The prayer run aimed to defend a 6-square-mile piece of land in rural Arizona outside of Phoenix called Chi’chil BiÅ‚dagoteel, or Oak Flat, where tribes have held ceremonies for centuries. The U.S. Forest Service, which owns the site, plans to trade a portion of it to a foreign-owned mining company, Resolution Copper, in exchange for other environmentally sensitive properties.

The battle over Oak Flat traces back 30 years, when prospectors found a massive copper deposit beneath the ground. The proposed land swap, which Congress approved in 2014 through a defense spending bill, has been stalled by three lawsuits.

But on April 17, the Trump administration pushed the project forward without waiting for the courts. The it would issue an environmental review as soon as June 16, which would pave the way for the land transfer. Trump issued an to expedite the Resolution Copper mine project, as part of a broader push to open more public lands .

The copper mine would be the largest in North America, producing up to a quarter of U.S. copper demand, the . But it also would destroy most of Oak Flat, leaving behind a sinkhole nearly 2 miles wide and as deep as the Eiffel Tower.

, a nonprofit that aims to protect sacred lands including Oak Flat, won a reprieve on May 9, when U.S. District Judge Steven Logan blocking the land swap while the Supreme Court considers its case. The high court is expected to decide whether to take it by early July.

“The federal government and Resolution Copper have put Oak Flat on death row — they are racing to destroy our spiritual lifeblood and erase our religious traditions forever,” Wendsler Nosie Sr., founder of Apache Stronghold, said in a statement. “We are grateful the judge stopped this land grab in its tracks so that the Supreme Court has time to protect Oak Flat from destruction.”

Apache Stronghold’s temporary victory came after the four-day journey from Oak Flat to the federal courthouse in Phoenix ahead of the injunction hearing. The prayer run drew 60 runners, running in segments. and are supporting Apache Stronghold’s Supreme Court appeal.

The fight over Oak Flat offers a glimpse into environmental, public health, and religious battles that may intensify as Trump prioritizes tapping into domestic sources of minerals such as copper, a key ingredient for electronics and renewable energy projects. The case also could set a legal precedent for whether religious freedom grants tribes the right to pray on ancestral lands outside of their reservations.

The Oak Flat case highlights some of the health concerns that arise when ancestral Native American lands owned by the federal government are opened to mining, from physical illness — due to water and air pollution — to psychological, spiritual, and existential distress.

In roadside prayers and rallies along the run, members of various tribes offered visceral accounts of the harm they’ve experienced after sacred lands were tapped for minerals, fossil fuels, and heavy metals. They described attacks on health, identity, religion, and culture that many referred to as ongoing genocide.

At Oak Flat Campground, Apache Stronghold supporters gathered for a ceremony before the prayer run began. Runners were blessed with ashes to protect them on a route that would traverse vast fields of cacti, narrow mountain passes, and even two combative drivers on city streets.

Among those lacing up running shoes was Nizhoni Pike, 24, one of Nosie’s granddaughters. Pike has a deep connection to Oak Flat, where her family holds ceremonies and gathers medicinal plants and food. For Pike, her distress is visceral, immediate.

“This fight means so much,” she said.

Oak Flat is where Pike had her sunrise ceremony, a coming-of-age ritual, at age 13. During the ceremony, she built her own wickiup, a traditional Apache dome-shaped dwelling made of wood and thatch from the land. Her body was painted with white clay, embodying the White Painted Woman, a revered cultural figure. At the end of a four-day ceremony involving dancing from morning to night, Pike walked to a spring to wash off the clay and return it to the land. Butterflies filled the air, she recalled. Her family named the area Nizhoni’s Butterfly Canyon.

The sunrise ceremony creates a cord by which women are forever connected to the land where they came of age, she said. Tribal elders have told her that women may suffer illness if the cords are cut.

“I’m really worried for me and the other girls that had their sunrise dances there,” she said.

She already had anxiety, she said, and it has grown worse because of the drying up and pending destruction of Oak Flat. Pike said when she returned to her butterfly canyon a few years after her sunrise ceremony, the spring was dry and a dead turtle floated in a nearby pool. She said she has seen large cracks in the earth there and old oak trees starting to die.

“I’ve never felt so much pain in my heart or spirit before,” she said.

She and other Apache members attribute the dryness to Resolution Copper, which has been of a 7,000-foot-deep mining shaft on its adjacent property for years.

In a statement, company spokesperson Tyson Nansel denied that extracting water at that depth affects the surface water. He said the company treats the removed water then gives it away to farmers to grow crops so they can “pump less fresh groundwater themselves.” He said the company has made significant changes to its proposed mine to “reduce potential impacts on Tribal, social, and cultural interests.”

Along the run, supporters gathered for blessings from various faith leaders, some of whom sprinkled them with holy water.

They first stopped in the nearby town of Superior, part of the Copper Triangle, which has a long history of mining. The mayor there supports the new mine, which the company has said will create 1,500 jobs during its projected 60-year lifespan. But opponents in Superior warned that mining has left the area with high cancer rates, toxic dumps, and ghost towns.

In the city of Mesa, runners stopped at an of the O’odham people to receive support from two Native leaders with roots there.

Su:k Chu:vak Fulwilder, a council member of the Salt River Pima-Maricopa Indian Community, said loss of land and identity is taking a toll on her people. Fulwilder said her tribe suffers from high suicide rates, and her own son took his life in 2022.

“These sacred lands being disturbed — our spirits feel that pain and that anger,” she said.

Other supporters raised concerns about water quantity and quality in a time of long-term drought. Resolution Copper’s plans to conduct would require nearly and the natural water systems would be “altered forever and, in many cases, ,” according to a federal environmental impact statement and hydrology report.

Henry Muñoz, 69, who worked in mines for nearly 24 years and is now chair of the Concerned Citizens and Retired Miners Coalition in Superior, noted that the mine would require scarce water to pipe away toxic waste and copper concentrate. The toxic slurry would be sent to a tailings site, he said, where it would require more water so that dust laden with arsenic and sulfur doesn’t blow away. He noted that Resolution Copper is owned by foreign mining companies Rio Tinto and BHP, so much of the profit would go overseas.

With cuts to the and and agencies, Muñoz added, “the company is going to have free rein to do as they please with the environment, and the public won’t have any recourse.”

The prayer run concluded in downtown Phoenix, merging into a march to the courthouse.

Cadence Hardy, 16, who is Diné, said she grew up in Black Mesa, Arizona, where intensive coal mining and , deeply affecting Hopi and Diné communities. Her great-grandfather worked in a coal mine there and got lung disease and cancer, she said.

She said she’s inspired to support Apache Stronghold “to stop what happened to my family from happening to their family.”

In the May 7 federal court hearing, Victoria Peacey, president of Resolution Copper, took the stand, facing a courtroom packed with Apache Stronghold supporters, and testified that it would be at least 16 years until Oak Flat would begin to sink.

Nizhoni Pike later said she felt overwhelmed. Sixteen years is a short time, and the consequence would be huge, she said. “My ancestors’ history could literally be wiped.”

In the courtroom, Pike said, she looked Peacey in the eye.

“Look at me,” Pike recalled thinking. “You are going to destroy me if you destroy Oak Flat.”

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

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“There was so much water, they thought it would never end,” Mestas said of the agricultural region at the headwaters of the Rio Grande.

Now decades of climate change-driven drought, combined with the overpumping of aquifers, is making the valley desperately dry — and appears to be intensifying the levels of heavy metals in drinking water.

Like a third of people who live in this high alpine desert, Mestas relies on a private well that draws from an aquifer for drinking water. And, like many farmers there, he taps an aquifer to water the alfalfa that feeds his 550 cows.

“Water is everything here,” he said.

Mestas, 71, is now one of the hundreds of well owners participating in a study that tackles the question: How does drought affect not just the quantity, but the quality, of water?

The study, led by Kathy James, an associate professor at the Colorado School of Public Health, focuses on arsenic in private drinking wells. Arsenic, a carcinogen that occurs naturally in soil, has been appearing in rising levels in drinking water in the valley, she said. In California, , and Vietnam, research has linked rising arsenic levels in groundwater to drought and the overpumping of aquifers.

As the West that has lasted more than two decades, and states risk cutbacks in water from the , the San Luis Valley offers clues to what the future may hold.

Nationwide, rely on domestic wells, estimated Melissa Lombard, a research hydrologist for the U.S. Geological Survey. Nevada, Arizona, and Maine have the highest percentage of domestic well users — ranging from about a quarter to a fifth of well users — using water with elevated arsenic levels, she found .

During drought, the number of people in the contiguous U.S. exposed to elevated arsenic from domestic wells may rise from about 2.7 million to 4.1 million, Lombard estimated, using statistical models.

Arsenic has been shown to affect health across the human life span, beginning with sperm and eggs, James said. Even a small exposure, added up over the course of a person’s life, is enough to cause health problems, she said.

In a previous study in the valley, James found that lifetime exposure to low levels of inorganic arsenic in drinking water, between 10 and 100 micrograms per liter, or µg/L, was linked to a . Other research has tied chronic exposure to low-level arsenic to , diabetes, and cancer. Pregnant women and children are at greater risk for harm.

