The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
BEAUMONT, France — The vines were once demonized for causing madness and blindness, and had been banned decades ago. The French authorities, brandishing money and sanctions, nearly wiped them out.
But there they were. On a hillside off a winding mountain road in a lost corner of southern France, the forbidden crop was thriving. Early one recent evening, Hervé Garnier inspected his field with relief.
In a year when an April frost and disease have decimated France’s overall wine production, Mr. Garnier’s grapes — an American hybrid variety named jacquez, banned by the French government since 1934 — were already turning red. Barring an early-autumn cold snap, all was on track for a new vintage.
“There’s really no reason for its prohibition,” Mr. Garnier said. “Prohibited? I’d like to understand why, especially when you see the prohibition rests on nothing.”
Forgotten Fruits, a group fighting for the legalization of the American grapes. Showing off forbidden vines, including the clinton and isabelle varieties, on a property in the southern Cévennes region, near the town of Anduze, he added, “These vines are ideal for making natural wine.”
Memory of the Vine.” A membership fee of 10 euros, or about $12, yields a bottle.
With the growing threat of climate change and the backlash against the use of pesticides, Mr. Garnier is hoping that the forbidden grapes will be legalized and that France’s wine industry will open up to a new generation of hybrids — as Germany, Switzerland and other European nations already have.
“France is a great wine country,” he said. “To remain one, we have to open up. We can’t get stuck on what we already know.”
A centuries-old tradition in which women declared themselves men so they could enjoy male privilege is dying out as young women have more options available to them to live their own lives.
Text by Andrew Higgins
Photographs by Laura Boushnak
LEPUSHE, Albania — As a teenager locked in a patriarchal and tradition-bound mountain village in the far north of Albania, Gjystina Grishaj made a drastic decision: She would live the rest of her life as a man.
She did not want to be married off at a young age, nor did she like cooking, ironing clothes or “doing any of the things that women do,” so she joined a gender-bending Albanian fraternity of what are known as “burrneshat,” or “female-men.” She adopted a male nickname — Duni.
“I took a personal decision and told them: I am a man and don’t want to get married,” Duni recalled telling her family.
Few women today want to become what anthropologists call Albania’s “sworn virgins,” a tradition that goes back centuries. They take an oath of lifelong celibacy and enjoy male privileges, like the right to make family decisions, smoke, drink and go out alone.
Ms. Rakipi snorted with contempt when asked about people who undergo transition surgery. “It is not normal,” she said. “If God made you a woman, you are a woman.”
Duni, from Lepushe village, also has strong views on the subject, saying that altering the body goes “against God’s will,” and that people “should be put in jail” for doing so.
“I have not lived as a burrnesha because I want to be a man in any physical way. I have done this because I want to take on the role played by men and to get the respect of a man,” she said. “I am a man in my spirit, but having male genitals is not what makes you a man.”
Locals in Lepushe, including Manushaqe Shkoza, a server at a cafe in the village, said Duni’s decision to become a man initially came as a surprise, but it was accepted long ago. “Everyone sees it as normal,” Ms. Shkoza said.
Duni said she was sad that the tradition of sworn virgins would soon die out, but noted that her niece in Tirana had shown that there were now less drastic ways for a woman to live a full and respected life.
“Society is changing, but I think I made the right decision for my time,” Duni said. “I can’t resign from the role I have chosen. I took an oath to my family. This is a path you cannot go back on.”
The subway train in Zhengzhou, a city of five million in central China, was approaching its next station when the floodwaters began to rise ominously on the tracks. The passengers crowded forward as the water rose, submerging the cars at the rear first because they were deeper in the tunnel.
As the water reached their waists, then chests, finally their necks, the passengers called emergency services or relatives. One gave her parents the details for accessing her bank account. Some cried. Others retched or fainted. After two hours, it became difficult to breathe in the congested air that remained in the cars.
Ding Xiaopei, a radio host, was afraid to call her children, 13 and 4. What could she say? She posted a video that she thought might be her last message. “The water outside has reached this position,” she said, it having reached chest level, “and my mobile phone will soon run out of power.”
“Please save us!” she wrote.
