of the problems in veterans’ care.

 The bill directs the VA to create a program to recruit military medical personnel who are within 1 year of completing their military service. On average, 13,000 active-duty medical department members separate from the military each year at the end of enlistments or contracts, or through retirement. But until now, there has been no formal program to actively recruit them to stay.

The Act requires VA leaders to work with US Department of Defense officials to identify, refer, and transition service members who have critically needed skills. Moreover, the bill specifically mandates that if a member of the Armed Forces expresses an interest in working in a health care occupation within the VA, the VA Secretary “shall refer the member to a recruiter of the Department for consideration of open positions in the specialty and geography of interest to the member.”

Senator Hassan, in an official statement, said, “[W]e must always ensure that veterans have the support and resources that they need to succeed, and a critical way to do that is by expanding employment opportunities for our nation’s heroes and strengthening their health care.”

In his remarks, President Biden said, “For both our veterans and our military medical personnel, service isn’t just what they do, it’s who they are.”

It’s called the Momnibus—the Black Maternal Health Momnibus Act of 2021 (HR 959) with 12 bills addressing “every dimension of the maternal health crisis in America.” The first bill in the Momnibus to pass Congress is the Protecting Moms Who Served act, which sets up a $15 million maternal care program within the US Department of Veterans Affairs (VA). “There has never been a comprehensive evaluation of how our nation’s growing maternal mortality crisis is impacting our women veterans, even though they may be at higher risk due to their service,” said Sen. Tammy Duckworth (D-IL), a co-sponsor of the Momnibus. The bill has passed Congress and awaits President Biden’s signature.

Rep. Lauren Underwood (D-IL) along with Rep. Alma Adams (D- NC-12), Sen. Cory Booker D-NJ), and members of the Black Maternal Health Caucus reintroduced the bill (first introduced last year). According to Rep. Underwood, the act would codify and strengthen the VA maternity care coordination programs. It also will require the US Government Accountability Office to report the deaths of pregnant and postpartum veterans and to focus on any racial or ethnic disparities. The bill passed overwhelmingly, 414 to 9 and awaits President Biden’s signature.

The Momnibus’s cute name represents a very serious purpose. “Maternal mortality has historically been used as a key indicator of the health of a population,” say researchers from National Vital Statistics Reports. But American mothers are dying at the highest rate in the developed world, and the numbers have been rising dramatically. Between 1987, when the Centers for Disease Control and Prevention (CDC) launched the Pregnancy Mortality Surveillance System in 2017, the latest year for available data, the number of reported pregnancy-related deaths in the United States rose steadily from 7.2 deaths per 100,000 live births to 17.3 per 100,000.

The maternal morbidity crisis is particularly stark among certain groups of women. Black women are acutely at risk, dying at 3 to 4 times the rate of White women (41.7 deaths per 100,000 live births), and one-third higher than the next highest risk group, Native American women (28.3 deaths per 100,000 live births).

But just how accurate have the data been? The study published in National Vital Statistics Report found that using a checkbox for “cause of death” specifying maternal death identified more than triple the number of maternal deaths. Without the checkbox item, maternal mortality rates in 2015 and 2016 would have been reported as 8.7 deaths per 100,000 live births, compared with 8.9 in 2002. With the checkbox, the rate would be reported as 20.9 per 100,000 live births in 2015 and 21.8/100,000 in 2016.

The CDC states that the reasons for the rising numbers are unclear; advances in identification have improved over time, for one. But by and large, the women are dying of preventable causes, such as hypertension, diabetes mellitus, and chronic heart disease. Nearly 60% of maternal deaths are deemed preventable.

Black and other minority women, though, may be dying of biases. Researchers from Beth Israel and Harvard cite studies that have found racial and ethnic disparities in obstetric care delivery. Non-Hispanic Blacks women, Hispanic women, and Asian women, for instance, have lower odds of labor induction when compared with that of White women. The odds of receiving an episiotomy are lower in non-Hispanic Black and Hispanic women. The Listening to Mothers survey III found that 24% of participants perceived discrimination during birth hospitalization, predominantly among Black or Hispanic women and uninsured women.

A maternal health equity advocacy group, 4Kira4Moms, was founded by the husband of Kira Johnson who died of hemorrhage following a routine scheduled cesarean section. In the recovery room, her catheter began turning pink with blood. For 10 hours, her husband said, he and her family begged the medical staff for help but were told his wife was not a priority. Thus, the Momnibus also contains the Kira Johnson Act, which will establish funding for community-based groups to provide Black pregnant women with more support.

Among other changes, the Momnibus will:

• Make critical investments in social determinants of health that influence maternal health outcomes, such as housing, transportation, and nutrition;
• Provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity;
• Comprehensively study the unique maternal health risks facing pregnant and postpartum veterans and support VA maternity care coordination programs;
• Support mothers with mental health conditions and substance use disorders; and
• Promote innovative payment models to incentivize high-quality maternity care and nonclinical perinatal support

A variety of recent bills in Congress address maternal health. The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA) Act, for instance, also would specifically address maternal health disparities by improving data collection and reporting, improving maternal care, and advancing respectful, equitable care. It also would extend Medicaid and the Children’s Health Insurance Program coverage. Katie Shea Barrett, MPH, executive director of March for Moms, a coalition of families, health care practitioners, policy makers, and partners advocating for mothers’ and families’ health, notes in an essay for thehill.com that Medicaid coverage ends about 60 days postpartum, although half of the maternal deaths happen between 42 days and 1 year postpartum. 

She writes: “[W]e have to directly address the disproportionate impact of maternal mortality on women of color by training providers in offering care that is culturally competent and free of implicit bias. Health systems must be aware and respectful of cultural norms when providing care and be mindful of buying into stereotypes based on race, ethnicity, and even underlying medical conditions like diabetes, which often lead to perceived discrimination and perpetuate systems of injustice.”

In April, Vice President Kamala Harris called for sweeping action to curb racial inequities in pregnancy and childbirth. In an email Q&A with STAT, she said, “With every day that goes by and every woman who dies, the need for action grows more urgent.”

It’s called the Momnibus—the Black Maternal Health Momnibus Act of 2021 (HR 959) with 12 bills addressing “every dimension of the maternal health crisis in America.” The first bill in the Momnibus to pass Congress is the Protecting Moms Who Served act, which sets up a $15 million maternal care program within the US Department of Veterans Affairs (VA). “There has never been a comprehensive evaluation of how our nation’s growing maternal mortality crisis is impacting our women veterans, even though they may be at higher risk due to their service,” said Sen. Tammy Duckworth (D-IL), a co-sponsor of the Momnibus. The bill has passed Congress and awaits President Biden’s signature.

Rep. Lauren Underwood (D-IL) along with Rep. Alma Adams (D- NC-12), Sen. Cory Booker D-NJ), and members of the Black Maternal Health Caucus reintroduced the bill (first introduced last year). According to Rep. Underwood, the act would codify and strengthen the VA maternity care coordination programs. It also will require the US Government Accountability Office to report the deaths of pregnant and postpartum veterans and to focus on any racial or ethnic disparities. The bill passed overwhelmingly, 414 to 9 and awaits President Biden’s signature.

The Momnibus’s cute name represents a very serious purpose. “Maternal mortality has historically been used as a key indicator of the health of a population,” say researchers from National Vital Statistics Reports. But American mothers are dying at the highest rate in the developed world, and the numbers have been rising dramatically. Between 1987, when the Centers for Disease Control and Prevention (CDC) launched the Pregnancy Mortality Surveillance System in 2017, the latest year for available data, the number of reported pregnancy-related deaths in the United States rose steadily from 7.2 deaths per 100,000 live births to 17.3 per 100,000.

The maternal morbidity crisis is particularly stark among certain groups of women. Black women are acutely at risk, dying at 3 to 4 times the rate of White women (41.7 deaths per 100,000 live births), and one-third higher than the next highest risk group, Native American women (28.3 deaths per 100,000 live births).

But just how accurate have the data been? The study published in National Vital Statistics Report found that using a checkbox for “cause of death” specifying maternal death identified more than triple the number of maternal deaths. Without the checkbox item, maternal mortality rates in 2015 and 2016 would have been reported as 8.7 deaths per 100,000 live births, compared with 8.9 in 2002. With the checkbox, the rate would be reported as 20.9 per 100,000 live births in 2015 and 21.8/100,000 in 2016.

The CDC states that the reasons for the rising numbers are unclear; advances in identification have improved over time, for one. But by and large, the women are dying of preventable causes, such as hypertension, diabetes mellitus, and chronic heart disease. Nearly 60% of maternal deaths are deemed preventable.

Black and other minority women, though, may be dying of biases. Researchers from Beth Israel and Harvard cite studies that have found racial and ethnic disparities in obstetric care delivery. Non-Hispanic Blacks women, Hispanic women, and Asian women, for instance, have lower odds of labor induction when compared with that of White women. The odds of receiving an episiotomy are lower in non-Hispanic Black and Hispanic women. The Listening to Mothers survey III found that 24% of participants perceived discrimination during birth hospitalization, predominantly among Black or Hispanic women and uninsured women.

A maternal health equity advocacy group, 4Kira4Moms, was founded by the husband of Kira Johnson who died of hemorrhage following a routine scheduled cesarean section. In the recovery room, her catheter began turning pink with blood. For 10 hours, her husband said, he and her family begged the medical staff for help but were told his wife was not a priority. Thus, the Momnibus also contains the Kira Johnson Act, which will establish funding for community-based groups to provide Black pregnant women with more support.

Among other changes, the Momnibus will:

• Make critical investments in social determinants of health that influence maternal health outcomes, such as housing, transportation, and nutrition;
• Provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity;
• Comprehensively study the unique maternal health risks facing pregnant and postpartum veterans and support VA maternity care coordination programs;
• Support mothers with mental health conditions and substance use disorders; and
• Promote innovative payment models to incentivize high-quality maternity care and nonclinical perinatal support

A variety of recent bills in Congress address maternal health. The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA) Act, for instance, also would specifically address maternal health disparities by improving data collection and reporting, improving maternal care, and advancing respectful, equitable care. It also would extend Medicaid and the Children’s Health Insurance Program coverage. Katie Shea Barrett, MPH, executive director of March for Moms, a coalition of families, health care practitioners, policy makers, and partners advocating for mothers’ and families’ health, notes in an essay for thehill.com that Medicaid coverage ends about 60 days postpartum, although half of the maternal deaths happen between 42 days and 1 year postpartum. 

She writes: “[W]e have to directly address the disproportionate impact of maternal mortality on women of color by training providers in offering care that is culturally competent and free of implicit bias. Health systems must be aware and respectful of cultural norms when providing care and be mindful of buying into stereotypes based on race, ethnicity, and even underlying medical conditions like diabetes, which often lead to perceived discrimination and perpetuate systems of injustice.”

In April, Vice President Kamala Harris called for sweeping action to curb racial inequities in pregnancy and childbirth. In an email Q&A with STAT, she said, “With every day that goes by and every woman who dies, the need for action grows more urgent.”

It’s called the Momnibus—the Black Maternal Health Momnibus Act of 2021 (HR 959) with 12 bills addressing “every dimension of the maternal health crisis in America.” The first bill in the Momnibus to pass Congress is the Protecting Moms Who Served act, which sets up a $15 million maternal care program within the US Department of Veterans Affairs (VA). “There has never been a comprehensive evaluation of how our nation’s growing maternal mortality crisis is impacting our women veterans, even though they may be at higher risk due to their service,” said Sen. Tammy Duckworth (D-IL), a co-sponsor of the Momnibus. The bill has passed Congress and awaits President Biden’s signature.

Rep. Lauren Underwood (D-IL) along with Rep. Alma Adams (D- NC-12), Sen. Cory Booker D-NJ), and members of the Black Maternal Health Caucus reintroduced the bill (first introduced last year). According to Rep. Underwood, the act would codify and strengthen the VA maternity care coordination programs. It also will require the US Government Accountability Office to report the deaths of pregnant and postpartum veterans and to focus on any racial or ethnic disparities. The bill passed overwhelmingly, 414 to 9 and awaits President Biden’s signature.

The Momnibus’s cute name represents a very serious purpose. “Maternal mortality has historically been used as a key indicator of the health of a population,” say researchers from National Vital Statistics Reports. But American mothers are dying at the highest rate in the developed world, and the numbers have been rising dramatically. Between 1987, when the Centers for Disease Control and Prevention (CDC) launched the Pregnancy Mortality Surveillance System in 2017, the latest year for available data, the number of reported pregnancy-related deaths in the United States rose steadily from 7.2 deaths per 100,000 live births to 17.3 per 100,000.

The maternal morbidity crisis is particularly stark among certain groups of women. Black women are acutely at risk, dying at 3 to 4 times the rate of White women (41.7 deaths per 100,000 live births), and one-third higher than the next highest risk group, Native American women (28.3 deaths per 100,000 live births).

But just how accurate have the data been? The study published in National Vital Statistics Report found that using a checkbox for “cause of death” specifying maternal death identified more than triple the number of maternal deaths. Without the checkbox item, maternal mortality rates in 2015 and 2016 would have been reported as 8.7 deaths per 100,000 live births, compared with 8.9 in 2002. With the checkbox, the rate would be reported as 20.9 per 100,000 live births in 2015 and 21.8/100,000 in 2016.

The CDC states that the reasons for the rising numbers are unclear; advances in identification have improved over time, for one. But by and large, the women are dying of preventable causes, such as hypertension, diabetes mellitus, and chronic heart disease. Nearly 60% of maternal deaths are deemed preventable.

Black and other minority women, though, may be dying of biases. Researchers from Beth Israel and Harvard cite studies that have found racial and ethnic disparities in obstetric care delivery. Non-Hispanic Blacks women, Hispanic women, and Asian women, for instance, have lower odds of labor induction when compared with that of White women. The odds of receiving an episiotomy are lower in non-Hispanic Black and Hispanic women. The Listening to Mothers survey III found that 24% of participants perceived discrimination during birth hospitalization, predominantly among Black or Hispanic women and uninsured women.

A maternal health equity advocacy group, 4Kira4Moms, was founded by the husband of Kira Johnson who died of hemorrhage following a routine scheduled cesarean section. In the recovery room, her catheter began turning pink with blood. For 10 hours, her husband said, he and her family begged the medical staff for help but were told his wife was not a priority. Thus, the Momnibus also contains the Kira Johnson Act, which will establish funding for community-based groups to provide Black pregnant women with more support.

Among other changes, the Momnibus will:

• Make critical investments in social determinants of health that influence maternal health outcomes, such as housing, transportation, and nutrition;
• Provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity;
• Comprehensively study the unique maternal health risks facing pregnant and postpartum veterans and support VA maternity care coordination programs;
• Support mothers with mental health conditions and substance use disorders; and
• Promote innovative payment models to incentivize high-quality maternity care and nonclinical perinatal support

A variety of recent bills in Congress address maternal health. The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA) Act, for instance, also would specifically address maternal health disparities by improving data collection and reporting, improving maternal care, and advancing respectful, equitable care. It also would extend Medicaid and the Children’s Health Insurance Program coverage. Katie Shea Barrett, MPH, executive director of March for Moms, a coalition of families, health care practitioners, policy makers, and partners advocating for mothers’ and families’ health, notes in an essay for thehill.com that Medicaid coverage ends about 60 days postpartum, although half of the maternal deaths happen between 42 days and 1 year postpartum. 

She writes: “[W]e have to directly address the disproportionate impact of maternal mortality on women of color by training providers in offering care that is culturally competent and free of implicit bias. Health systems must be aware and respectful of cultural norms when providing care and be mindful of buying into stereotypes based on race, ethnicity, and even underlying medical conditions like diabetes, which often lead to perceived discrimination and perpetuate systems of injustice.”

In April, Vice President Kamala Harris called for sweeping action to curb racial inequities in pregnancy and childbirth. In an email Q&A with STAT, she said, “With every day that goes by and every woman who dies, the need for action grows more urgent.”

In May 2016, Tarrah Oliver had been working as a bench tech in hematology at Tséhootsooí Medical Center (TMC) for 4 years when the hospital launched a 5-point screen for detecting hantavirus cardiopulmonary syndrome (HCPS), a potentially fatal disease that disproportionately affects Native Americans.

Developed at the University of New Mexico, the 5-point screen was particularly useful for facilities like TMC, a 56-bed hospital in Arizona serving Navajo Nation patients. Although the Navajo make up only 1.7% of the population, they account for 18% of all reported HCPS cases in the US.

But Oliver, who was the laboratory Safety and Training supervisor, her department supervisor, and his assistant were the only people who knew how to do the screen. “I was storing completed worksheets in a folder,” Oliver said, “and soon I had to transfer them to a 3-inch binder because we had so many being ordered. I started saving slides that scored high so that I could show my fellow lab mates what certain characteristics looked like under the microscope.” She also created case studies to train staff using analyzer printouts and slides from the patients. “It was my little side project to take care of while I was working and training new employees in the hematology department.”

The screen was to become much more than a side project very quickly.

In 2017, there was a hantavirus outbreak in one of the nearby communities. A team from the Centers for Disease Control and Prevention (CDC) came out to visit the local hospitals to educate the medical staff on what to look for in their patients with suspected hantavirus. Among those: the TMC staff. The visit would prove both serendipitous and synergistic.

Mary Choi, MD, MPH, medical officer with the CDC Viral Special Pathogens Branch, said, “Members of my branch were asked to come to Navajo Nation [Lukachukai chapter, Arizona] because of a cluster of hantaviruses cases that had been occurring in the area over the course of a few years. During a meeting with medical providers at TMC, our team met Tarrah and she told us that TMC had implemented the screen. We were really intrigued and impressed by the initiative of this small community hospital.”

“We were excited that the CDC even knew we existed!” Oliver recalled. “This little lab in the middle of the reservation.”

HCPS is rare but severe. It can quickly progress from nonspecific initial symptoms, such as fever, body aches, and shortness of breath, to severe respiratory distress. Without immediate intervention, patients usually die within 24 to 48 hours of the onset of cardiopulmonary symptoms. “What makes the disease even more challenging,” said Choi, “is that some of the critical lifesaving measures that physicians normally employ to save a critically-ill patient can actually make the situation worse.

