By Oct. 5, Bendt was cuddling with her new baby, Willow, on the couch at home in Vancouver, Washington. She was excited to get Willow the new therapy for infants, called nirsevimab, which had started shipping in September — but Bendt, a pediatric home health nurse, couldn’t find it anywhere.

That very morning, at Willow’s two-week checkup, Bendt had asked the pediatrician when Willow could get it. “She literally just shrugged and was like, ‘Well, it’s coming, but we don’t know when,’” Bendt said. “I don’t know why I feel like I’m having to chase people down and still not get answers.”

Bendt searched online, too, for clinics or pharmacies or government websites offering nirsevimab — and found nothing.

By mid-October, demand for nirsevimab, sold under the brand name Beyfortus, had already , according to the pharmaceutical company Sanofi, which developed the drug with AstraZeneca.

In response, the CDC issued Oct. 23 to help pediatricians allocate the limited supply of doses, advising them to focus on the infants at highest risk of RSV complications: those under 6 months old, and those with underlying medical conditions.

RSV is the leading reason babies under 12 months old end up in the hospital, and an estimated from it in the U.S. every year.

Nirsevimab, a monoclonal antibody, is one of two available this fall that could dramatically reduce the risk of lung infections in infants.

The other option is an RSV vaccine from Pfizer called Abrysvo. It was first recommended for adults 60 and older, and then Sept. 22 the CDC in pregnant people, too, to confer some immunity on their infants.

But this adult vaccine is recommended only within a relatively short window in pregnancy, weeks 32 through 36, because of a potential but unproven concern preterm births. That might limit uptake during pregnancy.

By the time the vaccine was approved for pregnant people Sept. 22, Emily Bendt had given birth. So for Willow and other babies like her, nirsevimab will be the only option for protection from RSV this respiratory virus season.

Nirsevimab is approved for all infants up to 8 months old, and for some older babies and toddlers considered at higher risk of severe illness from RSV. The American Academy of Pediatrics recommends that every baby whose mother did not get the RSV vaccine while pregnant receive nirsevimab in the first week of life.

The CDC is now asking prenatal care providers to warn their patients about potential nirsevimab supply shortages, with the hope that driving up the maternal vaccination rate could help ease the demand for nirsevimab.

Nirsevimab’s Powerful but Pricey Potential

Pediatricians say the high cost of nirsevimab and bureaucratic obstacles in Medicaid’s vaccine allocation system for children are slowing down nirsevimab’s distribution. They fear these problems leave infants at risk — unnecessarily — of hospitalization this winter.

In clinical trials, nirsevimab reduced RSV hospitalizations and health care visits in infants by almost 80%.

“This is groundbreaking, honestly,” said , chief of infectious disease for Kaiser Permanente Northwest.

Nirsevimab is a monoclonal antibody treatment, not a traditional vaccine. The passive immunity it confers lasts about five months. That’s long enough to get babies through their first RSV season, when they’re at highest risk for complications.

After an infant’s first winter, “their airways develop and their lungs develop,” Sharff said. “So getting RSV later, as a child instead of as an infant, [means the child is] probably less likely to have severe complications of difficulty breathing, needing to be on a ventilator.”

Sharff’s own daughter had an RSV infection as an infant, needed care in the emergency department, and went on to develop asthma, a condition in children who had severe RSV infections.

For health systems worn down by the “tripledemic” of respiratory viruses — covid-19, flu, and RSV — keeping infants out of the hospital this winter could be a game-changer.

Last year was a historically bad season for RSV. Earlier in the pandemic, measures that states took to slow the spread of covid, such as masking, depressed RSV infections for a while, too. But as infection-control measures were rolled back, more babies and toddlers were exposed to RSV for the first time, at the same time.

In Oregon, the then-Gov. Kate Brown, a Democrat, to declare a and forced hospitals to add capacity to their pediatric intensive care units. Some hospitals even out of state.

“The promise of nirsevimab is that should never, never happen again,” said , a professor of pediatrics at Oregon Health & Science University’s Doernbecher Children’s Hospital in Portland and the president-elect of the American Academy of Pediatrics.

But that depends on the therapy’s availability, and whether providers can get it to newborns efficiently.

The Most Expensive Childhood Vaccine

For babies born without the protection of the maternal RSV vaccine, the American Academy of Pediatrics says the best time to get nirsevimab is at birth, before an infant is exposed to RSV at all.

But babies like Willow who were born before nirsevimab became available will need to get it from an outpatient clinic.

Except for the first dose of the hepatitis B vaccine, administration of childhood vaccines , in a pediatrician’s office, but the cost of nirsevimab might make that hard.

At $495 per dose, it’s the most expensive standard childhood shot, and insurers may not reimburse providers for it this year. That’s a particular problem for small pediatric practices, which can’t afford to lose that much money on a standard childhood vaccine.

“When all of a sudden you have a new product that you’re supposed to give to your entire birth cohort, and you’ve got to pay $500 that may or may not get paid back, that’s just not financially viable,” said , a pediatric infectious-disease specialist at the University of Colorado School of Medicine.

