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  • Medi-Cal will soon be open to all, 'papers or no papers.' She wants her neighbors to know

    Medi-Cal will soon be open to all, 'papers or no papers.' She wants her neighbors to know

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    As parents hustled to pick up their kids from a school in South Los Angeles, Juana Dominguez greeted one after another with the same question in Spanish: “Do you have Medi-Cal?”

    “Don’t be afraid to get it,” she urged mothers pushing strollers in the afternoon sun. She paused to chat up street vendors hawking raspados and hot dogs, encouraging them as well, as she handed out fliers.

    Many already knew Dominguez from the brightly painted Paloma Market nearby, where she can regularly be found selling tacos at a table out front. On this stretch of Main Street, she also dishes out health information through a program that turns vendors into “community messengers.”

    Dominguez is on a mission to make sure her neighbors know that “papers or no papers, you’re going to get help from Medi-Cal.” That’s because in January, the state will open its Medicaid program to anyone whose income is low enough to qualify, no matter their immigration status.

    It’s the culmination of a steady expansion of the California health insurance program, which has already grown to include children, young adults and seniors regardless of their legal status. As of last year, the uninsured rate among immigrants in California without U.S. citizenship was estimated to be 21% — lower than in 36 other states, according to a KFF analysis of data from the U.S. Census Bureau’s American Community Survey.

    Next year, California will extend Medi-Cal benefits to the last remaining group of undocumented people — those ages 26 to 49 — in what is expected to be its biggest expansion of coverage since key provisions in the Affordable Care Act were implemented in 2014. State officials have estimated that more than 700,000 people will be eligible to gain “full scope” coverage for the first time, helping them access important services such as preventative care and treatment for chronic conditions.

    Juana Dominguez hands out information about Medi-Cal in South Los Angeles. The government health insurance program gears up for an upcoming expansion to serve eligible people of all ages regardless of immigration status.

    (Wally Skalij / Los Angeles Times)

    Dominguez wants people to be aware of the opportunity, and to make use of their new coverage. In California, people who lack valid visas, green cards or U.S. citizenship have been less likely than other immigrants to go to the doctor, with 29% saying they had never gotten or tried to get medical care in the U.S., a KFF/L.A. Times survey this year found.

    Fear is rampant in the community, Dominguez said, as people worry that signing up for or using such benefits could jeopardize their chances of getting a green card or citizenship. Under the “public charge” rule, people can be blocked from legal status if they are likely to become “primarily dependent” on government aid.

    Medi-Cal benefits do not factor into those decisions except in cases involving long-term stays in mental health or nursing institutions, advocates said. As Dominguez made her rounds on Main Street, she repeatedly reassured people: “It’s not a public charge for the government.”

    Dozens of vendors such as Dominguez have been talking up Medi-Cal as part of an unusual program that mobilizes street vendors around public health issues that are important to them. The program, run by the community health network AltaMed in partnership with the nonprofit Inclusive Action for the City, launched nearly two years ago and provides vendors a quarterly stipend for their efforts.

    The street vendors “identified that their community members are undocumented people who have been historically excluded from all healthcare systems,” said Rosa Vazquez, manager for community mobilizing for the AltaMed Institute for Health Equity. Their biggest goal has been ensuring the people they reach get information “so that they can make the best choices for their own health.”

    This year, that “has meant a particular focus on Medi-Cal expansion,” Vazquez said.

    Rosa Vazquez talks with vendors Aurora Alejo and Juana Dominguez during a training for street vendors on Medi-Cal expansion.

    Rosa Vazquez, right, talks with Aurora Alejo, left, and Juana Dominguez during a training for street vendors by the AltaMed Institute for Health Equity.

    (Brian van der Brug / Los Angeles Times)

    In November, the vendors gathered at a Boyle Heights office to learn about the state effort. Vazquez laid out details about income limits for the program, what it would cover, and how people could apply.

    In the KFF/L.A. Times survey, more than a third of California immigrants who are probably undocumented — those who said they did not have valid visas, green cards or citizenship — said they steered clear of public programs that help pay for food, housing or healthcare because they didn’t want to draw attention to their own immigration status or that of a family member.

    The survey also found that 70% were unsure if using such programs could decrease their chances of getting a green card, while another 16% believed that it would.

    Under the Trump administration, a new rule added Medicaid to the list of assistance programs that could factor into public charge determinations. The rule was challenged in court and President Biden officially removed it shortly after taking office, but apprehension has remained.

    Sarah Dar, a policy director with the California Immigrant Policy Center, said that “especially under the previous presidential administration, there was a message being sent to these communities that you’re not deserving of public benefits and you shouldn’t access services.”

    For the Medi-Cal program to “all of a sudden be available to people, it’s going to take really trusted messengers to reach these folks,” she said during a November webinar hosted by the UCLA Latino Policy and Politics Institute and the California Endowment.

    In Fresno, those trusted messengers could include Centro La Familia Advocacy Services, a nonprofit founded more than half a century ago to help immigrants apply for government programs that had forms only in English. The nonprofit will be extending its hours on Saturdays to accommodate farmworkers, who often can’t make it to their centers during the week, as well as sharing information on Spanish-language Univision and heading directly to the fields to meet workers.

    “It is still difficult” for many immigrants who lack the literacy skills to navigate Medi-Cal paperwork, even when translated into Spanish, said its executive director, Margarita Rocha.

    TODEC Legal Center, an immigrant advocacy organization, provides similar outreach in the Inland Empire. Farmworkers there “don’t come to government institutions for aid because of the fear,” said Luz Gallegos, the group’s executive director. “We have to go to them.”

    Gallegos said TODEC has been trying to raise awareness about Medi-Cal for years, starting with the first expansion that covered children regardless of immigration status. It has recruited farmworkers who signed up for coverage for themselves or their kids to encourage others to apply. Now these volunteers show off their Medi-Cal cards and share stories about how they benefited from the program.

    The group has also brought Riverside and San Bernardino county officials out to work sites to register farmworkers for Medi-Cal, with its own volunteers on hand to help establish trust.

    And in Mendocino County, workers at Anderson Valley Health Center in Boonville have been heading out to local vineyards, asking companies to tuck informational fliers alongside pay stubs, and phoning uninsured patients to let them know about the upcoming expansion.

    “This group is probably the hardest” to reach compared with those who have gotten Medi-Cal so far, said Chloe Guazzone, executive director of the health center. As patients, “they don’t tend to come to us unless there’s an urgent issue because they’re uninsured,” she said, “so finding them in the first place” can be difficult.

    In Los Angeles, Dominguez said she was motivated to bring information to her community by the death of her friend Angel Vasquez, a kindly jokester who lived near Paloma Market.

    When Vasquez got COVID-19 the first winter of the pandemic, he held off on calling for an ambulance, Dominguez said. She says she believes he was worried about the cost. His son, also named Angel Vasquez, said family members in Guatemala told the man to go to the hospital, but Vasquez initially insisted it was just a fever.

    “He went to the hospital very late — I think too late,” his son said.

    Juana Dominguez hands out information about Medi-Cal along Main Street in South Los Angeles.

    Juana Dominguez hands out information about Medi-Cal along Main Street in South Los Angeles.

    (Wally Skalij / Los Angeles Times)

    Vasquez died in May 2021 at the age of 55, his son said. Dominguez was haunted by the thought that if he had gone to the hospital sooner, her friend might have lived.

    “My kids miss him a lot,” she said.

    As she finished up her rounds on Main Street, she paused to point out where Vasquez had once lived. When she had the opportunity to reach out to neighbors about Medi-Cal, “I thought, ‘Juana, your community needs this information.’ … This gives me the drive to persist with it.”

    California officials have estimated that more than 700,000 people will be able to transition from “restricted scope” to “full scope” Medi-Cal next year. Being in “restricted scope,” which helps reimburse hospitals for emergency care, means “they’re in the system, we know who they are … we know that they’re income-eligible for Medi-Cal,” said Anthony Wright, executive director of the healthcare consumer advocacy group Health Access California.

    “It is an incredibly useful way to automatically enroll” people who will now gain coverage for a range of care needed beyond the emergency room, Wright said. “We’re really glad the state has taken efforts to try to do this as automatically and seamlessly as possible.”

    California’s Department of Health Care Services said it’s unknown how many people who aren’t already in the “restricted scope” program will be newly eligible for Medi-Cal. The state has budgeted $1.4 billion for the expansion this fiscal year and $3.4 billion annually when it is fully implemented.

    Researchers at UC Berkeley and UCLA estimate that among Californians under the age of 65, the Medi-Cal expansion will reduce the uninsured rate among immigrants without legal status from 58.4% to 27.8%. Despite that sharp reduction, it would still remain far higher than the estimated uninsured rate of 7% for all Californians in that age group.

    Experts said hundreds of thousands of immigrants will remain uninsured because they make too much money to qualify for Medi-Cal, but don’t have affordable coverage through their employers.

    Wright said people in that situation can buy health insurance on their own, “but then the question is, is it accessible? Is it affordable? Is it administratively easy?”

    Those without legal status will remain ineligible for financial assistance to buy health coverage through Covered California, the state marketplace for insurance coverage. He and other advocates are now pushing the state to come up with an option to help them as well.

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    Emily Alpert Reyes, Melissa Gomez, Priscella Vega

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  • L.A. County delays implementation of new criteria for gravely disabled

    L.A. County delays implementation of new criteria for gravely disabled

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    The Los Angeles County Board of Supervisors voted Tuesday to delay the implementation of Senate Bill 43, the landmark legislation that expands the criteria by which people can be detained against their wills by police, crisis teams and mental health providers.

    The motion to delay, proposed by Supervisor Lindsey Horvath, was passed on a 4-1 vote. L.A. County now joins 45 other counties that have formally declared their intention to hold off implementation. Supervisor Janice Hahn cast the lone dissenting vote.

    “I know there are people on our streets who are not going to survive and maybe would have a chance if we implemented this sooner to help them get the treatment that they need,” Hahn said to her colleagues.

    SB 43 gave counties the option to implement the law either at the start of 2024 or not until Jan. 1, 2026. In her motion, Horvath cited “the immense amount of work” required to implement the law, which adds severe substance use disorder to the longstanding definition of gravely disabled.

    “We cannot afford the liability cases and the risk of civil right violations and risk getting this wrong,” Horvath said at the board meeting.

    Passed by state legislators in September and signed by Gov. Gavin Newsom in October, SB 43 represents the first major revision of the state’s 1967 conservatorship law, the Lanterman-Petris-Short Act.

    It is intended to address not only the epidemic of mental illness among homeless populations in the state but also the proliferation of highly addictive drugs, such as fentanyl and methamphetamine, which researchers say exacerbate psychotic disorders.

    However, according to the motion, the size of the crisis presents logistical problems for counties responsible for administering involuntary holds that proceed conservatorship hearings. Adding severe substance use disorder to the definition of gravely disabled could lead to a 10% increase of those involuntarily detained, according to the supervisor’s motion.

    Los Angeles County joins a majority of counties across the state tapping the brakes on what Newsom considers crucial legislation for transforming California’s behavioral health landscape. Last week, he lambasted those who chose to wait.

    “You have a crisis out there,” he said at a news conference. “There is a crisis on the streets, and people are talking about delaying the conservatorship efforts until 2026. We can’t afford to wait. The state has done its job. It’s time for the counties to do their job … with a deeper sense of urgency. They have to recognize that people are dying on their watch. People are literally losing their lives, and we can’t waste another day.”

    The supervisors’ decision to delay comes three weeks after the county Department of Mental Health issued a report on the feasibility of implementing SB 43 at the start of the new year. Written in conjunction with the county Department of Public Health’s Bureau of Substance Abuse Prevention and Control, the report recommended holding off on implementation.

