A coronavirus drive-through testing site at the Theodore Roosevelt Nature Center on March 17, 2020 at Jones Beach State Park, New York. It was the first drive-through coronavirus testing site on Long Island. The World Health Organization declared COVID-19 a global pandemic on March 11, 2020. (Photo by Al Bello/Getty Images)

WASHINGTON — Scientists debated the origins of COVID-19 on Tuesday, trading barbs over whether the bulk of evidence available points to a natural spillover event from a wild animal or a virus designed in a lab and then let loose through an inadvertent leak.

The hearing in front of the U.S. Senate Homeland Security and Governmental Affairs Committee was part of ongoing efforts in Congress to apply the lessons learned during the pandemic to prevent or blunt the next outbreak.

Gregory Koblentz, associate professor and director of the Biodefense Graduate Program at George Mason University in Virginia, said during the two-hour hearing that debate continues in the scientific community about the origins.

“The possibility that SARS-CoV-2 was deliberately developed as a biological weapon has been unanimously rejected by all U.S. intelligence agencies,” Koblentz testified. “While the intelligence community is divided on the origin of the pandemic, most of the agencies have determined that the virus was not genetically engineered.”

Residents in Wuhan, China, were first diagnosed with “an atypical pneumonia-like illness” in December 2019, according to a COVID-19 timeline from the Centers for Disease Control and Prevention.

Initial cases all appeared linked to the Huanan Seafood Wholesale Market at the time, though there has since been much speculation about the types of research taking place at the Wuhan Institute of Virology.

Koblentz said he believes the available evidence points to a spillover event from an animal, though he added a “research-related accident can’t be ruled out at this time.”

The lack of transparency and data from the Chinese government has significantly hindered scientists’ efforts to unify around the origin of COVID-19, he said.

Scientists battle over lab vs. spillover

Richard Ebright, board of governors professor of chemistry and chemical biology and laboratory director at the Waksman Institute of Microbiology at Rutgers University in New Jersey, testified he believes a “large preponderance of evidence indicates SARS-CoV-2, the virus that causes COVID-19, entered humans through a research incident.”

Ebright also leveled criticism at fellow panelist Robert Garry, who, along with a handful of co-authors, published an opinion article in the journal nature medicine in March 2020, titled “The proximal origin of SARS-CoV-2.”

In the commentary, Garry and the other scientists wrote, “we do not believe that any type of laboratory-based scenario is plausible.”

Ebright said during Tuesday’s hearing that the opinion article represented “scientific misconduct up to and including fraud,” a characterization that Garry rejected during the hearing.

“The authors were stating their opinion, but that opinion was not well-founded,” Ebright said. “In March of 2020, there was no basis to state that as a conclusion, as opposed to simply being a hypothesis.”

Garry, professor and associate dean of the School of Medicine at Tulane University in Louisiana, argued on behalf of the spillover event during the hearing, testifying that the virus likely didn’t move directly from a bat to humans, but went to an unidentified intermediary animal.

“The bat coronaviruses are viruses that are spread by the gastrointestinal route,” Garry said. “For a virus like this to become a respiratory virus — it’s just going to require too many mutations, too many changes for a bat virus to spill directly over to a human being. That could only really happen in nature with replication through an intermediate animal.”

Garry also defended gain-of-function research during the hearing, arguing that it has had some beneficial impact, though he noted that it does need “appropriate safeguards and restrictions.”

Lawmakers and pundits have used several, often evolving, definitions for gain-of-function research in the wake of the COVID-19 pandemic. The American Society for Microbiology defines it as techniques “used in research to alter the function of an organism in such a way that it is able to do more than it used to do.”

When research is “responsibly performed” on highly transmissible and pathogenic viruses, it can lead to advances in public health and national security, Garry testified.

“Without gain-of-function research, we’d have no Tamiflu. Without gain-of-function research, we wouldn’t have a vaccine to prevent cancer caused by infection by the human papilloma virus,” Garry said. “And without gain-of-function research, we won’t be able to identify how novel viruses infect us. And if we don’t know how they infect us, we cannot develop appropriate treatments and cures for the next potential pandemic creating virus.”

Oversight of funding, research 

New Hampshire Democratic Sen. Maggie Hassan raised several questions about whether there’s enough oversight of how the United States spends research dollars as well as what mechanisms are in place to monitor how private entities conduct certain types of research.

“While their research has the potential to cure diseases and boost our economy, unless they accept federal funding, there is very little federal oversight to ensure that private labs are engaged in safe and ethical research,” she said.

Koblentz from George Mason University said there is much less oversight of biosafety and biosecurity for private research facilities that don’t receive federal funding.

“In order to expand the scope of oversight to all privately funded research, (it) would require legislative action,” Koblentz said.

Congress, he said, should establish a national bio-risk management agency that would have authority over biosafety and biosecurity “regardless of the source of funding.”

“At the end of the day, it shouldn’t matter where the funding comes from in terms of making sure this research is being done safely, securely and responsibly,” Koblentz said.

Kentucky Republican Sen. Rand Paul, ranking member on the committee, said the panel will hold an upcoming hearing specifically on gain-of-function research, including what steps Congress should take to ensure it doesn’t put the public at risk.