Some insurers, but not all, have announced they will cover nirsevimab right away. Because of in the Affordable Care Act, commercial insurance plans can wait up to a year after a new therapy is approved before they are required to cover it.

Sanofi has announced an “order now, pay later” option for doctors, which would give them more time to work out reimbursement deals.

Could Hospitals Help?

A government program that supplies free shots to about half the children in the United States is structured in a way that makes it hard to get nirsevimab to babies right after birth.

is a safety-net program that provides vaccines to kids on Medicaid, uninsured children, and Alaska Native and American Indian children.

Health care providers can’t bill Medicaid for shots like nirsevimab. Instead, they must register and enroll in the VFC program. Through it, the federal government purchases shots from companies like Sanofi at a discount, and then arranges for them to be shipped free to VFC-enrolled providers, which tend to be pediatric practices or safety-net clinics.

But most hospitals aren’t part of VFC, which presents a problem.

“Many of our newborns go home to caring, affectionate, loving siblings who are actively dripping snot at the time that the child is born,” said , a pediatrician with Mid-Valley Children’s Clinic in Albany, Oregon. “The sooner we can protect them, the better.”

Right now, only about 10% of birthing hospitals nationwide are enrolled in VFC and can get nirsevimab free.

Until nirsevimab’s debut a few months ago, most hospitals didn’t have a strong incentive to participate in Vaccines for Children because childhood vaccines outside of hepatitis B are typically given to kids by pediatricians, in outpatient clinics.

VFC can be burdensome and bureaucratic, according to interviews with several Oregon hospitals and immunization experts. The program’s stringent anti-fraud measures discourage health care providers from enrolling, they say.

Once enrolled, providers must track and store VFC-provided vaccines separately, apart from other vaccine supplies. The person giving a pediatric shot has to know what insurance the child has, and account for each dose in a state-run electronic record system.

Mimi Luther, immunization program manager for Oregon, said the rules are nearly impossible for most hospitals to follow.

“I look forward to the day when the feds have the opportunity to modernize that system to make it easier for providers to enroll and stay enrolled,” she said.

The CDC has in light of the shortage of nirsevimab, allowing providers to “borrow” up to five VFC doses for infants covered by private insurance — as long as those doses are paid back within a month.

This has forced some health systems to make difficult choices. Many are allowing infants to leave the hospital without the shot, assuming they will get it at the first pediatric outpatient visit.

Frothingham said that also creates an equity problem. Newborns whose parents don’t have transportation, or financial resources, are more likely to miss those first pediatric appointments after birth.

Samaritan Health Services, the health system Frothingham works for, has decided to privately purchase a small number of doses to offer in its hospitals, for newborns whom doctors flag as high risk because of breathing problems or family poverty.

“It’s important to us that infants be able to access this regardless of their financial or social circumstances,” Frothingham said.

Nationwide, many birthing hospitals are trying to enroll in the VFC program for next year. But this fall, most won’t have free nirsevimab on hand.

Most babies who get RSV ultimately recover, including those who require hospitalization to help with their breathing. But it’s challenging to treat, and each year some babies die.

In his decades in medicine, OHSU’s Hoffman has lost infant patients to RSV.

“Knowing that some kids may potentially suffer because of delayed access or absence of access to a product that could potentially save their lives is awful,” Hoffman said. “No pediatrician in the country is happy right now.”

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Mental illness can be part of the story of how a person ends up homeless — or part of the price of survival on the streets, where sleep and safety are scarce. Homeless people in Multnomah County, which includes Portland, than the average American. These grim realities have ratcheted up the pressure on politicians to do something.

High housing costs and financial adversity are among the root causes of the burgeoning population on the streets.

About 1 in 3 people who are homeless in Portland a mental illness or a substance use disorder, and the combination of homelessness and substance use or untreated mental illness has led to very public tragedies.

People with schizophrenia, for example, on the city’s streets. One resident in a snowstorm to a stillborn infant. Methamphetamine, cheaper and more potent than it used to be, is of overdose and psychosis.

In Oregon, some politicians, including Portland Mayor Ted Wheeler, have so doctors have more leeway in compelling treatment for patients too sick to know they need care. Without such changes, they argue, people with untreated addictions or mental illnesses are stuck cycling between the streets, county jails, and state psychiatric hospitals.

“I think we can do better by people than allowing them to flounder,” said Janelle Bynum, a state legislator who represents suburbs southeast of Portland.

Bynum, a Democrat, signed on to a of , introduced by Republicans this year, that would expand the criteria for involuntary commitment in Oregon.

“My intention was to signal how cruel I think our current system is,” she said.

people live in California, and though only about a quarter to of homeless people are estimated to have a serious mental illness, they are the ones other residents are likely to encounter in California’s cities. Mayors from San Francisco, San Jose, and San Diego have all expressed frustration that the threshold for psychiatric intervention is so high.

‘Why Aren’t You Doing Something?’

