Yes. The F.D.A. has updated its authorizations to allow medical providers to boost people with a different vaccine than the one they initially received, a strategy known as “mix and match.” Whether you received Moderna, Johnson & Johnson or Pfizer-BioNTech, you may receive a booster of any other vaccine. Regulators have not recommended any one vaccine over another as a booster. They have also remained silent on whether it is preferable to stick with the same vaccine when possible.

The C.D.C. has said the conditions that qualify a person for a booster shot include: hypertension and heart disease; diabetes or obesity; cancer or blood disorders; weakened immune system; chronic lung, kidney or liver disease; dementia and certain disabilities. Pregnant women and current and former smokers are also eligible.

The F.D.A. authorized boosters for workers whose jobs put them at high risk of exposure to potentially infectious people. The C.D.C. says that group includes: emergency medical workers; education workers; food and agriculture workers; manufacturing workers; corrections workers; U.S. Postal Service workers; public transit workers; grocery store workers.

Yes. The C.D.C. says the Covid vaccine may be administered without regard to the timing of other vaccines, and many pharmacy sites are allowing people to schedule a flu shot at the same time as a booster dose.

Chris Hipkins, the minister responsible for New Zealand’s Covid-19 response, acknowledged earlier this month that the decision to enlist gang leaders was an unusual one.

“Our No. 1 priority here is to stop Covid-19 in its tracks, and that means doing what we need to do to get in front of the virus,” he said. “Where we have been able to enlist gang leaders to help with that, and where they have been willing to do so, we have done that.”

Some gang leaders have acted independently to help the vaccination effort. They have connected members of their community to health officials, organized events with health professionals like Dr. Jansen, and streamed events on Facebook Live to allow an open forum for questions about rare health risks. In some cases, they have taken vaccines to communities themselves.

“Our community is probably less well informed; they’re probably not as health literate,” said Mr. Tam, the Mongrel Mob member, who is a former civil servant and who received the border exemption. Constant media criticism has turned them off from reading traditional news outlets, he added.

“They then resort to social media, because they have much greater control,” he said. “It’s also a space that perpetuates conspiracy theories and false information and all the rest of it.” Health advice has to come from trusted individuals and leaders in the community, he said.

In the past week, Mr. Tam has traveled almost the length of the country organizing pop-up vaccination events for members and their communities, as well as coordinating with other chapter leaders to get their members vaccinated, he said.

It was difficult work that put him at personal risk, he said, and that invited intense skepticism from people who thought of gangs only as violent or connected to organized crime.

“Why do we bother?” Mr. Tam said. “We bother because we care about those people that others don’t care about, as simple as that. They can talk about my gang affiliation, all the rest of it. But it’s that affiliation that allows me to have that penetration, that foot in the door. I can do the stuff that they can’t do.”

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Stocks Hit a Record as Investors See Progress Toward a Spending Deal

Wall Street likes what it’s hearing from Washington lately.

The S&P 500 inched to a new high on Thursday, continuing a rally aided by signs of progress in spending talks that could pave the way for an injection of some $3 trillion into the U.S. economy.

The index rose 0.3 percent to 4,549.78, its seventh straight day of gains and a fresh peak after more than a month of volatile trading driven by nervousness over the still-wobbly economic recovery and policy fights in Washington.

market swoon that began in September.

Share prices began to rise this month when congressional leaders struck a deal to allow the government to avoid breaching the debt ceiling, ending a standoff that threatened to make it impossible for the country to pay its bills. The rally has gained momentum as investors and analysts grow increasingly confident about a government spending package using a recipe Wall Street can live with: big enough to bolster economic growth, but with smaller corporate tax increases than President Biden’s original $3.5 trillion spending blueprint.

continuing supply chain snarls, higher prices for businesses and consumers and the Federal Reserve’s signals that it would begin dialing back its stimulus efforts all helped sour investor confidence. The S&P 500’s 4.8 percent drop in September was its worst month since the start of the pandemic.