The next pandemic

Committee Chairman Gary Peters, a Michigan Democrat, said during the hearing that lawmakers “must learn from the challenges faced during this pandemic to ensure we can better protect Americans from future potential biological incidents.”

“Our government needs the flexibility to determine the origins of naturally occurring outbreaks, as well as potential outbreaks that could arise from mistakes or malicious intent,” Peters said.

Utah Republican Sen. Mitt Romney, after listening to some of the debate, expressed exasperation that so much attention is going toward what caused the last pandemic and not on how to prepare for the next one.

“Given the fact that it could have been either, we know what action we ought to take to protect from either,” Romney said. “And so why there’s so much passion around that makes me think it’s more political than scientific, but maybe I’m wrong.”

The United States, he said, shouldn’t be funding gain-of-function research and should “insist” that anyone who receives federal funding follow the standards of the International Organization for Standardization.

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WASHINGTON, DC - JUNE 03: Dr. Anthony Fauci, former Director of the National Institute of Allergy and Infectious Diseases, testifies before the House Oversight and Accountability Committee Select Subcommittee on the Coronavirus Pandemic at the Rayburn House Office Building on June 03, 2024 in Washington, DC. The Subcommittee is holding a hearing on the findings from a fifteen month Republican-led probe of former Director of the National Institute of Allergy and Infectious Diseases Dr. Anthony Fauci and the COVID-19 pandemic's origins. (Photo by Chip Somodevilla/Getty Images)

WASHINGTON — Dr. Anthony Fauci defended his decision-making during the COVID-19 pandemic on Monday, testifying before Congress about his work on the virus as the director of the National Institute of Allergy and Infectious Diseases during two presidencies.

House Republicans who called the hearing grilled Fauci during the contentious three-hour session about the origins of COVID-19, which killed more than 1 million Americans, as well as Fauci’s role in the response. It was the first time Fauci, 83, who also served as chief medical adviser to President Joe Biden, had appeared before Congress since leaving government employment in 2022.

Fauci repeatedly said he didn’t conduct official business using personal email in response to allegations he did so to avoid oversight. He also said he has kept an open mind about the origins of the virus, and explained to members of the Select Subcommittee on the Coronavirus Pandemic why guidance shifted so much during the first several months of the pandemic.

“When you’re dealing with a new outbreak, things change,” Fauci said. “The scientific process collects the information that will allow you, at that time, to make a determination or recommendation or a guideline.”

“As things evolve and change and you get more information, it is important that you use the scientific process to gain that information and perhaps change the way you think of things, change your guidelines and change your recommendation,” Fauci added.

Republicans on the panel repeatedly asked Fauci about how the Wuhan Institute of Virology in China received grant funding from the U.S. government, as well as whether it, or another lab, could have created COVID-19. That theory is counter to another that the virus emerged from a “spillover event” at an outdoor food market.

Fauci testified that it was impossible the viruses being studied at the Wuhan Institute under an NIH subgrant could have led to COVID-19, but didn’t rule out it coming from elsewhere.

“I cannot account, nor can anyone account, for other things that might be going on in China, which is the reason why I have always said and will say now, I keep an open mind as to what the origin is,” Fauci said. “But the one thing I know for sure, is that the viruses that were funded by the NIH, phylogenetically could not be the precursor of SARS-CoV-2.”

Fauci added that the $120,000 grant that was sent to another organization before being sent to the Wuhan Institute of Virology, was a small piece of the budget.

“If they were going to do something on the side, they have plenty of other money to do it. They wouldn’t necessarily have to use a $120,000 NIH grant to do it,” Fauci said.

The NIH subaward to the Wuhan Institute of Virology, he testified, “funded research on the surveillance of and the possibility of emerging infections.”

“I would not characterize it as dangerous gain-of-function research,” Fauci said. “I’ve already testified to that effect, a couple of times.”

Politicians have used multiple, often shifting, definitions for gain-of-function research during the last few years. The American Society for Microbiology writes in a two-page explainer that it is “used in research to alter the function of an organism in such a way that it is able to do more than it used to do.”

Saving lives

Actions taken during the first several months of the pandemic were essential to saving lives, Fauci testified. Those steps included encouraging people to socially distance, to wear masks and to obtain the vaccine once it was approved.

Fauci said that had public health officials just let the virus work its way through the country without any precautions or safety measures, “there very likely would have been another million people (who) would have died.”

Information about the COVID-19 vaccine, he said, was communicated as it came in, including particulars about whether it would stop the spread of the virus entirely or whether it predominantly worked by limiting severe illness and hospitalizations.

The issue is particularly “complicated,” Fauci said, because at the very beginning of the vaccine rollout, data showed the shot did “prevent infection and subsequently, obviously, transmission.”

“However, it’s important to point out, something that we did not know early on that became evident as the months went by, is that the durability of protection against infection, and hence transmission was relatively limited — whereas the duration of protection against severe disease, hospitalization and deaths was more prolonged,” Fauci testified.

“We did not know that in the beginning,” he added. “In the beginning it was felt that, in fact, it did prevent infection and thus transmission. But that was proven, as time went by, to not be a durable effect.”

Republican members on the subcommittee, as well as those sitting in from other committees, repeatedly asked Fauci about allegations that he avoided using his government email address to circumvent requests for those communications under the Freedom of Information Act, FOIA.