The World Health Organization sets the recommended limit on arsenic in drinking water at 10 µg/L, which is also the U.S. standard for public water supplies. But research has shown that, even at 5 µg/L, higher rates of skin lesions.

“I think it’s a problem that a lot of people are not aware of,” Lombard said. “Climate change is probably going to impact water quality,” she said, but more research is needed to understand how and why.

A Hotbed of Hope

The San Luis Valley, which has hosted a wealth of research and innovation, is the ideal place to explore those questions — and potential solutions.

Known for its stunning mountain views and the nearby Great Sand Dunes National Park and Preserve, the valley spans a region roughly the size of Massachusetts, making it North America’s largest alpine valley. Rich in Indigenous, Mexican, and Spanish heritage, the valley contains 500,000 acres of irrigated land producing potatoes, alfalfa for hay, and beer barley for Coors. It’s home to nearly 50,000 people, many of them farmworkers and about half of them Hispanic. It’s also a challenging place to live: Counties here rank among the poorest in the state, and .

Since it rains very little, on average, farmers rely on two large aquifers and the headwaters of the Rio Grande, which continues on to Mexico. Snowmelt from the looming Sangre de Cristo and San Juan mountain ranges recharges the supply each spring. But as the climate warms, there’s less snow, and water evaporates more quickly than usual from the ground and crops.

“This entire community, this culture, was built around irrigated agriculture,” said state Sen. Cleave Simpson of Alamosa, a Republican and a fourth-generation farmer. But since 2002, the valley’s has of water — or enough to cover 1 million acres of land in water 1 foot deep — due to persistent drought and overuse. Now the communities in the valley face a deadline to replenish the aquifer, or of hundreds of irrigation wells.

“We’re a decade ahead of what’s happening in the rest of Colorado” because of the intensity of water scarcity, said Simpson, who manages the Rio Grande Water Conservation District.

“This is not drought anymore — this is truly the ,” Simpson said. That’s how scientists are describing a long-term trend toward persistent dryness that can be stopped only by addressing human-caused climate change.

James, who is an epidemiologist and engineer, has been studying links between climate and health in the valley for the past 15 years. She found that during in the San Luis Valley, which have been growing more frequent, more people visit the hospital for asthma attacks. And she has surveyed farmworkers on how drought is affecting their mental health.

In the domestic well study, James is focusing on arsenic, which she said has been gradually increasing in valley drinking wells over the past 50 years. Arsenic levels in San Luis Valley groundwater are “markedly higher than [in] many other areas of the U.S.,” according to James. She is also investigating ethnic disparities, as one study there showed Hispanic adults had higher levels of arsenic in their urine than non-Hispanic white adults did. (Hispanic people can be of any race or combination of races.)

James now aims to test 1,000 private wells in the valley to explore the connections between drought, water quality, and health. So far, she said, a small proportion of wells show elevated levels of heavy metals, including arsenic, uranium, tungsten, and manganese, which occur naturally in the soil. Unlike public water supplies, private domestic wells are not regulated, and they may go untested for years. James is offering participants free water testing and consultation on the results.

In Conejos County, John Mestas’ daughter, Angie Mestas, jumped at the chance for a free test, which would cost $195 at a local lab. Angie, a 35-year-old schoolteacher, said she used a lifetime of savings to drill a drinking well on her plot of land, a wide-open field of chamisa with sweeping views of the San Luis Hills. But she won’t drink from it until she tests for arsenic and E. coli, which are common in the area. As she awaits test results, she has been hauling 5-gallon jugs of water from her father’s house each time she spends the weekend at her newly constructed yurt.

A Colorless, Odorless Threat

Meanwhile, Julie Zahringer, whose family settled in the valley from Spain nearly 400 years ago, has been watching water-quality trends firsthand. Zahringer, 47, grew up driving a tractor on her grandfather’s ranch near San Luis, Colorado’s oldest town — and hanging out in the lab with her mother, a scientist.

As a chemist and laboratory director of SDC Laboratory in Alamosa, Zahringer tests private and public drinking water in the valley. She estimated that 25% of the private wells tested by her lab show elevated arsenic.

“It’s colorless, it’s odorless,” Zahringer said. “Most families don’t know if they’re drinking arsenic.”

To Zahringer, the link to climate seems clear: During dry periods, a well that usually hovers around 10 µg/L of arsenic may easily double or triple in concentration, she said. One possible reason is that there’s less water to dilute the natural contaminants in the soil, though other factors are at play. The arsenic levels used to be fairly stable, she said, but after 20 years of drought, they’re fluctuating wildly.

“Now, more and more rapidly, I’m seeing the same well that I just tested three years ago — it doesn’t even look like the same well” because levels of contaminants have risen so much, said Zahringer, who also serves as a member of the Colorado Water Quality Control Commission. At her own drinking well, the arsenic level jumped from 13 to 20 µg/L this year, she said.

Zahringer’s observations are important firsthand anecdotes. James aims to explore, in a rigorous scientific study with a representative sample of wells and extensive geochemical data, the prevalence of arsenic and its connection to drought.

Research is still in the early stages, but scientists have several hypotheses for how drought could affect arsenic in drinking water.

In the San Joaquin Valley, a major agricultural hub in California, research led by hydrologist Ryan Smith linked rising arsenic in groundwater to “,” a phenomenon first documented .

Land subsidence — when the ground sinks due to aquifer overpumping — appears to release arsenic from the clay into the water, said Smith, an assistant professor at Colorado State University. In California, the overpumping was strongly correlated to drought, he said.

However, other factors, such as how deep a well is, also play a role: of the same California aquifer system found that while arsenic increased in deeper groundwater, it decreased in shallower water due in part to oxidation.

Smith is now working with James in the San Luis Valley study, where he hopes a wealth of geochemical data will offer more answers.

Meanwhile, community leaders in the valley are adapting in impressive and innovative ways, James said.

Zahringer said if arsenic shows up in a private well, she encourages clients to install reverse osmosis water filtration at the kitchen sink. The equipment costs about $300 from an outside supplier, though filters costing less than $50 may need to be changed every six to 18 months, she said. People who treat their water for arsenic should continue to test every six months to make sure the filters are effective, said Zahringer. SDC Laboratory offers an arsenic test for $25.

“People don’t want to test their water because it tastes good and their grandpa drank it,” she said. But “the cure for it is so easy.”

A water-quality campaign in 2009, led by the San Luis Valley Ecosystem Council, also found in . As part of its outreach, the nonprofit worked with real estate agents to make sure that domestic wells are tested before someone buys a home.

That’s what Sally Wier did when she bought a house five years ago on an 8-acre plot in Rio Grande County surrounded by fields of barley and alfalfa. The first time she tested her well, the arsenic level was 47 µg/L, nearly five times the EPA’s limit. Wier installed a reverse osmosis water filtration system, but she said the arsenic level rises before she changes the filters every few months.

“It makes me really anxious,” said Wier, 38. “I’m probably ingesting arsenic. That is not good for long-term health.”

Wier is one of many people working on innovative solutions to the water shortage. As a conservation project manager for Colorado Open Lands, she worked on a deal by which a local farmer, , was his 1,800-acre farm. The deal marks the first time in the country that a conservation easement has been used to save groundwater for aquifer replenishment, Wier said.

Funneling Money Toward a Solution

In Costilla County, the Move Mountains Youth Project has been paying local farmers, through a government grant, to convert a portion of their land to grow vegetables instead of water-intensive alfalfa. to grow crops like broccoli, spinach, and bolita beans, which are sold at a local grocery store. The project aims to nurture the next generation of farmers, and “beat diabetes” by providing locally grown food, said executive director . Her group worked with three farmers last summer and plans to work with seven this season, if enough water is available, she said.

In another effort, farmers like the Mestas to draw water from their own irrigation wells. And Simpson, of the Rio Grande Water Conservation District, recently secured $30 million in federal money to support water conservation. The plan includes per acre-foot of water to permanently retire their irrigation wells.

Since arsenic is not limited to private wells, public agencies have responded, too: The city of Alamosa in 2008 to bring its arsenic levels into compliance with federal standards. In 2020, the state of Colorado for exposing its workers to arsenic in tap water.

At the High Valley Park mobile home community in Alamosa County, a well serving 85 people has since 2006, when the Environmental Protection Agency from 50 to 10 µg/L. At the most recent test in February, the concentration was 19 µg/L.

On an April afternoon, four children bounced on a trampoline and chased one another up a tree.

“Uncle, I’m thirsty and there’s no bottled water left,” said one child, catching her breath.

The well serves 28 households. But tenants from five homes said they haven’t been drinking the water for years, not because of arsenic — which some said they were not aware of — but because the water often comes out brown.

Eduardo Rodriguez, 29, who works in excavation, said he buys two cases of bottled water every week for his wife and five children.

“It needs to be fixed,” he said.

“The water sucks,” agreed Craig Nelson, 51, who has lived in the mobile home park for two years. “You don’t drink it.” Because the well serves at least 25 people, it is regulated by the state.