    Among the reasons was the need to increase training to ensure appropriate and consistent understanding of the definition of “grave disability” among those qualified to initiate an involuntary hold and perhaps most crucially, to address a shortage of treatment facilities for those with medical, substance use and mental health treatment needs.

    The county currently has no locked facilities for treating substance use disorder.

    “Our mental health service system, while larger than it was in the 1960s, is still under-resourced and under-staffed,” according to Horvath’s motion, which references the “disastrous results” of not developing community services following the closure of state psychiatric hospitals in the 1970s. “This board cannot afford to make the same mistakes that our state leaders did decades ago.”

    Prior to the vote, Hahn had expressed disappointment with efforts to stall SB 43.

    “We have a drug addiction and mental health crisis on our streets, and I want to see a sense of urgency from our county departments,” she said in a statement. “I think we can get this done sooner, and I want to see us try.”

    In a letter of support for the motion, the Hospital Assn. of Southern California, representing 170 hospitals in six counties, recommended waiting.

    “The current behavioral health system is not prepared to support the influx of new patients meant to be served by this law and our hospital emergency departments are not prepared to hold and care for these patients until we can identify appropriate treatment,” wrote Adena Tessler, a regional vice president with the group. “A rushed implementation of this expanded definition, without proper preparation, is not in the best interest of the very patients it is intended to help.”

    San Francisco and San Luis Obispo counties have indicated that they will implement SB 43 at the start of the new year, and last week by a vote of 3 to 2, the San Diego County Board of Supervisors agreed to delay implementation until January 2025, when it will reevaluate its readiness to adapt the new criteria ahead of the 2026 deadline.

    But “the expectation is that it will be implemented within a year,” said Luke Bergmann, director of behavioral health services for San Diego County.

    While logistical constraints have led to the decision to delay implementation, there is also concern that SB 43 might be challenged in court as an impingement upon civil liberties. Soon after the CARE Act was passed in 2022, three civil rights groups challenged the law in court. Their petition was ultimately dismissed.

    Although no lawsuit has been filed against SB 43, Disability Rights California, which opposed the legislation, argued against a hurried roll-out.

    “It’s really disheartening to hear the governor criticize counties for exercising an option — deferral — he agreed to in SB 43,” said Deb Roth, a senior legislative advocate. “It seems very short-sighted not to want county-readiness before implementing such major changes.”

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    Thomas Curwen

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  • Prison for man who shot three people in Auckland CBD, including Jay-Jay Feeney’s brother – Medical Marijuana Program Connection

    Prison for man who shot three people in Auckland CBD, including Jay-Jay Feeney’s brother – Medical Marijuana Program Connection

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    Poull Andersen and two others were injured in the shooting on Fort St, Auckland, in March 2022. Photo / Supplied

    A man with gang ties who wounded three people with a single shot from a homemade firearm outside a central Auckland kebab shop – including business owner Poull Andersen, the brother of well-known radio personality Jay-Jay Feeney – has been sentenced to prison.

    The defendant, now 20 and with continuing interim name suppression, appeared before Judge Kathryn Maxwell in Auckland District Court this morning as she mused over his unusually substantive criminal history for someone so young.

    He has spent some of his time since the March 5, 2022, shooting remanded in a maximum security jail cell, where he has at times spent 23 hours per day in lockdown.

    “You have to take some responsibility, though, of course, for that difficulty on remand,” the judge said, blaming the difficult conditions on “how you are acting in prison”.

    AdvertisementAdvertise with NZME.

    The defendant was ordered to serve a sentence of five years and seven months for three counts of wounding with intent to cause grievous bodily harm with a firearm and a concurrent six-month sentence for receiving $1700 worth of stolen goods as the result of an unrelated road rage incident.

    He was 18 when arrested last year for the shooting, which took place around 2am on a Saturday on central Auckland’s Fort St, where some businesses catering to the nightclub scene remained open.

    Court documents state the teen…

    Original Author Link click here to read complete story..

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    MMP News Author

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  • 2023 is already San Francisco's deadliest year for drug overdoses

    2023 is already San Francisco's deadliest year for drug overdoses

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    The year isn’t over, but San Francisco has already hit a grim milestone: 2023 is the deadliest on record for fatal drug overdoses.

    More than 750 people died in accidental drug overdoses during the first 11 months of 2023, according to a report released this week from the city and county office of the chief medical examiner. That surpassed the 726 seen during the last recorded high, in 2020 — which was a horrific rise from the year before.

    “We have seen record numbers of deaths due to overdose in San Francisco in 2023, or are likely to,” Hillary Kunins, director of behavioral and mental health at the San Francisco Department of Public Health, said at a press conference Thursday.

    More than 80% of the overdose deaths in 2023 involved fentanyl, the data show. Black San Franciscans continued to make up a disproportionate share of the victims.

    Even as state and local leaders have shifted their response to the growing drug crisis, focusing in recent months on increased law enforcement crackdowns, health officials remain dedicated to a multifaceted approach to saving lives.

    This week, city officials announced a partnership with the National Institute of Drug Abuse that will test wastewater for certain drugs, including fentanyl, methamphetamine and cocaine, as well as naloxone, the opioid reversal medication most commonly known by its brand name, Narcan.

    “In an era when fentanyl is claiming lives at an unprecedented rate, we need all information available to us to give us a more complete picture and guide our response,” said Jeffrey Hom, director of population behavior health for the Public Health Department. He is hopeful the data will provide “a more complete picture of the trends in drug use … allowing us to act faster when emerging substances, like xylazine, are increasing in the local drug supply.”

    Xylazine, commonly known as “tranq,” has become a new concern for health officials and will be tested in wastewater under the program. The flesh-rotting drug has been linked to fatal overdoses in San Francisco and Los Angeles, and has sparked concerns that it could worsen the overdose crisis.

    San Francisco officials reported that 30 of the overdose deaths so far in 2023 involved xylazine.

    But fentanyl, the synthetic opioid that is 50 times more potent than heroin, continues to drive overdose deaths in San Francisco, a trend mirrored in Los Angeles and across the nation, in big cities and smaller metro areas.

    In San Francisco, Black people and those experiencing homelessness died at the highest rates from drug overdoses, the report found. Almost a third of the people who died of overdose this year were Black, although Black people make up only about 7% of the city’s population.

    Similarly, almost 30% of those who died of overdose in San Francisco did not have a fixed address, the report found. Of those who did have an address, the highest percentage — 21% — lived in the Tenderloin, the neighborhood that has become ground zero for the city’s exploding homelessness crisis.

    The 2023 spike comes after drug overdoses in San Francisco fell slightly in the previous two years. Analysis from the San Francisco Chronicle, which tracks the city’s overdoses, found that if current trends continue, another 68 deaths could be added to the count by the end of the year.

    Public health officials say they plan to continue working to expand treatment options for people with substance-use disorders, including medication-assisted treatment, increased awareness and supplies of naloxone and exploration of innovative solutions, such as contingency management programs, to help people get — and stay — off deadly drugs.

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    Grace Toohey

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  • COVID-19 and flu cases are rising in California. How bad will the holiday uptick be?

    COVID-19 and flu cases are rising in California. How bad will the holiday uptick be?

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    COVID-19 and flu are rising across California, sparking new warnings from health officials to take precautions as the wider winter holiday season looms.

    The uptick is modest and not wholly unexpected — wintertime surges have been an annual occurrence since the coronavirus first emerged. But experts say lagging uptake of the latest reformulated vaccines has left some populations particularly vulnerable to severe health outcomes that are largely preventable at this point.

    Over the week that ended Dec. 9, 2,449 Californians were newly admitted to hospitals with a coronavirus infection, up 40% over the last month, according to federal data.

    California was considered to have “high” viral illness activity level as of Dec. 9, among the worst designations in the country, the U.S. Centers for Disease Control and Prevention said.

    A color-coded map of the United States
    As of Dec. 9, California was considered to have a “high” level of flu-like illness, which includes viral illnesses such as COVID-19 and respiratory syncytial virus, or RSV.

    (U.S. Centers for Disease Control and Prevention )

    “Respiratory illness activity is rapidly increasing across the United States,” the CDC said in a bulletin Thursday afternoon. “Millions of people may get sick in the next month or two, and low vaccination rates mean more people will get more severe disease. Getting vaccinated now can help prevent hospitalizations and save lives.”

    A rise in viral illness is expected this time of year, but the prevalence of COVID-19 adds a considerable health burden that didn’t exist before the pandemic. COVID-19 remains the primary cause of new respiratory hospitalizations and deaths nationally, causing 1,000 fatalities a week.

    “COVID is still causing the most number of cases, the most number of hospitalizations and the most, unfortunately, number of deaths that we’re seeing week over week,” Dr. Mandy Cohen, director of the CDC, said in an online discussion Tuesday. “So while we all wish we could leave COVID in the rearview mirror, it is still here with us, and so we need to make sure we are continuing to take it very seriously.”

    Cohen last week urged people to take precautions such as getting vaccinated, avoiding people who are sick and staying home when ill, regular hand-washing, improving air ventilation and wearing a mask.

    “And get tested, so you know what you have and you can get treatment,” she said. “Getting tested and treated early can prevent you from getting severely ill, being hospitalized and can potentially save your life.”

    Relatively speaking, COVID-19, flu and another ailment — respiratory syncytial virus, or RSV — aren’t at the heights they were this time last year, when their simultaneous circulation spawned a “tripledemic” that stressed healthcare facilities across the state, especially children’s hospitals.

    Kaiser Permanente Southern California began noticing more COVID-19 illness starting in mid-November, with the rise accelerating after Thanksgiving, said Dr. Nancy Gin, regional medical director of quality and clinical analysis for the health system.

    Coronavirus levels in Los Angeles County wastewater were at 38% of last winter’s peak for the week that ended Dec. 2, the most recent data available. That’s exactly the same as the height seen late this summer, when the region experienced a prolonged uptick in infections.

    The latest figure signals a “medium” level of concern, as defined by L.A. County health officials.

    In the San Francisco Bay Area, coronavirus levels in the San Jose watershed’s sewage have been at a “high” level for weeks.

    Rising viral levels in wastewater is “like the canary in the coal mine,” said Dr. Peter Chin-Hong, a UC San Francisco infectious diseases expert. Higher concentrations could be followed by more illness, potentially severe enough to require hospital care.

    “I’m just worried that it’s going to translate into hospitalizations around Christmastime,” he said.

    Chin-Hong said he’s particularly concerned about seniors who haven’t received their updated vaccinations this autumn. Among Californians ages 65 and older, just 27% have received the latest COVID-19 vaccination that became available in September. Uptake is even lower in Los Angeles County — 21% — but higher in the Bay Area, where it’s around 40% in the most populous counties.

    Seniors who have not gotten the latest vaccine are “the population we’re seeing in the hospital,” Chin-Hong said, and, especially those who are older than 75, “the population that’s dying.” It’s also likely that many of those who are dying aren’t getting anti-COVID drugs in time.

    Flu vaccination rates are slightly lower than they were at this time last year, according to data shared by the CDC. As of early November, 36% of U.S. adults had received their flu shot, compared with 38% at that time last year. And for RSV, just 16% of adults ages 60 and older had received the newly available vaccine as of Dec. 2.

    Alarmed by low vaccination rates, the CDC issued a health advisory on “the urgent need to increase immunization coverage for influenza, COVID-19 and RSV.” The agency asked healthcare providers to strongly urge immunizations, noting that “low vaccination rates, coupled with ongoing increases in national and international respiratory disease activity … could lead to more severe disease and increased healthcare capacity strain in the coming weeks.”

    The CDC recommends virtually everyone ages 6 months and older get the latest flu and COVID-19 vaccinations. Adults ages 60 and older are also eligible to be vaccinated against RSV, which can be especially risky for older people with heart disease. There are two vaccines available for older adults: Abrysvo, made by Pfizer; and Arexvy, made by GSK.