“For example, when HCPS patients reach the cardiopulmonary phase of the illness, their blood pressure will drop. The normal response to this is to give IV fluids (IVF). But in hantavirus, giving IVF can actually make the signs and symptoms of the disease worse and only judicious use of IVF is recommended.”

She gave other examples of treatment challenges: “Physicians are taught to intubate critically ill patients. However, intubation of hanta patients during the cardiopulmonary phase can actually be detrimental. Also, in general, extracorporeal membrane oxygenation (ECMO) is an intervention of last resort for most critically-ill patients. As the procedure essentially involves hooking the patient up to a heart-lung machine, which has a lot of complications, doctors do not do this unless they have to. But in hantavirus disease, early initiation of ECMO has been shown to significantly improve survival.”

“Another tricky thing about ECMO is that not all hospitals have an ECMO machine… oftentimes patients have to be transferred from one hospital to another because they need ECMO and it is not available where they are.” The ECMO-equipped facility closest to TMC is 170 miles away, at the University of New Mexico Hospital in Albuquerque.

 For all those reasons, Dr. Choi said, it is critically important for physicians to know if the patient they are treating has hantavirus or not. The problem is, there is no rapid test for hantavirus disease. The tests have to be sent out to a laboratory and it can take days before physicians receive a test result. “This is where the 5-point screen is such a valuable tool. Although it is not a diagnostic test, it is a very accurate screening tool. Even better, it is readily and widely available, because to perform the screen, you only need a complete blood count (CBC) and a peripheral blood smear…which can be performed in the vast majority of laboratories and clinics. In addition, the CBC and peripheral blood smear are very commonly ordered tests.”

The screen could be particularly crucial for small community hospitals and clinics. “[TMC] took a screen developed by hematopathologists for hematopathologists,” Choi said, “and adapted it so that it could be performed by clinical laboratorians—because hematopathologists don’t exactly grow on trees! Once we heard about the work that TMC was doing, we knew that this was something we wanted to support and advocate for.”

“We started to throw around the idea of teaching this method to other laboratories on the reservation,” Oliver said. She and Mary Choi teamed up to “knock on everyone’s door to see who was utilizing the screening or if they had their own methods of detecting hantavirus in their patients.”

Two years later, they began holding training sessions at a nearby community college; they also trained an entire laboratory at their hospital in late 2019. Plans were to set up other training sessions towards the border towns before spring of 2020.

Then SARS-CoV-2 showed up.

Hantavirus or coronavirus?

COVID-19 hit the Navajo Nation like a sledgehammer. Native Americans in rural areas, as many Navajo are, may have multigenerational and extended families living in tight quarters, with limited access to running water, miles from the nearest healthcare facility. They were particularly vulnerable to a virus that thrives on close contact, at a time when the most common preventives were distancing, frequent handwashing, and testing. By May 2020, the Navajo Nation had surpassed the epicenters—New York and New Jersey—in cases of infection. Even as late as November 2021, the Navah Nation has reported > 37,000 positive cases, and nearly 1,500 confirmed deaths, despite reaching a 70% vaccination rate.

Making things ever more challenging: How do you know whether the patient has hantavirus or COVID-19? The distinction is critical because the disease courses of the 2 infections differ greatly. “The importance of [TMC’s] work was really brought home by the COVID pandemic,” Mary Choi said. “The signs and symptoms of early COVID and hantavirus are really indistinguishable. But the problem is that most people with COVID will live, while most people with hantavirus will die without critical care.”

The overall US case fatality rates are drastically different: 36% to 38% for hantavirus, 1.6% for COVID-19. In Arizona alone, of 81 patients who developed hantavirus (as of 2019), 27 died. In New Mexico, of 117 patients, 51 died.

“The scary part,” said Tarrah Oliver, “was that when patients were flooding our ER with symptoms exactly like those of hantavirus, I kept thinking that it was now up to us in the lab to scrutinize CBC results for any characteristics of hantavirus because our locum providers and permanent providers would likely not have hanta on their minds right now to suspect it.”

“Once COVID hit Navajo Nation, we really worried about how clinicians were going to distinguish between the two disease entities and worried about possible excess deaths of hanta because they were mistaken for COVID-19,” Choi says. “Unfortunately, in the spring of 2020, 2 fatal cases of hantavirus were reported. Their deaths were initially thought to be due to COVID, but later testing showed that they both died of hantavirus. We knew that we had to study whether the 5-point screen could distinguish between hantavirus disease and COVID.”

They conducted the comparison study at TMC and Emory, in Atlanta. TMC, as a small hospital, might not get many COVID cases while Emory, a large hospital system, had many COVID cases but rarely hantavirus cases (Box).

The researchers found that the screen did indeed work as they had hoped. No matter who performed the screen, the demographics of the population screened, or when in the COVID-19 disease course the sample was taken, individuals positive for COVID-19 received a low score on the screen. None of the participants who were positive for COVID-19 demonstrated all 5 hallmarks of hantavirus infection, and only 3 patients received a score of 4.

The screen was most accurate when the specimen was collected during the cardiopulmonary phase. Before the cardiopulmonary phase [BOX], there is a short febrile prodromal phase in which the platelets are starting to drop but aren’t low enough to be considered thrombocytopenic. Hematocrit and hemoglobin levels are still normal, and immunoblasts or plasma cells haven’t been released into the blood yet. “A patient’s score is likely to be pretty low or intermediate,” Tarrah Oliver said. “In the febrile prodromal phase, the patient will have chills, fever, headache and myalgia lasting 3 to 6 days, which might be written off as the flu or even COVID-19, especially if a provider is not familiar with the endemic regions of the Navajo Nation.”

“When we found that the screen could distinguish between the 2 diseases,” Choi said, “we worked frantically to write up the findings and publish so that healthcare providers would be aware of the value of this tool.”

“I couldn’t be more excited that the word is getting out in the medical community,” Oliver said. They plan to share the information as widely as possible, booking local radio spots, for instance. “We’re trying to disseminate our research across our partners on the reservation.”

The results of the research were recently published in the American Journal of Clinical Pathology. “Our next follow-up research will be an inter-rater reliability between TMC’s 2-year and 4-year-degree medical laboratorians and Emory’s pathologists performing the 5-point hantavirus screen on the same slides. We want to show that rural hospitals without the expertise of pathologists can perform this screen for their patients in a timely manner and still get the same outcomes.”

Lastly, and the most exciting, Oliver said, is putting that training manual she created to wider use. In addition to all the case studies she collected, analyzer printouts, and PowerPoint slides about the epidemiology, the manual includes a procedure, billing codes, and layout of what it looks like on certain medical record software that most Indian Health Service hospitals use. “With the manual, we may be able to expand our reach, so I won’t need to travel,” Oliver said. “We could use Zoom to reach further and I could explain it all while they have the manual right in front them.”

So far, nearly 200 screens have been performed at TMC. Four cases of hantavirus disease have been identified. The screen has proved successful, but for Oliver, there’s a personal reward. “I heard stories as a kid of relatives and friends succumbing to this mystery flu in the 1990s and how our parents protected us from it,” she said. “Now I feel like it’s my turn to take care of my family and friends from both hantavirus and COVID, our current ‘mystery flu.’ … I’ve realized that now I’m doing this for our people, the Diné (Navajo) people.”

This article offers some background and follow-up to Hantavirus Disease and COVID-19: Evaluation of the Hantavirus 5-Point Screen in 139 COVID-19 Patients

In May 2016, Tarrah Oliver had been working as a bench tech in hematology at Tséhootsooí Medical Center (TMC) for 4 years when the hospital launched a 5-point screen for detecting hantavirus cardiopulmonary syndrome (HCPS), a potentially fatal disease that disproportionately affects Native Americans.

Developed at the University of New Mexico, the 5-point screen was particularly useful for facilities like TMC, a 56-bed hospital in Arizona serving Navajo Nation patients. Although the Navajo make up only 1.7% of the population, they account for 18% of all reported HCPS cases in the US.

But Oliver, who was the laboratory Safety and Training supervisor, her department supervisor, and his assistant were the only people who knew how to do the screen. “I was storing completed worksheets in a folder,” Oliver said, “and soon I had to transfer them to a 3-inch binder because we had so many being ordered. I started saving slides that scored high so that I could show my fellow lab mates what certain characteristics looked like under the microscope.” She also created case studies to train staff using analyzer printouts and slides from the patients. “It was my little side project to take care of while I was working and training new employees in the hematology department.”

The screen was to become much more than a side project very quickly.

In 2017, there was a hantavirus outbreak in one of the nearby communities. A team from the Centers for Disease Control and Prevention (CDC) came out to visit the local hospitals to educate the medical staff on what to look for in their patients with suspected hantavirus. Among those: the TMC staff. The visit would prove both serendipitous and synergistic.

Mary Choi, MD, MPH, medical officer with the CDC Viral Special Pathogens Branch, said, “Members of my branch were asked to come to Navajo Nation [Lukachukai chapter, Arizona] because of a cluster of hantaviruses cases that had been occurring in the area over the course of a few years. During a meeting with medical providers at TMC, our team met Tarrah and she told us that TMC had implemented the screen. We were really intrigued and impressed by the initiative of this small community hospital.”

“We were excited that the CDC even knew we existed!” Oliver recalled. “This little lab in the middle of the reservation.”

HCPS is rare but severe. It can quickly progress from nonspecific initial symptoms, such as fever, body aches, and shortness of breath, to severe respiratory distress. Without immediate intervention, patients usually die within 24 to 48 hours of the onset of cardiopulmonary symptoms. “What makes the disease even more challenging,” said Choi, “is that some of the critical lifesaving measures that physicians normally employ to save a critically-ill patient can actually make the situation worse.

“For example, when HCPS patients reach the cardiopulmonary phase of the illness, their blood pressure will drop. The normal response to this is to give IV fluids (IVF). But in hantavirus, giving IVF can actually make the signs and symptoms of the disease worse and only judicious use of IVF is recommended.”

She gave other examples of treatment challenges: “Physicians are taught to intubate critically ill patients. However, intubation of hanta patients during the cardiopulmonary phase can actually be detrimental. Also, in general, extracorporeal membrane oxygenation (ECMO) is an intervention of last resort for most critically-ill patients. As the procedure essentially involves hooking the patient up to a heart-lung machine, which has a lot of complications, doctors do not do this unless they have to. But in hantavirus disease, early initiation of ECMO has been shown to significantly improve survival.”

“Another tricky thing about ECMO is that not all hospitals have an ECMO machine… oftentimes patients have to be transferred from one hospital to another because they need ECMO and it is not available where they are.” The ECMO-equipped facility closest to TMC is 170 miles away, at the University of New Mexico Hospital in Albuquerque.

 For all those reasons, Dr. Choi said, it is critically important for physicians to know if the patient they are treating has hantavirus or not. The problem is, there is no rapid test for hantavirus disease. The tests have to be sent out to a laboratory and it can take days before physicians receive a test result. “This is where the 5-point screen is such a valuable tool. Although it is not a diagnostic test, it is a very accurate screening tool. Even better, it is readily and widely available, because to perform the screen, you only need a complete blood count (CBC) and a peripheral blood smear…which can be performed in the vast majority of laboratories and clinics. In addition, the CBC and peripheral blood smear are very commonly ordered tests.”

The screen could be particularly crucial for small community hospitals and clinics. “[TMC] took a screen developed by hematopathologists for hematopathologists,” Choi said, “and adapted it so that it could be performed by clinical laboratorians—because hematopathologists don’t exactly grow on trees! Once we heard about the work that TMC was doing, we knew that this was something we wanted to support and advocate for.”

“We started to throw around the idea of teaching this method to other laboratories on the reservation,” Oliver said. She and Mary Choi teamed up to “knock on everyone’s door to see who was utilizing the screening or if they had their own methods of detecting hantavirus in their patients.”

Two years later, they began holding training sessions at a nearby community college; they also trained an entire laboratory at their hospital in late 2019. Plans were to set up other training sessions towards the border towns before spring of 2020.

Then SARS-CoV-2 showed up.

Hantavirus or coronavirus?

COVID-19 hit the Navajo Nation like a sledgehammer. Native Americans in rural areas, as many Navajo are, may have multigenerational and extended families living in tight quarters, with limited access to running water, miles from the nearest healthcare facility. They were particularly vulnerable to a virus that thrives on close contact, at a time when the most common preventives were distancing, frequent handwashing, and testing. By May 2020, the Navajo Nation had surpassed the epicenters—New York and New Jersey—in cases of infection. Even as late as November 2021, the Navah Nation has reported > 37,000 positive cases, and nearly 1,500 confirmed deaths, despite reaching a 70% vaccination rate.

Making things ever more challenging: How do you know whether the patient has hantavirus or COVID-19? The distinction is critical because the disease courses of the 2 infections differ greatly. “The importance of [TMC’s] work was really brought home by the COVID pandemic,” Mary Choi said. “The signs and symptoms of early COVID and hantavirus are really indistinguishable. But the problem is that most people with COVID will live, while most people with hantavirus will die without critical care.”

The overall US case fatality rates are drastically different: 36% to 38% for hantavirus, 1.6% for COVID-19. In Arizona alone, of 81 patients who developed hantavirus (as of 2019), 27 died. In New Mexico, of 117 patients, 51 died.

“The scary part,” said Tarrah Oliver, “was that when patients were flooding our ER with symptoms exactly like those of hantavirus, I kept thinking that it was now up to us in the lab to scrutinize CBC results for any characteristics of hantavirus because our locum providers and permanent providers would likely not have hanta on their minds right now to suspect it.”

“Once COVID hit Navajo Nation, we really worried about how clinicians were going to distinguish between the two disease entities and worried about possible excess deaths of hanta because they were mistaken for COVID-19,” Choi says. “Unfortunately, in the spring of 2020, 2 fatal cases of hantavirus were reported. Their deaths were initially thought to be due to COVID, but later testing showed that they both died of hantavirus. We knew that we had to study whether the 5-point screen could distinguish between hantavirus disease and COVID.”

They conducted the comparison study at TMC and Emory, in Atlanta. TMC, as a small hospital, might not get many COVID cases while Emory, a large hospital system, had many COVID cases but rarely hantavirus cases (Box).

The researchers found that the screen did indeed work as they had hoped. No matter who performed the screen, the demographics of the population screened, or when in the COVID-19 disease course the sample was taken, individuals positive for COVID-19 received a low score on the screen. None of the participants who were positive for COVID-19 demonstrated all 5 hallmarks of hantavirus infection, and only 3 patients received a score of 4.

The screen was most accurate when the specimen was collected during the cardiopulmonary phase. Before the cardiopulmonary phase [BOX], there is a short febrile prodromal phase in which the platelets are starting to drop but aren’t low enough to be considered thrombocytopenic. Hematocrit and hemoglobin levels are still normal, and immunoblasts or plasma cells haven’t been released into the blood yet. “A patient’s score is likely to be pretty low or intermediate,” Tarrah Oliver said. “In the febrile prodromal phase, the patient will have chills, fever, headache and myalgia lasting 3 to 6 days, which might be written off as the flu or even COVID-19, especially if a provider is not familiar with the endemic regions of the Navajo Nation.”

“When we found that the screen could distinguish between the 2 diseases,” Choi said, “we worked frantically to write up the findings and publish so that healthcare providers would be aware of the value of this tool.”

“I couldn’t be more excited that the word is getting out in the medical community,” Oliver said. They plan to share the information as widely as possible, booking local radio spots, for instance. “We’re trying to disseminate our research across our partners on the reservation.”

The results of the research were recently published in the American Journal of Clinical Pathology. “Our next follow-up research will be an inter-rater reliability between TMC’s 2-year and 4-year-degree medical laboratorians and Emory’s pathologists performing the 5-point hantavirus screen on the same slides. We want to show that rural hospitals without the expertise of pathologists can perform this screen for their patients in a timely manner and still get the same outcomes.”

Lastly, and the most exciting, Oliver said, is putting that training manual she created to wider use. In addition to all the case studies she collected, analyzer printouts, and PowerPoint slides about the epidemiology, the manual includes a procedure, billing codes, and layout of what it looks like on certain medical record software that most Indian Health Service hospitals use. “With the manual, we may be able to expand our reach, so I won’t need to travel,” Oliver said. “We could use Zoom to reach further and I could explain it all while they have the manual right in front them.”

So far, nearly 200 screens have been performed at TMC. Four cases of hantavirus disease have been identified. The screen has proved successful, but for Oliver, there’s a personal reward. “I heard stories as a kid of relatives and friends succumbing to this mystery flu in the 1990s and how our parents protected us from it,” she said. “Now I feel like it’s my turn to take care of my family and friends from both hantavirus and COVID, our current ‘mystery flu.’ … I’ve realized that now I’m doing this for our people, the Diné (Navajo) people.”

This article offers some background and follow-up to Hantavirus Disease and COVID-19: Evaluation of the Hantavirus 5-Point Screen in 139 COVID-19 Patients

In May 2016, Tarrah Oliver had been working as a bench tech in hematology at Tséhootsooí Medical Center (TMC) for 4 years when the hospital launched a 5-point screen for detecting hantavirus cardiopulmonary syndrome (HCPS), a potentially fatal disease that disproportionately affects Native Americans.

Developed at the University of New Mexico, the 5-point screen was particularly useful for facilities like TMC, a 56-bed hospital in Arizona serving Navajo Nation patients. Although the Navajo make up only 1.7% of the population, they account for 18% of all reported HCPS cases in the US.

But Oliver, who was the laboratory Safety and Training supervisor, her department supervisor, and his assistant were the only people who knew how to do the screen. “I was storing completed worksheets in a folder,” Oliver said, “and soon I had to transfer them to a 3-inch binder because we had so many being ordered. I started saving slides that scored high so that I could show my fellow lab mates what certain characteristics looked like under the microscope.” She also created case studies to train staff using analyzer printouts and slides from the patients. “It was my little side project to take care of while I was working and training new employees in the hematology department.”

The screen was to become much more than a side project very quickly.

In 2017, there was a hantavirus outbreak in one of the nearby communities. A team from the Centers for Disease Control and Prevention (CDC) came out to visit the local hospitals to educate the medical staff on what to look for in their patients with suspected hantavirus. Among those: the TMC staff. The visit would prove both serendipitous and synergistic.