It has made up for it in October, rising 5.6 percent this month. But it’s not just updates out of Washington that have renewed investors’ optimism.

The country has seen a sharp drop in coronavirus infections in recent weeks, raising, once again, the prospect that economic activity can begin to normalize. And the recent round of corporate earnings results that began in earnest this month has started better than many analysts expected. Large Wall Street banks, in particular, reported blockbuster results fueled by juicy fees paid to the banks’ deal makers, thanks to a surge of merger activity.

Elsewhere, shares of energy giants have also buoyed the broad stock market. The price of crude oil recently climbed back above $80 a barrel for the first time in roughly seven years, translating into an instant boost to revenues for energy companies.

debt limit, is a cap on the total amount of money that the federal government is authorized to borrow via U.S. Treasury bills and savings bonds to fulfill its financial obligations. Because the U.S. runs budget deficits, it must borrow huge sums of money to pay its bills.

On Thursday, analysts spotlighted the news that the White House and congressional Democrats were moving toward dropping corporate tax increases they had wanted to include in the bill, as they hoped to forge a deal that could clear the Senate. A spending deal without corporate tax increases would be a potential boon to profits and share prices.

“A stay of execution on higher corporate tax rates would seem a potentially noteworthy development,” Daragh Maher, a currency analyst with HSBC Securities, wrote in a note to clients on Thursday.

An agreement among Democrats on what’s expected to be a roughly $2 trillion spending plan would also open the door to a separate $1 trillion bipartisan infrastructure plan moving through Congress. Progressives in the House are blocking the infrastructure bill until agreement is reached on the larger bill.

But the prospects for an agreement have helped to lift shares of major engineering and construction materials companies. Terex, which makes equipment used for handling construction materials like stone and asphalt, has jumped more than 5 percent this week. The asphalt maker Vulcan Materials has risen more than 4 percent. Dycom, which specializes in construction and engineering of telecommunication networking systems, was up more than 9 percent.

The renewed confidence remains fragile, with good reason. The coronavirus continues to affect business operations around the world, and the Delta variant demonstrated just how disruptive a new iteration of the virus can be.

Another lingering concern involves the higher costs companies face for everything from raw materials to shipping to labor. If they are unable to pass those higher costs on to consumers, it will cut into their profits.

“That would be big,” Mr. McKnight said. “That would be a material impact to the markets.”

But going into the final months of the year — traditionally a good time for stocks — the market also has plenty of reasons to push higher.

The recent weeks of bumpy trading may have chased shareholders with low confidence — sometimes known as “weak hands” on Wall Street — out of the market, offering potential bargains to long-term buyers.

“Interest rates are relatively stable. Earnings are booming. Covid cases, thankfully, are dropping precipitously in the U.S.,” Mr. Zemsky said. “The weak hands have left the markets and there’s plenty of jobs. So why shouldn’t we have new highs?”

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Singapore Struggles to Reopen After Vaccinations

The country’s experience has become a sobering case study for other nations pursuing reopening strategies without first having had to deal with large outbreaks in the pandemic. For the Singapore residents who believed the city-state would reopen once the vaccination rate reached a certain level, there was a feeling of whiplash and nagging questions about what it would take to reopen if vaccines were not enough.

“In a way, we are a victim of our own success, because we’ve achieved as close to zero Covid as we can get and a very, very low death rate,” said Dr. Paul Tambyah, an infectious diseases specialist at National University Hospital. “So we want to keep the position at the top of the class, and it’s very hard to do.”

vaccinated people are already gathering at concerts, festivals and other large events. But unlike Singapore, both of those places had to manage substantial outbreaks early in the pandemic.

Lawrence Wong, Singapore’s finance minister and a chair of the country’s Covid-19 task force, said the lesson for “Covid-naive societies” like Singapore, New Zealand and Australia is to be ready for large waves of infections, “regardless of the vaccine coverage.”

up against the Delta variant, Mr. Wong said.