Landlord Rob Treat, of Salida, bought the property in February 2022 for nearly half a million dollars. Getting arsenic within federal standards has been difficult, he said, because arsenic levels fluctuate when nearby farmers tap the aquifer to irrigate their crops. Treat was using chlorine to convert one kind of arsenic into a more treatable form. But if he added too much chlorine, he said, that created its own toxic byproducts, which have also drawn regulators’ attention.

Under pressure from the state, Treat began upgrading the water treatment system in May, at a cost of $150,000. To cover the cost, he said, he aims to raise the monthly rent from $250 to $300 per lot.

“If the state would stay out of it,” he grumbled, “we could supply affordable housing.”

Meanwhile, John Mestas is still awaiting results on his drinking well.

When he returns from traveling to manage his cattle herd, “the first thing I do whenever I walk in the house is drink me two glasses of this water,” Mestas said. “That’s the one thing I miss, is my water and my dogs. They’re jumping all over me while I’m drinking my water. I don’t know who’s happier, me drinking the water or them jumping on me.”

This article was supported by The Water Desk, an independent journalism initiative based at the University of Colorado-Boulder’s Center for Environmental Journalism.

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Michael Keasling of Lakewood, Colorado, was an electrician who loved big trucks, fast cars, and Harley-Davidsons. He’d struggled with diabetes since he was a teenager, needing a kidney transplant from his sister to stay alive. He was already quite sick in August when he contracted West Nile virus after being bitten by an infected mosquito.

Keasling spent three months in hospitals and rehab, then died on Nov. 11 at age 57 from complications of West Nile virus and diabetes, according to his mother, Karen Freeman. She said she misses him terribly.

“I don’t think I can bear this,” Freeman said shortly after he died.

Spring rain, summer drought, and heat created ideal conditions for mosquitoes to spread the West Nile virus through Colorado last year, experts said. West Nile and caused 101 cases of neuroinvasive infections — those linked to serious illness such as meningitis or encephalitis — in Colorado in 2021, the highest numbers in 18 years.

The rise in cases may be a sign of what’s to come: As climate change brings more drought and pushes temperatures toward what is termed the “Goldilocks zone” for mosquitoes — not too hot, not too cold — scientists expect West Nile transmission to increase across the country.

“West Nile virus is a really important case study” of the connection between climate and health, said , a primary care physician and health equity fellow at the Center for Climate, Health, and the Global Environment at Harvard’s public health school.

Although most West Nile infections are mild, the virus is neuroinvasive in about 1 in 150 cases, causing serious illness that can lead to swelling in the brain or spinal cord, paralysis, or death, according to the Centers for Disease Control and Prevention. People older than 50 and transplant patients like Keasling are .

Over the past decade, the U.S. has seen an average of about 1,300 neuroinvasive West Nile cases each year. Basu saw his first one in Massachusetts several years ago, a 71-year-old patient who had swelling in his brain and severe cognitive impairment.

“That really brought home for me the human toll of mosquito-borne illnesses and made me reflect a lot upon the ways in which a warming planet will redistribute infectious diseases,” Basu said.

A rise in emerging infectious diseases “is one of our greatest challenges” globally, the result of increased human interaction with wildlife and “climatic changes creating new disease transmission patterns,” said a major United Nations released Feb. 28. Changes in climate have already been identified as drivers of West Nile infections in southeastern Europe, the report noted.

The relationship between lack of rainfall and West Nile virus is counterintuitive, said Sara Paull, a disease ecologist at the National Ecological Observatory Network in Boulder, Colorado, who studied connections between climate factors and West Nile in the U.S. as a postdoctoral researcher at the University of California-Santa Cruz.

“The thing that was most important across the nation was drought,” she said. As drought intensifies, the percentage of infected mosquitoes goes up, she found in a .

Why does drought matter? It has to do with birds, Paull said, since mosquitoes pick up the virus from infected birds before spreading it to humans. When the water supply is limited, birds congregate in greater numbers around water sources, . Drought also may , increasing the ratio of mosquitoes to birds and making each bird more vulnerable to bites and infection, Paull said. And research shows that , birds are more likely to get infectious viral loads of West Nile.

A single year’s rise in cases can’t be attributed to climate change, since cases naturally fluctuate by year, in part due to cycles of immunity in humans and birds, Paull said. But we can expect cases to rise with climate change, she found.

Increased drought could nearly double the number of annual neuroinvasive West Nile cases across the country by the mid-21st century, and triple it in areas of low human immunity, Paull’s research projected, compared with averages from 1999 to 2013.

Drought has become a major problem . The Southwest endured an “” from January 2020 through August 2021, with the lowest precipitation on record since 1895 and the third-hottest daily average temperatures in that time period, a National Oceanic and Atmospheric Administration report found.

“Exceptionally warm temperatures from human-caused warming” have made the Southwest more arid, and warm temperatures and drought will continue and increase without serious reduction of greenhouse gas emissions, the report said.

Ecologist Marta Shocket has studied how climate change may affect another important factor: the Goldilocks temperature. That’s the sweet spot at which it’s easiest for mosquitoes to spread a virus. For the three species of Culex mosquitoes that spread West Nile in North America, the Goldilocks temperature is 75 degrees Fahrenheit, Shocket found in her postdoctoral research at Stanford University and UCLA. It’s measured by the average temperature over the course of one day.

“Temperature has a really big impact on the way that mosquito-transmitted diseases are spread because mosquitoes are cold-blooded,” Shocket said. The outdoor temperature affects their metabolic rate, which “changes how fast they grow, how long they live, how frequently they bite people to get a meal. And all of those things impact the rate at which the disease is transmitted,” she said.

In a 2020 paper, that 70% of people in the U.S. live in places where average summer temperatures are below the Goldilocks temperature, based on averages from 2001 to 2016. Climate change is expected to change that.

“We would expect West Nile transmission to increase in those areas as temperatures rise,” she said. “Overall, the effect of climate change on temperature should increase West Nile transmission across the U.S. even though it’s decreasing it in some places and increasing it and others.”

, a research entomologist with the CDC’s Division of Vector-Borne Diseases in Fort Collins, Colorado, said climate change-influenced factors like drought could put people at greater risk for West Nile, but she cautioned against making firm predictions, since many factors are at play, including bird immunity.

Birds, mosquitoes, humans, and the virus itself may adapt over time, she said. For instance, hotter temperatures may drive humans to spend more time indoors with air conditioning and less time outside getting bitten by insects, she said.

Climate factors like rainfall are complex, McAllister added: While mosquitoes do need water to breed, heavy rain can flush out breeding sites. And because the Culex mosquitoes that spread the virus live close to humans, they can usually get enough water from humans’ sprinklers and birdbaths to breed, even during a dry spring.

West Nile is preventable, she noted: The CDC suggests limiting outdoor activity during dusk and dawn, wearing long sleeves and bug repellent, repairing window screens, and draining standing water from places like birdbaths and discarded tires. Some local authorities also spray larvicide and insecticide.

“People have a role to play in protecting themselves from West Nile virus,” McAllister said.

In the Denver suburbs, Freeman, 75, said she doesn’t know where her son got infected.

“The only thing I can think of, he has a house, they have a little baby swimming pool for the dogs to drink out of,” she said. “So maybe the mosquitoes were around that, I don’t know.”

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Months later, it appears that danger has faded. After the rollout of covid vaccines, the number of new covid cases among nursing home staff members fell 83% — from 28,802 for the week ending Dec. 20 to 4,764 for the week ending Feb. 14, data from the Centers for Medicare & Medicaid Services shows.

New covid-19 infections among nursing home residents fell even more steeply, by 89%, in that period, compared with 58% in the general public, CMS and Johns Hopkins University data shows.

These numbers suggest that “the vaccine appears to be having a dramatic effect on reducing cases, which is extremely encouraging,” said Beth Martino, spokesperson for the American Health Care Association and National Center for Assisted Living, an industry group.

“It’s a big relief for me,” said Phillips, who works at the North Beach Rehabilitation Center outside Miami. Now, she said, she’s urging hesitant co-workers and anyone else who can to “go out and take the vaccination.”

After a brutal year in which the pandemic killed half a million Americans, despite unprecedented measures to curb its spread — including mask-wearing, physical distancing, school closures and economic shutdowns — the vaccines are giving hope that an end is in sight.

Noting that more than 3 million doses of vaccine have been doled out in nursing homes, CMS issued new  Wednesday allowing indoor visits in the facilities, even among unvaccinated residents and visitors, under most circumstances.

National figures on health care worker infections in other settings are hard to come by, but some statewide trends look promising. In California and Arkansas, health care worker covid cases have dropped faster than for the general public since December, and in Virginia the number of hospital staffers out of work for covid-related reasons has fallen dramatically.