Mary Choi, MD, MPH, medical officer with the CDC Viral Special Pathogens Branch, said, “Members of my branch were asked to come to Navajo Nation [Lukachukai chapter, Arizona] because of a cluster of hantaviruses cases that had been occurring in the area over the course of a few years. During a meeting with medical providers at TMC, our team met Tarrah and she told us that TMC had implemented the screen. We were really intrigued and impressed by the initiative of this small community hospital.”

“We were excited that the CDC even knew we existed!” Oliver recalled. “This little lab in the middle of the reservation.”

HCPS is rare but severe. It can quickly progress from nonspecific initial symptoms, such as fever, body aches, and shortness of breath, to severe respiratory distress. Without immediate intervention, patients usually die within 24 to 48 hours of the onset of cardiopulmonary symptoms. “What makes the disease even more challenging,” said Choi, “is that some of the critical lifesaving measures that physicians normally employ to save a critically-ill patient can actually make the situation worse.

“For example, when HCPS patients reach the cardiopulmonary phase of the illness, their blood pressure will drop. The normal response to this is to give IV fluids (IVF). But in hantavirus, giving IVF can actually make the signs and symptoms of the disease worse and only judicious use of IVF is recommended.”

She gave other examples of treatment challenges: “Physicians are taught to intubate critically ill patients. However, intubation of hanta patients during the cardiopulmonary phase can actually be detrimental. Also, in general, extracorporeal membrane oxygenation (ECMO) is an intervention of last resort for most critically-ill patients. As the procedure essentially involves hooking the patient up to a heart-lung machine, which has a lot of complications, doctors do not do this unless they have to. But in hantavirus disease, early initiation of ECMO has been shown to significantly improve survival.”

“Another tricky thing about ECMO is that not all hospitals have an ECMO machine… oftentimes patients have to be transferred from one hospital to another because they need ECMO and it is not available where they are.” The ECMO-equipped facility closest to TMC is 170 miles away, at the University of New Mexico Hospital in Albuquerque.

 For all those reasons, Dr. Choi said, it is critically important for physicians to know if the patient they are treating has hantavirus or not. The problem is, there is no rapid test for hantavirus disease. The tests have to be sent out to a laboratory and it can take days before physicians receive a test result. “This is where the 5-point screen is such a valuable tool. Although it is not a diagnostic test, it is a very accurate screening tool. Even better, it is readily and widely available, because to perform the screen, you only need a complete blood count (CBC) and a peripheral blood smear…which can be performed in the vast majority of laboratories and clinics. In addition, the CBC and peripheral blood smear are very commonly ordered tests.”

The screen could be particularly crucial for small community hospitals and clinics. “[TMC] took a screen developed by hematopathologists for hematopathologists,” Choi said, “and adapted it so that it could be performed by clinical laboratorians—because hematopathologists don’t exactly grow on trees! Once we heard about the work that TMC was doing, we knew that this was something we wanted to support and advocate for.”

“We started to throw around the idea of teaching this method to other laboratories on the reservation,” Oliver said. She and Mary Choi teamed up to “knock on everyone’s door to see who was utilizing the screening or if they had their own methods of detecting hantavirus in their patients.”

Two years later, they began holding training sessions at a nearby community college; they also trained an entire laboratory at their hospital in late 2019. Plans were to set up other training sessions towards the border towns before spring of 2020.

Then SARS-CoV-2 showed up.

Hantavirus or coronavirus?

COVID-19 hit the Navajo Nation like a sledgehammer. Native Americans in rural areas, as many Navajo are, may have multigenerational and extended families living in tight quarters, with limited access to running water, miles from the nearest healthcare facility. They were particularly vulnerable to a virus that thrives on close contact, at a time when the most common preventives were distancing, frequent handwashing, and testing. By May 2020, the Navajo Nation had surpassed the epicenters—New York and New Jersey—in cases of infection. Even as late as November 2021, the Navah Nation has reported > 37,000 positive cases, and nearly 1,500 confirmed deaths, despite reaching a 70% vaccination rate.

Making things ever more challenging: How do you know whether the patient has hantavirus or COVID-19? The distinction is critical because the disease courses of the 2 infections differ greatly. “The importance of [TMC’s] work was really brought home by the COVID pandemic,” Mary Choi said. “The signs and symptoms of early COVID and hantavirus are really indistinguishable. But the problem is that most people with COVID will live, while most people with hantavirus will die without critical care.”

The overall US case fatality rates are drastically different: 36% to 38% for hantavirus, 1.6% for COVID-19. In Arizona alone, of 81 patients who developed hantavirus (as of 2019), 27 died. In New Mexico, of 117 patients, 51 died.

“The scary part,” said Tarrah Oliver, “was that when patients were flooding our ER with symptoms exactly like those of hantavirus, I kept thinking that it was now up to us in the lab to scrutinize CBC results for any characteristics of hantavirus because our locum providers and permanent providers would likely not have hanta on their minds right now to suspect it.”

“Once COVID hit Navajo Nation, we really worried about how clinicians were going to distinguish between the two disease entities and worried about possible excess deaths of hanta because they were mistaken for COVID-19,” Choi says. “Unfortunately, in the spring of 2020, 2 fatal cases of hantavirus were reported. Their deaths were initially thought to be due to COVID, but later testing showed that they both died of hantavirus. We knew that we had to study whether the 5-point screen could distinguish between hantavirus disease and COVID.”

They conducted the comparison study at TMC and Emory, in Atlanta. TMC, as a small hospital, might not get many COVID cases while Emory, a large hospital system, had many COVID cases but rarely hantavirus cases (Box).

The researchers found that the screen did indeed work as they had hoped. No matter who performed the screen, the demographics of the population screened, or when in the COVID-19 disease course the sample was taken, individuals positive for COVID-19 received a low score on the screen. None of the participants who were positive for COVID-19 demonstrated all 5 hallmarks of hantavirus infection, and only 3 patients received a score of 4.

The screen was most accurate when the specimen was collected during the cardiopulmonary phase. Before the cardiopulmonary phase [BOX], there is a short febrile prodromal phase in which the platelets are starting to drop but aren’t low enough to be considered thrombocytopenic. Hematocrit and hemoglobin levels are still normal, and immunoblasts or plasma cells haven’t been released into the blood yet. “A patient’s score is likely to be pretty low or intermediate,” Tarrah Oliver said. “In the febrile prodromal phase, the patient will have chills, fever, headache and myalgia lasting 3 to 6 days, which might be written off as the flu or even COVID-19, especially if a provider is not familiar with the endemic regions of the Navajo Nation.”

“When we found that the screen could distinguish between the 2 diseases,” Choi said, “we worked frantically to write up the findings and publish so that healthcare providers would be aware of the value of this tool.”

“I couldn’t be more excited that the word is getting out in the medical community,” Oliver said. They plan to share the information as widely as possible, booking local radio spots, for instance. “We’re trying to disseminate our research across our partners on the reservation.”

The results of the research were recently published in the American Journal of Clinical Pathology. “Our next follow-up research will be an inter-rater reliability between TMC’s 2-year and 4-year-degree medical laboratorians and Emory’s pathologists performing the 5-point hantavirus screen on the same slides. We want to show that rural hospitals without the expertise of pathologists can perform this screen for their patients in a timely manner and still get the same outcomes.”

Lastly, and the most exciting, Oliver said, is putting that training manual she created to wider use. In addition to all the case studies she collected, analyzer printouts, and PowerPoint slides about the epidemiology, the manual includes a procedure, billing codes, and layout of what it looks like on certain medical record software that most Indian Health Service hospitals use. “With the manual, we may be able to expand our reach, so I won’t need to travel,” Oliver said. “We could use Zoom to reach further and I could explain it all while they have the manual right in front them.”

So far, nearly 200 screens have been performed at TMC. Four cases of hantavirus disease have been identified. The screen has proved successful, but for Oliver, there’s a personal reward. “I heard stories as a kid of relatives and friends succumbing to this mystery flu in the 1990s and how our parents protected us from it,” she said. “Now I feel like it’s my turn to take care of my family and friends from both hantavirus and COVID, our current ‘mystery flu.’ … I’ve realized that now I’m doing this for our people, the Diné (Navajo) people.”

This article offers some background and follow-up to Hantavirus Disease and COVID-19: Evaluation of the Hantavirus 5-Point Screen in 139 COVID-19 Patients

“We each come to public service in our own unique way,” ADM Rachel Levine, MD, Assistant Secretary for Health at the US Department of Health and Human Services (HHS), told the Senate Health, Education, Labor and Pensions Committee at her confirmation hearing in February 2021.

In her case, unique and history-making. Levine was confirmed on Tuesday as the first-ever openly transgender—and firstwoman—four-star admiral in the history of the US Public Health Service Commissioned Corps. She is also the first openly transgender four-star officer and the first openly transgender person to be confirmed by the Senate. In fact, she is the nation’s highest-ranking openly transgender official—the first such across any of the eight uniformed services.

All those firsts aside, in her confirmation hearing remarks, ADM. Levine said, “At its core, my career has been about helping people live healthy lives.” She began her career at Mt. Sinai Medical Center in New York, in pediatric and adolescent medicine, focusing on mental and physical health. Moving to the Penn State College of Medicine, ADM Levine was a professor of pediatrics and psychiatry and vice-chair for clinical affairs for the Department of Pediatrics. At Penn State, she initiated the Division of Adolescent Medicine for the care of complex teens with medical and psychological problems. As chief of the Division of Adolescent Medicine and Eating Disorders at Penn State Hershey Medical Center, she also founded an eating disorders program, offering multidisciplinary treatment for children, adolescents, and adults.

In 2015, Pennsylvania Governor Tom Wolf nominated ADM Levine to be Physician General of the Commonwealth of Pennsylvania and she was confirmed unanimously by the state senate. In 2018, she was named Pennsylvania’s Secretary of Health. In these roles, she tackled the state’s massive opioid misuse and overdose crisis. She focused on opioid stewardship, developed continuing medical education programs, and established prescribing guidelines and a “robust” prescription drug monitoring program. She traveled extensively throughout small communities, doing public events with local officials and residents to talk about opioid abuse. The efforts began, slowly, to pay off. In 2015, 3,383 people died of drug overdose in Pennsylvania, a 23% increase from 2014. By 2018, 65% of drug overdose deaths involved opioids, but the total number of deaths fell to 2,866.

One of her most significant accomplishments as Physician General, Levine said, was to issue the first-ever statewide standing order for distribution of the anti-overdose drug naloxone, allowing law enforcement to carry the drug and Pennsylvania citizens to buy itover the counter. According to the Pennsylvania Opioid Data Dashboard, between January 1, 2018, and October 9, 2021, 62,954 doses of naloxone were administered by EMS.

In another of Levine’s projects, the Pennsylvania Rural Health Model, the goal was to move rural hospitals from fee-for-service models to global budget payments, which she said, “aligned incentives for providers to deliver value-based care and for rural hospitals to transform their care to better meet community health needs.”

Working in tandem with HHS, Levine’s teams also set up a maternal mortality review committee “to better understand and respond to the causes of maternal deaths,” and worked to improve childhood immunization rates.

“Of course, our focus changed dramatically last year,” Levine said, “and COVID-19 became my most urgent and primary focus.” She concentrated on three key priorities: containment with expansion of testing and contact tracing; mitigation with masks and distancing; and medical countermeasures, including monoclonal antibodies and vaccines. To carry out the strategies, she oversaw a health equity task force, which included community stakeholders such as the Black Coalition Against COVID-19, the Latino Connection, and a faith-based program that allowed people to get tested at their places of worship.

When lesbian, gay, bisexual, transgender, queer; lesbian, gay, bisexual, transgender, queer (LGBTQ+) advocates charged that states were not collecting data early in the pandemic on sexual orientation or gender identity, in another historic move, Levine announced in March 2020 that Pennsylvania would begin collecting demographic data on the coronavirus, making it the first state in the country to do so.

Levine has garnered praise from many sources. “This is a proud moment for us,” HHS Secretary Xavier Becerra said in a statement, calling her a “cherished and critical partner in our work to build a healthier America.” Alphonso David, then president of the Human Rights Campaign, said in a statement that Levine’s nomination to be the HHS Assistant Secretary for Health represented “real change” in the government’s approach to the coronavirus and LGBTQ+ health issues. Levine “led Pennsylvania’s public health response to the COVID-19 pandemic superbly,” he said.

She has also triggered a significant amount of outrage in conservative quarters. She was routinely castigated for her early actions in the pandemic. Writing for The American Spectator in May 2020, Paul Kengor, a former UPMC researcher, said UPMC’s overall handling of the virus was “impressive and inspired confidence.” However, tracking the data on fatalities, he said, he found the disproportionate number of deaths in nursing homes “alarming and strange.” Citing an investigative article in the Bucks County Courier Times, he blamed Pennsylvania officials—including Levine—for guidelines that directed licensed long-term care facilities to continue admitting new patients, including those discharged from hospitals back to nursing homes. However, Kengor claimed, the “partisan press” would protect Wolf and Levine: “Levine is a liberal darling as the nation’s first (and arguably highest-ranking) transgender public official.”

At the February 2021 federal confirmation hearing, Levine was pressed on data discrepancies in Pennsylvania’s public reports on nursing home coronavirus deaths and cases. Sen. Susan Collins (R-ME) cited Spotlight PA reporting that found weekly reports released by the state health department were consistently missing data for more than 100 of the 693 nursing homes. Levine, in response, pointed to lags in the state’s electronic death reporting system and to slow uploads. Pennsylvania health officials also referred to a state law that prohibits the release of disease records by state or local authorities.

In a June 2020 opinion article, Levine wrote that the Pennsylvania Health Department had followed Centers for Disease Control and Prevention (CDC) guidance, including limiting outside people from entering long-term care facilities. The Pennsylvania Health Department also sent thousands of shipments of personal protective equipment and conducted virtual inspections, including on-site inspections as warranted.

Despite those efforts, Levine said, “staff members who have dedicated their lives to caring for these vulnerable Pennsylvanians unknowingly contracted COVID-19 in their communities and carried it into these facilities.” She pointed out that residents who returned from hospitals had been isolated if they contracted COVID-19. Patients returning to nursing homes did not introduce COVID-19, Levine said, “because it was there that they first came into contact with the virus.” Moreover, those patients were isolated, just as they had been before they required hospital-level care, she added.

When a long-term care facility reports a case of COVID-19, Levine noted, the Pennsylvania Health Department considers it an outbreak and offers a variety of resources to the facility, including mitigation measures and the services of an infection control consultant, or even deploying the Pennsylvania National Guard to assist with staffing. Pennsylvania cannot force facilities to accept these services, she pointed out, but some refuse out of fear of receiving citations. “[O]ur top priority,” Levine said, “is halting COVID-19, not issuing citations.”

Her decisions on health restrictions and closures to combat the pandemic created controversy in the state, but much of the criticism also took aim at Levine identifying openly as transgender. Her selection as the first openly transgender official to be confirmed by the Senate has been targeted by conservative groups as a political gesture by President Biden. Tom Fitton, president of the conservative legal group Judicial Watch, posted on Facebook: “Biden gang playing quota politics with public health service.”

In her remarks to the Senate committee, however, Levine calmly noted that her appointment by Gov. Wolf was confirmed unanimously and that she was approved twice more on a bipartisan basis to be Secretary of Health. She met with nearly all of the senators personally. Her confirmation by the senate Republicans was particularly meaningful, she told NBC Out. “[They] judged me strictly on my professional qualifications.”

Social media has made much of Levine’s transgender identification, both pro and con. The Twitterverse, predictably, is packed with anti-Levine and anti-LGBTQ+ rants. But Levine’s rise has energized the LGBTQ+ community, who hail it as a breakthrough. Scout, the single-named executive director of the National LGBT Cancer Network, said, “The fact that she is trans is an inspiration for the many of us who have never had a role model this senior before.” Levine herself is determined to be a “beacon” in representing the LGBTQ+ community in her latest role at the corps: “Diversity makes us stronger,” she said.

“What people don’t understand, they fear,” Levine, who is a frequent public speaker, has said. “The more we can educate people and show that we’re productive members of the community—with families, lives, careers—that helps people understand us better.” That includes education of medical professionals. “We need to do a better job educating medical students about LGBT issues and transgender medicine,” she told NBC Out. She may need to start with the members of Congress. At Levine’s confirmation hearing to serve as Assistant Secretary for Health, Sen. Rand Paul, for instance, compared transgender surgery to “genital mutilation.”

HHS Secretary Becerra called Levine’s appointment as the first openly transgender four-star officer “a giant step forward toward equality as a nation.” US Surgeon General VADM Vivek Murthy, MD, MBA, said her appointment represents “an important step towards a more inclusive future and her service will undoubtedly advance the US Public Health Service Commissioned Corps’ mission to protect, promote, and advance the health and safety of our nation.”

Levine told the Senate committee, “There is still so much more to do.”

“We each come to public service in our own unique way,” ADM Rachel Levine, MD, Assistant Secretary for Health at the US Department of Health and Human Services (HHS), told the Senate Health, Education, Labor and Pensions Committee at her confirmation hearing in February 2021.

In her case, unique and history-making. Levine was confirmed on Tuesday as the first-ever openly transgender—and firstwoman—four-star admiral in the history of the US Public Health Service Commissioned Corps. She is also the first openly transgender four-star officer and the first openly transgender person to be confirmed by the Senate. In fact, she is the nation’s highest-ranking openly transgender official—the first such across any of the eight uniformed services.

All those firsts aside, in her confirmation hearing remarks, ADM. Levine said, “At its core, my career has been about helping people live healthy lives.” She began her career at Mt. Sinai Medical Center in New York, in pediatric and adolescent medicine, focusing on mental and physical health. Moving to the Penn State College of Medicine, ADM Levine was a professor of pediatrics and psychiatry and vice-chair for clinical affairs for the Department of Pediatrics. At Penn State, she initiated the Division of Adolescent Medicine for the care of complex teens with medical and psychological problems. As chief of the Division of Adolescent Medicine and Eating Disorders at Penn State Hershey Medical Center, she also founded an eating disorders program, offering multidisciplinary treatment for children, adolescents, and adults.