Fauci vehemently denied the accusations, saying he “never conducted official business using” his personal email.

Death threats

Michigan Democratic Rep. Debbie Dingell asked Fauci during the hearing about threats he and his family have faced during the last few years, especially as misinformation and disinformation about COVID-19 have spread.

“There have been credible death threats, leading to the arrests of two individuals. And credible death threats means someone who clearly was on their way to kill me,” Fauci testified.

Fauci and his wife and three daughters have received harassing emails, text messages and letters. Fauci said people targeting his family for his public health work makes him feel “terrible.”

“It’s required my having protective services, essentially all the time,” Fauci testified. “It is very troublesome to me.”

One of the most critical Republicans on the panel, Georgia Rep. Marjorie Taylor Greene, caused the hearing to grind to a halt during her questioning, refusing to address Fauci as a medical doctor and instead calling him “Mr. Fauci.”

Greene also alleged that Fauci should be in jail, though she didn’t present any evidence of actual crimes, nor has any police department or law enforcement agency charged him with a crime.

Maryland Democratic Rep. Jamie Raskin, ranking member on the Committee on Oversight and Accountability, of which the subcommittee is a part, said repeated GOP-led investigations into Fauci’s conduct show “he is an honorable public servant, who has devoted his entire career to the public health in the public interest. And he is not a comic book super villain.”

Raskin later apologized to Fauci for several GOP lawmakers treating him like a “convicted felon,” before seemingly referencing that former President Donald Trump, the presumptive Republican presidential nominee, is a convicted felon.

“Actually, you probably wish they were treating you like a convicted felon. They treat convicted felons with love and admiration,” Raskin said. “Some of them blindly worship convicted felons.”

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Gov. Phil Murphy and Essex County Executive Joseph DiVincenzo visiting an Essex County-run COVID vaccination site in West Orange on Jan. 8, 2021. (Courtesy of New Jersey Governor's Office)

It hasn’t been even a week since Gov. Phil Murphy was singing Essex County’s praises.

“There may be no county in America that’s better run than Essex County,” he said during WNYC’s Ask Governor Murphy program Wednesday night. “There are a handful of the best-run counties in America that are in New Jersey, and Essex happens to be one of them.”

But in a new report released Tuesday, a state watchdog says Essex County, which is run by six-term Democrat and Murphy ally Joe DiVincenzo, colossally fumbled oversight of its $40 million COVID-19 vaccination program. County officials flouted federal, state, and local procurement rules and exercised so little control over spending that one politically connected vendor pocketed an identical six-figure payment twice while at least eight workers regularly got paid despite logging full-time hours with other government agencies, the report says.

Acting State Comptroller Kevin D. Walsh found that Essex County officials improperly awarded millions of dollars as emergency contracts — continuing to do so long after vaccines were widely available — and bypassed the competitive bidding process, public review, and approvals required to guard against overspending and abuse.

“The government’s obligation to protect taxpayer funds doesn’t go away during an emergency,” Walsh said in a statement. “As we found in Essex County, overusing emergency contracts and failing to monitor vendors and implement basic financial controls increases the likelihood of fraud, waste, and abuse — risks that can and should be avoided.”

Investigators in the comptroller office’s COVID-19 compliance and oversight project launched the probe after an anonymous tipster reported concerns about the program, which administered more than 622,000 vaccines from December 2020 through August 2023 at five sites in Newark, West Caldwell, Livingston, and West Orange, plus from a mobile clinic that traveled around the county.

The investigators found that officials continued to flout the rules around spending federal vaccination funds even though they followed appropriate procedures for other emergencies during the pandemic, such as responses to Tropical Storm Isaias and Hurricane Ida and the handling of indigent burials due to COVID-19, according to the report.

Investigators determined officials failed to document the need for emergency contracts or execute vendor contracts that spelled out the terms required by federal grants, as required. These failures expose the county to the possibility that the federal government could act to recoup the funds, Walsh’s report notes.

In a statement, DiVincenzo called the comptroller’s report an unbalanced, unfair, and inaccurate “gotcha” document that identifies issues with a small fraction of the funds Essex County spent fighting COVID-19. DiVincenzo also chided Walsh’s office for not helping local officials prevent the misuse of public funds in the early months of the pandemic.

“It would have been helpful to have them stand shoulder to shoulder with us back then rather than have them unfairly criticize our performance years later,” the statement says.

Vendor problems

The investigators also discovered lax oversight of the 93 outside vendors the county hired to carry out its vaccination program, including 15 payments totaling $871,211 that were made without invoices, making it impossible to validate what goods or services were provided.

In one case, officials paid a vendor $264,000 for advertising services but couldn’t confirm those services were performed.

In another case, the county paid Dunton Consulting almost $1.3 million for robocall services from May 2020 through August 2021 without verifying the calls occurred, and even though the firm’s invoices were riddled with errors and charged fees that “varied wildly, without explanation.” The company also charged far more — 2.8 to 9.8 cents a minute — than county officials paid when they eventually put the contract out for competitive, public bidding, the report notes. The county paid less than 1 cent per minute under the newer contract.