Research in other countries suggests that vaccines have led to big drops in infection. A of publicly funded hospitals in England indicated that a first dose was 72% effective at preventing covid among workers after 21 days and 86% effective seven days after the second shot. At Sheba Medical Center — Israel’s largest hospital, with over 9,600 workers — 170 staff members tested positive from Dec. 19, the first day the vaccine was offered, through Jan. 24. Of those who tested positive, only three had already received both doses of the vaccine,

, a yearlong data and reporting project by KHN and The Guardian, is investigating over 3,500 covid deaths of U.S. health care workers. The monthly number has been declining since December, but deaths often lag weeks or months behind infections.

Along with other health care workers, nursing home staffers and residents were first in line to get vaccines in December because elderly people in congregate settings are among the most vulnerable to infection: More than 125,000 residents have died of covid, CMS data shows, while over 550,000 nursing home staff members have tested positive and more than 1,600 have died.

Yet the vaccination rate among staffers is far lower than that of residents. When the first clinics ran from mid-December to mid-January, a median of 78% of nursing home residents took a dose, while the median for staff was only 38%, according to the Centers for Disease Control and Prevention. Now several nursing home associations say the rate of staff vaccination has been climbing, based on informal surveys.

While vaccines are “contributing to the observed declines in COVID-19 cases in nursing homes, other factors, like effective infection prevention and control programs/practices,” are also at play, CDC spokesperson Jade Fulce said.

Vaccine uptake by nursing home residents has been “very promising,” said Dr. Morgan Katz, a specialist in infectious diseases at Johns Hopkins University who is advising covid responses in nursing homes. “I do think this is a huge contributing factor” to the drop in staff cases.

“When the immune system is activated more quickly” due to vaccination, “the virus is not able to multiply in your body and your respiratory tract,” Katz said. So, having even one or two vaccinated people in a building can slow transmission.

Another factor, Katz said, is that “many nursing homes have already experienced large outbreaks — so there are probably a significant proportion of residents and staff who are already immune.” Also, covid rates have fallen nationally after a spike from holiday travel and gatherings in November and December, so staff members have less exposure in their communities.

But “even though we’re seeing a really wonderful turn in the number of cases,” she said, “we need to remember that as long as the staff is 50 or 30% vaccinated, they remain vulnerable, and they’re also putting incredibly vulnerable long-term care residents at risk.”

Vaccination efforts are racing against time as new covid variants circulate and some states , making it easier for the virus to spread.

During the second week in February, 2,850 nursing homes still reported at least one new covid-positive test result for a staff member, CMS data shows.

When this happens, residents suffer, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. She said she’s hearing of cases in which one positive covid test result sends a facility into lockdown, preventing families from visiting their loved ones.

‘They’re Afraid’

The New Jersey Veterans Memorial Home at Menlo Park endured a major outbreak last year in which over 100 workers contracted covid and over 60 residents and a certified nurse assistant, , died. Shirley Lewis, a union president representing CNAs and other workers, said it was traumatizing. Still, only about half of workers there have taken the vaccine, Lewis said, and one is out sick with covid.

“A lot of my members are not too excited about taking this vaccine because they’re afraid,” Lewis said.

Some workers want to wait a little longer to see how safe the vaccine is, she said. Others tell her they don’t trust the vaccines because they were developed so quickly, she said.

Other staffers “feel like it’s an experimental drug,” Lewis said, “because as you know, Blacks, Latinos, other groups have been used for experiments” like the Tuskegee syphilis study, she said. She said her members are mostly Black or Hispanic.

Certified nursing assistants, who make up the bulk of long-term care workers, have historically been to get flu vaccines than other health care workers, noted Jasmine Travers, an assistant professor of nursing at New York University who studies vaccine hesitancy. Nursing homes typically don’t have nurse educators, who address worker concerns about vaccines in hospitals, she said, and CNAs also face structural barriers such as limited internet access. Nursing homes tend to be hierarchies commonly led by white staffers, while about 50% of CNAs, at the bottom of the power structure, are Black or Hispanic, and carry mistrust and different attitudes toward vaccination, she added.

With the covid vaccine, some are afraid they’ll have to take sick time to miss work and don’t want to burden their co-workers, who are already short-staffed, Travers said.

Vaccine hesitancy is higher among 30- to 49-year-olds, rural residents, and Black and Hispanic adults, according to . Hispanic adults are to say they will “definitely” get the covid vaccine, as are . Black adults have been by the pandemic and left behind in the vaccination rollout because of barriers stemming from structural racism.

Deliberate Misinformation

Low vaccine uptake among long-term care workers has been a concern nationally — so much so that LeadingAge, a national group representing not-for-profit long-term care facilities, held a about vaccine safety this month with the Black Coalition Against COVID-19.

The event, which drew over 45,000 viewers, was geared toward Black long-term care workers.

Dr. Reed Tuckson, co-founder of the Black Coalition Against COVID-19, said viewers raised concerns about fertility, pregnancy and contraindications. He said the event also had “a lot of provocateurs” who insisted, “It’s all a myth. It’s all a lie.”

His group plans to hold more public informational sessions aimed at Black audiences.

“There is no question that the three vaccines that we now have available to us are extraordinarily safe and tremendously effective,” said Tuckson, a former public health commissioner in Washington, D.C.

The nursing home industry has of having 75% of staff members vaccinated nationwide by the end of June.

A Vaccine Mandate?

Most nursing homes have not mandated vaccinations, industry officials say, for fear of losing staff members. Because the vaccines were authorized on an emergency basis, liability is also a concern.

Juniper Communities, which runs 22 long-term care facilities in four states and employs almost 1,300 people, had 30 workers leave the job after it mandated vaccines, according to Dr. Lynne Katzmann, president and CEO.

“At the end of the day, if you can make a choice to promote well-being and prevent illness, that’s the choice we want to make,” she said.

Greenbrier Nursing and Rehabilitation Center in Arkansas made the vaccine mandatory, but because of medical exemptions it hasn’t led to 100% vaccination.

However, Greenbrier has seen a significant drop in covid infections since vaccinations began. In late November and early December, over 60% of staff members tested positive, according to Regina Jones, Greenbrier’s director of nursing. After the staff started receiving the vaccine in late December, four workers who had already received a dose tested positive but were asymptomatic.

Hesitancy Doesn’t Mean Refusal

Tuckson said he’s seeing a “dramatic decrease” in vaccine hesitancy based on surveys of Black audiences. He has heard “a hunger for scientifically valid information delivered to them by trusted sources,” he said. “It’s not as if their opinions are locked in stone.”

Staff participation rates are rising with each round of vaccines, said Martino, the nursing home industry spokesperson.

At the Los Angeles Jewish Home, Chief Medical Officer Dr. Noah Marco said his staff has done “everything we could to counterbalance the nonsense out there on social media that has contributed to vaccine hesitancy,” including producing videos and a weekly newsletter.

“The vaccine may have some unknown side effects,” he recalled telling workers, “but we know the virus kills.”

About 80% of his staff of 1,600 — which includes workers in nursing homes and other settings — are vaccinated, he said, along with 99% of residents. No nursing home residents have contracted covid since Jan. 13, he said.

In southwestern Ohio, Kenn Daily runs two Ayden Healthcare nursing homes. About half his staff and 85% of residents got vaccinated by mid-February, he said, and they haven’t had a case of covid since. Still, he said, vaccine resistance persists among younger staffers who read misinformation online.

“Facebook is the bane of my existence,” Daily said. Workers tell him they worry that “they’re going to microchip me,” or that the vaccine will change their DNA.

Now that time has passed since the initial rollout, Daily said, “I’m hoping to put a little pressure on my staff to step up and get vaccinated.” His message: “It’s working, guys. It’s working very well.”

KHN data editor Elizabeth Lucas contributed to this report.

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During the week, Bruce practiced what he preached, caring for prisoners at a Georgia hospital. On March 27 he began coughing, and on April 1 he was hospitalized. He’d tested positive for covid-19. The virus swept through his household, infecting his wife and daughter and hospitalizing their disabled son. Ten days after landing in the hospital, Bruce died.

But when Gwendolyn Davis received her husband’s death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.

“He wouldn’t have had kidney failure if he didn’t have covid,” Gwendolyn said.

After Bruce died, his wife applied to two pandemic relief programs seeking help with $1,500 in missed payments on a truck and an electricity bill. But, she said, she was denied because his death certificate didn’t mention covid-19.

“I think it’s wrong,” Gwendolyn said. “It’s almost like we didn’t count.”

The count has profound implications for families and the country. Omitting covid-19 on death certificates threatens to undercount the toll of the pandemic nationwide. For Davis’ family and others, it can pile financial hardship onto emotional despair, as death benefits and other covid-19 relief programs are withheld. Interviews with families across the U.S. shed light on reasons covid deaths are being undercounted — and the consequences loved ones have endured.

When covid patients die, is always something else, such as respiratory failure or cardiac arrest. Residents, doctors, medical examiners and coroners make the call on whether covid was an underlying factor, or “contributory cause.” If so, the diagnosis should be included on the death certificate, according to the Centers for Disease Control and Prevention.

Even beyond the pandemic, there is wide variation in how certifiers describe causes of death: “There’s just no such thing as an objective measure of cause of death,” said Lee Anne Flagg, a statistician at the CDC’s National Center for Health Statistics.