    The CDC also recommends the Abrysvo vaccine for pregnant people and immunizing babies against RSV with an antibody known as nirsevimab, also known by the trademarked name Beyfortus.

    The agency is also urging doctors to recommend antiviral drugs for flu and COVID-19, such as Tamiflu and Paxlovid, for eligible patients. These “antiviral medications are currently underutilized, but are important to treat patients, especially persons at high-risk of progression to severe disease with influenza or COVID-19, including older adults and people with certain underlying medical conditions,” the CDC said.

    Such antiviral drugs “are most effective in reducing the risk of complications when treatment is started as early as possible after symptom onset,” the CDC said.

    So far, hospitals in Southern California and the Bay Area appear to be in fairly stable shape. More people are becoming ill, but so far, many aren’t needing to be hospitalized, Chin-Hong said.

    Kaiser Southern California has been noticing more people ill with COVID-19 in its clinics and urgent care centers, “but they’re not landing in the hospital nearly as much compared to last year, certainly compared to two years ago,” Gin said. “Time will tell if the numbers that we see continue to go up.”

    The health system, which serves 4.8 million members and operates 16 hospitals throughout the region, has observed a bit of a rise in the use of ventilators and intensive care units related to COVID-19, “but it’s certainly nothing dramatic,” Gin said.

    But cases of influenza type A virus nationally “are really shooting up quite a bit. We are seeing that as well,” Gin said.

    As for RSV, levels rose steadily from the end of September through mid-November. In the last few weeks, however, that virus seems to have flattened out at “less than half of what we saw last year at this time, at least by our testing numbers. So that’s a good sign,” Gin said.

    Increasing coronavirus transmission is probably being assisted by waning immunity from past infections and older booster shots.

    Officials are also monitoring the rapid rise of the JN.1 subvariant. Because of its unusually high number of mutations, this subvariant — described as a closely related offshoot of the BA.2.86, or Pirola strain — might be able to more easily infect people who had previously caught an older version of the coronavirus or haven’t yet received an updated shot.

    Nationally, JN.1 is estimated to account for about 21% of coronavirus cases for the two-week period that ended Dec. 9, up from 8% in the prior two-week period. It’s the fastest-growing subvariant being tracked.

    JN.1 is on the ascent while the current most dominant subvariant, HV.1, is declining. A descendant of the XBB subvariants that were dominant over the summer, HV.1 was estimated to account for 30% of coronavirus specimens for the most recent two-week period, down from 32% in the prior comparable period.

    The rise of the new subvariant should encourage people, especially those who are older, to get the new vaccine, as outdated booster shots or natural immunity from past infections may not be protective enough. The new vaccine will replenish antibodies, Chin-Hong said, which will be especially important for at-risk people.

    “Most people have gotten a previous infection, like during the summer, with one of the XBBs,” Chin-Hong said. The rise of JN.1 “just makes the clock tick faster before they’re more susceptible [to another coronavirus infection]. In other words, if the XBBs were the main game in town, you might have had a little bit more time before you would get infected again.”

    The CDC said available vaccines, tests and antiviral medication continue to work well against JN.1.

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    Rong-Gong Lin II

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  • Charles Mizzi to Succeed Carl Brincat as MGA CEO

    Charles Mizzi to Succeed Carl Brincat as MGA CEO

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    The Malta Gaming Authority has unveiled a new major leadership appointment. As reported by the regulator, its Board of Governors has chosen Charles Mizzi to succeed Carl Brincat as chief executive officer.

    Brincat’s departure from the MGA was announced in October when the outgoing CEO said that the decision to leave didn’t come easy.

    According to MGA’s announcement, Mizzi will step into the office on January 26, 2024. The appointment comes as a result of the public call issued on October 30, 2023 and the following selection process.

    Before joining the MGA, Mizzi served as the head of the Residency Malta Agency for five years. He played an important role in the organization’s ambition to solidify Malta’s reputation as one of the most reputable and desirable residencies by investment jurisdictions.

    According to the MGA, Mizzi is a “dynamic and results-driven professional” who boasts extensive experience in operations management. These qualities, the MGA Board of Governors believes, make him a perfect fit for the authority. The MGA is convinced that Mizzi will build on the solid foundations laid by his predecessor and the rest of the team.

    Speaking of Mizzi’s predecessor, before officially assuming responsibility as head of the MGA, the new CEO will spend several years shadowing Brincat. This step of the process will ensure a smooth transition at the helm of the authority, the MGA explained.

    Mizzi Hopes to Build on MGA’s Successes

    Mizzi commented on his new position, saying that he feels “honored” to have been given the opportunity to lead the MGA. He promised to work hard alongside the rest of the MGA team to build on past successes.

    I am keen to build on past successes and, together with the team under the guidance of the Minister responsible and the Board of Governors, to strategically steer the Authority forward so that Malta’s already robust position in the field may be further strengthened, while delivering value to all stakeholders.

    Charles Mizzi, to-be CEO, MGA

    Malta’s Minister for the Economy, EU Funds and Lands, Silvio Schembri, thanked Brincat for his exceptional service as CEO of the MGA. Schembri also welcomed Mizzi as the next head of the MGA, praising his vast operational experience and contributions toward major projects.

    Schembri concluded that “Charles Mizzi is undoubtedly the right candidate to continue building on what the MGA has achieved so far.”

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    Angel Hristov

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  • One of Tuberculosis’s Biggest, Scariest Numbers Is Probably Wrong

    One of Tuberculosis’s Biggest, Scariest Numbers Is Probably Wrong

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    Growing up in India, which for decades has clocked millions of tuberculosis cases each year, Lalita Ramakrishnan was intimately familiar with how devastating the disease can be. The world’s greatest infectious killer, rivaled only by SARS-CoV-2, Mycobacterium tuberculosis spreads through the air and infiltrates the airways, in many cases destroying the lungs. It can trigger inflammation in other tissues too, wearing away bones and joints; Ramakrishnan watched her own mother’s body erode in this way. The sole available vaccine was lackluster; the microbe had rapidly evolved resistance to the drugs used to fight it. And the disease had a particularly insidious trait: After entering the body, the bacterium could stow away for years or decades, before erupting without warning into full-blown disease.

    This state, referred to as latency, supposedly afflicted roughly 2 billion people—a quarter of the world’s population. Ramakrishnan, now a TB researcher at the University of Cambridge, heard that fact over and over, and passed it down to her own students; it was what every expert did with the dogma at the time. That pool of 2 billion people was understood to account for a large majority of infections worldwide, and it represented one of the most intimidating obstacles to eradicating the disease. To end TB for good, the thinking went, the world would need to catch and cure every latent case.

    In the years since, Ramakrishnan’s stance on latent TB has shifted quite a bit. Its extent, she argues, has been exaggerated for a good three decades, by at least an order of magnitude—to the point where it has scrambled priorities, led scientists on wild-goose chases, and unnecessarily saddled people with months of burdensome treatment. In her view, the term latency is so useless, so riddled with misinformation, that it should disappear. “I taught that nonsense forever,” she told me; now she’s spreading the word that TB’s largest, flashiest number may instead be its greatest, most persistent myth.

    Ramakrishnan isn’t the only one who thinks so. Together with her colleagues Marcel Behr, of Quebec’s McGill University, and Paul Edelstein, of the University of Pennsylvania (“we call ourselves the three BERs,” Ramakrishnan told me), she’s been on a years-long crusade to set the record straight. Their push has attracted its fair share of followers—and objectors. “I don’t think they’re wrong,” Carl Nathan, a TB researcher at Cornell, told me. “But I’m not confident they’re right.”

    Several researchers told me they’re largely fine with the basic premise of the BERs’ argument: Fewer than 2 billion isn’t that hard to get behind. But how many fewer matters. If current latency estimates overshoot by just a smidge, maybe no practical changes are necessary. The greater the overestimate, though, the more treatment recommendations might need to change; the more research and funding priorities might need to shift; the more plans to control, eliminate, and eventually eradicate disease might need to be wholly and permanently rethought.

    Read: A historical lesson in disease containment

    The muddled numbers on latency seem to be based largely on flawed assumptions about certain TB tests. One of the primary ways to screen people for the disease involves pricking harmless derivatives of the bacterium into skin, then waiting for an inflamed lump to appear—a sign that the immune system is familiar with the microbe (or a TB vaccine), but not direct proof that the bacterium itself is present. That means that positive results can guarantee only that the immune system encountered something resembling MTB at some point—perhaps even in the distant past, Rein Houben, an epidemiologist at the London School of Hygiene & Tropical Medicine, told me.

    But for a long time, a prevailing assumption among researchers was that all TB infections had the potential to be lifelong, Behr told me. The thought wasn’t entirely far-fetched: Other microbial infections can last a lifetime, and there are historical accounts of lasting MTB infections, including a case in which a man developed tuberculosis more than 30 years after his father passed the bacterium to him. Following that logic—that anyone once infected had a good enough chance of being infected now—researchers added everyone still reacting to the bug to the pool of people actively battling it. By the end of the 1990s, Behr and Houben told me, prominent epidemiologists had used this premise to produce the big 2 billion number, estimating that roughly a third of the population had MTB lurking within.

    That eye-catching figure, once rooted, rapidly spread. It was repeated in textbooks, academic papers and lectures, news articles, press releases, government websites, even official treatment guidelines. The World Health Organization parroted it too, repeatedly calling for research into vaccines and treatments that could shrink the world’s massive latent-TB cohort. “We were all taught this dogma when we were young researchers,” Soumya Swaminathan, the WHO’s former chief scientist, told me. “Each generation passed it on to the next.”

    But, as the BERs argue, for TB to be a lifelong sentence makes very little sense. Decades of epidemiological data show that the overwhelming majority of disease arises within the first two years after infection, most commonly within months. Beyond that, progression to symptomatic, contagious illness becomes vanishingly rare.

    The trio is convinced that a huge majority of people are clearing the bug from their body rather than letting it lie indefinitely in wait—a notion that recent modeling studies support. If the bacteria were lingering, researchers would expect to see a big spike in disease late in life among people with positive skin tests, as their immune system naturally weakens. They would also expect to see a high rate of progression to full-blown TB among people who start taking immunosuppressive drugs or catch HIV. And yet, neither of those trends pans out: At most, some 5 to 10 percent of people who have tested positive by skin test and later sustain a blow to their immune system develop TB disease within about three to five years—a hint that, for almost everyone else, there may not be any MTB left. “If there were a slam-dunk experiment, that’s it,” William Bishai, a TB researcher at Johns Hopkins, told me.

    Read: Tuberculosis got to South America through … seals?

    Nathan, of Cornell, was less sold. Immunosuppressive drugs and HIV flip very specific switches in the immune system; if MTB is being held in check by multiple branches, losing some immune defenses may not be enough to set the bacteria loose. But most of the experts I spoke with are convinced that lasting cases are quite uncommon. “Some people will get into trouble in old age,” Bouke de Jong, a TB researcher at the Institute of Tropical Medicine, in Antwerp, told me. “But is that how MTB hangs out in everybody? I don’t think so.”

    If anything, people with positive skin tests might be less likely to eventually develop disease, Ramakrishnan told me, whether because they harbor defenses against MTB or because they are genetically predisposed to clear the microbe from their airway. In either case, that could radically change the upshot of a positive test, especially in countries such as the U.S. and Canada, where MTB transmission rarely occurs and most TB cases can be traced from abroad. Traditionally, people in these places with positive skin tests and no overt symptoms have been told, “‘This means you’ve got sleeping bacteria in you,’” Behr said. “‘Any day now, it may pop out and cause harm.’” Instead, he told me, health-care workers should be communicating widely that there could be up to a 95 percent chance that these patients have already cleared the infection, especially if they’re far out from their last exposure and might not need a drug regimen. TB drugs, although safe, are not completely benign: Standard regimens last for months, interact with other meds, and can have serious side effects.