The flood that inundated Line 5 of Zhengzhou’s subway on Tuesday added to the grim global toll extreme weather has taken already this year, with scorching heat in the Pacific Northwest, forest fires in Siberia, and flooding in Germany and Belgium. Although flooding is common in China, researchers have attributed the extreme weather sweeping the planet to the consequences of climate change.
reported. At least one carrying 735 people came to a stop near Zhengzhou and, after more than 40 hours, had run out of food and water. By the afternoon, some passengers were able to leave, while railway workers brought supplies to those still waiting aboard for service to resume.
battled weeks of flooding along the Yangtze River that killed hundreds of people and displaced millions more. The rains at that time filled the Three Gorges Dam to its highest level since it opened in 2003, raising fears that the dam itself could fail.
The government often goes to great lengths to manage information about disasters, sensitive about its history of underreporting casualties. It is quick to limit news coverage and censor blogs and social media sites to mute public dissatisfaction with prevention and rescue efforts.
Some people on Chinese chat platforms and social media sites have raised questions about whether official news outlets in Zhengzhou and Henan Province initially downplayed the flood. When storms struck Beijing recently, the authorities warned people to stay home, but there was no order to shut businesses or schools in Zhengzhou ahead of Tuesday’s heavy rain.
In times of disaster, the country’s state news media often focuses on the efforts of rescue workers, including the military, while playing down the causes of disasters and their damage. A journalism professor, Zhan Jiang, posted a note on Weibo, the social media platform, on Tuesday complaining that a television station in Henan Province continued to show its regular programming instead of providing public safety information.
the news site Jiemian, part of the state-owned Shanghai United Media Group.
By 8:35 p.m., rescuers reached the train and devised a pulley system with ropes to help passengers pull themselves through the floodwaters along a ledge in the subway tunnel. The elderly and injured went first, followed by the women and then the men. State news organizations said that 500 people were evacuated in all.
One man still missing was Sha Tao. When the subway car first flooded, he called his wife and asked her to call the police. She has not heard from him since. She posted a message on Weibo asking people for help, describing his height and weight and the clothes he was wearing.
“I haven’t found him yet,” she said when reached by telephone in Zhengzhou on Wednesday. “I went to several hospitals, but the hospitals didn’t have any information and couldn’t find him. His phone is now off.”
Amy Chang Chien, Claire Fu, Li You, Liu Yi and Albee Zhang contributed research.
KUNDUZ, Afghanistan — The Afghan way of war in 2021 comes down to this: a watermelon vendor on a sweltering city street, a government Humvee at the front line just 30 feet away, and Taliban fighters lurking unseen on the other side of the road.
When the shooting starts, the vendor makes himself scarce, leaving his melons on the table and hoping for the best. When it stops, selling resumes, to customers now all too rare.
“I don’t have a choice. I’ve got to sell the melons,” said the vendor, Abdel Alim, speaking to New York Times journalists while he kept an eye on a lane within Kunduz city from which he said Taliban had emerged. “Most people have left,” he said. “There is fighting all the time.”
374,000 in Afghanistan’s north, and several other provincial capitals as well, as the Afghan government’s war with the Taliban enters a new and dangerous phase. For weeks, the insurgents have captured vulnerable districts across the country’s north, sometimes without even firing a shot. And on Wednesday, the Taliban said they had captured an important border crossing with Pakistan, at Spin Boldak — the fourth crossing they have seized in less than a month.
taken by the insurgents in 2015 and then again in 2016. Both times, the insurgents were eventually pushed back by the Afghan forces with help from American airstrikes. It was here that an American gunship mistakenly blasted a Doctors Without Borders hospital in 2015, killing 42 people.
This time, the Americans won’t be coming. The battle for Kunduz has become an intimate fight between Afghan opponents at close range.
“Every night they come to these houses and fire on us,” said the chief of police of Kunduz’s Third Municipal District, Sayed Mansoor Hashimi, looking out at now-vacant dwellings all around his police station. “Slowly, slowly they are tightening the circle.”
The war in Kunduz is intertwined with the fabric of the city. Shopping trips are planned between bursts of war. Residents no longer pay sufficient attention, said Marzia Salam Yaftali, the medical director at Kunduz Regional Hospital. “They are wounded in the streets or in the bazaar,” she said.
At the hospital, Ezzatullah, 14, lay in one of the wards, his legs wrapped in bandages: He lost both his feet when a mortar landed as he was playing outside his house. Three members of his family, including one of his parents, were killed.
“I can’t go to school now,” he said. Asked what he saw as his future, he replied firmly: “I want to be a man, to rebuild my country.”