“In Singapore, we think that you cannot just rely on vaccines alone during this intermediate phase,” he said. “And that’s why we do not plan an approach where we reopen in a big bang manner, and just declare freedom.”

highest since 2012, a trend that some mental health experts have attributed to the pandemic. People have called on the government to consider the mental health concerns caused by the restrictions.

“It’s just economically, sociologically, emotionally and mentally unsustainable,” said Devadas Krishnadas, chief executive at Future-Moves Group, a consultancy in Singapore. Mr. Krishnadas said the decision to reintroduce restrictions after reaching such a high vaccination rate made the country a global outlier.

granted full approval to Pfizer-BioNTech’s coronavirus vaccine for people 16 and up, paving the way for mandates in both the public and private sectors. Such mandates are legally allowed and have been upheld in court challenges.

  • College and universities. More than 400 colleges and universities are requiring students to be vaccinated against Covid-19. Almost all are in states that voted for President Biden.
  • Schools. California became the first state to issue a vaccine mandate for all educators and to announce plans to add the Covid-19 vaccine as a requirement to attend school, which could start as early as next fall. Los Angeles already has a vaccine mandate for public school students 12 and older that begins Nov. 21. New York City’s mandate for teachers and staff, which went into effect Oct. 4 after delays due to legal challenges, appears to have prompted thousands of last-minute shots.
  • Hospitals and medical centers. Many hospitals and major health systems are requiring employees to get vaccinated. Mandates for health care workers in California and New York State appear to have compelled thousands of holdouts to receive shots.
  • Indoor activities. New York City requires workers and customers to show proof of at least one dose of the Covid-19 for indoor dining, gyms, entertainment and performances. Starting Nov. 4, Los Angeles will require most people to provide proof of full vaccination to enter a range of indoor businesses, including restaurants, gyms, museums, movie theaters and salons, in one of the nation’s strictest vaccine rules.
  • At the federal level. On Sept. 9, President Biden announced a vaccine mandate for the vast majority of federal workers. This mandate will apply to employees of the executive branch, including the White House and all federal agencies and members of the armed services.
  • In the private sector. Mr. Biden has mandated that all companies with more than 100 workers require vaccination or weekly testing, helping propel new corporate vaccination policies. Some companies, like United Airlines and Tyson Foods, had mandates in place before Mr. Biden’s announcement.
  • “I think a lot of times we are so focused on wanting to get good results that we just have tunnel vision,” she said.

    Ms. Ng lives across from a testing center. Almost daily, she watched a constant stream of people go in for tests, a strategy that many public health experts say is a waste of resources in such a highly vaccinated country.

    “Freedom Day — as our ministers have said — is not the Singapore style,” said Jeremy Lim, an associate professor at the National University of Singapore and an expert on health policy, referring to England’s reopening in the summer. But moving too cautiously over the potential disadvantages of restrictions is a “bad public health” strategy, he said.

    The government should not wait for perfect conditions to reopen, “because the world will never be perfect. It’s so frustrating that the politicians are almost like waiting for better circumstances,” Dr. Lim said.

    Sarah Chan, a deputy director at Singapore’s Agency for Science, Technology and Research, said she had a fleeting taste of what normal life was like when she arrived in Italy last month to visit her husband’s family.

    No masks were required outdoors, vaccinated people could gather in groups, and Dr. Chan and her son could bop their heads to music in restaurants. In Singapore, music inside restaurants has been banned based on the notion that it could encourage the spread of the virus.

    Dr. Chan said she was so moved by her time in Italy that she cried.

    “It’s almost normal. You forget what that’s like,” she said. “I really miss that.”

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    How Asia, Once a Vaccination Laggard, Is Revving Up Inoculations

    Then came the Delta variant. Despite keeping their countries largely sealed off, the virus found its way in. And when it did, it spread quickly. In the summer, South Korea battled its worst wave of infections; hospitals in Indonesia ran out of oxygen and beds; and in Thailand, health care workers had to turn away patients.

    With cases surging, countries quickly shifted their vaccination approach.