County officials also erroneously paid Dunton $110,514.41 twice for the same services, but the East Orange-based firm’s owner Rasheida Smith and county officials said they didn’t notice the error until the Comptroller’s office brought it to their attention, according to the report. Instead of ordering the immediate return of the full overpayment, officials agreed Smith could repay a discounted amount, which they characterized as a “loan,” over five years without interest, the report notes.

That’s a “flawed” response because the state constitution prohibits governments from loaning public funds to private companies, the loan wasn’t signed by any county officials, county commissioners didn’t approve it at a public meeting, and the county hasn’t shown it “has the proper internal controls to monitor a long-term loan,” investigators wrote.

Smith is a Democratic political operative and former campaign manager who has worked for U.S. Sen. Cory Booker, former Rep. Charles Rangel, and other prominent politicians. She co-founded Dunton with Leroy Jones Jr., a former state assemblyman who now chairs the Essex County and statewide Democratic parties. Jones is no longer affiliated with Dunton, NorthJersey.com reported in 2022.

“The County’s contract with Dunton demonstrates that excessive emergency contracting without competitive bidding can result in a shocking price tag for taxpayers,” investigators wrote in the report.

Smith could not be reached to comment.

Lax oversight of staffing

More than 850 people worked in the vaccination program, and county officials allowed them to log their hours remotely and didn’t enforce on-site sign-in sheets meant to confirm their presence, investigators found.

As a result, the county spent $17 million on staffing without verifying that workers worked the hours they logged, investigators said.

Eight workers routinely worked other public jobs at the same time they worked for the county’s vaccination program, meaning they got paid by both public entities for the same hours — including one woman who collected $130,000 over 11 months under the vaccine program, even though the county health officer didn’t know who she was or what she did, according to the report.

Even after firing three workers who were found to have fudged their hours, officials didn’t tighten its timekeeping system or bother to investigate more broadly, according to the report. Officials also classified the vaccination workers as independent contractors, meaning the county then didn’t pay into unemployment funds or provide benefits.

Investigators shared their findings with the state Department of Labor and Workforce Development and other authorities for follow-up action.

DiVincenzo’s statement says Essex County immediately fired “no show” employees and “when possible,” funds were repaid.

“I’m not saying that we were perfect. But when any wrongdoing was identified, we acted swiftly,” it says.

Natalie Hamilton, a Murphy spokeswoman, said the governor is aware of the comptroller’s findings “but also recognizes that the speed of establishing a fully operational vaccine program in late 2020 and early 2021 was directly correlated with saving lives.”

“Under the leadership of County Executive Joe DiVincenzo, Essex County had one of the most efficient vaccine programs anywhere in America, helping establish New Jersey as a national leader in vaccine distribution,” Hamilton said.

Walsh and his investigators issued three recommendations, urging Essex County officials to:

• Hire an independent auditor to assess vaccination program spending to ensure all payments were appropriate.
• Use “all available legal mechanisms, including litigation if necessary,” to recover any overpayments, including the duplicative Dunton payment. Officials also should assess the federal grant implications of such improper payments and consult federal Treasury officials to report overpayments and ensure compliance with grant requirements.
• Conduct an internal review of the vaccination program and prepare a corrective action plan within 60 days to identify how county practices should improve for future emergencies, especially relating to the emergency procurement process, contract oversight, and staffing policies.

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Rutgers University in New Brunswick, NJ on Monday, Apr. 10, 2023. (Daniella Heminghaus for New Jersey Monitor)

A federal appeals court rejected a challenge to a Rutgers University requirement that called for most students to be vaccinated to attend on-campus courses, finding the 13 students and an anti-vaccine group that challenged the policy failed to state a viable claim against it.

The ruling reaffirms a September 2021 decision issued by a district court judge who found the students and Children’s Health Defense, the anti-vaccine group, had failed to meet all four of the legal bars they needed for injunctive relief.

Though Rutgers required students — and eventually faculty and staff — to be vaccinated to attend on-campus classes in person, it allowed exemptions for virtual students, those whose medical issues prevented a vaccination, and individuals with a bona fide religious reason for not getting vaccinated.

The students sued the university in July 2021, alleging the university illegally coerced individuals to use experimental medical products, exceeded its statutory authority, violated their due process rights, and trampled on constitutional equal protection guarantees, among other claims the plaintiffs did not revive on appeal.

But the appeals court rejected their claims. On the first claim, the panel noted that the law did not apply to state universities, adding students were not deprived of their rights since 12 of the 13 that sued remained unvaccinated.

That the university had given their students other options — to seek an exemption or pursue an education through remote courses or at a different university — further undercut that claim, the court said.

“That choice may have been difficult. But there is no unqualified right to decide whether to ‘accept or refuse’ an [emergency use authorization] product without consequence,” the judges wrote.

The panel found Rutgers had not exceeded its statutory authority, noting universities can and have long required students to be immunized against certain diseases to live in on-campus university housing.

State law also explicitly authorized the university to temporarily exclude students with vaccine exemptions from courses during an outbreak, the judges said.

The court rejected the plaintiffs’ due process claim because there is no fundamental right “to be free from a vaccine requirement at a public university.”

The U.S. Supreme Court in 1905 in Jacobson v. Massachusetts found governments could require their residents be vaccinated, rejecting Henning Jacobson’s claim that a state law requiring smallpox vaccinations was unconstitutional. Jacobson was subject to criminal charges for his refusal.