In 2015, Pennsylvania Governor Tom Wolf nominated ADM Levine to be Physician General of the Commonwealth of Pennsylvania and she was confirmed unanimously by the state senate. In 2018, she was named Pennsylvania’s Secretary of Health. In these roles, she tackled the state’s massive opioid misuse and overdose crisis. She focused on opioid stewardship, developed continuing medical education programs, and established prescribing guidelines and a “robust” prescription drug monitoring program. She traveled extensively throughout small communities, doing public events with local officials and residents to talk about opioid abuse. The efforts began, slowly, to pay off. In 2015, 3,383 people died of drug overdose in Pennsylvania, a 23% increase from 2014. By 2018, 65% of drug overdose deaths involved opioids, but the total number of deaths fell to 2,866.

One of her most significant accomplishments as Physician General, Levine said, was to issue the first-ever statewide standing order for distribution of the anti-overdose drug naloxone, allowing law enforcement to carry the drug and Pennsylvania citizens to buy itover the counter. According to the Pennsylvania Opioid Data Dashboard, between January 1, 2018, and October 9, 2021, 62,954 doses of naloxone were administered by EMS.

In another of Levine’s projects, the Pennsylvania Rural Health Model, the goal was to move rural hospitals from fee-for-service models to global budget payments, which she said, “aligned incentives for providers to deliver value-based care and for rural hospitals to transform their care to better meet community health needs.”

Working in tandem with HHS, Levine’s teams also set up a maternal mortality review committee “to better understand and respond to the causes of maternal deaths,” and worked to improve childhood immunization rates.

“Of course, our focus changed dramatically last year,” Levine said, “and COVID-19 became my most urgent and primary focus.” She concentrated on three key priorities: containment with expansion of testing and contact tracing; mitigation with masks and distancing; and medical countermeasures, including monoclonal antibodies and vaccines. To carry out the strategies, she oversaw a health equity task force, which included community stakeholders such as the Black Coalition Against COVID-19, the Latino Connection, and a faith-based program that allowed people to get tested at their places of worship.

When lesbian, gay, bisexual, transgender, queer; lesbian, gay, bisexual, transgender, queer (LGBTQ+) advocates charged that states were not collecting data early in the pandemic on sexual orientation or gender identity, in another historic move, Levine announced in March 2020 that Pennsylvania would begin collecting demographic data on the coronavirus, making it the first state in the country to do so.

Levine has garnered praise from many sources. “This is a proud moment for us,” HHS Secretary Xavier Becerra said in a statement, calling her a “cherished and critical partner in our work to build a healthier America.” Alphonso David, then president of the Human Rights Campaign, said in a statement that Levine’s nomination to be the HHS Assistant Secretary for Health represented “real change” in the government’s approach to the coronavirus and LGBTQ+ health issues. Levine “led Pennsylvania’s public health response to the COVID-19 pandemic superbly,” he said.

She has also triggered a significant amount of outrage in conservative quarters. She was routinely castigated for her early actions in the pandemic. Writing for The American Spectator in May 2020, Paul Kengor, a former UPMC researcher, said UPMC’s overall handling of the virus was “impressive and inspired confidence.” However, tracking the data on fatalities, he said, he found the disproportionate number of deaths in nursing homes “alarming and strange.” Citing an investigative article in the Bucks County Courier Times, he blamed Pennsylvania officials—including Levine—for guidelines that directed licensed long-term care facilities to continue admitting new patients, including those discharged from hospitals back to nursing homes. However, Kengor claimed, the “partisan press” would protect Wolf and Levine: “Levine is a liberal darling as the nation’s first (and arguably highest-ranking) transgender public official.”

At the February 2021 federal confirmation hearing, Levine was pressed on data discrepancies in Pennsylvania’s public reports on nursing home coronavirus deaths and cases. Sen. Susan Collins (R-ME) cited Spotlight PA reporting that found weekly reports released by the state health department were consistently missing data for more than 100 of the 693 nursing homes. Levine, in response, pointed to lags in the state’s electronic death reporting system and to slow uploads. Pennsylvania health officials also referred to a state law that prohibits the release of disease records by state or local authorities.

In a June 2020 opinion article, Levine wrote that the Pennsylvania Health Department had followed Centers for Disease Control and Prevention (CDC) guidance, including limiting outside people from entering long-term care facilities. The Pennsylvania Health Department also sent thousands of shipments of personal protective equipment and conducted virtual inspections, including on-site inspections as warranted.

Despite those efforts, Levine said, “staff members who have dedicated their lives to caring for these vulnerable Pennsylvanians unknowingly contracted COVID-19 in their communities and carried it into these facilities.” She pointed out that residents who returned from hospitals had been isolated if they contracted COVID-19. Patients returning to nursing homes did not introduce COVID-19, Levine said, “because it was there that they first came into contact with the virus.” Moreover, those patients were isolated, just as they had been before they required hospital-level care, she added.

When a long-term care facility reports a case of COVID-19, Levine noted, the Pennsylvania Health Department considers it an outbreak and offers a variety of resources to the facility, including mitigation measures and the services of an infection control consultant, or even deploying the Pennsylvania National Guard to assist with staffing. Pennsylvania cannot force facilities to accept these services, she pointed out, but some refuse out of fear of receiving citations. “[O]ur top priority,” Levine said, “is halting COVID-19, not issuing citations.”

Her decisions on health restrictions and closures to combat the pandemic created controversy in the state, but much of the criticism also took aim at Levine identifying openly as transgender. Her selection as the first openly transgender official to be confirmed by the Senate has been targeted by conservative groups as a political gesture by President Biden. Tom Fitton, president of the conservative legal group Judicial Watch, posted on Facebook: “Biden gang playing quota politics with public health service.”

In her remarks to the Senate committee, however, Levine calmly noted that her appointment by Gov. Wolf was confirmed unanimously and that she was approved twice more on a bipartisan basis to be Secretary of Health. She met with nearly all of the senators personally. Her confirmation by the senate Republicans was particularly meaningful, she told NBC Out. “[They] judged me strictly on my professional qualifications.”

Social media has made much of Levine’s transgender identification, both pro and con. The Twitterverse, predictably, is packed with anti-Levine and anti-LGBTQ+ rants. But Levine’s rise has energized the LGBTQ+ community, who hail it as a breakthrough. Scout, the single-named executive director of the National LGBT Cancer Network, said, “The fact that she is trans is an inspiration for the many of us who have never had a role model this senior before.” Levine herself is determined to be a “beacon” in representing the LGBTQ+ community in her latest role at the corps: “Diversity makes us stronger,” she said.

“What people don’t understand, they fear,” Levine, who is a frequent public speaker, has said. “The more we can educate people and show that we’re productive members of the community—with families, lives, careers—that helps people understand us better.” That includes education of medical professionals. “We need to do a better job educating medical students about LGBT issues and transgender medicine,” she told NBC Out. She may need to start with the members of Congress. At Levine’s confirmation hearing to serve as Assistant Secretary for Health, Sen. Rand Paul, for instance, compared transgender surgery to “genital mutilation.”

HHS Secretary Becerra called Levine’s appointment as the first openly transgender four-star officer “a giant step forward toward equality as a nation.” US Surgeon General VADM Vivek Murthy, MD, MBA, said her appointment represents “an important step towards a more inclusive future and her service will undoubtedly advance the US Public Health Service Commissioned Corps’ mission to protect, promote, and advance the health and safety of our nation.”

Levine told the Senate committee, “There is still so much more to do.”

“We each come to public service in our own unique way,” ADM Rachel Levine, MD, Assistant Secretary for Health at the US Department of Health and Human Services (HHS), told the Senate Health, Education, Labor and Pensions Committee at her confirmation hearing in February 2021.

In her case, unique and history-making. Levine was confirmed on Tuesday as the first-ever openly transgender—and firstwoman—four-star admiral in the history of the US Public Health Service Commissioned Corps. She is also the first openly transgender four-star officer and the first openly transgender person to be confirmed by the Senate. In fact, she is the nation’s highest-ranking openly transgender official—the first such across any of the eight uniformed services.

All those firsts aside, in her confirmation hearing remarks, ADM. Levine said, “At its core, my career has been about helping people live healthy lives.” She began her career at Mt. Sinai Medical Center in New York, in pediatric and adolescent medicine, focusing on mental and physical health. Moving to the Penn State College of Medicine, ADM Levine was a professor of pediatrics and psychiatry and vice-chair for clinical affairs for the Department of Pediatrics. At Penn State, she initiated the Division of Adolescent Medicine for the care of complex teens with medical and psychological problems. As chief of the Division of Adolescent Medicine and Eating Disorders at Penn State Hershey Medical Center, she also founded an eating disorders program, offering multidisciplinary treatment for children, adolescents, and adults.

In 2015, Pennsylvania Governor Tom Wolf nominated ADM Levine to be Physician General of the Commonwealth of Pennsylvania and she was confirmed unanimously by the state senate. In 2018, she was named Pennsylvania’s Secretary of Health. In these roles, she tackled the state’s massive opioid misuse and overdose crisis. She focused on opioid stewardship, developed continuing medical education programs, and established prescribing guidelines and a “robust” prescription drug monitoring program. She traveled extensively throughout small communities, doing public events with local officials and residents to talk about opioid abuse. The efforts began, slowly, to pay off. In 2015, 3,383 people died of drug overdose in Pennsylvania, a 23% increase from 2014. By 2018, 65% of drug overdose deaths involved opioids, but the total number of deaths fell to 2,866.

One of her most significant accomplishments as Physician General, Levine said, was to issue the first-ever statewide standing order for distribution of the anti-overdose drug naloxone, allowing law enforcement to carry the drug and Pennsylvania citizens to buy itover the counter. According to the Pennsylvania Opioid Data Dashboard, between January 1, 2018, and October 9, 2021, 62,954 doses of naloxone were administered by EMS.

In another of Levine’s projects, the Pennsylvania Rural Health Model, the goal was to move rural hospitals from fee-for-service models to global budget payments, which she said, “aligned incentives for providers to deliver value-based care and for rural hospitals to transform their care to better meet community health needs.”

Working in tandem with HHS, Levine’s teams also set up a maternal mortality review committee “to better understand and respond to the causes of maternal deaths,” and worked to improve childhood immunization rates.

“Of course, our focus changed dramatically last year,” Levine said, “and COVID-19 became my most urgent and primary focus.” She concentrated on three key priorities: containment with expansion of testing and contact tracing; mitigation with masks and distancing; and medical countermeasures, including monoclonal antibodies and vaccines. To carry out the strategies, she oversaw a health equity task force, which included community stakeholders such as the Black Coalition Against COVID-19, the Latino Connection, and a faith-based program that allowed people to get tested at their places of worship.

When lesbian, gay, bisexual, transgender, queer; lesbian, gay, bisexual, transgender, queer (LGBTQ+) advocates charged that states were not collecting data early in the pandemic on sexual orientation or gender identity, in another historic move, Levine announced in March 2020 that Pennsylvania would begin collecting demographic data on the coronavirus, making it the first state in the country to do so.

Levine has garnered praise from many sources. “This is a proud moment for us,” HHS Secretary Xavier Becerra said in a statement, calling her a “cherished and critical partner in our work to build a healthier America.” Alphonso David, then president of the Human Rights Campaign, said in a statement that Levine’s nomination to be the HHS Assistant Secretary for Health represented “real change” in the government’s approach to the coronavirus and LGBTQ+ health issues. Levine “led Pennsylvania’s public health response to the COVID-19 pandemic superbly,” he said.

She has also triggered a significant amount of outrage in conservative quarters. She was routinely castigated for her early actions in the pandemic. Writing for The American Spectator in May 2020, Paul Kengor, a former UPMC researcher, said UPMC’s overall handling of the virus was “impressive and inspired confidence.” However, tracking the data on fatalities, he said, he found the disproportionate number of deaths in nursing homes “alarming and strange.” Citing an investigative article in the Bucks County Courier Times, he blamed Pennsylvania officials—including Levine—for guidelines that directed licensed long-term care facilities to continue admitting new patients, including those discharged from hospitals back to nursing homes. However, Kengor claimed, the “partisan press” would protect Wolf and Levine: “Levine is a liberal darling as the nation’s first (and arguably highest-ranking) transgender public official.”

At the February 2021 federal confirmation hearing, Levine was pressed on data discrepancies in Pennsylvania’s public reports on nursing home coronavirus deaths and cases. Sen. Susan Collins (R-ME) cited Spotlight PA reporting that found weekly reports released by the state health department were consistently missing data for more than 100 of the 693 nursing homes. Levine, in response, pointed to lags in the state’s electronic death reporting system and to slow uploads. Pennsylvania health officials also referred to a state law that prohibits the release of disease records by state or local authorities.

In a June 2020 opinion article, Levine wrote that the Pennsylvania Health Department had followed Centers for Disease Control and Prevention (CDC) guidance, including limiting outside people from entering long-term care facilities. The Pennsylvania Health Department also sent thousands of shipments of personal protective equipment and conducted virtual inspections, including on-site inspections as warranted.

Despite those efforts, Levine said, “staff members who have dedicated their lives to caring for these vulnerable Pennsylvanians unknowingly contracted COVID-19 in their communities and carried it into these facilities.” She pointed out that residents who returned from hospitals had been isolated if they contracted COVID-19. Patients returning to nursing homes did not introduce COVID-19, Levine said, “because it was there that they first came into contact with the virus.” Moreover, those patients were isolated, just as they had been before they required hospital-level care, she added.

When a long-term care facility reports a case of COVID-19, Levine noted, the Pennsylvania Health Department considers it an outbreak and offers a variety of resources to the facility, including mitigation measures and the services of an infection control consultant, or even deploying the Pennsylvania National Guard to assist with staffing. Pennsylvania cannot force facilities to accept these services, she pointed out, but some refuse out of fear of receiving citations. “[O]ur top priority,” Levine said, “is halting COVID-19, not issuing citations.”

Her decisions on health restrictions and closures to combat the pandemic created controversy in the state, but much of the criticism also took aim at Levine identifying openly as transgender. Her selection as the first openly transgender official to be confirmed by the Senate has been targeted by conservative groups as a political gesture by President Biden. Tom Fitton, president of the conservative legal group Judicial Watch, posted on Facebook: “Biden gang playing quota politics with public health service.”

In her remarks to the Senate committee, however, Levine calmly noted that her appointment by Gov. Wolf was confirmed unanimously and that she was approved twice more on a bipartisan basis to be Secretary of Health. She met with nearly all of the senators personally. Her confirmation by the senate Republicans was particularly meaningful, she told NBC Out. “[They] judged me strictly on my professional qualifications.”

Social media has made much of Levine’s transgender identification, both pro and con. The Twitterverse, predictably, is packed with anti-Levine and anti-LGBTQ+ rants. But Levine’s rise has energized the LGBTQ+ community, who hail it as a breakthrough. Scout, the single-named executive director of the National LGBT Cancer Network, said, “The fact that she is trans is an inspiration for the many of us who have never had a role model this senior before.” Levine herself is determined to be a “beacon” in representing the LGBTQ+ community in her latest role at the corps: “Diversity makes us stronger,” she said.

“What people don’t understand, they fear,” Levine, who is a frequent public speaker, has said. “The more we can educate people and show that we’re productive members of the community—with families, lives, careers—that helps people understand us better.” That includes education of medical professionals. “We need to do a better job educating medical students about LGBT issues and transgender medicine,” she told NBC Out. She may need to start with the members of Congress. At Levine’s confirmation hearing to serve as Assistant Secretary for Health, Sen. Rand Paul, for instance, compared transgender surgery to “genital mutilation.”

HHS Secretary Becerra called Levine’s appointment as the first openly transgender four-star officer “a giant step forward toward equality as a nation.” US Surgeon General VADM Vivek Murthy, MD, MBA, said her appointment represents “an important step towards a more inclusive future and her service will undoubtedly advance the US Public Health Service Commissioned Corps’ mission to protect, promote, and advance the health and safety of our nation.”

Levine told the Senate committee, “There is still so much more to do.”

The US Department of Veterans Affairs (VA) has issued a new policy statement to help ensure that active-duty service members who were discharged for their sexual orientation under the Don’t Ask, Don’t Tell policy will be able to receive full VA benefits.

“[A] great injustice was remedied and a tremendous weight was finally lifted off the shoulders of tens of thousands of dedicated American service members,” President Biden said on September 20 as the country commemorated the 10th anniversary of the repeal of “Don’t Ask, Don’t Tell,” the policy that barred lesbian, gay, bisexual, transgender, and queer (LGBTQ+) service members from serving openly.

Prior to DADT, if active-duty service members spoke out about their sexual orientation, they ran the risk of being hounded, shunned, in some cases assaulted, and discharged. If they kept it a secret, they felt they were living a lie, unable to be their whole selves. More than 100,000 were discharged because of their sexual orientation or gender identity.

Although Don’t Ask, Don’t Tell was a “compromise” law that purposed to protect them, LGBTQ+ service members were still at risk for harassment and abuse. Nor did the law protect them from discharge. Some 14,000 LGBTQ+ service members were discharged while DADT was in effect. And those who received “other than honorable” (OTH) discharges could be excluded from receiving services and benefits.

The 2011 repeal followed a “hard-fought battle,” said a release from the Human Rights Campaign, which led a coalition of members, supporters, elected officials, 70+ organizations, and 20,000 veterans to get the law overturned. HRC staff coordinated grassroots efforts and sent 19 million e-mails to members and supporters, in turn generating an “unprecedented” 625,000 e-mails and 50,000 handwritten letters to members of Congress.

After the repeal, the VA began the long process of inclusion for LGBTQ+ veterans. “At VA, we continuously work not only to meet the needs of LGBTQ+ veterans, but also to address ongoing issues that LGBTQ+ veterans face as a result of the military’s decades-long official policy of homophobia and transphobia,” Kayla Williams, assistant secretary for public affairs in VA’s Office of Public and Intergovernmental Affairs wrote in the Secretary’s blog.

The VA “recognizes that the trauma caused by the military’s decades-long policy of discrimination against LGBTQ+ people cannot be undone in a few short months,” she continued, but the Biden administration and Secretary McDonough are “taking the steps necessary to begin addressing the pain that such policies have created.”