Partly because of a lack of training in how to fill them out, “the quality of the death certificates is not good,” said Dr. James Gill, vice president of the National Association of Medical Examiners. And in cases in which people had other chronic conditions, it can be difficult to determine whether covid was a contributing cause of death, he said. That was especially true early on, when reliable testing was not widely available.

Since early in the pandemic, the certifiers who suspect covid as a cause of death to list it on the death certificate as “probable” or “likely.”

Still, some clinicians are “reluctant to certify a death as a covid death without a test in hand,” Gill said.

It’s not clear how Bruce Davis’ case slipped under the radar. His death was certified by William Ken Garland, deputy coroner in Baldwin County. Reached by phone, Garland said the causes of death were provided by Dr. Joseph Coppiano, a medical resident who pronounced Davis dead at Augusta University Medical Center, about 90 miles away. No autopsy was done.

“I did certify the record, but that’s about all I did,” Garland said.

Hospital spokesperson Danielle Harris declined to comment on the case, citing patient privacy. She said the hospital follows Georgia Department of Public Health guidelines.

In the absence of certainty, the CDC has encouraged coroners to document the virus. “We’re not worried that we’re overcounting the number of [covid-19] deaths,” Farida Ahmad, epidemiologist and mortality surveillance team leader at NCHS, .

Missed cases are one reason that experts agree covid deaths are being undercounted nationwide. As evidence for that, they point to the vast number of excess deaths — additional deaths compared to what would be expected based on prior-year numbers and demographic trends.

Over the past year, the U.S. had as of Jan. 6, with 68% directly attributed to covid, according to the CDC.

These excess deaths “tend to track pretty closely with covid cases, trailing by a couple of weeks,” said Daniel Weinberger, an epidemiologist at Yale School of Public Health who has on this topic. “This strongly suggests that a large proportion of these uncounted deaths are due to covid but not recorded as such.”

We may never know how many covid deaths went uncounted: Postmortem tests can detect the virus, but it’s “unlikely that this type of testing will be performed at a [sufficient] scale,” Weinberger said. Early in the pandemic, especially in the Northeast, many of those who were treated clinically for covid and then died were not tested for the virus — so they never made it into the statistics.

Testing Troubles Affect Lawsuits, Hospital Bills

Inaccurate death certificates can make it harder to pursue a lawsuit or win a workers’ compensation case when a loved one dies after contracting covid on the job. Gwendolyn Davis did win workers’ compensation death benefits from Bruce’s employer, a state psychiatric facility in Milledgeville, by providing medical records. But problems with covid testing can complicate the process.

Bruce’s supervisor at work, Mark DeLong, also died after contracting covid, but it did not appear on his death certificate with the other causes: cardiopulmonary arrest, respiratory failure and diabetes.

The omission on DeLong’s certificate seemed to stem from a delay in test results: His covid-positive results didn’t arrive until three days after he died, according to his widow, Jan DeLong. She has asked the local coroner to correct the record.

In New Jersey, attorney Paul da Costa represents 75 family members who lost loved ones at veterans homes in Menlo Park and Paramus in April and May. He said he knows of at least five patients whose death certificates did not list covid-19 despite evidence suggesting it killed them.

The root problem, he said, was a “complete dearth of testing.” Patients were transferred to hospitals, or dying in the veterans facilities, without ever being tested, he said.

The gap between excess deaths and confirmed covid deaths has “narrowed over time as testing has increased,” Weinberger said.

Early testing inaccuracy may also have led to undercounting, which creates a different burden: hospital bills. Without a diagnosis, families can be on the hook for thousands of dollars in charges that otherwise under the CARES Act.

Correcting the Record

In some cases, families have sought to have death certificates changed to reflect covid. Dorothy Payton, 95, who lived in the ManorCare nursing home in Denver, first showed covid symptoms April 5. Five days later, Payton — known as “Nana Dee” — tested positive for it. And on April 13, her husband, Edward Benjamin, received a call that she had died.

The death certificate offered a litany of causes: vascular dementia, atrial fibrillation, congestive heart failure, gait instability, difficulty swallowing and

But not covid-19. So it “seemed logical to fight for listing her cause of death under her cause of death,” Benjamin said.

After a few calls, her husband was able to get the certificate amended. ManorCare could not be reached for comment.

For Benjamin, it wasn’t about public health statistics or financial considerations. It simply offers a sense of closure.

“I want her life and death remembered the way it was, and I’m glad we set the record straight,” he said. “It’s the first step towards moving on.”

This story is part of “,” an ongoing project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please .

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Fatalities from the coronavirus have skewed young, with the majority of victims under age 60 in the cases for which there is age data. People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data. After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate personal protective equipment.

Many of the deaths — about 680 — occurred in New York and New Jersey, which were hit hard early in the pandemic. Significant numbers also died in Southern and Western states in the ensuing months.

The findings are part of “Lost on the Frontline,” a nine-month data and investigative project by KHN and The Guardian to track every health care worker who dies of COVID-19.

One of those lost, Vincent DeJesus, 39, told his brother Neil that he’d be in deep trouble if he spent much time with a COVID-positive patient while wearing the surgical mask provided to him by the Las Vegas hospital where he worked. DeJesus died on Aug. 15.

Another fatality was Sue Williams-Ward, a 68-year-old home health aide who earned $13 an hour in Indianapolis, and bathed, dressed and fed clients without wearing any PPE, her husband said. She was intubated for six weeks before she died May 2.

“Lost on the Frontline” is prompting new government action to explore the root cause of health care worker deaths and take steps to track them better. Officials at the Department of Health and Human Services recently asked the National Academy of Sciences for a “rapid expert consultation” on why so many health care workers are dying in the U.S., citing the count of fallen workers by The Guardian and KHN.

“The question is, where are they becoming infected?” asked Michael Osterholm, a member of President-elect Joe Biden’s COVID-19 advisory team and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “That is clearly a critical issue we need to answer and we don’t have that.”

The by the national academies suggests a new federal tracking system and specially trained contact tracers who would take PPE policies and availability into consideration.

Doing so would add critical knowledge that could inform generations to come and give meaning to the lives lost.

“Those [health care workers] are people who walked into places of work every day because they cared about patients, putting food on the table for families, and every single one of those lives matter,” said Sue Anne Bell, a University of Michigan assistant professor of nursing and co-author of the national academies report.

The recommendations come at a fraught moment for health care workers, as some are getting the COVID-19 vaccine while others are fighting for their lives amid the highest levels of infection the nation has seen.

The toll continues to mount. In Indianapolis, for example, 41-year-old nurse practitioner Kindra Irons died Dec. 1. She saw seven or eight home health patients per week while wearing full PPE, including an N95 mask and a face shield, according to her husband, Marcus Irons.

The virus destroyed her lungs so badly that six weeks on the most aggressive life support equipment, ECMO, couldn’t save her, he said.

Marcus Irons said he is now struggling financially to support their two youngest children, ages 12 and 15. “Nobody should have to go through what we’re going through,” he said.

In Massachusetts, 43-year-old Mike “Flynnie” Flynn oversaw transportation and laundry services at North Shore Medical Center, a hospital in Salem, Massachusetts. He and his wife were also raising young children, ages 8, 10 and 11.

Flynn, who shone at father-daughter dances, fell ill in late November and died Dec. 8. He had a heart attack at home on the couch, according to his father, Paul Flynn. A hospital spokesperson said he had full access to PPE and free testing on-site.

Since the first months of the pandemic, more than 70 reporters at The Guardian and KHN have scrutinized numerous governmental and public data sources, interviewed the bereaved and spoken with health care experts to build a count.

The total number includes fatalities identified by labor unions, obituaries and news outlets and in online postings by the bereaved, as well as by relatives of the deceased. The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.

The tally has been widely cited by other media as well as by members of Congress.

Rep. Norma Torres (D-Calif.) referenced the data for a pending bill that would provide compensation to the families of health care workers who died or sustained long-term disabilities from COVID-19.

Sen. Ron Wyden (D-Ore.) mentioned the tally in a Senate Finance Committee hearing about the medical supply chain. “The fact is,” he said, “the shortages of PPE have put our doctors and nurses and caregivers in grave danger.”

This story is part of “,” an ongoing project from  and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please .

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

Democrats want to enact an emergency standard meant to bolster access to protective gear for health care and other workers and to bar employers from retaliating against them for airing safety concerns.

Republicans seek immunity for employers from lawsuits related to the pandemic, an effort they say would give businesses the confidence to return to normal. The Senate is scheduled to reconvene later this month.

The debate reflects a deepening schism between the major political parties, with Democrats focused on protecting lives and Republicans focused on protecting livelihoods.

Democratic House Speaker Nancy Pelosi expressed frustration over efforts to pass an emergency worker-protection standard, which keeps running into GOP resistance.

“They’re saying ‘Let’s give immunity — no liability — for employers,’” Pelosi said. “We’re saying the best protection for the employer is to protect the workers.”

Nearly 98,000 health care workers have contracted the novel coronavirus, according to Centers for Disease Control and Prevention data that the agency acknowledges is an undercount. KHN and The Guardian have identified more than 780 who have died and have told the personal stories of 139 of them.