    At the same time, researchers disagree on just how much risk remains once people are a couple of years past an MTB exposure. “We’ve known for decades that we are overtreating people,” says Madhu Pai, a TB researcher at McGill who works with Behr but was not directly involved in his research. But treating a lot of people with positive skin tests has been the only way to ensure that the people who are carrying viable bacteria get the drugs they need, Robert Horsburgh, an epidemiologist at Boston University, told me. That strategy squares, too, with the goal of elimination in places where spread is rare. To purge as much of the bug as possible, “clinicians will err on the side of caution,” says JoAnne Flynn, a TB researcher at the University of Pittsburgh.

    Elsewhere in the world, where MTB transmission is rampant and repeat infections are common, “to be honest, nobody cares if there’s latent TB,” Flynn told me. Many people with very symptomatic, very contagious cases still aren’t getting diagnosed or treated; in too many places, the availability of drugs and vaccines is spotty at best. Elimination remains a long-term goal, but active outbreaks demand attention first. Arguably, quibbling about latency now is like trying to snuff stray sparks next to an untended conflagration.

    Read: The dangers of ignoring tuberculosis

    One of the BERs’ main goals could help address TB’s larger issues. Despite decades of research, the best detection tools for the disease remain “fundamentally flawed,” says Keertan Dheda, a TB researcher at the London School of Hygiene & Tropical Medicine and the University of Cape Town. A test that could directly detect viable microbes in tissues, rather than an immune proxy, could definitively diagnose ongoing infections and prioritize people across the disease spectrum for treatment. Such a diagnostic would also be the only way to finally end the fuss over latent TB’s prevalence. Without it, researchers are still sifting through only indirect evidence to get at the global TB burden—which is probably still “in the hundreds of millions” of cases, Houben told me, though the numbers will remain squishy until the data improve.

    That 2 billion number is still around—though not everywhere, thanks in part to the BERs’ efforts. The WHO’s most recent annual TB reports now note that a quarter of the world’s population has been infected with MTB, rather than is infected with MTB; the organization has also officially discarded the term latent from its guidance on the disease, Dennis Falzon, of the WHO Global TB Programme, told me in an email. However subtle, these shifts signal that even the world’s biggest authorities on TB are dispensing with what was once conventional wisdom.

    Losing that big number does technically shrink TB’s reach—which might seem to minimize the disease’s impact. Behr argues the opposite. With a huge denominator, TB’s mortality rate ends up minuscule—suggesting that most infections are benign. Deflating the 2 billion statistic, then, reinforces that “this is one of the world’s nastiest pathogens, not some symbiont that we live with in peace,” Behr told me. Fewer people may be at risk than was once thought. But for those who are harboring the microbe, the dangers are that much more real.

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    Katherine J. Wu

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  • 2024 candidate Dean Phillips called Pelosi and Feinstein old. Biden is his next target

    2024 candidate Dean Phillips called Pelosi and Feinstein old. Biden is his next target

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    Democratic Rep. Dean Phillips swept into office in 2018 after promising not to vote for Rep. Nancy Pelosi for speaker of the House.

    The Gen X Minnesotan reasoned that the San Franciscan had been at the top too long and Democrats needed some fresh blood in House leadership. In the private sector, he argued, people rarely serve for two decades in top posts.

    Phillips ultimately backed Pelosi (D-San Francisco) for speaker as part of a deal that saw her leave leadership last year. But in the spring of this year, as another Californian, Sen. Dianne Feinstein, began missing votes, he spoke out again, writing an op-ed arguing that she needed to resign for the good of the country.

    Feinstein’s refusal to resign — she died in office on Sep. 29 — did the country a disservice, Phillips told The Times during a visit to California last month.

    “Who doesn’t know Congress is dysfunctional, but I did not know how horrifyingly so until I got there,” said Phillips, 54. “I encountered a culture filled with people who had been there for decades, that were so clearly focused more on the preservation of their positions than they were the priorities of the population.”

    Now Phillips is taking on 81-year-old President Biden for the Democratic nomination — and making the same argument he made about Feinstein and Pelosi. His longshot run has included several trips to California to appear on shows like Real Time with Bill Maher and court potential donors in Hollywood and Silicon Valley.

    Nearly 80% of voters in a September Reuters-Ipsos poll said that Biden is too old to run again. More than half said the same about the 77-year-old Donald Trump.

    Dean Phillips steps off his campaign bus at the New Hampshire State House. He filed a declaration of candidacy Oct. 27, 2023, to run in the state’s presidential primary.

    (Glen Stubbe / Star Tribune)

    Elected Democrats who refused to criticize Feinstein’s fitness to serve — or acknowledge publicly that Biden’s age is a challenge — are no better than Republicans who are unwilling to publicly criticize former President Trump, Phillips argued.

    “It is the same disease — the same danger and the same consequence, which is the reduction in faith and government,” he said, noting that Biden is far better than Trump as a leader.

    Phillips, who has voted with Biden 100% of the time in the House, has said repeatedly that he’s not in this race to tear down the president. He praised the Inflation Reduction Act, the bipartisan infrastructure bill and Biden’s “extraordinary” support for Israel.

    But in his interview with The Times, Phillips was quick to say that Biden didn’t do enough to respond as vice president to Russia’s invasion of Crimea and that the Israel-Hamas war “could have been prevented with more extraordinary intentional peace efforts over the course of his tenure, both as vice president and now president.” He supports an internationally monitored cease-fire once all the hostages held by Hamas militants in the Gaza Strip have been released and says a multinational peacekeeping force should be deployed to the region.

    He also attacked Biden’s unwillingness to legalize cannabis and the president’s response to “chaos” at the border.

    Phillips sees what he’s doing as a “hopeful run” meant to offer a respectful alternative to someone whom he considers a successful president. He believes that by May or June, after enough campaigning, head-to-head polls will show him beating former President Trump and will continue to show Biden losing.

    But his attacks on Biden over policy issues, and his recent claim that Biden — like Trump — is a threat to democracy have some political observers questioning whether he plans to run a purely positive campaign. They worry he could end up hurting Biden’s chances in a general election.

    Phillips’ effort recalls former Gov. Jerry Brown’s runs for president, where he got in late and never accumulated enough movement support, said Danielle Cendejas, who works for the Strategy Group, a national political consulting firm that advised Phillips’ congressional bids but is not working on his presidential campaign.

    “Phillips’ run feels like it’s more of a, ‘Hey, I’m an option’ campaign rather than, ‘I am trying to do something different because the president is not doing what I think should be done,’” she said. “Anytime you run against the White House, you are running on the fact that the president is just not doing a good enough job.”

    If Phillips was running far to Biden’s left, his challenge might galvanize the White House to respond more aggressively, Cendejas says. But so far, the Biden team doesn’t seem too worried. (A spokesperson for Biden’s campaign declined to comment for this article.)

    Phillips’ campaign counts Andrew Yang’s former campaign manager Zach Graumann as a senior advisor. Strategist Bradley Tusk, who managed Yang’s 2021 New York mayoral campaign and worked for Mayor Michael Bloomberg, said he was surprised that no nationally elected officials or activists had challenged Biden from the left.

    The risk for Biden is he “could really underperform in the primaries but not lose them,” Tusk said. “Then Trump picks up a lot more momentum, raises a lot more money and fundraising for Biden gets that much harder.”

    The two most urgent challenges Phillips faces are raising enough money to run a competitive campaign and getting on the ballot in as many states as possible. He already won’t be on the ballot in Nevada. He’s angry that he will likely be left off the ballot in Florida.

    The Minnesotan, who thinks he’ll make the ballot in 90% of states, will appear on California’s ballot for its March 5 primary, according to California Secretary of State Shirley Weber.

    Phillips and his team believe that a competitive primary is a healthy part of the democratic process. If the polls in May or June show Biden beating Trump “and me losing, I’ll be the first to acknowledge it and wrap it up,” he said.

    Snuffing out dissenting voices only hurts the voters, argued Jeff Weaver, a senior advisor to Phillips who had top roles in Sen. Bernie Sanders’ 2016 and 2020 presidential campaigns.

    Weaver thinks a strong showing for Phillips in New Hampshire, where Biden is not on the ballot but his supporters are marshaling a write-in campaign, will create momentum that will get him noticed by more voters. A poll last month in the state found Phillips with 15% support after two weeks of campaigning. Biden had 27% support.

    “Our primary system is one of the only feedback loops between people on the ground and the national party,” Weaver told The Times.

    “Issues and candidates affect how people vote. There should be a vigorous primary where people get to see their candidates talk about the issues. With there being no debates, the [Democratic] party has worked to stifle that process.”

    President Joe Biden arrives at Santa Monica Airport in Santa Monica, Calif., Friday, Dec. 8, 2023.

    President Joe Biden arrives at Santa Monica Airport in Santa Monica, Calif., Friday, Dec. 8, 2023. Rep. Ted Lieu, D-Calif., third from left, and California Gov. Gavin Newsom, left, and Los Angeles Mayor Karen Bass, right, look on.

    (Manuel Balce Ceneta / Associated Press)

    Phillips faces a steep financial challenge. In one weekend this month, Biden brought in about $15 million at two fundraisers in Los Angeles. Phillips said he will have trouble raising that kind of money—even as the Minnesotan who got rich running his family’s liquor business and later the Talenti gelato brand, has poured $2 million of own wealth into the campaign.

    But Phillips has found some pockets of support.

    Uber Chief Executive Dara Khosrowshahi, a college friend of Phillips, has supported his congressional races. Phillips said he has met in recent months with Open AI CEO Sam Altman — a meeting first reported by the news outlet Puck. Phillips told The Times he wasn’t sure if Altman, who gave $200,000 to the Biden reelection bid, had donated to his campaign.

    He declined to detail how Altman, whose representatives didn’t respond to requests for comment, had been advising his launch except to say “I found him to be an extraordinarily brilliant and principled and magnificent ideator and convener and community builder, and without getting too much into the details, yes, he’s been supportive.”

    Cryptocurrency billionaire Mike Novogratz has shifted his support away from Biden and will host a Phillips fundraiser, CNBC reported this week.

    Phillips has held several Southern California fundraisers since launching his campaign at the beginning of November, though his campaign has declined to say how much they’ve raised. Phillips said the events attracted many Biden backers who pined for an alternative.

    One was television executive Adam Goodman, who previously served as president of Paramount Pictures’ Motion Picture Group and DreamWorks SKG, and described how his high-school-age daughter heard Phillips speak and felt a connection to him. He’s been impressed by many of Biden’s successes over the last four years but still hosted a 100-person fundraiser for Phillips in his home early last month.

    “This is the time when we’re supposed to be listening and auditioning the best people for the job and then ultimately we will get to a convention and the best candidate will go forward at that point,” he said.

    Goodman said that politics — like show business — needs fresh perspectives in leadership.

    “Show business is really in jeopardy right now,” he said. “The people who are actually really running the businesses who are at the top top top — these are people that have been in authority for 35-plus years. They are not people who necessarily understand the generational shift.”

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    Benjamin Oreskes

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  • Are You Sure You Want an Ozempic Pill?

    Are You Sure You Want an Ozempic Pill?

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    Within the first five seconds of a recent Ozempic commercial, a sky-blue injector pen tumbles toward the viewer, encircled by a big red O. Obesity drugs have become so closely associated with injections that the two are virtually synonymous. Like Ozempic, whose name is now a catchall term for obesity drugs, Wegovy and Zepbound come packaged in Sharpie-like injection pens that patients self-administer once a week. Patients “don’t come in asking for Wegovy,” Laura Davisson, a professor of medical weight management at West Virginia University, told me. “They come in asking for one of ‘those injectables.’”