President Biden, in his remarks, noted that as a US Senator, he had supported allowing service members to serve openly and, as Vice President, championed the repeal. He said, “I am honored to be Commander-in-Chief of the strongest and most inclusive military in our nation’s history. Today, our military doesn’t just welcome LGBTQ+ service members—it is led at the highest levels by brave LGBTQ+ veterans, including Under Secretary of the Air Force Gina Ortiz Jones and Assistant Secretary of Defense for Readiness Shawn Skelly, who served under Don’t Ask, Don’t Tell. I was gratified to appoint the first openly gay Senate-confirmed Cabinet member, Secretary Pete Buttigieg, a lieutenant in the U.S. Navy Reserve and Afghanistan veteran who joined the military under the Don’t Ask, Don’t Tell policy. And during my first week in office, I proudly delivered on my pledge to repeal the discriminatory ban on open service by patriotic transgender service members.”

In early September, Rep. Chris Pappas (D-NH), a member of the House Veterans Affairs Committee and Co-Chair of the Equality Caucus, reintroduced the SERVE (Securing the Rights our Veterans Earned) Act. The act, which is co-sponsored by Reps. Mike Levin (D-CA), Kathleen Rice (D-NY), Anthony Brown (D-MD), and Jackie Speier (D-CA), would ensure LGBTQ+ veterans who received an OTH or Entry-Level Separation discharge solely due to sexual orientation or gender identity are afforded the VA benefits they rightfully earned, including access to VA healthcare, and education, burial and memorial services, and home loans. The act includes veterans who were issued “blue discharges” during World War II and veterans discharged under former President Trump’s ban on transgender service members. The legislation has been endorsed by the Congressional LGBTQ+ Equality Caucus and is supported by more than 45 representatives.

There are processes for those veterans through which they can have their discharge papers and separation statuses reviewed and modified, Pappas said in a release, but “it can take months for the changes to take effect, and many of these veterans do not even realize they are eligible.”

Earlier this year, Veterans Affairs Secretary Denis McDonough made it a priority to ensure that LGBTQ+ veterans have the same level of access to VA care and services that all other veterans have. Among other things, he established a task force to examine how VA policies hinder or prohibit access to care and services and remove barriers that transgender veterans face in accessing gender-affirming care.

The VA is also taking steps, Williams noted, to clarify VA policy for veterans who were given OTH discharges based on homosexual conduct, gender identity or HIV status. Under this newly issued guidance, VA adjudicators shall find that all discharged service members whose separation was due to sexual orientation, gender identity or HIV status are considered “Veterans” who may be eligible for VA benefits, like VR&E, home loan guaranty, compensation and pension, health care, homeless program and/or burial benefits, so long as the record does not implicate a statutory or regulatory bar to benefits.

The policy statement does not represent a change in law, as veterans who were discharged under DADT alone have been generally eligible for benefits under current statute and regulation. However, it reiterates what constitutes eligibility for benefits under law. In addition, every Character of Discharge case that is initially considered for denial will also get a second look before that action is taken.

“Given that large numbers of LGBTQ+ veterans who were affected by previous homophobic and transphobic policies have not applied for a discharge upgrade due to the perception that the process could be onerous,” Williams wrote, “we are hopeful that this policy statement encourages more of them to contact VA to determine their eligibility for care and services.”

Today, according to the Human Right Campaign, nearly 6.1% of US military personnel self-identify as LGBTQ. Williams, herself a bisexual veteran, said she chose to present as straight during the push to repeal DADT. “I could talk credibly about how the lack of sufficient Arabic linguists harmed our effectiveness downrange, and my own identity seemed irrelevant. It took many years for me to shed the toxic legacy of having served under DADT and come back out of the closet; I’m proud to recognize this anniversary as my authentic self.”

The US Department of Veterans Affairs (VA) has issued a new policy statement to help ensure that active-duty service members who were discharged for their sexual orientation under the Don’t Ask, Don’t Tell policy will be able to receive full VA benefits.

“[A] great injustice was remedied and a tremendous weight was finally lifted off the shoulders of tens of thousands of dedicated American service members,” President Biden said on September 20 as the country commemorated the 10th anniversary of the repeal of “Don’t Ask, Don’t Tell,” the policy that barred lesbian, gay, bisexual, transgender, and queer (LGBTQ+) service members from serving openly.

Prior to DADT, if active-duty service members spoke out about their sexual orientation, they ran the risk of being hounded, shunned, in some cases assaulted, and discharged. If they kept it a secret, they felt they were living a lie, unable to be their whole selves. More than 100,000 were discharged because of their sexual orientation or gender identity.

Although Don’t Ask, Don’t Tell was a “compromise” law that purposed to protect them, LGBTQ+ service members were still at risk for harassment and abuse. Nor did the law protect them from discharge. Some 14,000 LGBTQ+ service members were discharged while DADT was in effect. And those who received “other than honorable” (OTH) discharges could be excluded from receiving services and benefits.

The 2011 repeal followed a “hard-fought battle,” said a release from the Human Rights Campaign, which led a coalition of members, supporters, elected officials, 70+ organizations, and 20,000 veterans to get the law overturned. HRC staff coordinated grassroots efforts and sent 19 million e-mails to members and supporters, in turn generating an “unprecedented” 625,000 e-mails and 50,000 handwritten letters to members of Congress.

After the repeal, the VA began the long process of inclusion for LGBTQ+ veterans. “At VA, we continuously work not only to meet the needs of LGBTQ+ veterans, but also to address ongoing issues that LGBTQ+ veterans face as a result of the military’s decades-long official policy of homophobia and transphobia,” Kayla Williams, assistant secretary for public affairs in VA’s Office of Public and Intergovernmental Affairs wrote in the Secretary’s blog.

The VA “recognizes that the trauma caused by the military’s decades-long policy of discrimination against LGBTQ+ people cannot be undone in a few short months,” she continued, but the Biden administration and Secretary McDonough are “taking the steps necessary to begin addressing the pain that such policies have created.”

President Biden, in his remarks, noted that as a US Senator, he had supported allowing service members to serve openly and, as Vice President, championed the repeal. He said, “I am honored to be Commander-in-Chief of the strongest and most inclusive military in our nation’s history. Today, our military doesn’t just welcome LGBTQ+ service members—it is led at the highest levels by brave LGBTQ+ veterans, including Under Secretary of the Air Force Gina Ortiz Jones and Assistant Secretary of Defense for Readiness Shawn Skelly, who served under Don’t Ask, Don’t Tell. I was gratified to appoint the first openly gay Senate-confirmed Cabinet member, Secretary Pete Buttigieg, a lieutenant in the U.S. Navy Reserve and Afghanistan veteran who joined the military under the Don’t Ask, Don’t Tell policy. And during my first week in office, I proudly delivered on my pledge to repeal the discriminatory ban on open service by patriotic transgender service members.”

In early September, Rep. Chris Pappas (D-NH), a member of the House Veterans Affairs Committee and Co-Chair of the Equality Caucus, reintroduced the SERVE (Securing the Rights our Veterans Earned) Act. The act, which is co-sponsored by Reps. Mike Levin (D-CA), Kathleen Rice (D-NY), Anthony Brown (D-MD), and Jackie Speier (D-CA), would ensure LGBTQ+ veterans who received an OTH or Entry-Level Separation discharge solely due to sexual orientation or gender identity are afforded the VA benefits they rightfully earned, including access to VA healthcare, and education, burial and memorial services, and home loans. The act includes veterans who were issued “blue discharges” during World War II and veterans discharged under former President Trump’s ban on transgender service members. The legislation has been endorsed by the Congressional LGBTQ+ Equality Caucus and is supported by more than 45 representatives.

There are processes for those veterans through which they can have their discharge papers and separation statuses reviewed and modified, Pappas said in a release, but “it can take months for the changes to take effect, and many of these veterans do not even realize they are eligible.”

Earlier this year, Veterans Affairs Secretary Denis McDonough made it a priority to ensure that LGBTQ+ veterans have the same level of access to VA care and services that all other veterans have. Among other things, he established a task force to examine how VA policies hinder or prohibit access to care and services and remove barriers that transgender veterans face in accessing gender-affirming care.

The VA is also taking steps, Williams noted, to clarify VA policy for veterans who were given OTH discharges based on homosexual conduct, gender identity or HIV status. Under this newly issued guidance, VA adjudicators shall find that all discharged service members whose separation was due to sexual orientation, gender identity or HIV status are considered “Veterans” who may be eligible for VA benefits, like VR&E, home loan guaranty, compensation and pension, health care, homeless program and/or burial benefits, so long as the record does not implicate a statutory or regulatory bar to benefits.

The policy statement does not represent a change in law, as veterans who were discharged under DADT alone have been generally eligible for benefits under current statute and regulation. However, it reiterates what constitutes eligibility for benefits under law. In addition, every Character of Discharge case that is initially considered for denial will also get a second look before that action is taken.

“Given that large numbers of LGBTQ+ veterans who were affected by previous homophobic and transphobic policies have not applied for a discharge upgrade due to the perception that the process could be onerous,” Williams wrote, “we are hopeful that this policy statement encourages more of them to contact VA to determine their eligibility for care and services.”

Today, according to the Human Right Campaign, nearly 6.1% of US military personnel self-identify as LGBTQ. Williams, herself a bisexual veteran, said she chose to present as straight during the push to repeal DADT. “I could talk credibly about how the lack of sufficient Arabic linguists harmed our effectiveness downrange, and my own identity seemed irrelevant. It took many years for me to shed the toxic legacy of having served under DADT and come back out of the closet; I’m proud to recognize this anniversary as my authentic self.”

The US Department of Veterans Affairs (VA) has issued a new policy statement to help ensure that active-duty service members who were discharged for their sexual orientation under the Don’t Ask, Don’t Tell policy will be able to receive full VA benefits.

“[A] great injustice was remedied and a tremendous weight was finally lifted off the shoulders of tens of thousands of dedicated American service members,” President Biden said on September 20 as the country commemorated the 10th anniversary of the repeal of “Don’t Ask, Don’t Tell,” the policy that barred lesbian, gay, bisexual, transgender, and queer (LGBTQ+) service members from serving openly.

Prior to DADT, if active-duty service members spoke out about their sexual orientation, they ran the risk of being hounded, shunned, in some cases assaulted, and discharged. If they kept it a secret, they felt they were living a lie, unable to be their whole selves. More than 100,000 were discharged because of their sexual orientation or gender identity.

Although Don’t Ask, Don’t Tell was a “compromise” law that purposed to protect them, LGBTQ+ service members were still at risk for harassment and abuse. Nor did the law protect them from discharge. Some 14,000 LGBTQ+ service members were discharged while DADT was in effect. And those who received “other than honorable” (OTH) discharges could be excluded from receiving services and benefits.

The 2011 repeal followed a “hard-fought battle,” said a release from the Human Rights Campaign, which led a coalition of members, supporters, elected officials, 70+ organizations, and 20,000 veterans to get the law overturned. HRC staff coordinated grassroots efforts and sent 19 million e-mails to members and supporters, in turn generating an “unprecedented” 625,000 e-mails and 50,000 handwritten letters to members of Congress.

After the repeal, the VA began the long process of inclusion for LGBTQ+ veterans. “At VA, we continuously work not only to meet the needs of LGBTQ+ veterans, but also to address ongoing issues that LGBTQ+ veterans face as a result of the military’s decades-long official policy of homophobia and transphobia,” Kayla Williams, assistant secretary for public affairs in VA’s Office of Public and Intergovernmental Affairs wrote in the Secretary’s blog.

The VA “recognizes that the trauma caused by the military’s decades-long policy of discrimination against LGBTQ+ people cannot be undone in a few short months,” she continued, but the Biden administration and Secretary McDonough are “taking the steps necessary to begin addressing the pain that such policies have created.”

President Biden, in his remarks, noted that as a US Senator, he had supported allowing service members to serve openly and, as Vice President, championed the repeal. He said, “I am honored to be Commander-in-Chief of the strongest and most inclusive military in our nation’s history. Today, our military doesn’t just welcome LGBTQ+ service members—it is led at the highest levels by brave LGBTQ+ veterans, including Under Secretary of the Air Force Gina Ortiz Jones and Assistant Secretary of Defense for Readiness Shawn Skelly, who served under Don’t Ask, Don’t Tell. I was gratified to appoint the first openly gay Senate-confirmed Cabinet member, Secretary Pete Buttigieg, a lieutenant in the U.S. Navy Reserve and Afghanistan veteran who joined the military under the Don’t Ask, Don’t Tell policy. And during my first week in office, I proudly delivered on my pledge to repeal the discriminatory ban on open service by patriotic transgender service members.”

In early September, Rep. Chris Pappas (D-NH), a member of the House Veterans Affairs Committee and Co-Chair of the Equality Caucus, reintroduced the SERVE (Securing the Rights our Veterans Earned) Act. The act, which is co-sponsored by Reps. Mike Levin (D-CA), Kathleen Rice (D-NY), Anthony Brown (D-MD), and Jackie Speier (D-CA), would ensure LGBTQ+ veterans who received an OTH or Entry-Level Separation discharge solely due to sexual orientation or gender identity are afforded the VA benefits they rightfully earned, including access to VA healthcare, and education, burial and memorial services, and home loans. The act includes veterans who were issued “blue discharges” during World War II and veterans discharged under former President Trump’s ban on transgender service members. The legislation has been endorsed by the Congressional LGBTQ+ Equality Caucus and is supported by more than 45 representatives.

There are processes for those veterans through which they can have their discharge papers and separation statuses reviewed and modified, Pappas said in a release, but “it can take months for the changes to take effect, and many of these veterans do not even realize they are eligible.”

Earlier this year, Veterans Affairs Secretary Denis McDonough made it a priority to ensure that LGBTQ+ veterans have the same level of access to VA care and services that all other veterans have. Among other things, he established a task force to examine how VA policies hinder or prohibit access to care and services and remove barriers that transgender veterans face in accessing gender-affirming care.

The VA is also taking steps, Williams noted, to clarify VA policy for veterans who were given OTH discharges based on homosexual conduct, gender identity or HIV status. Under this newly issued guidance, VA adjudicators shall find that all discharged service members whose separation was due to sexual orientation, gender identity or HIV status are considered “Veterans” who may be eligible for VA benefits, like VR&E, home loan guaranty, compensation and pension, health care, homeless program and/or burial benefits, so long as the record does not implicate a statutory or regulatory bar to benefits.

The policy statement does not represent a change in law, as veterans who were discharged under DADT alone have been generally eligible for benefits under current statute and regulation. However, it reiterates what constitutes eligibility for benefits under law. In addition, every Character of Discharge case that is initially considered for denial will also get a second look before that action is taken.

“Given that large numbers of LGBTQ+ veterans who were affected by previous homophobic and transphobic policies have not applied for a discharge upgrade due to the perception that the process could be onerous,” Williams wrote, “we are hopeful that this policy statement encourages more of them to contact VA to determine their eligibility for care and services.”

Today, according to the Human Right Campaign, nearly 6.1% of US military personnel self-identify as LGBTQ. Williams, herself a bisexual veteran, said she chose to present as straight during the push to repeal DADT. “I could talk credibly about how the lack of sufficient Arabic linguists harmed our effectiveness downrange, and my own identity seemed irrelevant. It took many years for me to shed the toxic legacy of having served under DADT and come back out of the closet; I’m proud to recognize this anniversary as my authentic self.”

Last summer, a team of US Department of Veterans Affairs (VA) health care professionals deployed to Alabama’s Bill Nichols State Veterans Home to help during the COVID-19 crisis. They were there as part of the “Fourth Mission”—supporting national, state, and local emergency management, public health, safety and homeland security efforts. “It was a really humbling experience,” said Mary Holloway, an RN with the Birmingham VA Health Care System. “Seeing the dedication of the staff there, some coming back to work after recovering from COVID themselves, was inspiring.”

But that turned out to be only one battle in a sadly long and drawn-out war. Since March 2020, more than 5,000 military medical personnel have deployed to 14 states and the Navajo Nation, 51 cities, 71 hospitals, all struggling to keep their heads above a cresting tsunami of new COVID patients.

Last year, the crisis spots for deployments included major metropolitan areas in coastal states: New York, California, and New Jersey. The urgency now is in the Southern states. Those tend to be reporting the highest numbers of new cases and deaths. Alabama, Arkansas, Florida, Louisiana, and Mississippi, for example, have all ranked among the highest rates of cases and hospitalizations per 100,000 people across the country in the last seven days.

This year, military teams have also deployed to support vaccination centers in 25 states and 42 cities. Nearly all—97%—of the new COVID patients in recent months are unvaccinated. And, again, they predominate in Southern states. In Alabama, for instance, only 37% of the population are fully vaccinated. In Louisiana, that number is 40%.

The at-risk states also tend to be the ones that are rapidly running out of space to put the patients in, ICU or otherwise. Where patients who might have been in the intensive care unit (ICU) are housed in the emergency department and in hallways, and where patients without COVID-19 who might have been hospitalized are being turned away. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

These states are at a breaking point. Take Alabama. On August 18, it was “negative 11.” It had 1,568 patients with COVID-19 who needed ICU beds. Only 1,557 beds were available. Patients “may even stay on the regular floor where you’re already stretched for capacity to take care of these people because so many of our staff are out with COVID,” Jeanne Marrazzo, director, Division of Infectious Diseases at the University of Alabama at Birmingham, told a CNN reporter. “It’s really just a domino effect that then clogs up our ERs, clogs up everything else. … It’s a very very tenuous situation.”

The state reported more than 4,000 new cases of COVID-19—“a new high for us,” Marrazzo said. “If you project these numbers out, you can expect that we will at some point, probably around Sept. 1, have at least 5,000 people in our hospitals. If the ratio of people who have to go to the ICU remains stable. That means that probably a third of those people are going to require ICU beds,” she continued. “That is frankly untenable, given the infrastructure, the resources, and really importantly, the staff that we have. I think it is basically apocalyptic. I do not use that word lightly.”

Thus, the US Defense Department (DoD) must once again rise to a sad and desperate occasion. At the request of Federal Emergency Management Agency and the state of Louisiana, the first of five teams of Navy doctors, nurses, and respiratory therapists were sent last week to Ochsner Lafayette General Medical Center in Lafayette, Louisiana.

The teams, consisting of approximately 20 members each, are coming from throughout the DoD’s universe, including the National Guard. US Army North, under US Northern Command’s oversight, is providing operational command of the active-duty military COVID-19 response. Lt. Gen. Laura J. Richardson, ARNORTH commander, noting that “[t]his is the second time Department of Defense medical assets have deployed to support Louisiana during the pandemic,” calls it a “whole-of-government fight against COVID-19.”