In May, the House passed a $3 trillion that would require the Occupational Safety and Health Administration to put in place an emergency standard that would call on employers to create a plan based, in part, on CDC or OSHA guidance to protect workers from COVID-19.

It would cover health care workers and also those “at occupational risk of exposure to COVID19.” The measure would allow workers to bring protective gear “if not provided by the employer.” Similar rules in place in California health care workers have come under fire for offering little added protection.

In action, the new measure would allow OSHA inspectors to request to review an employers’ plan and hold them accountable for following it, said David Michaels, former U.S. assistant secretary of Labor and OSHA administrator, who has called for . Federal guidance is currently optional, not required.

“Many employers want to be law-abiding,” Michaels said, “and they know they risk enforcement and possibly a monetary fine if they don’t attempt to do this.”

Top Democrats, including presumptive presidential nominee Joe Biden, have better worker protections, while GOP leaders have called for stronger employer protections.

Senate Majority Leader Mitch McConnell has insisted that the next pandemic relief bill include immunity for employers against coronavirus-related lawsuits.

“If we do another bill, it will have liability protections in it for doctors, for hospitals, for nurses, for businesses, for universities, for colleges,” McConnell said July 1. “Nobody knew how to deal with the coronavirus,” he said, and unless they’ve committed gross negligence or intentional harm, those parties should be protected from an “epidemic of lawsuits.”

He a five-year period of immunity from December 2019 through 2024. (McConnell’s office declined to comment for this story.)

Such a measure could derail lawsuits already filed by grieving family members such as Florence Dotson, the mother of 51-year-old certified nursing assistant Maurice Dotson, who died in April. Her son cared for nursing home residents with COVID-19 in Austin, Texas, and did not have proper personal protective equipment (PPE), her suit alleges. He later died of complications from the virus.

Another lawsuit an anonymous New York nurse requested but was denied proper PPE when she was assigned to care for a patient in intensive care with COVID-19 symptoms but who was tested for the virus only after death. The nurse, who contracted COVID-19 shortly after, is seeking $1 million in damages.

U.S. workers in every industry have filed more than 13,300 COVID-related complaints with OSHA, records show, demonstrating widespread concern over their lack of protection at work. Twenty-three complaints reference a fear of retaliation, including among hospital workers who say they were pressured to work while sick.

The agency has closed investigations into those complaints but is investigating 6,600 more open complaints. OSHA has so far issued one citation against an employer, a spokesperson confirmed.

Employers are also struggling, evidenced by layoffs and an 11% , which the Congressional Budget Office hit 16% in the coming weeks.

States have taken some matters in their own hands during months of federal inaction. At least 25 states have created some degree of legal immunity for doctors or facilities, through new laws or executive orders, the National Conference of State Legislatures.

Officials and have taken steps to enact their own heightened worker-protection rules related to the virus.

The effort to pass an OSHA rule to protect workers from infectious diseases dates , when regulators saw the need to better protect health care workers after the H1N1 flu pandemic.

Michaels, the former OSHA director under President Barack Obama, said the effort has under the Trump administration. Trump administration OSHA officials their track record, saying adequate rules are in place to protect workers.

But a similar push succeeded in California in 2009. State officials passed a plan requiring health care employers to create a plan to protect health care workers from airborne viruses.

The California measure went further, requiring hospitals and nursing homes to stockpile or be prepared to supply workers with an N95 respirator — or an even more protective device — if treating patients with a virus like COVID-19.

Workplace safety experts in California, though, said it hasn’t worked as intended.

As more than 17,600 health care workers have become sick and 99 have died in the state, it’s become apparent that health care employers did not have plans in place, said Stephen Knight, executive director of Worksafe, a nonprofit focused on workplace safety.

“This was just a massive missed opportunity and one that cost people their lives,” Knight said. “People are just dying … with frightening regularity.”

California nurses who died after caring for COVID patients without an N95 respirator include Sandra Oldfield, 52, who wore a less-protective surgical mask while caring for a patient who wasn’t initially thought to have the virus.

A complaint to OSHA about a lack of N95 respirators that preceded her death put her hospital, Kaiser Permanente Fresno Medical Center, in violation of the state’s standard, the state labor department confirmed.

However, alternative guidance is now in place because of global PPE shortages, according to the California Department of Industrial Relations. Kaiser Permanente, which is not affiliated with KHN, confirmed that the patient was not initially thought to have COVID-19 and that the company has followed state, local and CDC guidance on patient screening and use of PPE.

Hospital officials, who have come out against a national , said the plans that were in place did not account for the scope of the current pandemic and global supply chain breakdown.

“It is not for a lack of caring or trying to keep our workers safe,” said Gail Blanchard-Saiger, vice president for labor and employment with the California Hospital Association.

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By late March, new COVID cases in Bucks County, Pennsylvania, had ramped up to as many as . At the hospital, Anderson handled air filters and other surfaces that might have been contaminated with the deadly virus, also known to hang in the air.

In early April, Anderson, 51, came down with what he thought was a cold, according to his family’s lawyer, . On April 13 Anderson was rushed to the hospital, where he died of acute respiratory distress syndrome from COVID-19, according to the county coroner. He left behind a wife and two children, ages 5 and 9.

Anderson was exposed to the virus at work, the lawyer contends, making his family eligible for workers’ compensation death benefits paid by his employer’s insurer.

“His family deserves to have that income replaced,” Stern said. “Their husband and father certainly can’t be.”

But in a June 16 response to Stern’s death benefits claim, St. Mary Medical Center denied all allegations.

As the COVID toll climbs, sick workers and families of the dead face another daunting burden: fighting for benefits from workers’ compensation systems that, in some states, are stacked against them.

In interviews with lawyers and families across the nation, KHN found that health care workers ― including nurses’ aides, physician assistants and maintenance workers ― have faced denials or long-shot odds of getting benefits paid. In some cases, those benefits amount to an ambulance bill. In others, they would provide lifetime salary replacement for a spouse.

Legal experts say that in some states COVID-19 falls into a long-standing category of diseases like a cold or the flu — conditions not covered by workers’ compensation — with no plans to change that. Other states force workers to prove they caught the virus at work, rather than from a family member or in the community.

“We are asking people to risk their lives every single day — not just doctors, nurses and first responders, but also nurses’ aides and grocery store clerks,” said Laurie Pohutsky, a Democratic Michigan lawmaker who proposed a bill to help essential workers get coverage more easily. “These people are heroes, but we have to actually back those words up with actions.”

In at least 16 states and Puerto Rico, officials have passed measures to make it easier for workers infected with the coronavirus to qualify for benefits for lost wages, hospital bills or death. Similar bills are pending in other states, but some face opposition from business groups over costs.

Many of the proposed actions would turn the tables on the status quo, forcing employers to prove workers did not catch the virus at work. Bills vary in the scope of workers they cover. Some protect all who left home to work during stay-at-home orders. Others are limited to first responders and health care workers. Some would cover only workers who get sick during states of emergency, while others would cover a longer period.

An early glimpse of data shows that health care workers and first responders, two groups hit hard by the virus, make up the majority of those seeking benefits. Data from the Centers for Disease Control and Prevention more than 95,000 health care workers have been infected, a figure the agency acknowledges is an undercount. KHN and The Guardian U.S. have identified more than 700 who have died and told the story of 139 of them. For these workers’ families, the stakes of the pending laws are enormous.

In Virginia, attorney Michele Lewane is representing a nurse and a physician assistant who contracted the coronavirus while working at the same urgent care center. The physician assistant, who administered COVID tests, was hospitalized with COVID-19 and pneumonia for about a week. He missed five weeks of work.

When the physician assistant asked the urgent care center for paperwork to file a workers’ compensation claim to cover his hospital bill, an administrator refused to hand it over, saying coronavirus treatment wouldn’t be covered, Lewane said. He was laid off days later and left with a $60,000 hospital bill.

Lewane said the law in Virginia will likely consider COVID-19 an “ordinary disease of life,” akin to a cold or the flu. She said she’d have to prove by “clear and convincing evidence” that he caught the coronavirus at work.

The bar is so high, she said, that she’s waiting to file a claim in hopes that Virginia joins many other that make it easier for health workers to prove their cases.

Craig Davis, president-elect of the Virginia Trial Lawyers Association, said he took on a test case and received a quick denial of workers’ compensation benefits for a COVID-positive physician assistant.

“We think there’s an infinitesimal possibility of prevailing under our laws as currently written,” he said. His group is pushing for a legislative change.

In Montana, which has largely been spared by the pandemic, workers face even longer odds. A 64-year-old nurse at a small hospital there was hospitalized for eight days with COVID-19 in April, according to her Great Falls lawyer, Thomas Murphy. She remains at home on oxygen, unable to work.

The woman filed a workers’ compensation claim, which could qualify her for up to $800 a week in lost wages plus lifetime coverage of medical bills related to her condition. Instead of agreeing to those benefits, Murphy said, the insurer offered to settle for $17,000, which she declined because it would not cover her medical bills.