The war, and the enemy, are inescapable. “We have to live here. Where can we go?” asked Ezamuddin Safi, a telecommunications worker who had to flee his home inside the city in early July. He was passing the day inside a small downtown restaurant.
“My 3-year-old boy, he screams when he hears the firing. He’s tired,” said Mr. Safi, 25. “Taliban are everywhere.”
BOGNOR REGIS, England — Little has changed in the 40 years that Jean Sheppard has been calling numbers at Crown Bingo here in the heart of Bognor Regis, one of Britain’s oldest seaside resort towns, about 60 miles south of London. The regulars still line up before the doors open at 11 a.m., hoping to nab their upholstered seat of choice in a converted cinema built in the ’30s.
When the games begin, there are no distractions.
“We had an elderly lady here once whose family came to tell her that her husband had passed away,” Ms. Sheppard recalled recently. “And this woman said, ‘Well, there’s nothing I can do for him now,’ and kept right on playing.”
The other constant over the years is the decline of Bognor Regis. Like most of the country’s seaside resorts, the town’s heyday in the ’50s and ’60s is the stuff of dim memories. Bognor and its many rival destinations — Brighton, Hastings, Margate, Skegness, Blackpool and others — once thronged with summer travelers who packed the beaches, seafood shacks and amusement arcades in search of a good time and, for those lucky enough to encounter a cloudless sky, a tan.
Then in the 1970s came the rise of cheap jet travel and overseas package tours. For the same price as a trip here, a family could fly to the beaches of Spain, where blazing sunshine was essentially guaranteed. The resort towns of Britain went into an economic free fall from which they have never recovered.
“Pubs have shut down, theaters have shut down, lots of buildings were knocked down,” said Ms. Sheppard, speaking after her shift on Sunday evening. “There’s been talk about regeneration for years, but nobody seems to know how to do it.”
Now, the limitations imposed by the pandemic are succeeding where all else has failed — at least for the moment. Government-imposed air travel restrictions and warnings have curbed the national appetite for overseas trips. Brits are still allowed to fly to Spain, and elsewhere in Europe, but unless you’re heading to Gibraltar — where infection rates are low — you must quarantine for 10 days after returning home and pay for two Covid-19 tests.
This past week, the British health secretary, Matt Hancock, said the policy would soon be revisited and liberalized. That good news was offset by Chancellor Angela Merkel of Germany and Prime Minister Emmanuel Macron of France, who on Thursday urged all countries in the European Union to require British travelers to quarantine upon arrival.
So towns like Bognor Regis are getting a second look. There were more than 180 new players last week at Crown Bingo, said Jenny Barrett, the assistant manager. And for the first time in decades, hotels here are reporting occupancy rates well above 90 percent.
“This weekend we’re at 95 percent,” said André Gonçalves, a manager at the Beachcroft Hotel. “And our prices are up about 20 to 30 percent.”
The owner of the mini golf course right next to the beach-side promenade, Paul Tiernan, is relishing the payoff from a renovation during the height of the pandemic. He refurbished and cleaned the whole course, in part because during lockdown there was nothing else to do. Lately, on weekends there has been a waiting line that extends around the corner and down the street.
“British seasides are having a massive renaissance, everywhere you go,” he said. “Everyone is just filling their boots.”
Daily Business Briefing
Mr. Tiernan sat in a chair near the edge of the first hole of his course, directly in the line of fire of any overzealous putters. He moved to Bognor Regis 50 years ago, as a child, which makes him just old enough to have glimpsed the last vestiges of the town’s halcyon days.
“There was a pier over there,” he said, pointing across the street. “Honest to God, it was beautiful. Right at the end there was a pavilion. And there was a theater there.”
Today, the pier is short and looks hazardous. Across a different street stands an empty lot with nothing but debris from a building that burned down four years ago under what Mr. Tiernan called dubious circumstances.
It’s all a long slide from the days when Bognor was prestigious enough to serve as a place for King George V, Queen Elizabeth’s grandfather, to convalesce after lung surgery in 1929. The royal connection was memorialized when “Regis,” Latin for “of the King,” was added to the town’s name. But its most famous link to the monarchy is the story — surely as false as it is amusing — that his last words were an alliterative, impolite put-down of Bognor, uttered after aides suggested that he’d soon be well enough to return. (Polite version: “I don’t want to go to Bognor.”)