When plaintiffs pointed to other precedent that found competent individuals could refuse medical treatment, the court said those were irrelevant.

“These cases, however, are categorically distinct,” the judges wrote. “In stark contrast to Jacobson and its progeny, they involved health decisions with consequences for only the individual involved, rather than broad-based matters of ‘public health and safety.’”

The appellate panel dismissed the equal protection claim as moot because the university expanded its vaccination requirement to include Rutgers employees, adding it wasn’t clear the university could legally mandate vaccinations for faculty and staff in the summer of 2021.

That authority only became clear with an executive order President Joe Biden issued in September 2021.

Julio C. Gomez, lead counsel for the plaintiffs, in a statement charged the court improperly rejected plaintiffs assertions that COVID-19 vaccines were not effective, adding they would petition the U.S. Supreme Court for an appeal.

“By law, Appellants’ facts must be accepted as true at this stage in the litigation, and had the Third Circuit done so, it would have to conclude that Rutgers has no legal authority to mandate these vaccines and that students have every right to say ‘no’ without any coercion,” he said.

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Smoking is largely banned in indoor public spaces in New Jersey, except casinos. (Photo by Mark Makela/Getty Images)

New Jersey’s highest court will decide whether to revive an Atlantic City casino’s claim that it should receive compensation for a monthslong closure it said was caused by COVID-19.

New Jersey’s Supreme Court on Wednesday heard oral arguments in a case lodged by the firm that operates the Ocean Casino Resort, whose suit charges its insurers improperly denied it a business interruption payout on its $50 million policy.

Nationwide, courts have routinely dismissed claims seeking compensation because of government-ordered shutdowns. But business interruption claims rooted in different reasons could spur numerous and hefty awards from insurers in what Ocean called a “generational legal dispute” in its filings.

In arguments, Stephen Orlofsky, an attorney representing the casino, charged the casino’s three-and-a-half-month closure, though required under a March 2020 executive order issued by Gov. Phil Murphy, would have happened anyway because of the prevalence of COVID-19.

“The closure required by Gov. Murphy’s executive orders was something we had to comply with as a matter of law, but we’re alleging more than that — that we would have been required to close the facilities even without Gov. Murphy’s executive orders,” Orlofsky told the court.

Ocean’s case reached the high court after an appellate panel dismissed the case, overturning a decision issued by a Superior Court judge.

Justices and attorneys for the insurers — American Guarantee and Liability Insurance Company, AIG Specialty Insurance Company, and Interstate Fire and Casualty Company — noted that Ocean’s closure and reopening coincided exactly with Murphy’s executive orders launching and lifting the shutdown.

The insurers argue the timing is more than coincidental, saying Ocean failed to state a claim linking the presence of the virus in its casino to the establishment’s closure.

“Whatever the virus particle is doing on the property, however you characterize that, there is no allegation that that caused them to close in this complaint,” said David Roth, representing the American Guarantee and Liability Insurance Company. “And if it did cause them to close, they wouldn’t be open from July 3rd and wouldn’t have been open for the last three years.”

Orlofsky said Ocean was not given an opportunity to amend its filings to include a direct link between the virus and its closure that did not touch on Murphy’s orders.

The insurers further claimed Ocean is not eligible for business interruption benefits because provisions of its coverage expressly bar payouts for costs spurred by viruses and some other pathogens.

Orlofsky argued that exclusion is meant to apply only in cases of environmental pollution — like the illegal dumping of medical waste that contains a virus — and noted that the insurance policy’s definition of “contaminant” does not include viruses, unlike its definition of “contamination.”

Including both terms is confusing to policyholders, Orlofsky said, invoking a legal doctrine that calls for unclear contract terms to be read against the interests of the side that drafted them. Ocean is not a sophisticated party that would have understood the terms of its insurance policy, he added.

Justices appeared skeptical, noting only the word “contamination” is used in the exclusion provision.

“Here you have the word that’s used in the exclusion, which is ‘contamination’, with a definition that includes a virus, and you have this entire case premised on a virus. Yes, you have ‘contaminant’ also. Insurance policies certainly include, sometimes, definitions of terms that aren’t the focus of the case,” said Justice Anne Patterson.

The parties also sparred over what constitutes “direct physical loss or damage” to Ocean’s property.

The casino argues the closure and ensuant loss of use of its property meet that bar, but the insurers say only physical damage or loss — like that a housefire might create — would trigger business interruption benefits, and only after the insured seeks to make repairs or other remediations.

The insurers noted Nevada’s Supreme Court, in a similar case, found allowing illnesses to meet the bar for physical loss or damage would allow schools, hospitals, gyms, and others to “convert its property insurance policy into a ‘maintenance contract’ for the ‘inevitable’ risk of illness in public spaces.”

“This ‘cannot be right,’” Nevada Justice Elissa Cadish wrote for a unanimous court.

 It’s not clear when New Jersey’s high court will rule on this case.

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An inmate at Men’s Central Jail in Los Angeles holds his covid vaccine immunization card after getting a first dose in 2021. (Heidi de Marco/KFF Health News)

The Centers for Disease Control and Prevention recommends new covid-19 booster vaccines for all — but many who need them most won’t get them. About 75% of people in the United States appear to have skipped last year’s bivalent booster, and nothing suggests uptake will be better this time around.