Murphy said the employer, which he did not name to protect his client from retaliation, is arguing that she was the first person at the hospital to contract the virus, so she likely didn’t get it at work. However, he noted that two other hospital employees and six patients tested positive within the next two weeks and his client went few places other than work.

In Montana law, the burden of proof lies on the employee to show an illness was work-related.

“We’re going to have to try to piece together all of the sources” that might have infected her — “and prove that it’s more probable than not that she got it at work,” Murphy said. “Women like this woman are going to have a hard road ahead of them.”

The Montana Legislature isn’t set to meet until January, and an executive order appears unlikely.

In New Jersey, attorney Rick Rubenstein is representing the widow of a man who worked as a housekeeper at a nursing home, doing laundry and occasional patient care. Not given protective gear by his employer, the man caught COVID-19 and had a lengthy stay in the intensive care unit before he died.

His wife has the virus now and was faced with a default — no answer in 35 days — after seeking benefits in New Jersey’s workers’ compensation system. They would cover her husband’s $188,000 hospital bill and survivor’s pay of $308 per week.

“She’s isolated, doesn’t know what her own health future holds and doesn’t have an explanation of why this stuff is happening,” Rubenstein said. “It’s terrible.”

A bill proposed in New Jersey would make it easier for essential workers who got COVID-19 during the state of emergency to prove that they got it on the job. The bill was passed by the state Senate and is pending before the General Assembly.

The New Jersey Business & Industry Association has opposed the bill, saying it would push higher workers’ compensation insurance rates onto businesses that are “struggling to survive.”

“Our concerns are primarily that the cost of these claims can overwhelm the system, which was not designed to handle claims during a worldwide pandemic,” NJBIA Chief Government Affairs Officer Chrissy Buteas said in a statement.

While there are no national estimates of how many are filing claims for workers’ compensation ― or getting approvals ― Massachusetts provided KHN with a summary of its coronavirus reports from March, April and May.

During those months, employers filed 3,482 “first reports of injury” regarding a worker with COVID-19 ― 2,915 were for health care workers. Insurers denied benefits to 216 health care workers, according to Massachusetts records.

Florida posted , showing a higher rate of denied claims for health care workers. While 1,740 health care workers sought benefits related to COVID-19, about 30%, or 521 claims, were fully denied. Among the 1,200 who were paid benefits, the amount paid added up to $1.3 million.

The cost of covering 9.6 million first responders and health workers nationally from $1 billion to $16 billion, according to the National Council on Compensation Insurance, which provides insurance rate recommendations for 38 states. The bill is paid by employers who buy workers’ compensation insurance, employers that self-insure and taxpayers, who support government agencies.

Those estimates do not include New York or California, where Gov. Gavin Newsom’s executive order broadening coverage through July 5 is projected about $1.2 billion to California’s costs.

In many states, business associations consider proposals to expand workers’ compensation too costly and too broad.

A proposed would extend Newsom’s executive order and put the burden on employers to prove that “critical workers,” including those in retail, warehousing and delivery, who got the coronavirus did not get it at work. The bill has critics.

“California employers have been significantly impacted by this crisis and simply cannot be the safety net for this pandemic by providing workers’ compensation benefits for all employees, even when they are not injured at work,” according to a letter of concern signed by the California Chamber of Commerce, California Hospital Association and others.

A federal backstop may become available. Sen. Tammy Duckworth (D-Ill.) and a bipartisan group of lawmakers that would create a federal fund for essential workers, including health care personnel, who get sick or die from the coronavirus. The Pandemic Heroes Compensation Act would be modeled after the September 11th Victim Compensation Fund.

In Pennsylvania, there is no presumption that COVID-19 is acquired on the job.

Stern, the lawyer for Anderson’s family, filed a “fatal claim” in May with the state workers’ compensation board, which passed it on to the employer.

A St. Mary Medical Center spokesperson confirmed in an email that Anderson worked there for 23 years and was a maintenance mechanic. She would not discuss his case. “We are extremely saddened by his death,” she wrote. “We are not able to provide additional information out of respect for his and his family’s privacy.”

Mark Banchi volunteers with hospital chaplains and knew Anderson for over 30 years. He said co-workers are reeling from the death of a man who “was enthusiastic, gregarious, friendly.”

“His loss to the hospital is real,” Banchi said. “Some people lift spirits, some people make you glad you came that day, and Mike was one of those people.”

In addition to working at St. Mary for $22 an hour, Anderson had a cleaning job at a car dealership. Stern said Anderson was unlikely to be exposed to the virus there. If Stern prevails, the family would receive two-thirds of Anderson’s combined pay, capped at $1,081 a week.

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But the hospital denied his request, said Kelly Indish, president of the American Federation of State, County and Municipal Employees Local 875.

On March 30, Liddell posted on Facebook that he had worked the previous week in both the critical care unit and the ICU and had contracted the virus. “Pray for me God is still in control,” he wrote. He died April 10.

The hospital’s problems with personal protective equipment (PPE) were well documented. In mid-March, the state office of the Occupational Safety and Health Administration (OSHA) received five complaints, which described employees receiving “zero PPE.” The cases were closed April 21, after the hospital presented paperwork saying problems had been resolved. There was no onsite inspection, and the hospital’s written response was deemed sufficient to close the complaints, a local OSHA spokesperson confirmed.

The grief and fear gripping workers and their families reflect a far larger pattern. Since March, more than 4,100 regarding health care facilities have poured into the nation’s network of federal and state OSHA offices, which are tasked with protecting workers from harm on the job.

A KHN investigation found that at least 35 health care workers died after OSHA received safety complaints about their workplaces. Yet by June 21, the agency had quietly closed almost all of those complaints, and none of them led to a citation or a fine.

The complaint logs, which have been made public, show thousands of desperate pleas from workers seeking better protective gear for their hospitals, medical offices and nursing homes.

The quick closure of complaints underscores the Trump administration’s hands-off approach to oversight, said former OSHA official Deborah Berkowitz. Instead of cracking down, the agency simply sent letters reminding employers to follow Centers for Disease Control and Prevention guidelines, said Berkowitz, now a director at the National Employment Law Project.

“This is a travesty,” she said.

A third of the health care-related COVID-19 complaints, about 1,300, remain open and about 275 fatality investigations are ongoing.

During a June 9 legislative hearing, Labor Secretary Eugene Scalia said OSHA had issued one coronavirus-related citation for violating federal standards. A Georgia nursing home was fined $3,900 for failing to report worker hospitalizations on time, OSHA’s .

“We have a number of cases we are investigating,” Scalia said at the Senate Finance Committee hearing. “If we find violations, we will certainly not hesitate to bring a case.”

A March 16 complaint regarding Clara Maass Medical Center in Belleville, New Jersey, illustrates the life-or-death stakes for workers on the front lines. The complaint says workers were “not allowed to wear” masks in the hallway outside COVID-19 patients’ rooms even though the highly contagious virus can spread throughout a health care facility. It also said workers “were not allowed adequate access” to PPE.

Nine days later, veteran Clara Maass registered nurse Barbara Birchenough texted her daughter: “The ICU nurses were making gowns out of garbage bags. … Dad is going to pick up large garbage bags for me just in case.”

Kristin Carbone, the eldest of four, said her mother was not working in a COVID area but was upset that patients with suspicious symptoms were under her care.

In a text later that day, Birchenough admitted: “I have a cough and a headache … we were exposed to six patients who we are now testing for COVID 19. They all of a sudden got coughs and fevers.”

“Please pray for all health care workers,” the text went on. “We are running out of supplies.”

By April 15, Birchenough, 65, had died of the virus. “They were not protecting their employees in my opinion,” Carbone said. “It’s beyond sad, but then I go to a different place where I’m infuriated.”

OSHA records show six investigations into a fatality or cluster of worker hospitalizations at the hospital. A Labor Department spokesperson said the initial complaints about Clara Maass remain open and did not explain why they continue to appear on a “closed” case list.

Nestor Bautista, 62, who worked closely with Birchenough, died of COVID-19 the same day as she did, according to Nestor’s sister, Cecilia Bautista. She said her brother, a nursing aide at Clara Maass for 24 years, was a quiet and devoted employee: “He was just work, work, work,” she said.

Responding to allegations in the OSHA complaint, Clara Maass Medical Center spokesperson Stacie Newton said the virus has “presented unprecedented challenges.”

“Although the source of the exposure has not been determined, several staff members” contracted the virus and “a few” have died, Newton said in an email. “Our staff has been in regular contact with OSHA, providing notifications and cooperating fully with all inquiries.”

Other complaints have been filed with OSHA offices across the U.S.

Twenty-one closed complaints alleged that workers faced threats of retaliation for actions such as speaking up about the lack of PPE. At a Delaware hospital, workers said they were not allowed to wear N95 masks, which protected them better than surgical masks, “for fear of termination or retaliation.” At an Atlanta hospital, workers said they were not provided proper PPE and were also threatened to be fired if they “raise[d] concerns about PPE when working with patients with Covid-19.”