    Sydney, Australia, announced a lockdown in June after an unvaccinated limousine driver caught the Delta variant from an American aircrew. Then, Prime Minister Scott Morrison, who had previously said vaccination “was not a race,” called in July on Australians to “go for gold” in the country’s inoculation drive.

    He moved to overcome a supply shortage, compounded by the slow regulatory approval. In August, Australia bought one million Pfizer doses from Poland; this month, Mr. Morrison announced a purchase of a million Moderna shots from Europe.

    When the Delta outbreak emerged, fewer than 25 percent of Australians over the age of 16 had received a single shot. In the state of New South Wales, which includes Sydney, 86 percent of the adult population has now received a first dose, and 62 percent of adults are fully vaccinated. The country expects to fully inoculate 80 percent of its population over the age of 16 by early November.

    “There was great community leadership — there were people from across the political divide who came out to support vaccination,” said Greg Dore, an infectious-disease expert at the University of New South Wales. “It really helped us turn around a level of hesitancy that was there.”

    Many governments have used incentives to encourage inoculations.

    In South Korea, the authorities eased restrictions in August on private gatherings for fully vaccinated people, allowing them to meet in larger groups while maintaining stricter curbs for others. Singapore, which has fully vaccinated 82 percent of its population, previously announced similar measures.

    Researchers there have also analyzed the pockets of people who refuse to be inoculated and are trying to persuade them.

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    Phony Diagnoses Hide High Rates of Drugging at Nursing Homes

    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.

    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.

    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.)

    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.”

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    Why Would an Economist Ever Look on the Bright Side?

    “Economists are not known for looking at the glass half full,” said Ms. Coronado.

    (It is an enduring observation about her profession. Thomas Carlyle in the 19th century labeled the entire economics profession “the dismal science,” and given its ring of truth, the dreary title stuck.)

    Besides inflation, economists are worrying about possible asset bubbles. Central bank officials including Robert S. Kaplan, head of the Dallas Fed, and James Bullard, head of the St. Louis branch, have warned that policymakers should be keeping a careful eye on rising real estate prices. And as Delta surges, analysts of all stripes are watching closely to ensure that it does not slow shopping, traveling and dining out — while worrying that it will.

    The gray cloud that seems to hang over the profession might have a silver lining. It could be the case that by monitoring the risks around high inflation and watching for impending doom, the profession is setting up America for a more sustainable expansion down the road — one where government spending policy is more carefully crafted not to tax overextended industries, and where investors believe the Fed will act if needed, keeping exuberance in check.

    Mr. Dutta, an eternal optimist who has a habit of releasing all-caps tirades against his profession’s endemic pessimism, thinks people could be a little bit more excited without overdoing it.

    “THIS IS A CONSUMER SLOWDOWN??” he wrote in a recent note, pointing out that credit card spending data is holding up. He celebrated the last employment report, a robust reading, by titling it “JULY FIREWORKS.”

    He points out that many people think the economy would be even stronger right now if supply bottlenecks weren’t holding back production and preventing spending. At least some of that spending will presumably eventually take place when those holdups clear, setting up for stronger future growth. Plus, he points out that people are making decisions that they would not if they had a glum future in mind: Families are buying houses, which he calls the “the most irreversible-decision asset.” Businesses are buying equipment.

    He talks with an air of exasperation, like someone who has been right before. That is, in part, because he recently has been: Mr. Dutta, who has a bachelor’s from New York University but who lacks the fancy doctorates many of his counterparts claim, correctly argued that the economy would not slump headed into 2021, at a time when some Wall Street economists were looking for flat or even negative growth readings as infections surged.

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    Covid Vaccines Produced in Africa Are Being Exported to Europe

    Johnson & Johnson’s Covid vaccine was supposed to be one of Africa’s most important weapons against the coronavirus.

    The New Jersey-based company agreed to sell enough of its inexpensive single-shot vaccine to eventually inoculate a third of the continent’s residents. And the vaccine would be produced in part by a South African manufacturer, raising hopes that those doses would quickly go to Africans.