Why Louisiana and Mississippi, with so many states in dire need? “Our joint forces go where FEMA needs us,” Richardson says. “[R]ight now FEMA has determined the military’s unique surge capabilities are most needed in these two states.”

In a press briefing at the time, Pentagon Press Secretary Rear Adm. John Kirby said, “We expect that there could be additional requests from other states for other teams, so that’s why we’re being prepared to stand up five teams.” He was right: An Air Force team has now headed to Our Lady of the Lake Regional Medical Center in Baton Rouge. Mississippi also asked for assistance; an Air Force team will be supporting at University of Mississippi Medical Center in Jackson, and an Army team at North Mississippi Medical Center-Tupelo. 

The support will likely include bolstering and extending the infrastructure. From July to December 2020, the Veterans Health Administration (VHA) Emergency Management Coordination Cell delivered Fold-Out Rigid Temporary Shelters (FORTS), C-FORTS (clinics), mobile ICUs and isolation units to locations across the US, such as North Chicago, El Paso, and Oklahoma City. In 2021, they’ll be needed in more hospitals unprepared to house the spiking numbers of patients. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

The first go-round with COVID taught hard lessons that can help hone the Fourth Mission responses. One lesson, according to the VHA COVID-19 Response Report- Annex A, published this May, was the need to conduct due diligence, to be both efficient and effective. VHA, it says, now works to determine actual need before deploying resources. “For example, VHA might receive a request from a [State Veterans Home] for 50 RNs. But once VHA delved into the request and worked with the associated VISNs, it would find that 20 RNs or 10 LPNs could meet the needs of the request.”

Meeting the requests is, for the beleaguered hospitals, like answering letters to Santa. When the team of doctors, nurses, and respiratory therapists arrived at Ochsner Lafayette General Medical Center (OLGMC) last week the hospital staff greeted them with cheers and applause.

OLGMC CEO Al Patin said, "We're already in a nursing shortage, coupled with high numbers of this pandemic [which] creates a situation where we need additional support. We have patients boarding in our emergency rooms, patients in our ICU setting that can't transition out. That creates a bottleneck and does not allow us to continue to take in patients from our community."

That day, OLG posted on Twitter:

“Today, we received some much-needed assistance in the fight against COVID-19. Our team at Ochsner Lafayette General Medical Center is being expanded by four doctors, 14 nurses and two respiratory therapists – all highly trained personnel on loan from the U.S. Navy.

“These healthcare professionals are being onboarded in our facility today and are specially trained for the emergency department, ICU and Med Surg. Because of them, we’ll be able to staff an additional 16-18 beds – beds sorely needed as cases continue to rise in our area.

“We requested support from the Federal Emergency Management Agency and we were one of five U.S. cities to receive it.. We are most grateful and humbled.”

Last summer, a team of US Department of Veterans Affairs (VA) health care professionals deployed to Alabama’s Bill Nichols State Veterans Home to help during the COVID-19 crisis. They were there as part of the “Fourth Mission”—supporting national, state, and local emergency management, public health, safety and homeland security efforts. “It was a really humbling experience,” said Mary Holloway, an RN with the Birmingham VA Health Care System. “Seeing the dedication of the staff there, some coming back to work after recovering from COVID themselves, was inspiring.”

But that turned out to be only one battle in a sadly long and drawn-out war. Since March 2020, more than 5,000 military medical personnel have deployed to 14 states and the Navajo Nation, 51 cities, 71 hospitals, all struggling to keep their heads above a cresting tsunami of new COVID patients.

Last year, the crisis spots for deployments included major metropolitan areas in coastal states: New York, California, and New Jersey. The urgency now is in the Southern states. Those tend to be reporting the highest numbers of new cases and deaths. Alabama, Arkansas, Florida, Louisiana, and Mississippi, for example, have all ranked among the highest rates of cases and hospitalizations per 100,000 people across the country in the last seven days.

This year, military teams have also deployed to support vaccination centers in 25 states and 42 cities. Nearly all—97%—of the new COVID patients in recent months are unvaccinated. And, again, they predominate in Southern states. In Alabama, for instance, only 37% of the population are fully vaccinated. In Louisiana, that number is 40%.

The at-risk states also tend to be the ones that are rapidly running out of space to put the patients in, ICU or otherwise. Where patients who might have been in the intensive care unit (ICU) are housed in the emergency department and in hallways, and where patients without COVID-19 who might have been hospitalized are being turned away. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

These states are at a breaking point. Take Alabama. On August 18, it was “negative 11.” It had 1,568 patients with COVID-19 who needed ICU beds. Only 1,557 beds were available. Patients “may even stay on the regular floor where you’re already stretched for capacity to take care of these people because so many of our staff are out with COVID,” Jeanne Marrazzo, director, Division of Infectious Diseases at the University of Alabama at Birmingham, told a CNN reporter. “It’s really just a domino effect that then clogs up our ERs, clogs up everything else. … It’s a very very tenuous situation.”

The state reported more than 4,000 new cases of COVID-19—“a new high for us,” Marrazzo said. “If you project these numbers out, you can expect that we will at some point, probably around Sept. 1, have at least 5,000 people in our hospitals. If the ratio of people who have to go to the ICU remains stable. That means that probably a third of those people are going to require ICU beds,” she continued. “That is frankly untenable, given the infrastructure, the resources, and really importantly, the staff that we have. I think it is basically apocalyptic. I do not use that word lightly.”

Thus, the US Defense Department (DoD) must once again rise to a sad and desperate occasion. At the request of Federal Emergency Management Agency and the state of Louisiana, the first of five teams of Navy doctors, nurses, and respiratory therapists were sent last week to Ochsner Lafayette General Medical Center in Lafayette, Louisiana.

The teams, consisting of approximately 20 members each, are coming from throughout the DoD’s universe, including the National Guard. US Army North, under US Northern Command’s oversight, is providing operational command of the active-duty military COVID-19 response. Lt. Gen. Laura J. Richardson, ARNORTH commander, noting that “[t]his is the second time Department of Defense medical assets have deployed to support Louisiana during the pandemic,” calls it a “whole-of-government fight against COVID-19.”

Why Louisiana and Mississippi, with so many states in dire need? “Our joint forces go where FEMA needs us,” Richardson says. “[R]ight now FEMA has determined the military’s unique surge capabilities are most needed in these two states.”

In a press briefing at the time, Pentagon Press Secretary Rear Adm. John Kirby said, “We expect that there could be additional requests from other states for other teams, so that’s why we’re being prepared to stand up five teams.” He was right: An Air Force team has now headed to Our Lady of the Lake Regional Medical Center in Baton Rouge. Mississippi also asked for assistance; an Air Force team will be supporting at University of Mississippi Medical Center in Jackson, and an Army team at North Mississippi Medical Center-Tupelo. 

The support will likely include bolstering and extending the infrastructure. From July to December 2020, the Veterans Health Administration (VHA) Emergency Management Coordination Cell delivered Fold-Out Rigid Temporary Shelters (FORTS), C-FORTS (clinics), mobile ICUs and isolation units to locations across the US, such as North Chicago, El Paso, and Oklahoma City. In 2021, they’ll be needed in more hospitals unprepared to house the spiking numbers of patients. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

The first go-round with COVID taught hard lessons that can help hone the Fourth Mission responses. One lesson, according to the VHA COVID-19 Response Report- Annex A, published this May, was the need to conduct due diligence, to be both efficient and effective. VHA, it says, now works to determine actual need before deploying resources. “For example, VHA might receive a request from a [State Veterans Home] for 50 RNs. But once VHA delved into the request and worked with the associated VISNs, it would find that 20 RNs or 10 LPNs could meet the needs of the request.”

Meeting the requests is, for the beleaguered hospitals, like answering letters to Santa. When the team of doctors, nurses, and respiratory therapists arrived at Ochsner Lafayette General Medical Center (OLGMC) last week the hospital staff greeted them with cheers and applause.

OLGMC CEO Al Patin said, "We're already in a nursing shortage, coupled with high numbers of this pandemic [which] creates a situation where we need additional support. We have patients boarding in our emergency rooms, patients in our ICU setting that can't transition out. That creates a bottleneck and does not allow us to continue to take in patients from our community."

That day, OLG posted on Twitter:

“Today, we received some much-needed assistance in the fight against COVID-19. Our team at Ochsner Lafayette General Medical Center is being expanded by four doctors, 14 nurses and two respiratory therapists – all highly trained personnel on loan from the U.S. Navy.

“These healthcare professionals are being onboarded in our facility today and are specially trained for the emergency department, ICU and Med Surg. Because of them, we’ll be able to staff an additional 16-18 beds – beds sorely needed as cases continue to rise in our area.

“We requested support from the Federal Emergency Management Agency and we were one of five U.S. cities to receive it.. We are most grateful and humbled.”

Last summer, a team of US Department of Veterans Affairs (VA) health care professionals deployed to Alabama’s Bill Nichols State Veterans Home to help during the COVID-19 crisis. They were there as part of the “Fourth Mission”—supporting national, state, and local emergency management, public health, safety and homeland security efforts. “It was a really humbling experience,” said Mary Holloway, an RN with the Birmingham VA Health Care System. “Seeing the dedication of the staff there, some coming back to work after recovering from COVID themselves, was inspiring.”

But that turned out to be only one battle in a sadly long and drawn-out war. Since March 2020, more than 5,000 military medical personnel have deployed to 14 states and the Navajo Nation, 51 cities, 71 hospitals, all struggling to keep their heads above a cresting tsunami of new COVID patients.

Last year, the crisis spots for deployments included major metropolitan areas in coastal states: New York, California, and New Jersey. The urgency now is in the Southern states. Those tend to be reporting the highest numbers of new cases and deaths. Alabama, Arkansas, Florida, Louisiana, and Mississippi, for example, have all ranked among the highest rates of cases and hospitalizations per 100,000 people across the country in the last seven days.

This year, military teams have also deployed to support vaccination centers in 25 states and 42 cities. Nearly all—97%—of the new COVID patients in recent months are unvaccinated. And, again, they predominate in Southern states. In Alabama, for instance, only 37% of the population are fully vaccinated. In Louisiana, that number is 40%.

The at-risk states also tend to be the ones that are rapidly running out of space to put the patients in, ICU or otherwise. Where patients who might have been in the intensive care unit (ICU) are housed in the emergency department and in hallways, and where patients without COVID-19 who might have been hospitalized are being turned away. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

These states are at a breaking point. Take Alabama. On August 18, it was “negative 11.” It had 1,568 patients with COVID-19 who needed ICU beds. Only 1,557 beds were available. Patients “may even stay on the regular floor where you’re already stretched for capacity to take care of these people because so many of our staff are out with COVID,” Jeanne Marrazzo, director, Division of Infectious Diseases at the University of Alabama at Birmingham, told a CNN reporter. “It’s really just a domino effect that then clogs up our ERs, clogs up everything else. … It’s a very very tenuous situation.”

The state reported more than 4,000 new cases of COVID-19—“a new high for us,” Marrazzo said. “If you project these numbers out, you can expect that we will at some point, probably around Sept. 1, have at least 5,000 people in our hospitals. If the ratio of people who have to go to the ICU remains stable. That means that probably a third of those people are going to require ICU beds,” she continued. “That is frankly untenable, given the infrastructure, the resources, and really importantly, the staff that we have. I think it is basically apocalyptic. I do not use that word lightly.”

Thus, the US Defense Department (DoD) must once again rise to a sad and desperate occasion. At the request of Federal Emergency Management Agency and the state of Louisiana, the first of five teams of Navy doctors, nurses, and respiratory therapists were sent last week to Ochsner Lafayette General Medical Center in Lafayette, Louisiana.

The teams, consisting of approximately 20 members each, are coming from throughout the DoD’s universe, including the National Guard. US Army North, under US Northern Command’s oversight, is providing operational command of the active-duty military COVID-19 response. Lt. Gen. Laura J. Richardson, ARNORTH commander, noting that “[t]his is the second time Department of Defense medical assets have deployed to support Louisiana during the pandemic,” calls it a “whole-of-government fight against COVID-19.”

Why Louisiana and Mississippi, with so many states in dire need? “Our joint forces go where FEMA needs us,” Richardson says. “[R]ight now FEMA has determined the military’s unique surge capabilities are most needed in these two states.”

In a press briefing at the time, Pentagon Press Secretary Rear Adm. John Kirby said, “We expect that there could be additional requests from other states for other teams, so that’s why we’re being prepared to stand up five teams.” He was right: An Air Force team has now headed to Our Lady of the Lake Regional Medical Center in Baton Rouge. Mississippi also asked for assistance; an Air Force team will be supporting at University of Mississippi Medical Center in Jackson, and an Army team at North Mississippi Medical Center-Tupelo. 

The support will likely include bolstering and extending the infrastructure. From July to December 2020, the Veterans Health Administration (VHA) Emergency Management Coordination Cell delivered Fold-Out Rigid Temporary Shelters (FORTS), C-FORTS (clinics), mobile ICUs and isolation units to locations across the US, such as North Chicago, El Paso, and Oklahoma City. In 2021, they’ll be needed in more hospitals unprepared to house the spiking numbers of patients. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

The first go-round with COVID taught hard lessons that can help hone the Fourth Mission responses. One lesson, according to the VHA COVID-19 Response Report- Annex A, published this May, was the need to conduct due diligence, to be both efficient and effective. VHA, it says, now works to determine actual need before deploying resources. “For example, VHA might receive a request from a [State Veterans Home] for 50 RNs. But once VHA delved into the request and worked with the associated VISNs, it would find that 20 RNs or 10 LPNs could meet the needs of the request.”

Meeting the requests is, for the beleaguered hospitals, like answering letters to Santa. When the team of doctors, nurses, and respiratory therapists arrived at Ochsner Lafayette General Medical Center (OLGMC) last week the hospital staff greeted them with cheers and applause.

OLGMC CEO Al Patin said, "We're already in a nursing shortage, coupled with high numbers of this pandemic [which] creates a situation where we need additional support. We have patients boarding in our emergency rooms, patients in our ICU setting that can't transition out. That creates a bottleneck and does not allow us to continue to take in patients from our community."

That day, OLG posted on Twitter:

“Today, we received some much-needed assistance in the fight against COVID-19. Our team at Ochsner Lafayette General Medical Center is being expanded by four doctors, 14 nurses and two respiratory therapists – all highly trained personnel on loan from the U.S. Navy.

“These healthcare professionals are being onboarded in our facility today and are specially trained for the emergency department, ICU and Med Surg. Because of them, we’ll be able to staff an additional 16-18 beds – beds sorely needed as cases continue to rise in our area.

“We requested support from the Federal Emergency Management Agency and we were one of five U.S. cities to receive it.. We are most grateful and humbled.”

Last summer, a team of US Department of Veterans Affairs (VA) health care professionals deployed to Alabama’s Bill Nichols State Veterans Home to help during the COVID-19 crisis. They were there as part of the “Fourth Mission”—supporting national, state, and local emergency management, public health, safety and homeland security efforts. “It was a really humbling experience,” said Mary Holloway, an RN with the Birmingham VA Health Care System. “Seeing the dedication of the staff there, some coming back to work after recovering from COVID themselves, was inspiring.”

But that turned out to be only one battle in a sadly long and drawn-out war. Since March 2020, more than 5,000 military medical personnel have deployed to 14 states and the Navajo Nation, 51 cities, 71 hospitals, all struggling to keep their heads above a cresting tsunami of new COVID patients.

Last year, the crisis spots for deployments included major metropolitan areas in coastal states: New York, California, and New Jersey. The urgency now is in the Southern states. Those tend to be reporting the highest numbers of new cases and deaths. Alabama, Arkansas, Florida, Louisiana, and Mississippi, for example, have all ranked among the highest rates of cases and hospitalizations per 100,000 people across the country in the last seven days.

This year, military teams have also deployed to support vaccination centers in 25 states and 42 cities. Nearly all—97%—of the new COVID patients in recent months are unvaccinated. And, again, they predominate in Southern states. In Alabama, for instance, only 37% of the population are fully vaccinated. In Louisiana, that number is 40%.

The at-risk states also tend to be the ones that are rapidly running out of space to put the patients in, ICU or otherwise. Where patients who might have been in the intensive care unit (ICU) are housed in the emergency department and in hallways, and where patients without COVID-19 who might have been hospitalized are being turned away. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

These states are at a breaking point. Take Alabama. On August 18, it was “negative 11.” It had 1,568 patients with COVID-19 who needed ICU beds. Only 1,557 beds were available. Patients “may even stay on the regular floor where you’re already stretched for capacity to take care of these people because so many of our staff are out with COVID,” Jeanne Marrazzo, director, Division of Infectious Diseases at the University of Alabama at Birmingham, told a CNN reporter. “It’s really just a domino effect that then clogs up our ERs, clogs up everything else. … It’s a very very tenuous situation.”

The state reported more than 4,000 new cases of COVID-19—“a new high for us,” Marrazzo said. “If you project these numbers out, you can expect that we will at some point, probably around Sept. 1, have at least 5,000 people in our hospitals. If the ratio of people who have to go to the ICU remains stable. That means that probably a third of those people are going to require ICU beds,” she continued. “That is frankly untenable, given the infrastructure, the resources, and really importantly, the staff that we have. I think it is basically apocalyptic. I do not use that word lightly.”

Thus, the US Defense Department (DoD) must once again rise to a sad and desperate occasion. At the request of Federal Emergency Management Agency and the state of Louisiana, the first of five teams of Navy doctors, nurses, and respiratory therapists were sent last week to Ochsner Lafayette General Medical Center in Lafayette, Louisiana.

The teams, consisting of approximately 20 members each, are coming from throughout the DoD’s universe, including the National Guard. US Army North, under US Northern Command’s oversight, is providing operational command of the active-duty military COVID-19 response. Lt. Gen. Laura J. Richardson, ARNORTH commander, noting that “[t]his is the second time Department of Defense medical assets have deployed to support Louisiana during the pandemic,” calls it a “whole-of-government fight against COVID-19.”

Why Louisiana and Mississippi, with so many states in dire need? “Our joint forces go where FEMA needs us,” Richardson says. “[R]ight now FEMA has determined the military’s unique surge capabilities are most needed in these two states.”