James Joyce left behind kinder impressions after a stay here in 1923. “The weather is very fine and the country here restful,” he wrote to a patron. Joyce scholars believe he picked up the improbable name of the lead character of “Finnegans Wake,” Humphrey Chimpden Earwicker, from a nearby cemetery.
The flow of out-of-towners picked up when entrepreneur Billy Butlin opened his second Butlin’s Holiday Camp here in 1960, bringing his vision of a family vacation, filled with vigorous activities and all-inclusive buffets, to the south of the country. Today, the Butlin’s here is one of only three originals still in operation, and it is curiously walled off from the rest of town. A fence stands between the ocean and the Butlin’s campus, which features a gleaming, massive structure that looks like a circus tent from the future.
The logic of a beachside holiday camp with little access to the beach, designed around indoor amusements, seems baffling. Until it starts raining, which it did often last weekend. Bognor boasts that it’s the sunniest place in the United Kingdom, a title claimed by other towns as well. Even when it’s sunny, though, the beach here is not exactly inviting. It’s made of small stones, which are comfortable to lay atop only if you bring a futon.
The water rarely gets much above 60 degrees, a temperature described by the National Center for Cold Water Safety as “very dangerous.”
“We all have wet suits,” said Sara Poffenberger, a Brit who was toweling off with her son and grandson. “But lots of British people will swim without wet suits and tell you the water is boiling.”
The beaches here helped Bognor Regis earn the title of worst U.K. seaside resort in a 2019 survey of 3,000 holidaymakers. Bognor and the fellow bottom dweller Clacton-on-Sea received low ratings for their “attractions, scenery, peace and quiet and value for the money,” the publication found.
Reviews like this explain why even optimists believe Bognor’s boomlet is unlikely to last. Business owners here understand that they are banking the upsides of what could most charitably be described as exceptional circumstances. Someday soon, normal will return.
“Next year, every man and his dog will go abroad,” Mr. Tiernan said, sitting at his mini golf course. “But next year is next year, so I’m enjoying the moment.”
Sarah Cavey, a real estate agent in Denver, was thrilled last fall when Colorado introduced an app to warn people of possible coronavirus exposures.
Based on software from Apple and Google, the state’s smartphone app uses Bluetooth signals to detect users who come into close contact. If a user later tests positive, the person can anonymously notify other app users whom the person may have crossed paths with in restaurants, on trains or elsewhere.
Ms. Cavey immediately downloaded the app. But after testing positive for the virus in February, she was unable to get the special verification code she needed from the state to warn others, she said, even after calling Colorado’s health department three times.
“They advertise this app to make people feel good,” Ms. Cavey said, adding that she had since deleted the app, called CO Exposure Notifications, in frustration. “But it’s not really doing anything.”
announced last year that they were working together to create a smartphone-based system to help stem the virus, their collaboration seemed like a game changer. Human contact tracers were struggling to keep up with spiking virus caseloads, and the trillion-dollar rival companies — whose systems run 99 percent of the world’s smartphones — had the potential to quickly and automatically alert far more people.
Soon Austria, Switzerland and other nations introduced virus apps based on the Apple-Google software, as did some two dozen American states, including Alabama and Virginia. To date, the apps have been downloaded more than 90 million times, according to an analysis by Sensor Tower, an app research firm.
But some researchers say the companies’ product and policy choices limited the system’s usefulness, raising questions about the power of Big Tech to set global standards for public health tools.
Stephen Farrell and Doug Leith, computer science researchers at Trinity College in Dublin, wrote in a report in April on Ireland’s virus alert app.
CA Notify in December, about 65,000 people have used the system to alert other app users, the state said.
“Exposure notification technology has shown success,” said Dr. Christopher Longhurst, the chief information officer of UC San Diego Health, which manages California’s app. “Whether it’s hundreds of lives saved or dozens or a handful, if we save lives, that’s a big deal.”
In a joint statement, Apple and Google said: “We’re proud to collaborate with public health authorities and provide a resource — which many millions of people around the world have enabled — that has helped protect public health.”
Let Us Help You Protect Your Digital Life
Based in part on ideas developed by Singapore and by academics, Apple and Google’s system incorporated privacy protections that gave health agencies an alternative to more invasive apps. Unlike virus-tracing apps that continuously track users’ whereabouts, the Apple and Google software relies on Bluetooth signals, which can estimate the distance between smartphones without needing to know people’s locations. And it uses rotating ID codes — not real names — to log app users who come into close contact for 15 minutes or more.
said last year in a video promoting the country’s alert system, called Corona-Warn-App.