“Urging people to get boosters has really only worked for Democrats, college graduates, and people making over $90,000 a year,” said Gregg Gonsalves, an epidemiologist at Yale University. “Those are the same people who will get this booster because it’s not like we’re doing anything differently to confront the inequities in place.”

As the effects of vaccines offered in 2021 have diminished over time, boosters have been shown to strongly protect people against severe covid and death, and more modestly prevent infection. They can have a dramatic impact on those most likely to die from covid, such as older adults and immunocompromised people. Public health experts say re-upping vaccination is also important for those in group housing, like prisons and nursing homes, where the virus can move swiftly between people in close quarters. A boost in protection is also needed to offset the persistent disparities in the toll of covid between racial and ethnic groups.

However, the intensive outreach efforts that successfully led to decent vaccination rates in 2021 have largely ended, along with mandates and the urgency of the moment. Data now suggests that the people getting booster doses are often not those most at risk, which means the toll of covid in the U.S. may not be dramatically reduced by this round of vaccines. Hospitalizations and deaths due to covid have risen in recent weeks, and covid remains a leading cause of death, with roughly 7,300 people dying of the disease in the past three months.

Tyler Winkelman, a health services researcher at Hennepin Healthcare in Minneapolis, said outreach of the intensity of 2021 is needed again. Back then, throngs of people were hired to tailor communication and education to various communities, and to administer vaccines in churches, homeless encampments, and stadiums. “We can still save lives if we are thoughtful about how we roll out the vaccines.”

Complicating matters, this is the first round of covid vaccines not fully covered by the federal government. Private and public health insurers will get them to members at no cost, but some 25 million-30 million uninsured adults — predominantly low-income people and people of color — don’t yet have a guaranteed way to access vaccines free of charge. On Sept. 12, the CDC said it plans to provide vaccines for the uninsured, at least partly through $1.1 billion left over in pandemic emergency funds through the Bridge Access Program.

Costs are probably an issue, said Peter Maybarduk, at Washington-based advocacy organization Public Citizen. Moderna and Pfizer have more than quadrupled the price of the vaccines to about $130 a dose, compared with about $20 for the first vaccines and $30 for the last boosters, raising overall health care costs. Maybarduk pointed out that the U.S. government funded research involved in developing mRNA vaccines, and said the government missed an opportunity to request price caps in return for that investment. Both companies earned billions from vaccine sales in 2021 and 2022. Moderna’s latest investor report predicts another $6 billion to $8 billion in covid vaccine sales this year and Pfizer expects $14 billion. Maybarduk suggests the government would have more funds for equity initiatives if so much weren’t being spent on the boosters through Medicare, Medicaid, and its access program. “If these vaccines had been kept at the same price, what decisions would be made to expand the response?”

People age 75 and up have accounted for more than half of the country’s pandemic deaths. But whereas the first vaccines were quickly taken up in nursing homes, boosters have been less popular, with fewer than 55% of residents in Arizona, Florida, Nevada, and Texas getting the bivalent booster released last year. At some facilitiesnationwide, rates are below 10%.

Jails and prisons have seen some of the largest U.S. outbreaks — yet booster uptake there often appears to be poor. In Minnesota, just 8% of incarcerated people in jails and 11% in prisons have gotten last year’s booster, according to analyses of electronic health records by the Minnesota EHR Consortium. About 38% of people in prisons in California are up to date on boosters. Boosters make a difference. A study of California prisons found that among incarcerated people, the effectiveness of the first two doses was about 20% against infection, compared with 40% for three doses. (Prison staff saw larger benefits from three doses, an effectiveness of 72%, presumably because the chance of infection is lower when not living within the facilities.)

Low-income groups are also at heightened risk, for reasons including a lack of paid sick leave and medical care. In surveys of homeless people in California, about 60% reported chronic health conditions, said Tiana Moore, the policy director at the Benioff Homelessness and Housing Initiative at the University of California-San Francisco. Studies have found that members of this community age more rapidly, with people in their 50s experiencing strokes, falls, and urinary incontinence at rates typical of people in their late 70s and 80s.

Booster rates among people who lack housing are largely unknown, but Moore is concerned, saying they face high barriers to vaccination since many also lack medical providers, knowledge about where to go for vaccines, and the means to get there. “Many of our participants talked about concerns about leaving their belongings when unsheltered since they don’t have a door to lock,” she said. “That underscores the need to meet people where they are in an effective booster campaign.”

Black and Hispanic people have faced higher hospitalization and death rates than white people throughout the pandemic. And these groups are significantly less likely to be treated with the covid drug Paxlovid than white patients. (Hispanic people can be of any race or combination of races.)

Uneven rates of booster uptake may exacerbate these inequalities. An analysis of Medicare claims across the U.S. found that 53% of Hispanic people and 57% of Black people age 66 and older had received a booster by May 2022, compared with about 68% of their white and Asian counterparts. Disparities were most dramatic in cities where booster uptake among white people was above average. In Boston, for example, 73% of white people were boosted compared with 58% of Black people.