    That has not happened.

    South Africa is still waiting to receive the overwhelming majority of the 31 million vaccine doses it ordered from Johnson & Johnson. It has administered only about two million Johnson & Johnson shots. That is a key reason that fewer than 7 percent of South Africans are fully vaccinated — and that the country was devastated by the Delta variant.

    At the same time, Johnson & Johnson has been exporting millions of doses that were bottled and packaged in South Africa for distribution in Europe, according to executives at Johnson & Johnson and the South African manufacturer, Aspen Pharmacare, as well as South African government export records reviewed by The New York Times.

    donated by the United States. But about four million of the country’s 60 million residents are fully vaccinated.

    That left the population vulnerable when a third wave of cases crested over the country. At times in recent months, scores of Covid-19 patients at Helen Joseph Hospital in Johannesburg were waiting in the emergency department for a bed, and the hospital’s infrastructure struggled to sustain the huge volumes of oxygen being piped into patients’ lungs, said Dr. Jeremy Nel, an infectious-disease doctor there.

    “The third wave, in terms of the amount of death we saw, was the most heartbreaking, because it was the most avoidable,” Dr. Nel said. “You see people by the dozens dying, all of whom are eligible for a vaccine and would’ve been among the first to get it.”

    a United Nations-backed clearinghouse for vaccines that has fallen behind on deliveries. South Africa was slow to enter negotiations with manufacturers for its own doses. In January, a group of vaccine experts warned that the government’s “lack of foresight” could cause “the greatest man-made failure to protect the population since the AIDS pandemic.”

    announced in November. Aspen’s facility in Gqeberha, on South Africa’s southern coast, was the first site in Africa to produce Covid vaccines. (Other companies subsequently announced plans to produce vaccines on the continent.)

    South African officials hailed Aspen’s involvement as indispensable.

    Aspen “belongs to us as South Africans, and it is making lifesaving vaccines,” South Africa’s president, Cyril Ramaphosa, said during a visit to Aspen’s plant in March. He said he had pushed Johnson & Johnson to prioritize the doses made there for Africans.

    “I want them now,” Mr. Ramaphosa added. “I’ve come to fetch our vaccines.”

    results of a clinical trial suggested that the vaccine from AstraZeneca offered little protection from mild or moderate infections caused by the Beta variant that was circulating in South Africa.

    Weeks later, Johnson & Johnson and the government signed a contract for 11 million doses. South Africa ordered another 20 million doses in April. That would be enough to vaccinate about half the country.

    South Africa agreed to pay $10 per dose for the 11 million shots, according to the contract. That was the same price that the United Statespaid and slightly more than the $8.50 that the European Commission agreed to pay. The South African contract prohibited the government from banning exports of the vaccine, citing the need for doses to “move freely across national borders.”

    introduced export controls this year to conserve scarce supplies. India halted exports produced by the Serum Institute, which was supposed to be a major vaccine supplier to poor countries. In the United States, officials said they didn’t ban exports, but they didn’t need to. The combination of the extensive vaccine production on American soil and the high prices the U.S. government was willing to pay meant that companies made the delivery of shots for Americans a priority.

    Other benefits for Johnson & Johnson were embedded in the South African contract.

    While such contracts typically protect companies from lawsuits brought by individuals, this one shielded Johnson & Johnson from suits by a wider range of parties, including the government. It also imposed an unusually high burden on potential litigants to show that any injuries caused by the vaccine were the direct result of company representatives engaging in deliberate misconduct or failing to follow manufacturing best practices.

    “The upshot is that you have moved almost all of the risk of something being wrong with the vaccine to the government,” said Sam Halabi, a health law expert at Georgetown University who reviewed sections of the South African contract at the request of The Times.

    Mr. Halabi said the contract’s terms appeared more favorable to the pharmaceutical company than other Covid vaccine contracts he had seen. South African officials have said Pfizer, too, sought aggressive legal protections.