    Needles are the present, but supposedly not the future. Nobody really likes injections, and taking a pill would be far easier. In the frenzy over obesity drugs, a class known as GLP-1 agonists, drugmakers have raced to create them in pill form, and Wall Street investors are hungry at the prospect. Earlier this year, Pfizer’s CEO, Albert Bourla, estimated that obesity pills could be worth $30 billion, or a third of the total obesity-drug market. Because people have a “preference” for pills, he said at a conference, they will be what ultimately “unlocks the market” for obesity medications. By one count, at least 32 oral GLP-1 drugs, from many different companies, are in the works.

    But a future dominated by obesity pills is hardly certain. So far, the only oral GLP-1 that exists is a pill for diabetes called Rybelsus. Like Ozempic and Wegovy, its active ingredient is a compound called semaglutide, but the shots come in far more powerful doses, making it possible to lose even more weight. Developing oral obesity drugs that are as tolerable and effective as their injectable counterparts has so far been a challenge. Earlier this month, Pfizer stopped testing one of its pill candidates, citing concerns about side effects and patient adherence. Even when pills do come to market, doctors told me, there’s no guarantee that people will flock to them.

    That drugmakers view the injectable nature of GLP-1s as one of their biggest flaws is no surprise. Getting a shot is a broadly despised experience, something people generally tolerate rather than choose. Children get stickers for enduring immunizations; adults who get vaccinated do so only because they must (and they are often rewarded with stickers too). The CDC estimates that one in four adults, and two out of three children, have strong fears about needles. “Some people hate needles, plain and simple,” Ted Kyle, an obesity-policy expert, told me.

    But not all needles are made equal. Wegovy and Zepbound are injected subcutaneously, or just under the skin. Relative to COVID or flu shots, which are jabbed into muscle, they don’t cause much discomfort. “I’ve been really surprised at how receptive my patients have been to using injectable medications,” Davisson said. Other doctors I spoke with agreed. “More patients than you would expect really don’t mind injectables,” because they’re easy and relatively painless to administer, Katherine Saunders, a clinical-medicine professor at Weill Cornell Medicine, told me.

    The unobtrusive dosing schedule of the injectables adds to their appeal. Wegovy and Zepbound are administered once weekly, unlike many of the pills in development, which are meant to be taken once or more daily. That can be a hassle, especially if they have to be taken at the same time every day, or if they come with restrictions on eating or drinking. “For some people, it’s easier to take an injection and forget about it for a week” than to remember to take a pill every day, Eduardo Grunvald, an obesity-medicine physician at UC San Diego Health, told me. Assuming pills are preferable to shots is a “knee-jerk reaction,” he added.

    Despite the unexpected upsides of the shots, they’re far from perfect. Making injectable pens is generally more expensive than pills and requires a lot of hardware, including the pen casing, cap, and needle cover. On top of that, the injectable obesity drugs must be refrigerated before they are first used, adding to storage and production costs. Pills are generally shelf-stable and don’t require much packaging beyond a child-proof bottle. Saunders predicts they would be less expensive and less prone to shortages that have plagued Wegovy.

    Still, creating an obesity pill isn’t as simple as packaging the same drugs in capsule form. Drugmakers have already run into a number of issues. Absorption is a big one: Because pills pass through the stomach before entering the bloodstream, they must be able to withstand a large degree of degradation. One way to get these drugs to lead to greater weight loss is to increase the dose. While the highest dose of Wegovy is 2.4 milligrams, Rybelsus maxes out at 14 milligrams.

    Hiking up the dose seems to work, though doing so could have consequences beyond weight loss. All GLP-1 drugs come with a range of unpleasant side effects involving the gastrointestinal system, and patients report nausea at similar rates in Rybelsus and Ozempic, according to the FDA. But this may differ in practice, as other doctors have noted. Saunders said that her patients on oral semaglutide report more nausea than those using injectables. Regardless, newer oral medications may have even more distinct differences, as drugmakers race to create more potent pills. In Pfizer’s discontinued trial of danuglipron, nausea rates reached up to 73 percent.

    Drugmakers also skirt the issue of degradation by pursuing sturdier drugs. The problem with semaglutide is that it’s a peptide—essentially a small protein—precisely the kind of molecule that the stomach excels at digesting. Some new drugs in the pipeline are so-called non-peptide small molecules, which are sturdier but still have the same biological effect. Orforglipron, a pill that Eli Lilly is testing, falls into this category, as does danuglipron, the drug responsible for Pfizer’s recent setbacks. Small-molecule drugs have the added benefit of being cheaper to produce at scale than peptides, Kyle, the obesity-policy expert, added.

    Another pesky problem with oral drugs is that they tend to come with strict dosing requirements. People on Rybelsus, for example, are instructed to take it 30 minutes before eating or drinking anything and can drink only four ounces of plain water along with it, because otherwise absorption could be compromised. “It can be a nuisance,” Grunvald said. Similarly bothersome instructions likely played a part in the drop-out rates reaching more than 50 percent in Pfizer’s recently discontinued trial: Danuglipron had to be taken twice daily. “A lot of people found it not worth the trouble,” Kyle said, noting that Pfizer is still pursuing a once-daily version of the same drug. A recent review of GLP-1 drugs showed that, compared with the injectable form, oral semaglutide is associated with lower rates of side-effect reporting but higher discontinuation rates, potentially reflecting its bothersome dosage requirements.

    Despite these hurdles, it seems inevitable that obesity-drug pills will eventually become available. Novo Nordisk is expected to file for FDA approval for its high-dose semaglutide obesity pill this year; Pfizer is forging ahead with a once-daily version of danuglipron, with more data expected “in the first half of 2024,” a spokesperson told me. A report from BMO Equity Research published in September predicted that oral formulations could be approved “by the late 2020s.” The biggest upside to pills may not be that they are pills but that they will, eventually, be cheaper than injectables—and cost is among the biggest impediments to more people taking obesity drugs.

    Whether they’ll replace injectables outright is far from certain. “It will come down to patient preference,” Grunvald said. Most likely, pills and injections will coexist to meet different needs, and perhaps even be used together to treat individual patients. In the so-called phased approach, obesity treatment could start with more expensive and powerful injectable drugs, then transition to less potent but cheaper orals for the long term. Eli Lilly, for one, sees its oral candidate, orforglipron, as a potential weight-loss-maintenance drug.

    There is so much competition in the obesity-drug space that future medications may take more unexpected forms. Amgen is studying a once-monthly injection; Novo Nordisk is developing a hydrogel form of semaglutide that would need to be taken only three times a year. If the future of obesity drugs will come down to what patients prefer, then the more options, the better.

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    Yasmin Tayag

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  • 5 hospitalized after Amtrak train car derails in Ventura County crash

    5 hospitalized after Amtrak train car derails in Ventura County crash

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    A train car derailed and five people were hospitalized after an Amtrak train crashed into a parked semi truck, according to the Ventura County Fire Department.

    The crash occurred around 6:20 p.m. near Sand Canyon Road and East Los Angeles Avenue, also known as California 118, in the unincorporated community of Somis.

    The train, an Amtrak Pacific SurfLiner headed south toward Los Angeles, crashed into a semi that was stopped on the level grade railroad crossing, according to VCFD spokesman Andy VanSciver.

    Five people were injured in the crash, which involved six train cars, though only the lead car derailed.

    Four of the hospitalized victims suffered minor injuries, while the fifth suffered minor to moderate injuries, according to authorities. The train was carrying 90 passengers and five train employees.

    California 118 was closed between Balcom Canyon Road and Somis Road, also known as California 34, and was expected to remain shut down until the morning, according to the California Highway Patrol.

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    Jeremy Childs

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  • Column: Shohei Ohtani is just the latest young person to leave O.C. for L.A. Surprise, surprise.

    Column: Shohei Ohtani is just the latest young person to leave O.C. for L.A. Surprise, surprise.

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    When Japanese superstar Shohei Ohtani joined the Angels in 2018, my cousins and I made a bet. How long until he leaves Orange County to join the Los Angeles Dodgers?

    We knew it wasn’t a matter of if, but when.

    Not just because the Blue Crew is one of baseball’s marquee franchises, while the Halos are as respected as a soul patch. Or because Angels owner Arte Moreno makes Ebeneezer Scrooge seem as free-spending as, well, the Dodgers, who just signed Ohtani to the richest contract ever in professional sports, at $700 million for 10 years.

    Nah, we knew Ohtani was fated to leave because he’s a young, talented person — and folks like him usually get the hell out of O.C. the moment they can.

    We saw the best minds of my generation flee for Austin, Texas, Chicago, New York, the Inland Empire, but especially L.A. — the place our elders taught us to fear as full of crime and liberals. Our friends and relatives left to find opportunities that were impossible in staid, conservative, expensive Orange County. They rarely looked back. When their new neighbors asked where they were from, most would demur and say “Southern California” or “near Los Angeles.”

    City, civic and county leaders didn’t care about this exodus, since O.C. was never meant to be cool. We were the spot where people moved after they made it. Orange County was aspirational, and if you couldn’t afford to hack it here, good riddance and don’t forget to take along other underachievers like you.

    This thinking went on, unchecked, for decades. But it’s finally dawning on the lords of O.C. that losing our young to Los Angeles and elsewhere portends doom.

    Fans line up to enter Angel Stadium in 2021.

    (Gina Ferazzi/Los Angeles Times)

    Orange County has shrunk in population three out of the last four years — a once-unthinkable development in a region that has always bragged about its growth. O.C’s median age has gone from 33.3 years in the 2000 census to 39.5 years in 2022, a rate of aging that has outpaced the nation. About 17,000 people between the ages of 20 and 35 left in 2016 and 2017 alone, according to the Orange County Business Council’s most recent Workforce Housing Scorecard, which called the youthful exodus a “troubling trend” and a “drain on the county’s future workforce.”

    Like Orange County, the Angels have historically preferred established and over-the-hill players and barely blinked when homegrown prospects left for better opportunities. The team rarely invests in its farm system, the way Orange County cities have never really cared about creating affordable housing, good-paying jobs or other necessities that would help to keep young people here. Ohtani, like so many of the smart people who have left O.C. in my lifetime, finally got fed up with his situation — and could you blame him?

    Even Moreno couldn’t resist the siren call of L.A. — he renamed his team the Los Angeles Angels shortly after buying it 20 years ago.

    This is an apples-to-oranges comparison, of course — or rather, Dodgers-to-Angels. The 29-year-old Ohtani, unlike most millennials, is a once-in-an-epoch phenom with enough money to buy a series of homes from Angel Stadium to Dodger Stadium. But his departure means the Angels are now staring at years of irrelevancy if Moreno continues his youth-averse ways.

    That’s where Orange County finds itself today.

    It’s sad to say this about a place where I was born and raised and plan to live my entire life, because heaven knows, people outside of the power structure have tried to stop this brain drain. From the late 1990s through the 2010s, I followed and eventually wrote about those who were trying to make O.C. a cool place, one we could proudly proclaim to be as hip as L.A. Homegrown stars shined in clubs, restaurants, galleries, fashion and other culture scenes. Cities like Costa Mesa, Anaheim and Santa Ana became creative hubs that — gasp — even Angelenos would visit.

    No one exemplified this creativity more than Gwen Stefani, Orange County’s most famous musician and someone whom the Board of Supervisors included this month as an inaugural member of the Orange County Hall of Fame. She and her band, No Doubt, became global stars with their breakout album “Tragic Kingdom,” a title that was a play on Disneyland’s nickname and meant to reflect how people of Stefani’s generation hated boring, old Orange County and were committed to do something about it.