People opt out of vaccination for many reasons. Those living farther from vaccine sites, on average, have lower rates of uptake. Misinformation spread by politicians may account for disparities seen along political lines, with 41% of Democrats having gotten a bivalent booster compared with 11% of Republicans. Lower vaccine coverage among Black communities has been found to stem from discrimination by the medical system, along with worse health care access. However, many Black people who hesitated at first eventually got vaccines when given information and easy access to them, suggesting it could happen again.

But Georges Benjamin, executive director of the American Public Health Association, said the downturn of reporting on vaccination and covid rates makes it harder to tailor outreach.

“If we had the data, we could pivot quickly,” he said, adding that this was once possible but that reporting lapsed after the end of the public health emergency this spring. “We’ve gone back to the old way, re-creating the conditions in which inequities are possible.”

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

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SAN RAFAEL, CALIFORNIA - APRIL 06: Registered Nurse Orlyn Grace (L) administers a COVID-19 booster vaccination to Jeanie Merriman (R) at a COVID-19 vaccination clinic on April 06, 2022 in San Rafael, California. The U.S. Food and Drug Administration has authorized a second COVID-19 booster of Pfizer-BioNTech and Moderna vaccines for people over 50 years old four months after their first booster. (Photo by Justin Sullivan/Getty Images)

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Governor Phil Murphy toured the Elizabeth Seaport COVID-19 vaccination site on April 6, 2021. (Photo by Edwin J. Torres/Governor's Office)

The firms reviewing New Jersey’s COVID-19 response have billed the state nearly $3 million so far, with months left before the findings are expected to reach the public, according to public records obtained by the New Jersey Monitor.

The state commissioned two firms, the Boston Consulting Group and Montgomery McCracken Walker & Rhoads, to review the state’s virus response last November, with Gov. Phil Murphy saying the long-promised review would help the state “take the steps to better prepare future administrations for a public health crisis.”

So far, Montgomery McCracken Walker & Rhoads has billed the state $932,638, according to invoices obtained through Open Public Records Act requests. And in May, the state placed $2 million into an escrow account controlled by the firm so it could pay the Boston Consulting Group.

It’s unclear how much has been paid from the escrow account.

New Jersey was among the earliest states to face COVID-19 and fared poorly in the pandemic’s early months, when thousands of residents died from the virus each week, including many in the state’s long-term care centers.

The pending review is the second New Jersey has commissioned into its virus response. An earlier review conducted by Manatt Health that probed coronavirus death tolls in the state’s nursing homes found the long-term care centers were understaffed and ill-equipped to respond to the pandemic.

The more recent review will carry a heftier price tag. Manatt’s review cost taxpayers roughly $500,000.

The review of the state’s COVID response, a long-awaited assessment, is expected to be released late this year, though it’s unclear whether the report will reach the public before November’s legislative elections.

Spokespeople for the governor declined to provide comment or a firmer timeline for the report’s release.

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The Food & Drug Administration’s panel of vaccine experts will vote on whether the benefits of Pfizer’s COVID-19 vaccine outweigh the risks for kids ages 5 to 11. (Photo by Win McNamee/Getty Images)

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A researcher works in a lab developing testing for COVID-19 at Hackensack Meridian Health Center for Discovery and Innovation in New Jersey in 2020. New Jersey was the first state hit by high COVID-19 death rates in 2020 but now is the only state to have fewer deaths than before the pandemic. Kena Betancur/Getty Images

Several months after President Joe Biden ended the national emergency for COVID-19, preliminary health data indicates the historic degree to which the pandemic increased death rates nationwide — not just because of the virus itself, but also through the pandemic’s reverberating effects on society.

Deaths from vehicle crashes, homicides, suicides and overdoses spiked in many states during the national health emergency that began in January 2020. Deaths of despair, which include people who died by suicide or from an accidental overdose, reached their highest numbers during the first year of the pandemic. And even as fewer cars were on the roads during shutdowns, vehicle fatalities jumped.

Yet after historic increases during the pandemic, deaths in most of the country are nearing a return to pre-pandemic levels, according to a Stateline analysis of preliminary federal statistics.

Still, in the first half of this year, the death count in some states and the District of Columbia was much higher than it was during the first half of 2019. The District’s death count was 35% higher than before the pandemic, and in six states the count was at least 15% higher: Arizona, Delaware, Nevada, Tennessee, Texas and Utah.

Nationally, death counts for the first six months of 2023 are about 7.7% higher than they were for the same period in 2019, before the pandemic, the analysis found. That’s just a bit above the 6.7% increase to be expected anyway; counts routinely inch up annually with the United States’ aging population.

Before the pandemic, the historical trend since 1900 was for the number of deaths to rise a little every year as the population got larger and older, and for age-adjusted death rates to go down and life expectancy to rise every year due to advances in health and medicine.

COVID-19 played havoc with that pattern, bringing historic spikes in both death counts and death rates. Between 2019 and 2020, the number of U.S. deaths from all causes jumped 19%, a 100-year record. The current U.S. death toll from the virus is more than 1.1 million people, according to the World Health Organization.

The year-over-year spike in death rates between 2019 and 2020 surpassed that of the 1918 flu epidemic. In 2020, the death rate rose 17% to 835.4 per 100,000 people, compared with a 12% jump between 1917 and 1918. The death rate peaked at 879.7 in 2022.