But the apps never received the large-scale efficacy testing typically done before governments introduce public health interventions like vaccines. And the software’s privacy features — which prevent government agencies from identifying app users — have made it difficult for researchers to determine whether the notifications helped hinder virus transmission, said Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
“The apps played virtually no role at all in our being able to investigate outbreaks that occurred here,” Dr. Osterholm said.
Some limitations emerged even before the apps were released. For one thing, some researchers note, exposure notification software inherently excludes certain vulnerable populations, such as elderly people who cannot afford smartphones. For another thing, they say, the apps may send out false alarms because the system is not set up to incorporate mitigation factors like whether users are vaccinated, wearing masks or sitting outside.
Proximity detection in virus alert apps can also be inconsistent. Last year, a study on Google’s system for Android phones conducted on a light-rail tram in Dublin reported that the metal walls, flooring and ceilings distorted Bluetooth signal strength to such a degree that the chance of accurate proximity detection would be “similar to that of triggering notifications by randomly selecting” passengers.
Kimbley Craig, the mayor of Salinas, Calif. Last December, when virus rates there were spiking, she said, she downloaded the state’s exposure notification app on her Android phone and soon after tested positive for Covid-19. But after she entered the verification code, she said, the system failed to send an alert to her partner, whom she lives with and who had also downloaded the app.
“If it doesn’t pick up a person in the same household, I don’t know what to tell you,” Mayor Craig said.
In a statement, Steph Hannon, Google’s senior director of product management for exposure notifications, said that there were “known challenges with using Bluetooth technology to approximate the precise distance between devices” and that the company was continuously working to improve accuracy.
The companies’ policies have also influenced usage trends. In certain U.S. states, for instance, iPhone users can activate the exposure notifications with one click — by simply turning on a feature on their settings — but Android users must download a separate app. As a result, about 9.6 million iPhone users in California had turned on the notifications as of May 10, the state said, far outstripping the 900,000 app downloads on Android phones.
Google said it had built its system for states to work on the widest range of devices and be deployed as quickly as possible.
Some public health experts acknowledged that the exposure alert system was an experiment in which they, and the tech giants, were learning and incorporating improvements as they went along.
One issue they discovered early on: To hinder false alarms, states verify positive test results before a person can send out exposure notifications. But local labs can sometimes take days to send test results to health agencies, limiting the ability of app users to quickly alert others.
In Alabama, for instance, the state’s GuideSafe virus alert app has been downloaded about 250,000 times, according to Sensor Tower. But state health officials said they had been able to confirm the positive test results of only 1,300 app users. That is a much lower number than health officials would have expected, they said, given that more than 10 percent of Alabamians have tested positivefor the coronavirus.
“The app would be a lot more efficient if those processes were less manual and more automated,” said Dr. Scott Harris, who oversees the Alabama Department of Public Health.
Colorado, which automatically issues the verification codes to people who test positive, has reported higher usage rates. And in California, UC San Diego Health has set up a dedicated help line that app users can call if they did not receive their verification codes.
Dr. Longhurst, the medical center’s chief information officer, said the California app had proved useful as part of a larger statewide public health push that also involved mask-wearing and virus testing.
“It’s not a panacea,” he said. But “it can be an effective part of a pandemic response.”
LONDON — He suggested that a doctor inject him with the coronavirus live on television to play down the dangers to a nervous public. He modeled himself after the small-town mayor in the movie “Jaws,” who ignored warnings to close the beaches even though there was a marauding shark offshore. As the pandemic closed in on Britain, he was distracted by an unflattering story about his fiancée and her dog.
That was the portrait of Prime Minister Boris Johnson painted by his disaffected former chief adviser, Dominic Cummings, in parliamentary testimony on Wednesday. While Mr. Johnson flatly rejected several of the assertions in his own appearance in Parliament on Wednesday, they nevertheless landed with a thud in a country still struggling to understand how the early days of the pandemic were botched so badly.
“When the public needed us most, the government failed,” said Mr. Cummings, the political strategist who masterminded Britain’s campaign to leave the European Union and engineered Mr. Johnson’s rise to power before falling out bitterly with his boss and emerging as a self-styled whistle-blower.
a much-criticized road trip he made with his family that breached lockdown rules, saying he had fled London because of threats against his family. And he apologized for his failure to act sooner when he realized that Britain’s delay in imposing a lockdown last March was courting disaster.