In a press briefing at the time, Pentagon Press Secretary Rear Adm. John Kirby said, “We expect that there could be additional requests from other states for other teams, so that’s why we’re being prepared to stand up five teams.” He was right: An Air Force team has now headed to Our Lady of the Lake Regional Medical Center in Baton Rouge. Mississippi also asked for assistance; an Air Force team will be supporting at University of Mississippi Medical Center in Jackson, and an Army team at North Mississippi Medical Center-Tupelo. 

The support will likely include bolstering and extending the infrastructure. From July to December 2020, the Veterans Health Administration (VHA) Emergency Management Coordination Cell delivered Fold-Out Rigid Temporary Shelters (FORTS), C-FORTS (clinics), mobile ICUs and isolation units to locations across the US, such as North Chicago, El Paso, and Oklahoma City. In 2021, they’ll be needed in more hospitals unprepared to house the spiking numbers of patients. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

The first go-round with COVID taught hard lessons that can help hone the Fourth Mission responses. One lesson, according to the VHA COVID-19 Response Report- Annex A, published this May, was the need to conduct due diligence, to be both efficient and effective. VHA, it says, now works to determine actual need before deploying resources. “For example, VHA might receive a request from a [State Veterans Home] for 50 RNs. But once VHA delved into the request and worked with the associated VISNs, it would find that 20 RNs or 10 LPNs could meet the needs of the request.”

Meeting the requests is, for the beleaguered hospitals, like answering letters to Santa. When the team of doctors, nurses, and respiratory therapists arrived at Ochsner Lafayette General Medical Center (OLGMC) last week the hospital staff greeted them with cheers and applause.

OLGMC CEO Al Patin said, "We're already in a nursing shortage, coupled with high numbers of this pandemic [which] creates a situation where we need additional support. We have patients boarding in our emergency rooms, patients in our ICU setting that can't transition out. That creates a bottleneck and does not allow us to continue to take in patients from our community."

That day, OLG posted on Twitter:

“Today, we received some much-needed assistance in the fight against COVID-19. Our team at Ochsner Lafayette General Medical Center is being expanded by four doctors, 14 nurses and two respiratory therapists – all highly trained personnel on loan from the U.S. Navy.

“These healthcare professionals are being onboarded in our facility today and are specially trained for the emergency department, ICU and Med Surg. Because of them, we’ll be able to staff an additional 16-18 beds – beds sorely needed as cases continue to rise in our area.

“We requested support from the Federal Emergency Management Agency and we were one of five U.S. cities to receive it.. We are most grateful and humbled.”

Last summer, a team of US Department of Veterans Affairs (VA) health care professionals deployed to Alabama’s Bill Nichols State Veterans Home to help during the COVID-19 crisis. They were there as part of the “Fourth Mission”—supporting national, state, and local emergency management, public health, safety and homeland security efforts. “It was a really humbling experience,” said Mary Holloway, an RN with the Birmingham VA Health Care System. “Seeing the dedication of the staff there, some coming back to work after recovering from COVID themselves, was inspiring.”

But that turned out to be only one battle in a sadly long and drawn-out war. Since March 2020, more than 5,000 military medical personnel have deployed to 14 states and the Navajo Nation, 51 cities, 71 hospitals, all struggling to keep their heads above a cresting tsunami of new COVID patients.

Last year, the crisis spots for deployments included major metropolitan areas in coastal states: New York, California, and New Jersey. The urgency now is in the Southern states. Those tend to be reporting the highest numbers of new cases and deaths. Alabama, Arkansas, Florida, Louisiana, and Mississippi, for example, have all ranked among the highest rates of cases and hospitalizations per 100,000 people across the country in the last seven days.

This year, military teams have also deployed to support vaccination centers in 25 states and 42 cities. Nearly all—97%—of the new COVID patients in recent months are unvaccinated. And, again, they predominate in Southern states. In Alabama, for instance, only 37% of the population are fully vaccinated. In Louisiana, that number is 40%.

The at-risk states also tend to be the ones that are rapidly running out of space to put the patients in, ICU or otherwise. Where patients who might have been in the intensive care unit (ICU) are housed in the emergency department and in hallways, and where patients without COVID-19 who might have been hospitalized are being turned away. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

These states are at a breaking point. Take Alabama. On August 18, it was “negative 11.” It had 1,568 patients with COVID-19 who needed ICU beds. Only 1,557 beds were available. Patients “may even stay on the regular floor where you’re already stretched for capacity to take care of these people because so many of our staff are out with COVID,” Jeanne Marrazzo, director, Division of Infectious Diseases at the University of Alabama at Birmingham, told a CNN reporter. “It’s really just a domino effect that then clogs up our ERs, clogs up everything else. … It’s a very very tenuous situation.”

The state reported more than 4,000 new cases of COVID-19—“a new high for us,” Marrazzo said. “If you project these numbers out, you can expect that we will at some point, probably around Sept. 1, have at least 5,000 people in our hospitals. If the ratio of people who have to go to the ICU remains stable. That means that probably a third of those people are going to require ICU beds,” she continued. “That is frankly untenable, given the infrastructure, the resources, and really importantly, the staff that we have. I think it is basically apocalyptic. I do not use that word lightly.”

Thus, the US Defense Department (DoD) must once again rise to a sad and desperate occasion. At the request of Federal Emergency Management Agency and the state of Louisiana, the first of five teams of Navy doctors, nurses, and respiratory therapists were sent last week to Ochsner Lafayette General Medical Center in Lafayette, Louisiana.

The teams, consisting of approximately 20 members each, are coming from throughout the DoD’s universe, including the National Guard. US Army North, under US Northern Command’s oversight, is providing operational command of the active-duty military COVID-19 response. Lt. Gen. Laura J. Richardson, ARNORTH commander, noting that “[t]his is the second time Department of Defense medical assets have deployed to support Louisiana during the pandemic,” calls it a “whole-of-government fight against COVID-19.”

Why Louisiana and Mississippi, with so many states in dire need? “Our joint forces go where FEMA needs us,” Richardson says. “[R]ight now FEMA has determined the military’s unique surge capabilities are most needed in these two states.”

In a press briefing at the time, Pentagon Press Secretary Rear Adm. John Kirby said, “We expect that there could be additional requests from other states for other teams, so that’s why we’re being prepared to stand up five teams.” He was right: An Air Force team has now headed to Our Lady of the Lake Regional Medical Center in Baton Rouge. Mississippi also asked for assistance; an Air Force team will be supporting at University of Mississippi Medical Center in Jackson, and an Army team at North Mississippi Medical Center-Tupelo. 

The support will likely include bolstering and extending the infrastructure. From July to December 2020, the Veterans Health Administration (VHA) Emergency Management Coordination Cell delivered Fold-Out Rigid Temporary Shelters (FORTS), C-FORTS (clinics), mobile ICUs and isolation units to locations across the US, such as North Chicago, El Paso, and Oklahoma City. In 2021, they’ll be needed in more hospitals unprepared to house the spiking numbers of patients. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

The first go-round with COVID taught hard lessons that can help hone the Fourth Mission responses. One lesson, according to the VHA COVID-19 Response Report- Annex A, published this May, was the need to conduct due diligence, to be both efficient and effective. VHA, it says, now works to determine actual need before deploying resources. “For example, VHA might receive a request from a [State Veterans Home] for 50 RNs. But once VHA delved into the request and worked with the associated VISNs, it would find that 20 RNs or 10 LPNs could meet the needs of the request.”

Meeting the requests is, for the beleaguered hospitals, like answering letters to Santa. When the team of doctors, nurses, and respiratory therapists arrived at Ochsner Lafayette General Medical Center (OLGMC) last week the hospital staff greeted them with cheers and applause.

OLGMC CEO Al Patin said, "We're already in a nursing shortage, coupled with high numbers of this pandemic [which] creates a situation where we need additional support. We have patients boarding in our emergency rooms, patients in our ICU setting that can't transition out. That creates a bottleneck and does not allow us to continue to take in patients from our community."

That day, OLG posted on Twitter:

“Today, we received some much-needed assistance in the fight against COVID-19. Our team at Ochsner Lafayette General Medical Center is being expanded by four doctors, 14 nurses and two respiratory therapists – all highly trained personnel on loan from the U.S. Navy.

“These healthcare professionals are being onboarded in our facility today and are specially trained for the emergency department, ICU and Med Surg. Because of them, we’ll be able to staff an additional 16-18 beds – beds sorely needed as cases continue to rise in our area.

“We requested support from the Federal Emergency Management Agency and we were one of five U.S. cities to receive it.. We are most grateful and humbled.”

Last summer, a team of US Department of Veterans Affairs (VA) health care professionals deployed to Alabama’s Bill Nichols State Veterans Home to help during the COVID-19 crisis. They were there as part of the “Fourth Mission”—supporting national, state, and local emergency management, public health, safety and homeland security efforts. “It was a really humbling experience,” said Mary Holloway, an RN with the Birmingham VA Health Care System. “Seeing the dedication of the staff there, some coming back to work after recovering from COVID themselves, was inspiring.”

But that turned out to be only one battle in a sadly long and drawn-out war. Since March 2020, more than 5,000 military medical personnel have deployed to 14 states and the Navajo Nation, 51 cities, 71 hospitals, all struggling to keep their heads above a cresting tsunami of new COVID patients.

Last year, the crisis spots for deployments included major metropolitan areas in coastal states: New York, California, and New Jersey. The urgency now is in the Southern states. Those tend to be reporting the highest numbers of new cases and deaths. Alabama, Arkansas, Florida, Louisiana, and Mississippi, for example, have all ranked among the highest rates of cases and hospitalizations per 100,000 people across the country in the last seven days.

This year, military teams have also deployed to support vaccination centers in 25 states and 42 cities. Nearly all—97%—of the new COVID patients in recent months are unvaccinated. And, again, they predominate in Southern states. In Alabama, for instance, only 37% of the population are fully vaccinated. In Louisiana, that number is 40%.

The at-risk states also tend to be the ones that are rapidly running out of space to put the patients in, ICU or otherwise. Where patients who might have been in the intensive care unit (ICU) are housed in the emergency department and in hallways, and where patients without COVID-19 who might have been hospitalized are being turned away. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

These states are at a breaking point. Take Alabama. On August 18, it was “negative 11.” It had 1,568 patients with COVID-19 who needed ICU beds. Only 1,557 beds were available. Patients “may even stay on the regular floor where you’re already stretched for capacity to take care of these people because so many of our staff are out with COVID,” Jeanne Marrazzo, director, Division of Infectious Diseases at the University of Alabama at Birmingham, told a CNN reporter. “It’s really just a domino effect that then clogs up our ERs, clogs up everything else. … It’s a very very tenuous situation.”

The state reported more than 4,000 new cases of COVID-19—“a new high for us,” Marrazzo said. “If you project these numbers out, you can expect that we will at some point, probably around Sept. 1, have at least 5,000 people in our hospitals. If the ratio of people who have to go to the ICU remains stable. That means that probably a third of those people are going to require ICU beds,” she continued. “That is frankly untenable, given the infrastructure, the resources, and really importantly, the staff that we have. I think it is basically apocalyptic. I do not use that word lightly.”

Thus, the US Defense Department (DoD) must once again rise to a sad and desperate occasion. At the request of Federal Emergency Management Agency and the state of Louisiana, the first of five teams of Navy doctors, nurses, and respiratory therapists were sent last week to Ochsner Lafayette General Medical Center in Lafayette, Louisiana.

The teams, consisting of approximately 20 members each, are coming from throughout the DoD’s universe, including the National Guard. US Army North, under US Northern Command’s oversight, is providing operational command of the active-duty military COVID-19 response. Lt. Gen. Laura J. Richardson, ARNORTH commander, noting that “[t]his is the second time Department of Defense medical assets have deployed to support Louisiana during the pandemic,” calls it a “whole-of-government fight against COVID-19.”

Why Louisiana and Mississippi, with so many states in dire need? “Our joint forces go where FEMA needs us,” Richardson says. “[R]ight now FEMA has determined the military’s unique surge capabilities are most needed in these two states.”

In a press briefing at the time, Pentagon Press Secretary Rear Adm. John Kirby said, “We expect that there could be additional requests from other states for other teams, so that’s why we’re being prepared to stand up five teams.” He was right: An Air Force team has now headed to Our Lady of the Lake Regional Medical Center in Baton Rouge. Mississippi also asked for assistance; an Air Force team will be supporting at University of Mississippi Medical Center in Jackson, and an Army team at North Mississippi Medical Center-Tupelo. 

The support will likely include bolstering and extending the infrastructure. From July to December 2020, the Veterans Health Administration (VHA) Emergency Management Coordination Cell delivered Fold-Out Rigid Temporary Shelters (FORTS), C-FORTS (clinics), mobile ICUs and isolation units to locations across the US, such as North Chicago, El Paso, and Oklahoma City. In 2021, they’ll be needed in more hospitals unprepared to house the spiking numbers of patients. Some Louisiana hospitals, for instance, have been sending patients in ambulances to Texas for care.

The first go-round with COVID taught hard lessons that can help hone the Fourth Mission responses. One lesson, according to the VHA COVID-19 Response Report- Annex A, published this May, was the need to conduct due diligence, to be both efficient and effective. VHA, it says, now works to determine actual need before deploying resources. “For example, VHA might receive a request from a [State Veterans Home] for 50 RNs. But once VHA delved into the request and worked with the associated VISNs, it would find that 20 RNs or 10 LPNs could meet the needs of the request.”

Meeting the requests is, for the beleaguered hospitals, like answering letters to Santa. When the team of doctors, nurses, and respiratory therapists arrived at Ochsner Lafayette General Medical Center (OLGMC) last week the hospital staff greeted them with cheers and applause.

OLGMC CEO Al Patin said, "We're already in a nursing shortage, coupled with high numbers of this pandemic [which] creates a situation where we need additional support. We have patients boarding in our emergency rooms, patients in our ICU setting that can't transition out. That creates a bottleneck and does not allow us to continue to take in patients from our community."

That day, OLG posted on Twitter:

“Today, we received some much-needed assistance in the fight against COVID-19. Our team at Ochsner Lafayette General Medical Center is being expanded by four doctors, 14 nurses and two respiratory therapists – all highly trained personnel on loan from the U.S. Navy.

“These healthcare professionals are being onboarded in our facility today and are specially trained for the emergency department, ICU and Med Surg. Because of them, we’ll be able to staff an additional 16-18 beds – beds sorely needed as cases continue to rise in our area.

“We requested support from the Federal Emergency Management Agency and we were one of five U.S. cities to receive it.. We are most grateful and humbled.”

New policy hopes to be in line with full FDA approval expected in September. When the largest employer in the world makes any significant decision, everyone sits up and takes notice.

That’s what happened when Secretary of Defense Lloyd Austin III sent out a memo to all US Department of Defense (DoD) employees saying he was seeking President Biden’s approval to make COVID-19 vaccines mandatory. His decision affects not only the 3.2 million employees on the payroll, but their families, communities, and states. Florida, for instance, where approximately 40% of the population remains unvaccinated has about 55,000 active duty service members and 36,000 reservists.

Vaccination rates in the military have lagged behind other populations, especially among Black and Hispanic service members. An April study published in Medical Surveillance Monthly Report found that “non-Hispanic Blacks, as well as those who were female, younger, of lower rank, with lower education levels, and those serving in the Army were less likely to initiate COVID-19 vaccination after adjusting for other factors.”

The decision had been in the offing for some time but when cases of the Delta variant of the virus began to spike in July, President Biden asked Sec. Austin to consider how and when the COVID vaccine could be added to the list of required vaccines for service members. It’s a long list already: Depending on their location, service members can get as many as 17 vaccines. It also folllows on the heals of the decision by the US Department of Veterans Affairs to require vaccinations for frontline health care workers.

Austin promised to “not let grass grow.” He consulted with Army Gen. Mark Milley, the Joint Chiefs of Staff, service chiefs, service secretaries, and medical professionals. Based on those discussions, he decided to ask for approval to make the vaccines mandatory no later than mid-September or immediately upon FDA licensure, whichever comes first.

However, he added, “[t]o defend this Nation, we need a healthy and ready force. I strongly encourage all DoD military and civilian personnel—as well as contractor personnel—to get vaccinated now and for military Service members to not wait for the mandate.” Currently, 73% of active-duty personnel have had at least one dose of the vaccine.

Leaping upon the news—and based on the wording in the memo—some in the media were reporting that it meant all troops have to be vaccinated by mid-September. “He’ll make the request by mid-September, unless or until FDA licensure occurs before that time, at which point the Secretary has the authority he needs…to make whatever vaccine is then given that license mandatory.”  That’s not the case, said Pentagon press secretary John Kirby in a briefing. Some voices also have called on the DoD to do more to dispel vaccine hesitancy among the troops.

In the meantime, Kirby said, “[T]wo things are going to happen. One, the services are going to be tasked to come back to the Secretary with implementation plans for how they’re going to get this moving.” Noting that mid-September isn’t far away, he pointed out that the services have a “fair but limited amount of time” to arrange their implementation plans. “I have every confidence that service leadership and your commanders will implement this new vaccination program with professionalism, skill, and compassion,” Austin wrote in his memo.

The second thing, Kirby said, was that DoD would be developing policies that comply with the President’s direction that the unvaccinated will have to be subjected to “certain requirements and restrictions.” The Delta variant is hitting the unvaccinated hardest. Austin said the DoD will keep a close eye on infection rates “and the impact these rates might have on our readiness. I will not hesitate to act sooner or recommend a different course to the President if I feel the need to do so.”

Kirby said he didn’t have all the details for that yet, but the department is “working hard” on a policy directive that will clarify what those requirements and restrictions might be.

President Biden replied almost immediately to Austin’s message. “I strongly support Secretary Austin’s message to the force today…. Secretary Austin and I share an unshakeable commitment to making sure our troops have every tool they need to do their jobs as safely as possible. These vaccines will save lives. Period.”

“All FDA-authorized COVID-19 vaccines are safe and highly effective,” Austin said in the close to his memo. “They will protect you and your family. They will protect your unit, your ship, and your co-workers. …Get the shot. Stay healthy. Stay ready.”

New policy hopes to be in line with full FDA approval expected in September. When the largest employer in the world makes any significant decision, everyone sits up and takes notice.