    Stefani has always proudly repped Orange County, caring enough to be the headliner when Irvine Meadows Amphitheatre closed down in 2016 and when Anaheim’s Honda Center celebrated its 30th anniversary in September. But Ms. O.C. hasn’t lived down here for decades. After spending a few years in Oklahoma with her husband, country superstar Blake Shelton, she’s back in Los Angeles.

    Gwen Stefani sits next to her Hollywood Walk of Fame star and waves, wearing a silvery dress, boots and cutouts of stars.

    Gwen Stefani attends a ceremony honoring her with a star on the Hollywood Walk of Fame on Oct. 19 in Los Angeles.

    (Chris Pizzello/Associated Press)

    The scenes that birthed Stefani and others fizzled out, as people aged out and fled their old haunting grounds to the suburban limbo of south Orange County, or to places like Nashville. Some are still fighting the good fight — but more than ever, they look to L.A. for their creative and professional salvation.

    Including me.

    When I joined The Times five years ago this month, I had spent my career almost exclusively covering Orange County. I wanted to show the rest of the world that my homeland was worthy of respect and to highlight those battling against the forces that kept driving out too many talented people.

    I planned to continue focusing on O.C. in my new job. Once I began to cover Los Angeles, that changed. I quickly discovered an excitement and energy to L.A. that doesn’t exist in Orange County and can’t be replicated elsewhere, that intoxicates you and makes you wonder what took you so long to get it.

    Ohtani will soon experience that for himself. That’s why I don’t blame him for leaving the Halos, as cool as it would have been to see him in Orange County for the rest of his career. He and too many others before him saw no future down here, especially once they realized there are far more welcoming places out there.

    To paraphrase a famous World War I song, how ya gonna keep us down in Anaheim after we’ve seen the City of Angels?

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    Gustavo Arellano

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  • Column: Is L.A. actually solving homelessness? The answer will start with perception, not reality

    Column: Is L.A. actually solving homelessness? The answer will start with perception, not reality

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    For as long as people have watched tents take over sidewalks and RVs deteriorate under freeways, politicians have been making promises about solving homelessness in Los Angeles.

    And for just as long, those same politicians have been breaking them.

    This is undoubtedly why, back in March, as Mayor Karen Bass was approaching her first 100 days in office, only 17% of Angelenos believed her administration would make “a lot of progress” getting people off the streets, according to a Suffolk University/Los Angeles Times poll. Far more — 45% — predicted just “a little progress” would be made.

    I was thinking about this deep well of public skepticism while listening to Bass, all smiles in a bright green suit on Wednesday morning, enthusiastically explain why the progress she has actually made is a reason for renewed optimism.

    Flanked by members of the L.A. City Council outside a school in Hollywood, she announced that her administration had, in its first year, moved more than 21,694 people out of encampments and into interim housing. That’s an increase of 28% over the final year of former Mayor Eric Garcetti’s administration, taking into account the work of various government programs, including Bass’ signature one, Inside Safe.

    In addition, the majority of those directed to motel and hotel rooms, congregate shelters and tiny homes have decided to stay, rather than head back out onto the streets.

    “We have tried to set a new tone in the city. This is an example of that new tone. Forty-one people used to sleep here, and now it’s clear,” Bass said Wednesday over the shrieks of schoolchildren. “Students and parents don’t need to walk around tents on their way to school, and the Angelenos who were living here do not need to die on our streets.”

    It was a convincing message, backed up by a thick packet of numbers distributed to reporters at City Hall a few hours later.

    But numbers are funny. They can be crunched in many ways and interpreted to mean many different things.

    As my Times colleague David Zahniser pointed out, all of the people who now live in interim housing are still considered homeless by the federal government. And while Bass had originally thought most of them would be there for only three to six months, it’s now looking more like 18 months to two years. Permanent housing is that scarce.

    So, numbers-wise, don’t expect a decline in the next annual homelessness count, which is scheduled for January. There might even be an increase, thanks to the expiration of pandemic-era tenant protections. As of the last count, there were more than 46,000 unhoused people living in the city, mostly in encampments.

    But again, numbers are funny. They tend not to mean half as much as what people see and experience for themselves, just like the disconnect between public perceptions of crime and actual crime data.

    So, when Bass declares at a news conference that “we have proved this year that we will make change,” and she talks about the encampment that used to be where she’s standing, and all the encampments that her administration has cleared, even if a few more tents have popped up down the street, skeptical Angelenos just might believe her.

    And maybe, just maybe, that’s not such a bad thing.

    “What I see most powerfully is increased hope,” Va Lecia Adams Kellum, chief executive of the Los Angeles Homeless Services Authority, told reporters on Wednesday. “Hope among the folks who are living in those encampments who had given up and [thought] they’ll always live in that level of despair. Hope that the community now believes that we could possibly get out of this terrible crisis.”

    Kellie Waldon, 54, cries near what’s left of her encampment, left, as Skid Row West is dismantled under the 405 Freeway along Venice Boulevard in Los Angeles in October. Waldon was hoping to receive housing through the city’s Inside Safe program, like others in the encampment had. “You get your hopes up and you don’t know what to believe,” Waldon said.

    (Genaro Molina/Los Angeles Times)

    Hope is a thing difficult to quantify, especially among people who have been homeless for years, and have suffered so much and have been let down so often by government.

    I’ve talked to some who took a chance and decided to leave their tents and RVs, and are now thrilled to be in a motel room with a door, running water and air conditioning. Others have had it with curfews and jail-like rules, and are getting tired of waiting on promised permanent housing.

    I’ve also talked to those who have been booted out of interim housing for one reason or another, and are back on the streets. They are feeling hopeless, like many cash-strapped Angelenos who are on the verge of an eviction.

    But peak hopelessness? That’s what we saw on the first days of December.

    At a hastily called news conference, Los Angeles Police Chief Michel Moore announced that officers were searching for a man who had fatally shot three homeless people — one sleeping on a couch in an alley and another while pushing a shopping cart.

    “This is a killer preying on the unhoused,” Bass said.

    Moore and Bass didn’t know then, but their suspect, Jerrid Joseph Powell, had already been arrested by Beverly Hills police after a traffic stop in which his $60,000 BMW was linked to a deadly follow-home robbery.

    Police have yet to elaborate on Powell’s alleged motive, but Bass brought up the horrific case several times on Wednesday — and with good reason. Violence and acts of cruelty against people living on the streets are increasingly common not just locally, but nationally.

    In addition to shootings, there have been stabbings and beheadings. And let’s not forget about the gallery owner in San Francisco who was caught on video spraying a homeless woman with a hose.

    Advocates blame this trend of nastiness on the pandemic-era surge in homelessness, particularly in unsheltered homelessness, and the subsequent spike in interactions between housed and unhoused residents. Fear and frustration can lead to dehumanization and that, in turn, can lead to violence, said Dr. Margot Kushel, director of the Benioff Homelessness and Housing Initiative.

    “I do really worry that it’s become normalized in public discourse to speak about people experiencing homelessness as, like, a problem for those who are not homeless — as opposed to fundamentally a massive societal failure that’s left usually older, vulnerable people terrified and totally unprotected,” she told me. “And I do think that there is a connection, like the more we dehumanize people, the less protected they are.”

    Stephanie Klasky-Gamer has watched this happen in real-time as president and CEO of L.A. Family Housing. The seeming permanency of encampments, and the trash, fires and unsanitary conditions they often generate, have led to what she describes as widespread impatience.

    “I don’t mean big, systemic impatience, like ‘I wish we could end homelessness faster,’” she said. “It’s the ‘I’m just sick of seeing you in front of me’ kind of impatience.”

    On some level, she gets it, though. As does Kushel. As do I.

    “It has to be OK to say, ‘Yeah, this sucks that I’m walking my kids to school and I’m walking over people in tents,’” Kushel told me. “But there has to be a way to hold that with being able to recognize how we got to this position and also how we’re going to get out. And to sort of restore [our] collective humanity.”

    For Klasky-Gamer, this has meant focusing on what has changed since Bass became mayor.

    “I know how much good is getting done,” she told me. “The frustration I may feel at seeing the tent every day I turn the corner, at least I can temper it knowing that 10 people yesterday moved into an apartment. These three people haven’t. But these 10 did.”

    A street lined with parked RVs.

    RVs in an encampment along West Jefferson Boulevard near the Ballona Wetlands in Playa del Rey in 2021.

    (Al Seib / Los Angeles Times)

    The mayor has told me many times that getting people off the streets isn’t just a humanitarian imperative — and, as a serial killer reminded us, a safety imperative. It’s also a demonstration to a fed up public that progress is possible.

    “What distresses Angelenos the most are encampments. That’s where people were dying on the street,” Bass told reporters. “And to me, what was clear, was that we come up with a way to get people out of the tents.”

    Some will dismiss that. They’ll insist that all her administration is doing is reducing visible homelessness to score easy political points. And that instead of doing the hard work of actually helping L.A.’s most vulnerable residents get back on their feet, the mayor is hiding them so that they’ll be forgotten and abandoned in interim housing.

    In this city, defined by its haves and have nots, I understand the cynicism and skepticism. But that’s why what Bass does next, namely expanding and stabilizing the city’s crumbling supply of permanent housing, will matter even more than what she has done thus far.

    “We’ve got to somehow make people believe again that this is solvable,” Kushel told me, “and it is solvable.”

    Hope can be elusive. But Annelisa Stephan was looking for it anyway when she came to the Ballona Wetlands on a recent Saturday morning.

    She and more than 100 other volunteers — many of them from the nearby neighborhoods of Playa Vista and Playa del Rey — had descended on the Westside ecological reserve to dig holes, spread soil, and put in plants and trees.

    Just a few months ago, RVs had been parked here along Jefferson Boulevard, bumper to bumper in a sprawling encampment that dozens of unhoused people had come to call home.

    They built a close-knit community, looking out for one another and mourning one another after deadly fires. But they also decimated the Ballona Wetlands’ freshwater marsh with everything from battery acid to trash to human waste, and scared off nearby residents who once walked the trails.

    And then one day, after almost three years, the encampment was gone, replaced by concrete barricades and metal fencing. The residents were mostly sent to interim housing and the RVs were mostly towed away.

    “It’s like, hard to know what to think or feel,” Stephan told me. “I’m happy that the land is being stewarded, but just sad about the suffering that so many people face.”

    She lamented the “fervent, anti-homeless mania” that she has heard from some of her neighbors.

    “It’s just been really a painful time,” Stephan said.

    Not far away, L.A. City Councilmember Traci Park, whose Westside district includes the Ballona Wetlands and got elected on promises to aggressively crack down on homeless encampments, was more circumspect.

    “At the end of the day, everybody wants the same thing, which is to get folks off the streets and into safe settings and connected to the help that they need,” she said. “There’s a lot of different points of view about how we get there. And I think that’s where a lot of the conflict and the division lie.”

    She paused, as traffic whizzed by on Jefferson Boulevard.

    “But,” Park said, “we have great leadership.”

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    Erika D. Smith

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  • Riverside County confirms first 2 flu-related deaths this season; L.A. County has reported 1 so far

    Riverside County confirms first 2 flu-related deaths this season; L.A. County has reported 1 so far

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    With flu season in full swing, Riverside County public health officials are urging residents to get their vaccines and to take other precautions against respiratory viruses after reporting the county’s first two flu-related deaths this winter.

    The deaths include a 73-year-old man and a 79-year-old woman from mid- and western Riverside County, respectively. Both had underlying health issues and died at local hospitals, according to county officials. No further information was immediately provided.

    Last month, Los Angeles County confirmed its first flu death of the season. The deceased was an elderly resident with multiple underlying conditions and had no record of influenza vaccination this season, according to county health officials.