“It’s true that I hit the panic button and said we’ve got to ditch the official plan,” Mr. Cummings said. “I think it’s a disaster that I acted too late. The fundamental reason was that I was really frightened of acting.”
testing 100,000 people a day. Mr. Cummings said he told Mr. Johnson to dismiss Mr. Hancock, as did the then-cabinet secretary, Mark Sedwill.
move patients from hospitals to nursing homes without testing them.
“Hancock told us that people were going to be tested before they went back to care homes, what the hell happened?” he said. “Quite the opposite of putting a shield round them, we sent people with Covid back to the care homes.”
A spokesman for Downing Street said on Wednesday that Mr. Johnson did not believe Mr. Hancock had lied to him.
reported by the BBC but denied by Downing Street.
Asked if Mr. Johnson was the right person to guide the country through the pandemic, Mr. Cummings responded simply: “No.”
All over the world, countries are confronting population stagnation and a fertility bust, a dizzying reversal unmatched in recorded history that will make first-birthday parties a rarer sight than funerals, and empty homes a common eyesore.
Maternity wards are already shutting down in Italy. Ghost cities are appearing in northeastern China. Universities in South Korea can’t find enough students, and in Germany, hundreds of thousands of properties have been razed, with the land turned into parks.
Like an avalanche, the demographic forces — pushing toward more deaths than births — seem to be expanding and accelerating. Though some countries continue to see their populations grow, especially in Africa, fertility rates are falling nearly everywhere else. Demographers now predict that by the latter half of the century or possibly earlier, the global population will enter a sustained decline for the first time.
A planet with fewer people could ease pressure on resources, slow the destructive impact of climate change and reduce household burdens for women. But the census announcements this month from China and the United States, which showed the slowest rates of population growth in decades for both countries, also point to hard-to-fathom adjustments.
spirals exponentially. With fewer births, fewer girls grow up to have children, and if they have smaller families than their parents did — which is happening in dozens of countries — the drop starts to look like a rock thrown off a cliff.
“It becomes a cyclical mechanism,” said Stuart Gietel Basten, an expert on Asian demographics and a professor of social science and public policy at the Hong Kong University of Science and Technology. “It’s demographic momentum.”
Some countries, like the United States, Australia and Canada, where birthrates hover between 1.5 and 2, have blunted the impact with immigrants. But in Eastern Europe, migration out of the region has compounded depopulation, and in large parts of Asia, the “demographic time bomb” that first became a subject of debate a few decades ago has finally gone off.
South Korea’s fertility rate dropped to a record low of 0.92 in 2019 — less than one child per woman, the lowest rate in the developed world. Every month for the past 59 months, the total number of babies born in the country has dropped to a record depth.
schools shut and abandoned, their playgrounds overgrown with weeds, because there are not enough children.
To goose the birthrate, the government has handed out baby bonuses. It increased child allowances and medical subsidies for fertility treatments and pregnancy. Health officials have showered newborns with gifts of beef, baby clothes and toys. The government is also building kindergartens and day care centers by the hundreds. In Seoul, every bus and subway car has pink seats reserved for pregnant women.
But this month, Deputy Prime Minister Hong Nam-ki admitted that the government — which has spent more than $178 billion over the past 15 years encouraging women to have more babies — was not making enough progress. In many families, the shift feels cultural and permanent.
projections by an international team of scientists published last year in The Lancet, 183 countries and territories — out of 195 — will have fertility rates below replacement level by 2100.
municipalities have been consolidated as towns age and shrink. In Sweden, some cities have shifted resources from schools to elder care. And almost everywhere, older people are being asked to keep working. Germany, which previously raised its retirement age to 67, is now considering a bump to 69.
Going further than many other nations, Germany has also worked through a program of urban contraction: Demolitions have removed around 330,000 units from the housing stock since 2002.
recently increased to 1.54, up from 1.3 in 2006. Leipzig, which once was shrinking, is now growing again after reducing its housing stock and making itself more attractive with its smaller scale.
“Growth is a challenge, as is decline,” said Mr. Swiaczny, who is now a senior research fellow at the Federal Institute for Population Research in Germany.