Of the 4,100-plus complaints that flooded OSHA offices, over two-thirds are now marked as “closed” in an OSHA database. Among them was a complaint that staffers handling dead bodies in a small room off the lobby of a Manhattan nursing home weren’t given appropriate protective gear.

More than 100 of those cases were resolved within 10 days. One of those complaints said home health nurses in the Bronx were sent to treat COVID-19 patients without full protective gear. At a Massachusetts nursing home that housed COVID patients, staff members were asked to wash and reuse masks and disposable gloves, another complaint said. A complaint about an Ohio nursing home said workers were not required to wear protective equipment when caring for COVID patients. That complaint was closed three days after OSHA received it.

It remains unclear how OSHA resolved hundreds of the complaints. A Department of Labor spokesperson said in an email that some are closed based on an exchange of information between the employer and OSHA, and advised reporters to file Freedom of Information Act requests for details on others.

“The Department is committed to protecting America’s workers during the pandemic,” the Labor Department said in a statement. “OSHA has standards in place to protect employees, and employers who fail to take appropriate steps to protect their employees may be violating them.”

The agency on May 19 to place reports of fatalities and imminent danger as a top priority, with a special focus on health care settings. Since late March, OSHA has opened more than 250 investigations into fatalities at health care facilities, government records show. Most of those cases are ongoing.

According to the mid-March complaints against McLaren Flint, workers did not receive needed N95 masks and “are not allowed to bring them from home.” They also said patients with COVID-19 were kept throughout the hospital.

Filing complaints, though, did little for Liddell, or for his colleague, Patrick Cain, 52. After the complaints were filed, Cain, a registered nurse, was treating people still awaiting the results of COVID-19 diagnostic tests — potentially positive patients ― without an N95 respirator. He was also working outside a room where potential COVID-19 patients were undergoing treatments that can spread the virus widely in the air.

At the time, there was a debate over whether supply chain breakdowns of PPE and on protective gear were putting workers at risk.

Cain felt vulnerable working outside of rooms where COVID patients were undergoing infection-spreading treatments, he wrote in a text to Indish on March 26.

“McLaren screwed us,” he wrote.

He fell ill in mid-March and died April 4.

McLaren has since revised its face-covering policy to provide N95s or controlled air-purifying respirators (CAPRs) to workers on the COVID floor, union members said.

A spokesperson for the McLaren Health Care system said the OSHA complaints are “unsubstantiated” and that its protocols have consistently followed government guidelines. “We have always provided appropriate PPE and staff training that adheres to the evolving federal, state, and local PPE guidelines,” Brian Brown said in an email.

Separate from the closed complaints, OSHA into Liddell and Cain’s deaths are ongoing, according to a spokesperson for the state’s Department of Labor and Economic Opportunity.

Nurses at Kaiser Permanente Fresno Medical Center also said the complaints they aired before a nurse’s death have not been resolved. (KHN is not affiliated with Kaiser Permanente.)

On March 18, nurses filed an initial complaint. They told OSHA they were given surgical masks, instead of N95s. Less than a week later, other complaints said staffers were forced to reuse those surgical masks and evaluate patients for COVID without wearing an N95 respirator.

Several nurses who cared for one patient who wasn’t initially suspected of having COVID-19 in mid-March wore no protective gear, according to Amy Arlund, a Kaiser Fresno nurse and board member of the National Nurses Organizing Committee board of directors. Sandra Oldfield, a 53-year-old RN, was among them.

Arlund said Oldfield had filed an internal complaint with management about inadequate PPE around that time. Arlund said the patient’s illness was difficult to pin down, so dozens of workers were exposed to him and 10 came down with COVID-19, including Oldfield.

Lori Rodriguez, Oldfield’s sister, said Sandra was upset that the patient she cared for who ended up testing positive for COVID-19 hadn’t been screened earlier.

“I don’t want to see anyone else lose their life like my sister did,” she said. “It’s just not right.”

Wade Nogy, senior vice president and area manager of Kaiser Permanente Fresno, confirmed that Oldfield had exposure to a patient before COVID-19 was suspected. He said Kaiser Permanente “has years of experience managing highly infectious diseases, and we are safely treating patients who have been infected with this virus.”

Kaiser Permanente spokesperson Marc Brown said KP “responded to these complaints with information, documents and interviews that demonstrated we are in compliance with OSHA regulations to protect our employees.” He said the health system provides nurses and other staff “with the appropriate protective equipment.”

California OSHA officials said the initial complaints were accurate and the hospital was not in compliance with a state law requiring workers treating COVID patients to have respirators. However, the officials said the requirement had been waived due to global shortages.

Kaiser Fresno is now in compliance, Cal/OSHA said in a statement, but the agency has ongoing investigations at the facility.

Arlund said tension around protective gear remains high at the hospital. On each shift, she said, nurses must justify their need for a respirator, face shield or hair cap. She expressed surprise that the OSHA complaints were considered “closed.”

“I’m very concerned to hear they are closing cases when I know they haven’t reached out to front-line nurses,” Arlund said. “We do not consider any of them closed.”

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The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers, who have put their own lives at risk during the pandemic to help care for others. Lost on the Frontline has now published the names and obituaries for more than 100 workers.

A majority of those documented were identified as people of color, mostly African American and Asian/Pacific Islander. Profiles of more victims, and an updated count, will be added to our news sites twice weekly going forward.

There is no other comprehensive accounting of U.S. health care workers’ deaths. The Centers for Disease Control and Prevention 368 COVID deaths among health care workers, but acknowledges its tally is an undercount. The CDC does not identify individuals.

The Guardian and KHN are building an interactive, public-facing database that will also track factors such as race and ethnicity, age, profession, location and whether the workers had adequate access to protective gear. The database — to be released this summer — will offer insight into the workings and failings of the U.S. health care system during the pandemic.

In addition to tracking deaths, Lost on the Frontline reports on the challenges health care workers are facing during the pandemic. Many were forced to reuse masks countless times amid widespread equipment shortages. Others had only trash bags for protection. Some deaths have been met with employers’ silence or denials that they were infected at work.

The number released today reflects the 586 names currently in the Lost on the Frontline internal database, which have been collected from family members, friends and colleagues of the deceased, health workers unions, media reports, unions, among other sources. Reporters at KHN and The Guardian are independently confirming each death by contacting family members, employers, medical examiners and others before publishing names and obituaries on our sites. More than a dozen journalists across two newsrooms — as well as student journalists ― are involved in the project.

Many of the health care workers included here studied physiology and anatomy for years. They steeled themselves against the long hours they’d endure. Emergency medical technicians raced by ambulance to help. Others did the cleanup, maintenance, security or transportation jobs needed to keep operations running smoothly.

They undertook their work with passion and dedication. They were also beloved spouses, parents, friends, military veterans and community activists.

None started 2020 knowing that simply showing up to work would expose them to a virus that would kill them.

This project aims to capture the human stories, compassion and heroism behind the statistics. Among those lost were Dr. , a nephrologist, who continued to review her patients’ charts until she was put on a ventilator. Her father, a retired surgeon, succumbed to the disease just days after his daughter.

Susana Pabatao, one of thousands of Philippine health providers in the United States, became a nurse in her late 40s. Susana died just days after her husband, Alfredo, who was also infected with COVID-19.

Dr. James Goodrich, , acclaimed for separating conjoined twins, was also remembered as a renaissance man who collected antique medical books, loved fine wines and played the didgeridoo.

Some of the first to die faced troubling conditions at work. Rose Harrison, 60, a registered nurse, wore no mask while taking care of a COVID-19 patient at an Alabama nursing home, according to her daughter. She felt pressured to work until the day she was hospitalized. The nursing home did not respond to requests for comment.

Thomas Soto, 59, a Brooklyn radiology clerk faced delays in accessing protective gear, including a mask, even as the hospital where he worked was overwhelmed with COVID-19 patients, his son said. The hospital did not respond to requests for comment.

The Lost on the Frontline team is documenting other worrying trends. Health care workers across the U.S. said failures in communication left them unaware they were working alongside people infected with the virus. And occupational safety experts raised alarms about CDC guidance permitting workers treating COVID patients to wear surgical masks ― which are far less protective than N95 masks.

The Occupational Safety and Health Administration, the federal agency responsible for protecting workers, has launched dozens of fatality investigations into health workers’ deaths. But recent agency memos raise doubts that many employers will be held responsible for negligence.

As public health guidelines have largely prevented traditional gatherings of mourners, survivors have found new ways to honor the dead: In Manhattan, a medical resident played a tribute for a fallen co-worker; a nurses union placed 88 pairs of outside the White House commemorating those who had died among their ranks; fire departments have trucks for funeral processions and held for EMTs.

The Lost on the Frontline death toll includes only health care workers who were potentially exposed while caring for or supporting COVID-19 patients. It does not, for example, include retired doctors who died from the virus but were not working during the pandemic.

The number of reported deaths is expected to grow. But as reporters work to confirm each case, individual deaths may not meet our criteria for inclusion — and, therefore, may be removed from our count.

You can read our first 100 profiles here. And if you know of a health care worker who died of COVID-19, please with us.

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