    According to Riverside County’s weekly influenza surveillance report, current influenza-like illnesses activity levels are moderate in the area. The county typically logs people aged 65 and older as the bulk of pneumonia and influenza deaths in the county with few occurring among those 24 and younger. Data collected between Nov. 19-25 show pneumonia contributed to the bulk of deaths, which were largely affected by other diseases such as COVID-19.

    “These tragedies remind us that influenza can be serious, especially for those who have health issues or weakened immune systems,” Dr. Geoffrey Leung, public health officer for Riverside County, said in a statement. “There are simple steps that can be taken to protect ourselves. Most important of these is to get vaccinated. We recommend that everyone over 6 months of age receive the flu vaccine.”

    Respiratory viruses such as the flu and COVID-19 spread year-round but are more common in the United States between October and March. The virus is spread through coughing and sneezing. Anyone is prone to catch the virus but elderly people, children and those with weakened immune systems are more at risk.

    Health officials urge people to stay up-to-date on vaccines, remain at home if sick, consider wearing a face mask, cover a cough or sneeze and wash hands throughout the day.

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    Priscella Vega

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  • Los Angeles County demographic changes: What you need to know about new 2022 U.S. Census data

    Los Angeles County demographic changes: What you need to know about new 2022 U.S. Census data

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    The U.S. Census Bureau released the 2022 American Community Survey this week. The survey, which looks at demographic data in five-year increments, introduced several new detailed tables and demographic breakdowns. We looked at some trends in the data.

    Nearly 6 million people 65 and older live in California, a figure that is slowly growing. In the last five years, 716,000 people became senior citizens in the state. That number will nearly double by 2030. Los Angeles County is home to roughly a quarter of the senior citizens in the state.

    As the cost of living increases, the number of Golden State senior citizens in poverty is also rising, with nearly 14% of Los Angeles County senior citizens living below the poverty line. The national poverty rate declined significantly to 12.5% during the five-year period from 2018-22.

    Across the country, housing costs continue to rise. Financial planners advise that no more than 30% of household income be spent on housing costs. The latest data show that is far from the reality for 41% of homeowners with a mortgage in Los Angeles County. For homeowners without a mortgage, roughly 16% are house burdened. It’s also not easy for renters. More than half of renters spend more than 30% of their household income on housing costs.

    The data also point to how the pandemic changed the way people work. In Los Angeles County, the number of people working from home tripled from more than 270,000 to 810,000 in just five years. That number tracks with the rest of the state’s pool of people working from home, which tripled from 1 million to more than 3.2 million. For those having to commute into the office daily, the mean travel time to work has stayed the same with most L.A. County residents getting to work in 30 minutes (although most L.A. city residents would laugh at this figure.) The number of unemployed people in the county has gone down by 4% since 2017 with roughly 300,000 without work.

    The new American Community Survey includes updated race data. They show the county has grown in its Asian and Latino population. Roughly 1.4 million people identified as Asian in Los Angeles County, up 2.4% from a decade ago. Those who identify as Latino and Hispanic account for nearly half of the population of the county. The county lost 80,000 Black people over the last decade.

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    Sandhya Kambhampati

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  • AGA Selects Industry Veteran Michael Rumbolz as Next Chair

    AGA Selects Industry Veteran Michael Rumbolz as Next Chair

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    Two days after naming an ex-Washington Commanders executive as SVP of strategic communications, the American Gaming Association (AGA) has elected Michael Rumbolz as its new chairman.

    Rumbolz currently serves as the executive chair of Everi Holdings’ board. As chair of the AGA, he will succeed Hard Rock International Chairman and Seminole Gaming CEO Jim Allen. The new appointee’s term is set to begin in January 2024.

    Rumbolz boasts a colorful track record that saw him rise “from a busboy to the c-suite,” the AGA said. His career spans across all levels and aspects of the gaming industry with experience encompassing gaming equipment manufacturing and distribution, hotel and casino operations, casino financial technology, iGaming and compliance.

    Some of the hire’s most notable prior positions include time as chief executive officer of Everi Holdings, member and chair of the Nevada Gaming Control Board and chief deputy attorney general of Nevada.

    Rumbolz’ predecessor, Allen, played a key role in the industry’s impressive post-COVID recovery and the war on illegal gambling. The new hire will be responsible for maintaining the existing momentum and reinforcing the industry.

    Rumbolz Will Be a Valuable Asset to the AGA

    Rumbolz commented on his new position, expressing his gratitude about the opportunity to help shape gaming’s future. He promised to leverage his new position to build on the progress his predecessor made.

    From stopping illegal gambling to evolving responsible gambling, the AGA is tackling transformational issues and I am eager to build on the progress made during Jim’s tenure.

    Michael Rumbolz, chair, AGA

    Bill Miller, the AGA’s president and chief executive officer, welcomed the new hire on board, praising him as “an industry legend in his own right.” Miller is certain that Rumbolz’ prior career has taught him all the skills needed to make him an invaluable addition to the AGA team.

    Mike’s career as an operator, manufacturer and regulator is unparalleled and will be vital to driving meaningful progress on industry priorities.

    Bill Miller, president & CEO, AGA

    Miller also commented on Allen’s departure, thanking him for his exceptional service and help in maximizing the AGA’s impact on the industry. The CEO described the outgoing chair as a “trusted advisor” and said that he is thankful for his partnership.

    Allen also shared his thoughts on the matter, saying that the AGA is poised for reshaping the industry under Miller and Rumbolz’ leadership. He concluded: “Our industry and this association have never been stronger. I am immensely proud of our success over the last two years accelerating gaming’s recovery while defining and advancing new priorities.”

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    Angel Hristov

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  • Trump Isn’t Bluffing

    Trump Isn’t Bluffing

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    Mandel Ngan / Getty

    We’ve become inured to his rhetoric, but his message has grown darker.

    Editor’s Note: This article is part of “If Trump Wins,” a project considering what Donald Trump might do if reelected in 2024.

    “We pledge to you that we will root out the Communists, Marxists, fascists, and the radical-left thugs that live like vermin within the confines of our country, that lie and steal and cheat on elections,” Donald Trump said this past November, in a campaign speech that was ostensibly honoring Veterans Day. “The real threat is not from the radical right; the real threat is from the radical left … The threat from outside forces is far less sinister, dangerous, and grave than the threat from within. Our threat is from within.”

    David A. Graham: Trump says he’ll be a dictator on “day one”

    What immediately leaps out here is the word vermin, with its echoes of Hitler and Mussolini. But Trump’s inflammatory language can overshadow and distract from the substance of what he’s saying—in this case, appearing to promise a purge or repression of those who disagree with him politically.

    Explore the January/February 2024 Issue

    Check out more from this issue and find your next story to read.

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    This sort of language isn’t entirely new. Trump spoke in Manichaean terms throughout his first campaign and term, encouraging chants to lock up Hillary Clinton in 2016, and in 2018 referring to undocumented immigrants as “animals” who would “infest our country.” Over time, the shock of Trump’s rhetoric has worn off, making it easy to miss the fact that his message has grown even darker.

    Trump himself has changed, too—the old Trump seemed to be running for office partly for fun and partly in service of his signature views, such as opposition to immigration and support for protectionism. Today’s Trump is different. His fury over his 2020 election defeat, the legal cases against him, and a desire for revenge against political opponents have come to eclipse everything else.

    From the January/February 2024 issue: David Frum on the revenge presidency

    In the past few months, the former president has described himself as a “very proud election denier.” He has repeatedly threatened and intimidated judges, witnesses, prosecutors, and even the family of prosecutors involved in the cases against him, going so far as to say that his legal opponents will be consigned to mental asylums if he’s reelected. He has suggested that the man he picked for chairman of the Joint Chiefs of Staff deserves to be executed on grounds of treason. He’s called for investigating NBC and possibly yanking the network off the air, also on grounds of treason—one of his most direct attacks on the First Amendment. And he’s vowed to arrest and indict President Joe Biden and other political opponents for no apparent reason other than that they oppose him.

    The fact that Trump’s ideas have become more authoritarian is not yet fully appreciated. One reason is people have heard Trump say outlandish things for so long that they can’t identify what’s new, or they’ve become numb. Another is venue: Once Trump left the White House and stopped tweeting, his vitriol became less noticeable to anyone who didn’t attend his rallies, seek out videos of them, or join Trump’s own Truth Social network.

    Even when a comment is so extreme that it does break into the mainstream, what happens next is predictable. The first time Trump says something, people react with shock and compare him to Hitler. The second time, people say Trump is at it again. By the third time, it becomes background noise—an appalling but familiar part of the Trump shtick.

    David A. Graham: Trump isn’t merely unhinged

    This is just the sort of “normalization” that Trump’s critics warned against from the start, but it’s also a natural human response to repeated exposure. The result is that Trump has been able to acclimate the nation to authoritarianism by introducing it early and often. When a second-term President Trump directs the Justice Department to lock up Democratic politicians or generals or reporters or activists on flimsy or no grounds at all, people will wring their hands, but they’ll also shrug and wonder why he didn’t do it sooner. After all, he’s been promising to do it forever, right?

    This article appears in the January/February 2024 print edition with the headline “Trump Isn’t Bluffing.”

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    David A. Graham

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  • Trump’s Plan to Police Gender

    Trump’s Plan to Police Gender

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    After decades of gains in public acceptance, the LGBTQ community is confronting a climate in which political leaders are once again calling them weirdos and predators. Texas Governor Greg Abbott has directed the Department of Family and Protective Services to investigate the parents of transgender children; Governor Ron DeSantis has tried to purge Florida classrooms of books that acknowledge the reality that some people aren’t straight or cisgender; Missouri has imposed rules that limit access to gender-affirming care for trans people of all ages. Donald Trump is promising to nationalize such efforts. He doesn’t just want to surveil, miseducate, and repress children who are exploring their emerging identities. He wants to interfere in the private lives of millions of adults, revoking freedoms that any pluralistic society should protect.

    Explore the January/February 2024 Issue

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    During his 2016 campaign, Trump seemed to think that feigning sympathy for queer people was good PR. “I will do everything in my power to protect our LGBTQ citizens,” he promised. Then, while in office, he oversaw a broad rollback of LGBTQ protections, removing gender identity and sexuality from federal nondiscrimination provisions regarding health care, employment, and housing. His Defense Department restricted soldiers’ right to transition and banned trans people from enlisting; his State Department refused to issue visas to the same-sex domestic partners of diplomats. Yet when seeking reelection in 2020, Trump still made a show of throwing a Pride-themed rally.

    Carter Sickels: Being trans shouldn’t exclude me from health laws

    Now, recognizing that red-state voters have been energized by anti-queer demagoguery, he’s not even pretending to be tolerant. “These people are sick; they are deranged,” Trump said during a speech, amid a rant about transgender athletes in June. When the audience cheered at his mention of “transgender insanity,” he marveled, “It’s amazing how strongly people feel about that. You see, I’m talking about cutting taxes, people go like that.” He pantomimed weak applause. “But you mention transgender, everyone goes crazy.” The rhetoric has become a fixture of his rallies.

    Trump is now running on a 10-point “Plan to Protect Children From Left-Wing Gender Insanity.” Its aim is not simply to interfere with parents’ rights to shape their kids’ health and education in consultation with doctors and teachers; it’s to effectively end trans people’s existence in the eyes of the government. Trump will call on Congress to establish a national definition of gender as being strictly binary and immutable from birth. He also wants to use executive action to cease all federal “programs that promote the concept of sex and gender transition at any age.” If enacted, those measures could open the door to all sorts of administrative cruelties—making it impossible, for example, for someone to change their gender on their passport. Low-income trans adults could be blocked from using Medicaid to pay for treatment that doctors have deemed vital to their well-being.