Life expectancy in the United States dropped 2.7 years by 2021, the biggest dip in almost 100 years.

States where COVID-19 hit first, such as New Jersey and New York, are the closest to complete recovery.

Public health experts debate why deaths might be stubbornly high in some areas of the country — as in Arizona, where death rates rose the most between 2019 and 2022, and where increases in deaths continue to be high in preliminary 2023 data.

There’s some evidence that COVID-19 deaths have gone unrecognized, and that the chaos from the pandemic caused still more deaths by shutting sick people out of hospitals packed with COVID-19 patients.

“There’s a lot of things going on that might cause [continued high death rates]. It’s not just one thing,” said Robert Anderson, chief of the mortality statistics branch at the federal National Center for Health Statistics in Maryland.

Nationally, only about 62% of the increase in death rates between 2019 and 2022 is directly attributed to COVID-19, according to the Stateline analysis. But that might be an undercount because COVID-19 was not always detected as a cause, according to Boston University School of Public Health research published in January.

In the pandemic, unexplained or “excess deaths” tended to peak earlier than COVID-19 deaths did, suggesting that many deaths really were undetected COVID-19 deaths.

COVID-19 cases were more likely to be misclassified in Arizona, the Rocky Mountain states, the South and rural areas, than in New England and in mid-Atlantic states such as New Jersey and New York, the article said.

As deaths peaked in New Jersey in 2020, a report from the New Jersey Hospital Association said two trends suggested people were dying from lack of hospital care as well as COVID-19: an increase in deaths at home from conditions usually treated in hospitals, and a decrease in hospital admission for life-threatening emergencies like heart attacks and strokes.

New Jersey, despite being the first state hit hard by COVID-19 in 2020, is now the only state with fewer deaths in early 2023 compared with the first six months of 2019. Eight other states saw increases of about 2% or less, including New York, another of the states slammed early in the pandemic.

The other seven states with death rates falling back to normal are Connecticut, Illinois, Maryland, Mississippi, South Dakota, West Virginia and Wyoming.

COVID-19 is listed as a contributing cause of only 1,143 deaths in New Jersey so far this year, down from more than 14,000 in the same time frame in 2020. Similarly in New York, COVID-19 deaths were down to 2,685 from more than 32,000 early on.

New Jersey, like many other states, has worked hard to get the virus under control, reaching its goal to vaccinate 4.7 million people who live or work in the state by mid-2021, and zeroing in on hot spots as they popped up with concentrated publicity campaigns to boost testing and vaccination, said Nancy Kearney, a spokesperson for the state Department of Health, in a statement.

As an early epicenter of the virus, New Jersey became a laboratory for techniques that became standard practices in the rest of the country, said Cathy Bennett, president of the New Jersey Hospital Association.

“New Jersey health care providers were writing their own playbook for responding to this novel virus,” Bennett said. “Our hospital teams were among the first to use new medication and tactics like proning [turning patients face down] to ease the burden on COVID-19 patients’ lungs.”

But even Arizona is slowly returning to normal death patterns, despite spikes in February, April and May, according to an analysis by Allan Williams, an Arizona epidemiologist who collaborates on state reports. COVID-19 deaths in the state are down to fewer than a thousand so far this year, compared with about 7,000 at the peak during the same time period in 2021.

“Deaths are returning to normal,” Williams said.

The state faces unique challenges in that COVID-19 deaths spiked late compared with the East Coast, with peaks coming in late 2020 and early 2021 at much higher rates than nationally, according to Williams’ analysis.

Williams said Arizona also saw increases in deaths from a multitude of other factors, including traffic accidents, overdoses, firearms, heart disease and strokes.

The state-by-state difference in COVID-19 deaths has been studied and discussed by experts for years. COVID-19 had the biggest cumulative impact on Arizona from 2020 to mid-2022, according to a study published this March in The Lancet, which concluded some states did better than others in extending health care access equitably and in convincing residents to get vaccinated.

Hawaii, which took an early hit economically when tourism from Asia stopped even before the pandemic hit the United States, has been one of the least-affected states in terms of deaths.

A White House Council of Economic Advisers analysis last year calculated that if deaths in the whole country followed Hawaii’s pattern, another 780,000 people would have survived the pandemic. Hawaii and New England states got high marks for health care during the pandemic, though Hawaii is facing new challenges from COVID-19 as well as wildfire deaths on Maui.

The Council of Economic Advisers study also suggested that lower rates of health insurance were associated with more deaths. Health insurance rates have been rising and reached an all-time high last year, the latest figures available. Among those states with death counts that are at least 15% higher this year than they were during the first six months of 2019, Arizona, Texas and Nevada were also in the top 10 for uninsurance rates as of 2021, and Tennessee was 11th.

Changes in population could explain some of the differences among states. Many of the states with large death count increases also grew rapidly in 2022, and many of those with small increases are losing population.

But in some states, such as Arizona, the increase in deaths outpaced population gains. Between 2019 and 2021, the height of pandemic death rates nationally, Arizona’s age-adjusted death rate rose 38%, the biggest increase among states. Arizona also had the highest change in death totals between 2019 and 2022 at 21%.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and Twitter.

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