    The contract said Johnson & Johnson would aim to deliver 2.8 million doses to South Africa by the end of June, another 4.1 million doses by the end of September and another 4.1 million doses by the end of December. (The government expects the 20 million additional doses to be delivered by the end of this year, Mr. Maja said.)

    The company has so far fallen far short of those goals. As of the end of June, South Africa had received only about 1.5 million of the doses from its order. The small number of doses that have been delivered to the African Union were on schedule.

    The difficulties in procuring doses have revealed the limits of fill-and-finish sites, which leave countries dependent on vaccines from places like the European Union or the United States, said Dr. Salim Abdool Karim, who until March was co-chairman of South Africa’s ministerial advisory committee on Covid.

    “Ultimately,” he said, “the solution to our problem has to be in making our own vaccines.”

    Lynsey Chutel and Choe Sang-Hun contributed reporting.

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    July C.P.I. Report: Inflation Rose Quickly Again

    Fed officials are willing to look past the elevated readings specifically because they are expected to be, as central bankers often say, “transitory.” They would worry more about a generalized, economywide pickup in prices that happens year after year, chipping away at consumer paychecks and potentially influencing how businesses and households live their economic lives.

    But policymakers are still eager to see their expectation for an inflation slowdown borne out.

    A “narrative for why the current supply and demand constraints might be expected to ease over time strikes me as a reasonable baseline,” Esther George, president of the Federal Reserve Bank of Kansas City, said in a speech Wednesday after the report, while emphasizing that the “narrative would be incomplete without acknowledging the risks.”

    Ms. George pointed to the rise in coronavirus infections tied to the Delta variant, which could keep supply chains kinked, and to household savings, which could keep consumers spending strongly and economic conditions “tight.”

    Economists have flagged other forces that could sustain inflation. Goldman Sachs noted in a recent research note that revised-down production schedules at automakers suggest that some price pressures in the car industry could last into the fall. Shipping experts report continued delays and cost increases, which could also feed into consumer prices.

    And moderation alone is not enough to take the pressure off the Fed and White House: Policymakers need a substantial cool-down. July’s 0.5 percent monthly increase was less rapid than the 0.9 percent gain from May to June, but if the current pace continued for a year, inflation would pick up by nearly 6 percent on an annual basis. That could leave consumers with substantially less purchasing power.

    Fed officials will be watching for signs that today’s price increases are getting locked into consumer and business expectations, which could make them more lasting.

    Wage increases and inflation expectations offer key signals about the future of inflation. If pay takes off on a sustained basis, employers may find that they need to charge more to cover their expenses. Likewise, if consumers and businesses start to expect rapid price increases, they may be more willing to accept higher prices, setting off a self-fulfilling prophecy.

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    Companies Begin to Mandate Covid Vaccines for Employees

    Some of the nation’s largest employers, for months reluctant to wade into the fraught issue of whether Covid-19 vaccinations should be mandatory for workers, have in recent days been compelled to act as infections have surged again.

    On Tuesday, Tyson Foods told its 120,000 workers in offices, slaughterhouses and poultry plants across the country that they would need to be vaccinated by Nov. 1 as a “condition of employment.” And Microsoft, which employs roughly 100,000 people in the United States, said it would require proof of vaccination for all employees, vendors and guests to gain access to its offices.

    Last week, Google said it would require employees who returned to the company’s offices to be vaccinated, while Disney announced a mandate for all salaried and nonunion hourly workers who work on site.

    Other companies, including Walmart, the largest private employer in the United States, and Lyft and Uber, have taken a less forceful approach, mandating vaccines for white-collar workers but not for millions of frontline workers. Those moves essentially set up a divide between the employees who work in offices and employees who deal directly with the public and, collectively, have been more reluctant to get the shots.

    different set of reasons that are not primarily political. They say many of their members are worried about potential health side effects or bristle at the idea of an employer’s interfering in what they regard as a personal health decision.