    The Biden administration reinstated many of the protections Trump had eliminated, and the judiciary has thus far curbed the most extreme aspects of the conservative anti-trans agenda. In 2020, the Supreme Court ruled that, contrary to the assertions of Trump’s Justice Department, the Civil Rights Act protects LGBTQ people from employment discrimination. A federal judge issued a temporary restraining order preventing the investigations that Governor Abbott had ordered in Texas. But in a second term, Trump would surely seek to appoint more judges opposed to queer causes. He would also resume his first-term efforts to promote an interpretation of religious freedom that allows for unequal treatment of minorities. In May 2019, his Housing and Urban Development Department proposed a measure that would have permitted federally funded homeless shelters to turn away transgender individuals on the basis of religious freedom. A 2023 Supreme Court decision affirming a Christian graphic designer’s refusal to work with gay couples will invite more attempts to narrow the spaces and services to which queer people are guaranteed access.

    Listen: When the state has a problem with your identity

    The social impact of Trump’s reelection would only further encourage such discrimination. He has long espoused old-fashioned ideas about what it means to look and act male and female. Now the leader of the Republican Party is using his platform to push the notion that people who depart from those ideas deserve punishment. As some Republicans have engaged in queer-bashing rhetoric in recent years—including the libel that queerness is pedophilia by another name—hate crimes motivated by gender identity and sexuality have risen, terrifying a population that was never able to take its safety for granted. Victims of violence have included people who were merely suspected of nonconformity, such as the 59-year-old woman in Indiana who was killed in 2023 by a neighbor who believed her to be “a man acting like a woman.”

    If Trump’s stoking of gender panic proves to be a winning national strategy, everyday deviation from outmoded and rigid norms could invite scorn or worse. And children will grow up in a more repressive and dangerous America than has existed in a long time.

    This article appears in the January/February 2024 print edition with the headline “Trump Will Stoke a Gender Panic.”

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    Spencer Kornhaber

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  • In wake of UNLV, how California colleges gird against active shooters

    In wake of UNLV, how California colleges gird against active shooters

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    As another mass shooting traumatizes a college campus — this time the University of Nevada, Las Vegas — California universities have developed a set of tools, including video trainings, text alerts and enhanced door locks, to protect their students, faculty and staff.

    The UNLV shooting that left three dead and one injured comes as all University of California campuses are currently providing “refresher training” on active shooter situations for communities and first responders — a task made more urgent Wednesday, said UC Davis Police Chief Joe Farrow, coordinator of the UC Council of Police Chiefs.

    He said requests for campus trainings have escalated in recent weeks due to rising tensions over the Israel-Hamas war, which has triggered multiple rallies and reports of vandalism, violence, harassment and threats on both sides.

    Now, he said, campus security needs to be alert for any incidents that might be inspired by the violence at UNLV.

    “I’m not sure about copycat acts, but there are probably some people who look at that and think that’s the solution to their problems,” he said.

    “Our hearts and prayers go out to UNLV. They have just suffered every community’s greatest nightmare,” he said. “First responders across America train constantly to prevent and respond to these horrific incidents. We are all saddened by yet another senseless act.”

    The UNLV shooting took place about noon Wednesday a few miles from the Las Vegas Strip.

    It was the latest of at least nine other mass shootings at or near college campuses in the last 15 years — including one at Michigan State University in February, where the gunman killed three students and injured five others, and Morgan State University during homecoming week in October, which injured five people.

    Preparing for an active shooter at colleges has been a regular part of safety planning for nearly two decades in California — home to the nation’s largest systems of public higher education and a state that has experienced its share of campus tragedies.

    In 2016, a UCLA professor was fatally shot in his office by a former doctoral student. In 2014, a man killed six UC Santa Barbara students in the nearby town of Isla Vista and wounded 14 others before shooting himself in the head at the wheel of a BMW. In 2013, a gunman killed five people and injured three others in a shooting rampage that ended at Santa Monica College. At Cal State Fullerton in 1976, seven people were killed by a custodian who stormed the library.

    In one common protocol at colleges, UNLV students said they received emergency messages from the university at 11:51 a.m. Jason Whipple Kelly, a second-year law school student at UNLV, was walking onto campus to take a final exam when he saw the text:

    “University Police responding to report of shots fire in BEH evacuate to safe area, RUN-HIDE-FIGHT.” He soon heard sirens and he saw police run onto campus. “I was walking to the law school, got the text and turned around and ran back to the car,” he said.

    He praised the university communication, saying updates and instructions were sent out every couple of minutes.

    Another law student, Carlos Eduardo Espina, said in the midst of the emergency, some students were confused by the messaging about the shooter’s location, leading them to believe there was a second shooter on campus.

    The 10-campus UC and 23-campus California State University systems generally share the same practices for responding to active shooters. UC offers a list of resources on how to handle active shooters, including online classes, instructional pocket cards and video trainings by the FBI and other federal agencies.

    The UC website advised students to keep three key words in mind: Run, hide, fight.”

    UC campuses have worked to improve safety by upgrading technology, enhancing training and adding unarmed security officers, mental health professionals and other resources to supplement their sworn police forces, Farrow said.

    Here is more about how California’s colleges prepare for that possibility.

    What are colleges required to do to protect students?

    Under the Clery Act, a federal law enacted in 1990 and expanded since then, each time a school is notified of a campus crime, an official must review the crime and decide if it represents a “serious or ongoing” threat. All higher-education institutions — public and private — that receive money for federal student aid programs are required by law to follow the Clery Act.

    If the threat is deemed serious or ongoing, the school must issue a timely warning to the entire campus.

    Colleges and universities must also establish and put into effect emergency responses and notification systems. They must inform the school community about any “significant emergency or dangerous situations involving an immediate threat to the health or safety of students or employees on the campus.” That includes shootings, fires, earthquakes and crimes of sexual violence.

    Campus police agencies are required to have a rapid response plan for mass shootings, said Melinda Latas, director of campus safety compliance for CSU. Those plans, which are posted to school websites, detail how authorities manage the first response in a shooting and how campuses must train for them.

    The federal law was named for Jeanne Clery, a first-year student at Lehigh University in Pennsylvania, who in 1986 was sexually assaulted and killed in her dorm room by another student she did not know.

    What does training look like?

    Training is critically important, for both security officers and the wider community, campus security experts said.

    Cal State Fullerton holds an active shooter drill every two years in specific locations on campus, such as a parking structure or the student union, Police Capt. Scot Willey said. The university trains about 200 students on run, hide, fight procedures. During one drill, Willey said, a police officer is dressed in a padded suit while carrying a rubber rifle. Students are taught where to run and locations that are good for hiding. They’re also taught to use items around them — staplers, laptops, iPads — to fend off an attacker if there are no other options.

    At UC Davis, students are given training on active shooter situations during required orientations; the workshops are also available to all campus members.

    Students are taught to silence their cellphones, although it helps officers when people message about what is happening in their part of campus, as first responders are sometimes “going in blind,” Farrow said.

    What security challenges do open campuses present?

    Unlike K-12 schools, public college campuses are not gated, with access open to anyone.

    “You don’t know everybody that comes on your campus,” Farrow said. “That’s the disadvantage that you have, and that’s what they experienced in Michigan State.”

    When police receive the first reports of a shooter on campus, the protocols are generally consistent across universities, Farrow said. The dispatchers write up a notification that an active shooter is present, giving a location if known, and urge people to leave the area or shelter in place. This is automatically sent to the entire campus community and to parents and families who have signed up for such notifications, Farrow said.

    How has the technology evolved?

    Improvements to technology, including enhanced door-locking systems and closed-circuit cameras that help authorities identify potential shooters, have helped campuses to be better prepared.

    Notification systems that allow campuses to send out mass alerts are mandatory for all higher-education institutions, said John Ojeisekhoba, president of the International Assn. of Campus Law Enforcement Administrators.

    At Cal State Fullerton, police can consult hundreds of surveillance cameras throughout the campus, Willey said. The school can blast “shelter in place” warnings over indoor and outdoor speakers, along with sending email and text alerts.

    “Text is the most efficient thing that we can use and probably the quickest way that we can communicate with our community,” he said.

    Under UC Davis Chancellor Gary May, the campus has launched a $32-million, seven-year plan to enhance security with such technology as an automatic door-locking system, allowing officials to close all buildings simultaneously rather than having to use individual keys.

    UC Davis also has added a sophisticated camera system that monitors public access. Other U.S. campuses have invested in “shot spotter” devices that detect gunshots and quickly identify where they are coming from, Farrow said.

    UC Davis has increased unarmed security officers on its safety staff. The officers help patrol the campus, check building locks and escort students to classes and dorms when requested; some are trained to take down crime reports.

    Similar steps are being taken throughout the UC system as President Michael V. Drake has led efforts to reshape campus safety practices by supplementing the traditional reliance on sworn police officers.

    “One thing all chancellors say is that we have to keep these open campuses as safe as we can,” Farrow said.

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    Teresa Watanabe, Debbie Truong, Angie Orellana Hernandez, Richard Winton

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  • Pro-Palestinian protesters wanted Newsom to hear them at tree lighting. He moved the event online

    Pro-Palestinian protesters wanted Newsom to hear them at tree lighting. He moved the event online

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    In an abrupt shift of plans, California’s annual holiday tree lighting at the Capitol was postponed a day and moved online, a change state officials attributed to potential protests.

    The event had been planned as a public gathering Tuesday night but was rescheduled to a pre-recorded, virtual ceremony that will be streamed Wednesday evening, according to a statement from Gov. Gavin Newsom’s office.

    “As we continue to see protests across the country impacting the safety of events of all scales — and for the safety and security of all participating members and guests including children and families — the ceremony this year will be virtual,” a spokesperson for the governor’s office said in a statement.

    It wasn’t immediately clear which protests were a concern or whether there were any threats, but KCRA reported that the Sacramento Regional Coalition for Palestinian Rights had planned a protest and march to the Capitol for California’s 92nd annual tree lighting. The group’s Instagram promoted a rally for a cease-fire in the Gaza Strip during the original in-person event, calling for “no celebrations while silent on genocide.”

    About 200 people protested outside the Capitol on Tuesday evening despite the cancellation of the in-person ceremony, KCRA reported.

    “He has chosen to keep [the tree lighting] behind closed doors with select people only and not enjoy it with the public,” Makeez Sawez, a member of Youth for Palestine and an organizer of Tuesday’s rally, told KCRA. “Our goal was originally to come and have conversations and have the governor see us.”

    Newsom has largely followed President Biden’s pro-Israel stance; in October, he visited Israel and met with Prime Minister Benjamin Netanyahu, as well as Israelis who were injured in Hamas’ Oct. 7 attack. California sent medical aid to Israel, though Newsom said officials were also working to do so for Gaza.

    Earlier this week, pro-Palestinian protesters disrupted New York’s tree lighting ceremony, with some demonstrators clashing with police. Other ceremonies across the country, including in Boston and Seattle, have also seen protests, though no issues were reported in those cities.

    Newsom and First Partner Jennifer Siebel Newsom, joined by honored guest 5-year-old Harley Goodpasture, will now light the 60-foot red fir tree in a streamed video shared Wednesday at 6 p.m.

    Harley is the first Native American child to assist with the annual ceremony, the governor’s office said. Her presence will also continue the state’s tradition that the governor’s special guest is chosen from one of the Department of Developmental Services’ nonprofit regional centers, which provide local services for people with intellectual and developmental disabilities. Ornaments for this year’s tree were made by people with disabilities from across the state’s 21 regional centers.

    Harley’s parents, Season and James Goodpasture, founded Acorns to Oak Trees, the first service provider utilized by a regional center on tribal land.

    Despite the new schedule and shift to a virtual event, the ceremony will be otherwise unchanged, officials said, and will still feature the Oakland Interfaith Gospel Choir and the Wilton Rancheria.

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    Grace Toohey

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