That’s what happened when Secretary of Defense Lloyd Austin III sent out a memo to all US Department of Defense (DoD) employees saying he was seeking President Biden’s approval to make COVID-19 vaccines mandatory. His decision affects not only the 3.2 million employees on the payroll, but their families, communities, and states. Florida, for instance, where approximately 40% of the population remains unvaccinated has about 55,000 active duty service members and 36,000 reservists.

Vaccination rates in the military have lagged behind other populations, especially among Black and Hispanic service members. An April study published in Medical Surveillance Monthly Report found that “non-Hispanic Blacks, as well as those who were female, younger, of lower rank, with lower education levels, and those serving in the Army were less likely to initiate COVID-19 vaccination after adjusting for other factors.”

The decision had been in the offing for some time but when cases of the Delta variant of the virus began to spike in July, President Biden asked Sec. Austin to consider how and when the COVID vaccine could be added to the list of required vaccines for service members. It’s a long list already: Depending on their location, service members can get as many as 17 vaccines. It also folllows on the heals of the decision by the US Department of Veterans Affairs to require vaccinations for frontline health care workers.

Austin promised to “not let grass grow.” He consulted with Army Gen. Mark Milley, the Joint Chiefs of Staff, service chiefs, service secretaries, and medical professionals. Based on those discussions, he decided to ask for approval to make the vaccines mandatory no later than mid-September or immediately upon FDA licensure, whichever comes first.

However, he added, “[t]o defend this Nation, we need a healthy and ready force. I strongly encourage all DoD military and civilian personnel—as well as contractor personnel—to get vaccinated now and for military Service members to not wait for the mandate.” Currently, 73% of active-duty personnel have had at least one dose of the vaccine.

Leaping upon the news—and based on the wording in the memo—some in the media were reporting that it meant all troops have to be vaccinated by mid-September. “He’ll make the request by mid-September, unless or until FDA licensure occurs before that time, at which point the Secretary has the authority he needs…to make whatever vaccine is then given that license mandatory.”  That’s not the case, said Pentagon press secretary John Kirby in a briefing. Some voices also have called on the DoD to do more to dispel vaccine hesitancy among the troops.

In the meantime, Kirby said, “[T]wo things are going to happen. One, the services are going to be tasked to come back to the Secretary with implementation plans for how they’re going to get this moving.” Noting that mid-September isn’t far away, he pointed out that the services have a “fair but limited amount of time” to arrange their implementation plans. “I have every confidence that service leadership and your commanders will implement this new vaccination program with professionalism, skill, and compassion,” Austin wrote in his memo.

The second thing, Kirby said, was that DoD would be developing policies that comply with the President’s direction that the unvaccinated will have to be subjected to “certain requirements and restrictions.” The Delta variant is hitting the unvaccinated hardest. Austin said the DoD will keep a close eye on infection rates “and the impact these rates might have on our readiness. I will not hesitate to act sooner or recommend a different course to the President if I feel the need to do so.”

Kirby said he didn’t have all the details for that yet, but the department is “working hard” on a policy directive that will clarify what those requirements and restrictions might be.

President Biden replied almost immediately to Austin’s message. “I strongly support Secretary Austin’s message to the force today…. Secretary Austin and I share an unshakeable commitment to making sure our troops have every tool they need to do their jobs as safely as possible. These vaccines will save lives. Period.”

“All FDA-authorized COVID-19 vaccines are safe and highly effective,” Austin said in the close to his memo. “They will protect you and your family. They will protect your unit, your ship, and your co-workers. …Get the shot. Stay healthy. Stay ready.”

New policy hopes to be in line with full FDA approval expected in September. When the largest employer in the world makes any significant decision, everyone sits up and takes notice.

That’s what happened when Secretary of Defense Lloyd Austin III sent out a memo to all US Department of Defense (DoD) employees saying he was seeking President Biden’s approval to make COVID-19 vaccines mandatory. His decision affects not only the 3.2 million employees on the payroll, but their families, communities, and states. Florida, for instance, where approximately 40% of the population remains unvaccinated has about 55,000 active duty service members and 36,000 reservists.

Vaccination rates in the military have lagged behind other populations, especially among Black and Hispanic service members. An April study published in Medical Surveillance Monthly Report found that “non-Hispanic Blacks, as well as those who were female, younger, of lower rank, with lower education levels, and those serving in the Army were less likely to initiate COVID-19 vaccination after adjusting for other factors.”

The decision had been in the offing for some time but when cases of the Delta variant of the virus began to spike in July, President Biden asked Sec. Austin to consider how and when the COVID vaccine could be added to the list of required vaccines for service members. It’s a long list already: Depending on their location, service members can get as many as 17 vaccines. It also folllows on the heals of the decision by the US Department of Veterans Affairs to require vaccinations for frontline health care workers.

Austin promised to “not let grass grow.” He consulted with Army Gen. Mark Milley, the Joint Chiefs of Staff, service chiefs, service secretaries, and medical professionals. Based on those discussions, he decided to ask for approval to make the vaccines mandatory no later than mid-September or immediately upon FDA licensure, whichever comes first.

However, he added, “[t]o defend this Nation, we need a healthy and ready force. I strongly encourage all DoD military and civilian personnel—as well as contractor personnel—to get vaccinated now and for military Service members to not wait for the mandate.” Currently, 73% of active-duty personnel have had at least one dose of the vaccine.

Leaping upon the news—and based on the wording in the memo—some in the media were reporting that it meant all troops have to be vaccinated by mid-September. “He’ll make the request by mid-September, unless or until FDA licensure occurs before that time, at which point the Secretary has the authority he needs…to make whatever vaccine is then given that license mandatory.”  That’s not the case, said Pentagon press secretary John Kirby in a briefing. Some voices also have called on the DoD to do more to dispel vaccine hesitancy among the troops.

In the meantime, Kirby said, “[T]wo things are going to happen. One, the services are going to be tasked to come back to the Secretary with implementation plans for how they’re going to get this moving.” Noting that mid-September isn’t far away, he pointed out that the services have a “fair but limited amount of time” to arrange their implementation plans. “I have every confidence that service leadership and your commanders will implement this new vaccination program with professionalism, skill, and compassion,” Austin wrote in his memo.

The second thing, Kirby said, was that DoD would be developing policies that comply with the President’s direction that the unvaccinated will have to be subjected to “certain requirements and restrictions.” The Delta variant is hitting the unvaccinated hardest. Austin said the DoD will keep a close eye on infection rates “and the impact these rates might have on our readiness. I will not hesitate to act sooner or recommend a different course to the President if I feel the need to do so.”

Kirby said he didn’t have all the details for that yet, but the department is “working hard” on a policy directive that will clarify what those requirements and restrictions might be.

President Biden replied almost immediately to Austin’s message. “I strongly support Secretary Austin’s message to the force today…. Secretary Austin and I share an unshakeable commitment to making sure our troops have every tool they need to do their jobs as safely as possible. These vaccines will save lives. Period.”

“All FDA-authorized COVID-19 vaccines are safe and highly effective,” Austin said in the close to his memo. “They will protect you and your family. They will protect your unit, your ship, and your co-workers. …Get the shot. Stay healthy. Stay ready.”

How many epidemics can one country contain? Nearly all of our national attention has been focused on the COVID-19 epidemic but, lest we forget, there’s still another one to be reckoned with: the HIV epidemic is still going strong. In fact, it’s gathering strength, in part, because of the economic and health devastation wrought by COVID.

                Over nearly 4 decades, the epidemiology of HIV has changed, according to The Lancet’s HIV in the USA series. Current data, the report says, “illustrate an epidemic defined by stark health inequities that largely fall along lines of disadvantages in economic opportunity and social capital.” Moreover, the US, the authors say, “continues to lag behind other G-7 nations when it comes to controlling its HIV epidemic and is the only high-income country among the top 10 countries most affected by HIV.”

                The 6-paper series’ release comes 2 years after the launch of the US Department of Health and Human Services’ (HHS) announcement of its goal to reduce HIV transmissions by at least 90% by 2030.

                The authors analyzed publicly available HIV surveillance and census data to describe current prevalence and new HIV diagnoses by region, race, ethnicity, and age, as well as trends in those categories over time. They also reviewed literature to “explore the reasons” for the distribution of cases and important disparities in prevalence. Among other things, the researchers found “pronounced” racial, sexual, and gender disparities, “substantial” gaps in domestic program funding, and a “patchwork healthcare system” that limited access to treatment and prevention services.

                Although when it began, the HIV epidemic was focused largely on the bicoastal big cities, mainly New York and San Francisco, in recent years the South has been hit particularly hard, with 52% of new HIV transmissions in 2018, despite representing only 37% of the US population. Six Southern states (Florida, Georgia, Louisiana, Maryland, Mississippi, and Tennessee) and the District of Columbia had the highest annual HIV diagnosis rates between 2010 and 2018, likely reflecting the higher burden of infection among black residents: In 2018, 38% of all new HIV diagnoses among men who have sex with men (MSM) were in the black population, and 63% of those were in the South.

                The South’s HIV problem is intensified by disparities, the report says, that are probably driven by the restricted expansion of Medicaid, health care provider shortages, low health literacy, and stigma. The South also has the lowest number of pre-exposure prophylaxis (PrEP) users per new HIV diagnosis, in part because of the longer distances to PrEP services relative to other regions. More than half of MSM who live at least 60 minutes away from PrEP services live in the South. While HIV in the rural South largely is due to sexual transmission, the researchers note, the largest clusters of the concurrent opioid epidemic have been detected in rural and periurban counties of West Virginia and Indiana.

                Identifying HIV transmission clusters and outbreaks has traditionally been challenging for several reasons, the researchers say, including delays between infection and diagnosis, mobility of populations, and limitations in tracing sex and drug partners. They suggest that analysis of molecular data can help overcome some of those barriers, making it possible to identify clusters of ongoing HIV transmission.

                The report also recommends other approaches to better understand and respond to ongoing HIV infections, such as mapping and data visualization, telemedicine, and automated data systems to facilitate linkage to care. However, the authors add, gaps in data and data systems remain that prevent full understanding of some key impacts of the epidemic. But any interventions to promote HIV prevention and treatment adherence, the authors suggested, should take a multifaceted approach and address the whole individual.

                Chris Beyrer, MD, MPH, investigator at the Johns Hopkins Bloomberg School of Public Health, Baltimore, and a lead author on the series, says, “We have incredible tools to prevent and treat HIV, but people may not fully utilize them if they are facing personal or structural issues that pose more immediate hardship, like substance use and mental health disorders. You may struggle to take a daily medication if you are facing food insecurity or cannot find affordable treatment for your substance use disorder.”

                Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, and now also Chief Medical Advisor to President Biden, says, “To end the HIV epidemic, we must continue to develop and deploy novel HIV treatment and prevention strategies suited to the different needs and preferences of diverse populations disproportionately affected by HIV. It is also essential that HIV health services continue during the COVID-19 pandemic.”

How many epidemics can one country contain? Nearly all of our national attention has been focused on the COVID-19 epidemic but, lest we forget, there’s still another one to be reckoned with: the HIV epidemic is still going strong. In fact, it’s gathering strength, in part, because of the economic and health devastation wrought by COVID.

                Over nearly 4 decades, the epidemiology of HIV has changed, according to The Lancet’s HIV in the USA series. Current data, the report says, “illustrate an epidemic defined by stark health inequities that largely fall along lines of disadvantages in economic opportunity and social capital.” Moreover, the US, the authors say, “continues to lag behind other G-7 nations when it comes to controlling its HIV epidemic and is the only high-income country among the top 10 countries most affected by HIV.”

                The 6-paper series’ release comes 2 years after the launch of the US Department of Health and Human Services’ (HHS) announcement of its goal to reduce HIV transmissions by at least 90% by 2030.

                The authors analyzed publicly available HIV surveillance and census data to describe current prevalence and new HIV diagnoses by region, race, ethnicity, and age, as well as trends in those categories over time. They also reviewed literature to “explore the reasons” for the distribution of cases and important disparities in prevalence. Among other things, the researchers found “pronounced” racial, sexual, and gender disparities, “substantial” gaps in domestic program funding, and a “patchwork healthcare system” that limited access to treatment and prevention services.

                Although when it began, the HIV epidemic was focused largely on the bicoastal big cities, mainly New York and San Francisco, in recent years the South has been hit particularly hard, with 52% of new HIV transmissions in 2018, despite representing only 37% of the US population. Six Southern states (Florida, Georgia, Louisiana, Maryland, Mississippi, and Tennessee) and the District of Columbia had the highest annual HIV diagnosis rates between 2010 and 2018, likely reflecting the higher burden of infection among black residents: In 2018, 38% of all new HIV diagnoses among men who have sex with men (MSM) were in the black population, and 63% of those were in the South.

                The South’s HIV problem is intensified by disparities, the report says, that are probably driven by the restricted expansion of Medicaid, health care provider shortages, low health literacy, and stigma. The South also has the lowest number of pre-exposure prophylaxis (PrEP) users per new HIV diagnosis, in part because of the longer distances to PrEP services relative to other regions. More than half of MSM who live at least 60 minutes away from PrEP services live in the South. While HIV in the rural South largely is due to sexual transmission, the researchers note, the largest clusters of the concurrent opioid epidemic have been detected in rural and periurban counties of West Virginia and Indiana.

                Identifying HIV transmission clusters and outbreaks has traditionally been challenging for several reasons, the researchers say, including delays between infection and diagnosis, mobility of populations, and limitations in tracing sex and drug partners. They suggest that analysis of molecular data can help overcome some of those barriers, making it possible to identify clusters of ongoing HIV transmission.

                The report also recommends other approaches to better understand and respond to ongoing HIV infections, such as mapping and data visualization, telemedicine, and automated data systems to facilitate linkage to care. However, the authors add, gaps in data and data systems remain that prevent full understanding of some key impacts of the epidemic. But any interventions to promote HIV prevention and treatment adherence, the authors suggested, should take a multifaceted approach and address the whole individual.

                Chris Beyrer, MD, MPH, investigator at the Johns Hopkins Bloomberg School of Public Health, Baltimore, and a lead author on the series, says, “We have incredible tools to prevent and treat HIV, but people may not fully utilize them if they are facing personal or structural issues that pose more immediate hardship, like substance use and mental health disorders. You may struggle to take a daily medication if you are facing food insecurity or cannot find affordable treatment for your substance use disorder.”

                Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, and now also Chief Medical Advisor to President Biden, says, “To end the HIV epidemic, we must continue to develop and deploy novel HIV treatment and prevention strategies suited to the different needs and preferences of diverse populations disproportionately affected by HIV. It is also essential that HIV health services continue during the COVID-19 pandemic.”

How many epidemics can one country contain? Nearly all of our national attention has been focused on the COVID-19 epidemic but, lest we forget, there’s still another one to be reckoned with: the HIV epidemic is still going strong. In fact, it’s gathering strength, in part, because of the economic and health devastation wrought by COVID.

                Over nearly 4 decades, the epidemiology of HIV has changed, according to The Lancet’s HIV in the USA series. Current data, the report says, “illustrate an epidemic defined by stark health inequities that largely fall along lines of disadvantages in economic opportunity and social capital.” Moreover, the US, the authors say, “continues to lag behind other G-7 nations when it comes to controlling its HIV epidemic and is the only high-income country among the top 10 countries most affected by HIV.”

                The 6-paper series’ release comes 2 years after the launch of the US Department of Health and Human Services’ (HHS) announcement of its goal to reduce HIV transmissions by at least 90% by 2030.

                The authors analyzed publicly available HIV surveillance and census data to describe current prevalence and new HIV diagnoses by region, race, ethnicity, and age, as well as trends in those categories over time. They also reviewed literature to “explore the reasons” for the distribution of cases and important disparities in prevalence. Among other things, the researchers found “pronounced” racial, sexual, and gender disparities, “substantial” gaps in domestic program funding, and a “patchwork healthcare system” that limited access to treatment and prevention services.

                Although when it began, the HIV epidemic was focused largely on the bicoastal big cities, mainly New York and San Francisco, in recent years the South has been hit particularly hard, with 52% of new HIV transmissions in 2018, despite representing only 37% of the US population. Six Southern states (Florida, Georgia, Louisiana, Maryland, Mississippi, and Tennessee) and the District of Columbia had the highest annual HIV diagnosis rates between 2010 and 2018, likely reflecting the higher burden of infection among black residents: In 2018, 38% of all new HIV diagnoses among men who have sex with men (MSM) were in the black population, and 63% of those were in the South.

                The South’s HIV problem is intensified by disparities, the report says, that are probably driven by the restricted expansion of Medicaid, health care provider shortages, low health literacy, and stigma. The South also has the lowest number of pre-exposure prophylaxis (PrEP) users per new HIV diagnosis, in part because of the longer distances to PrEP services relative to other regions. More than half of MSM who live at least 60 minutes away from PrEP services live in the South. While HIV in the rural South largely is due to sexual transmission, the researchers note, the largest clusters of the concurrent opioid epidemic have been detected in rural and periurban counties of West Virginia and Indiana.

                Identifying HIV transmission clusters and outbreaks has traditionally been challenging for several reasons, the researchers say, including delays between infection and diagnosis, mobility of populations, and limitations in tracing sex and drug partners. They suggest that analysis of molecular data can help overcome some of those barriers, making it possible to identify clusters of ongoing HIV transmission.

                The report also recommends other approaches to better understand and respond to ongoing HIV infections, such as mapping and data visualization, telemedicine, and automated data systems to facilitate linkage to care. However, the authors add, gaps in data and data systems remain that prevent full understanding of some key impacts of the epidemic. But any interventions to promote HIV prevention and treatment adherence, the authors suggested, should take a multifaceted approach and address the whole individual.

                Chris Beyrer, MD, MPH, investigator at the Johns Hopkins Bloomberg School of Public Health, Baltimore, and a lead author on the series, says, “We have incredible tools to prevent and treat HIV, but people may not fully utilize them if they are facing personal or structural issues that pose more immediate hardship, like substance use and mental health disorders. You may struggle to take a daily medication if you are facing food insecurity or cannot find affordable treatment for your substance use disorder.”

                Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, and now also Chief Medical Advisor to President Biden, says, “To end the HIV epidemic, we must continue to develop and deploy novel HIV treatment and prevention strategies suited to the different needs and preferences of diverse populations disproportionately affected by HIV. It is also essential that HIV health services continue during the COVID-19 pandemic.”