Demographers warn against seeing population decline as simply a cause for alarm. Many women are having fewer children because that’s what they want. Smaller populations could lead to higher wages, more equal societies, lower carbon emissions and a higher quality of life for the smaller numbers of children who are born.
But, said Professor Gietel Basten, quoting Casanova: “There is no such thing as destiny. We ourselves shape our lives.”
The challenges ahead are still a cul-de-sac — no country with a serious slowdown in population growth has managed to increase its fertility rate much beyond the minor uptick that Germany accomplished. There is little sign of wage growth in shrinking countries, and there is no guarantee that a smaller population means less stress on the environment.
Many demographers argue that the current moment may look to future historians like a period of transition or gestation, when humans either did or did not figure out how to make the world more hospitable — enough for people to build the families that they want.
Surveys in many countries show that young people would like to be having more children, but face too many obstacles.
Anna Parolini tells a common story. She left her small hometown in northern Italy to find better job opportunities. Now 37, she lives with her boyfriend in Milan and has put her desire to have children on hold.
She is afraid her salary of less than 2,000 euros a month would not be enough for a family, and her parents still live where she grew up.
“I don’t have anyone here who could help me,” she said. “Thinking of having a child now would make me gasp.”
Elsie Chen, Christopher Schuetze and Benjamin Novak contributed reporting.
CAPRI, Italy — The ferry docked next to the blue “Capri a Covid Free Island” billboard and the residents and workers disembarked, carrying luggage and antibodies.
Among them was Mario Petraroli, 37, freshly vaccinated and ready for the grand reopening of the luxurious hotel where he works as director of marketing.
“The big day,” he said as he rode a funicular up above turquoise waters, terraced gardens dripping with lemons and winding cliff-side footpaths.
He reached the summit and stepped out onto a glamorous town famous for its Jackie O and J Lo sightings, exorbitantly priced Caprese salads, and reputation as a billionaire’s playground. Everyone around him — the shopkeepers unpacking the Pucci, Gucci and Missoni garments from plastic bags, the bartenders sliding ice into Spritzes, the carpenters hammering finishing touches on the underground Anema e Core Taverna dance club — had been vaccinated.
Mr. De Luca came to Capri’s famous piazzetta in the center of town to declare Mission Accomplished and to urge tourists to book their vacations on the islands.
Mr. Petraroli, the hotel marketing director, now crossed the same square, past copper-toned Capri enthusiasts who sipped and smoked, their faces pointed at the sun. He entered a warren of narrow streets, lined with Rolex outlets, brand name boutiques and Hangout, a popular pub in town owned by Simone Aversa.
Capri Tiberio Palace, which Kylie Jenner repaired to in a recent summer after, workers at the port told him, she felt unwell on her yacht.
The hotel is named for Tiberius, who ran the Roman Empire from Capri, throwing people off cliffs and training Caligula how to have a good time. Many here call him Capri’s first tourist.
Mr. Petraroli said modern hedonists were already calling, sending scouts to make sure that the vaccine situation, and vibe, is what they want.
“The real issue for them is once they are here, do they have something to do,” he said as workers carried an espresso machine and dusted the blinds.
Upstairs, Mr. Petraroli opened the Suite Bellevue, booked mostly by “sheikhs and sultans and very famous guys.” It leads to a terrace tiled with hand-painted ceramics, topped with a Jacuzzi plunge pool. Mr. Petraroli said the late basketball star Kobe Bryant had such a “special bond with our top suite” that he named his daughter Capri after staying there.
Outside the room, Alessandro De Simone, 23, dusted crystal decanters filled with cognac and whiskey. Mr. De Simone, who is also vaccinated, said none of his friends back home in Naples had been.
oldest cooperative of motorboat owners (“All our skippers and staff have been completely vaccinated!” reads their website) sped uninhibited around the island. He navigated through the island’s trademark Faraglione rock formations (“This is where Heidi Klum got married on a yacht”) and by La Fontelina beach club where three sunbathers, their knees bent and gleaming, laid under the cliff.
He lamented the “hysterical polemics about us getting vaccinated,” arguing that without a hospital, “if there was a cluster here, we had nothing to save our lives.”
He moored the boat back at the dock where more ferries brought a trickle of tourists, but also returning residents. Dario Portale, a local greengrocer, and his family, were among them.
The day after getting their shot, the couple left for Milan, in the country’s hard hit region of Lombardy, to introduce their 10-month-old son to his mother. She is 62, works in a post office and is not vaccinated.