    Marc Perrone, the president of the United Food and Commercial Workers union, representing 1.3 million employees in grocery chains such as Kroger and at large meatpacking plants, said he would not support employer mandates until the Food and Drug Administration gave full approval to the vaccine, which is being administered on an emergency basis.

    “You can’t just say, ‘Accept the mandate or hit the door,’” Mr. Perrone said in an interview on Monday.

    After Tyson announced its vaccine mandate on Tuesday, Mr. Perrone issued a statement that the union “will be meeting with Tyson in the coming weeks to discuss this vaccine mandate and to ensure that the rights of these workers are protected and this policy is fairly implemented.”

    several meat plants became virus hot spots. Now, it is requiring its leadership team to be vaccinated by Sept. 24 and the rest of its office workers by Oct. 1. Frontline employees have until Nov. 1 to be fully inoculated, extra time the company is providing because there are “significantly more frontline team members than office workers who still need to be vaccinated,” a Tyson spokesman said.

    Throughout the pandemic, companies have treaded carefully in carrying out public health measures while trying to avoid harm to their businesses.

    Last year, when major retailers began requiring customers to wear masks, they quietly told their employees not to enforce the rule if a customer was adamant about not wearing one.

    Companies like Walmart have tried a similarly tentative approach with vaccine requirements.

    Walmart announced last week that it was requiring the roughly 17,000 workers in its Arkansas headquarters to be vaccinated but not those in stores and distribution centers, who make up the bulk of its 1.6 million U.S. employees.

    In a statement, the retailer said the limited mandate would send a message to all workers that they should get vaccinated.

    “We’re asking our leaders, which already have a higher vaccination rate, to make their example clear,” the company said. “We’re hoping that will influence even more of our frontline associates to become vaccinated.”

    Lyft told their corporate employees last week that they would need to show proof they had been inoculated before returning to company offices.

    Requiring vaccinations “is the most effective way to create a safe environment and give our team members peace of mind as we return to the office,” said Ashley Adams, a spokeswoman for Lyft.

    But those mandates did not extend to the workers the companies contract with to drive millions of customers to and from their destinations. The drivers are being encouraged to be vaccinated, but neither Lyft or Uber has plans to require them.

    Public health experts warn that limited mandates may reinforce the gaping divide between the nation’s high- and low-wage workers without furthering the public health goal of substantially increasing vaccination rates.

    They also say it’s naïve to think that workers who resisted vaccines for ideological reasons would suddenly change their mind after seeing a company’s higher-paid executives receive the shots.

    “Ultimately we want to ensure that they really have the broadest reach,” Dr. Kirsten Bibbins-Domingo, the vice dean for population health and health equity at the University of California, San Francisco, said of company directives. “Failing to do that, I think, will only cause others to be more suspicious of these types of mandates.”

    Legally, companies are likely to be on solid ground if they mandate vaccines. Last year, the Equal Employment Opportunity Commission said employers could require immunization, though companies that do could still face lawsuits.

    George W. Ingham, a partner at the law firm Hogan Lovells, said companies with mandates would potentially have to make difficult decisions.

    “They are going to have to fire high performers and low performers who refuse vaccines,” he said. “They have to be consistent.” Reasons an employee could be exempted include religious beliefs or a disability, though the process of sorting those out on an individual basis promises to be an arduous one.

    Companies may also have to contend with pushback from state governments. Ten states have passed legislation limiting the ability to require vaccines for students, employees or the public, according to the National Conference of State Legislatures.

    Disney is among the few big companies pursuing a broad vaccine mandate for their work forces, even in the face of pushback from some employees.

    In addition to mandating vaccines for nonunion workers who are on-site, Disney said all new hires — union and nonunion — would be required to be fully vaccinated before starting their jobs. Nonunion hourly workers include theme park guest-relations staff, in-park photographers, executive assistants and some seasonal theme park employees.

    It was the furthest that Disney could go without a sign-off from the dozen unions that represent the bulk of its employees. Walt Disney World in Florida, for instance, has more than 65,000 workers; roughly 38,000 are union members.

    Disney is now seeking union approval for the mandate both in Florida and in California, where tens of thousands of workers at the Disneyland Resort in Anaheim are unionized. Most of the leaders of Disney’s unions appear to be in favor of a mandate — as long as accommodations can be worked out for those refusing the vaccine for medical, religious or other acceptable reasons.

    “Vaccinations are safe and effective and the best line of defense to protect workers, frontline or otherwise,” Eric Clinton, the president of UNITE HERE Local 362, which represents roughly 8,000 attraction workers and custodians at Disney World, said in a phone interview.

    Mr. Clinton declined to comment on any pushback from his membership, but another union leader at Disney World, speaking on the condition of anonymity so he could speak candidly, said “a fair number” of his members were up in arms over Disney-mandated vaccinations, citing personal choice and fear of the vaccine.

    “The company has probably done a calculation and decided that some people will unfortunately quit rather than protect themselves, and so be it,” the person said.

    Lananh Nguyen contributed reporting.

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    Why Tunisia’s Promise of Democracy Struggles to Bear Fruit

    GAZIANTEP, Turkey — In the 10 years since its popular uprising set off the Arab Spring, Tunisia has often been praised as the one success story to emerge from that era of turbulence. It rejected extremism and open warfare, it averted a counterrevolution, and its civic leaders even won a Nobel Peace Prize for consensus building.

    Yet for all the praise, Tunisia, a small North African country of 11 million, never fixed the serious economic problems that led to the uprising in the first place.

    It also never received the full-throated support of Western backers, something that might have helped it make a real transition from the inequity of dictatorship to prosperous democracy, analysts and activists say. Instead, at critical points in Tunisia’s efforts to remake itself, many of its needs were overlooked by the West, for which the fight against Islamist terrorism overshadowed all other priorities.

    Now, as Tunisians grapple with their latest upheaval, which began when President Kais Saied dismissed the prime minister and suspended Parliament over the weekend, many seem divided on whether to condemn his actions — or embrace them.

    terrorism and the pandemic, Mr. Kaboub said.

    overthrew the country’s authoritarian president of 23 years, Zine el-Abidine Ben Ali.

    But Western officials were obsessively focused on the Islamists — namely the Ennahda, or Renaissance, party that swept early elections — and where they were going and what they represented.

    “In conversations, those sorts of questions ate up almost all the oxygen in the room,” Ms. Marks said. “It was almost impossible to get anybody to ask another question.”

    awarded the Nobel Peace Prize in 2015 — to the point that it became a “fetish,” she said.

    After the 2011 revolution, Al Qaeda and other extremists were quick to mobilize networks of recruits.

    Terrorism burst into the open in 2012 when the U.S. Embassy in Tunis came under attack from a mob. Over the years that followed, extremist cells carried out a string of political assassinations and suicide attacks that shattered Tunisians’ optimism and nearly derailed the democratic transition.

    training and assisting Tunisian security forces, and supplying them with military equipment, but so discreetly that the American forces themselves were virtually invisible.

    By 2019, some 150 Americans were training and advising their Tunisian counterparts in one of the largest missions of its kind on the African continent, according to American officials. The value of American military supplies delivered to the country increased to $119 million in 2017 from $12 million in 2012, government data show.

    The assistance helped Tunisia defeat the broader threat of terrorism, but government ministers noted that the cost of combating terrorism, while unavoidable, burned a larger hole in the national budget.

    But it is the structure of the economy that remains the root of the problem, Mr. Kaboub said. All of Tunisia’s political parties have identical economic plans, based on World Bank and International Monetary Fund guidelines. It was the same development platform used by the ousted president, Mr. Ben Ali, Mr. Kaboub said.

    “Right now,” he said, “everybody in Tunisia is begging for an I.M.F. loan, and it is going to be seen as the solution to the crisis. But it is really a trap. It’s a Band-Aid — the infection is still there.”

    Lilia Blaise contributed reporting from Tunis.

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