“When I’m often asked, ‘Mayor, why aren’t you doing something about this person who is screaming at the top of their lungs on the street corner?’ and I said, ‘Well, they’re not a threat to themselves or to others,’ that rings hollow,” said , mayor of San Diego.

Now, state lawmakers in Sacramento, backed by mayors, have introduced laws and bills that would help bring more people into treatment, even against their will.

Last year, legislators approved a new approach to mental health care — called — that allows judges to issue treatment plans for people with certain diagnoses. That program begins on a pilot basis this fall in seven counties, including San Diego and San Francisco counties, with the rest of the state expected to join next year.

This year, a bill moving through the legislature would expand who qualifies for a conservatorship or involuntary psychiatric hold.

The bill is gathering support and sponsors are optimistic that Democratic Gov. Gavin Newsom will sign it if it passes. But it’s been controversial: Opponents fear a return to bygone policies of locking people up just for being sick.

Half a century ago, California policymakers , denouncing them as inhumane. Involuntary commitment was de-emphasized, and state laws ensured that it was used only as a last resort. The thinking was that the patient should have autonomy and participate in their care.

But politicians across California are now reconsidering involuntary commitments. They argue that not helping people who are seriously ill and living in squalor on the streets is inhumane. Psychiatrists who support the bill say it would constitute a modest update to .

The shift is dividing liberals over the very meaning of compassion and which rights should take precedence: civil rights like freedom of movement and medical consent, or the right to appropriate medical care in a crisis?

“The status quo has forced too many of our loved ones to die with their rights on,” said Teresa Pasquini, an activist with the . Her son has schizophrenia and has spent the past 20 years being “failed, jailed, treated, and streeted” by what she called a broken public health system.

“We are doctors who have to watch these people die,” said psychiatrist Emily Wood, chair of the government affairs committee of the , a sponsor of the conservatorship bill, . “We have to talk to their families who know that they need that care, and we have to say we don’t have any legal basis to bring them into the hospital right now.”

Under current California law, a person can be held in the hospital involuntarily if they are a danger to themselves or others or if they are unable to seek food, clothing, or shelter as a result of mental illness or alcoholism. Doctors want to add other substance use disorders to the criteria, as well as an inability to look out for one’s own safety and medical care. (The state law defines what is known as “mental health conservatorship,” which is separate from the that Britney Spears was under.)

Wood, who practices in Los Angeles, gave two examples of people she and her colleagues have tried, but struggled, to care for under the current rules. One is a man who doesn’t take his diabetes medication because he’s not taking his schizophrenia medication and doesn’t understand the consequences of not managing either condition.

Wood explained that even if he repeatedly ends up in the emergency room with dangerously high blood sugar, no one can compel him to take either medication under current law, because poorly managing one’s health is not a trigger for conservatorship.

Another man Wood described has a developmental disability that went untreated in childhood. He developed an addiction to methamphetamine in his 20s. Wood said the man is now regularly found sleeping in a park and acting inappropriately in public. His family members have begged doctors to treat him, but they can’t, because substance use disorder is not a trigger for conservatorship.

To Wood, treating these people, even when they’re unable to consent, is the compassionate, moral thing to do.

“It’s essential that we respect all the rights of our patients, including the right to receive care from us,” she said.

But other advocates, including some of those working for Californians with mental illnesses, see the issue very differently.

Lawyers from the nonprofit said the proposed expansion of conservatorship and the ongoing rollout of CARE Courts are misguided efforts, focused on depriving people of their liberty and privacy.

Instead, they said, the state should invest in better voluntary mental health services, which help maintain people’s dignity and civil rights. The group in January to try to of CARE Courts.

These advocates are particularly concerned that people of color, specifically Black residents, who are overrepresented in the homeless population and , will now be disproportionately targeted by more forceful measures.

“When people are told that they have to go to court to get what they should be getting voluntarily in the community, and then they get a care plan that subjugates them to services that still do not meet their cultural needs, that is not compassion,” said , an advocate who has schizophrenia and has experienced homelessness.

More Housing: Another Badly Needed Prescription

Under current state law in Oregon, a person can be held for involuntary treatment if they are a danger to themselves or others or are at risk of serious physical harm because they cannot provide for their basic personal needs due to a mental illness.

Oregon, like California, does not include substance use disorders as grounds for commitment.

But its law is slightly broader than California’s, at least in one respect: Legislators in 2015 to give doctors more leeway to step in if a person’s psychosis or other chronic mental illness is putting them at risk of a medical crisis.

Terry Schroeder, a civil commitment coordinator with the Oregon Health Authority, said that, before the change, a person would have to be nearly comatose or within a few days of death to meet the criteria for doctors to forcibly treat them for their own welfare.

The law now allows care providers to intervene earlier in an ongoing medical crisis.

In Oregon and California, the lack of adequate treatment options is frequently invoked in the ongoing debates over forced commitment and conservatorship.

“Expanding conservatorships doesn’t solve for those structural issues around the lack of housing and the lack of funding for treatment services,” said Michelle Doty Cabrera, executive director of the .

Cabrera’s group also questions the premise that forced treatment works, and there is indeed that compulsory treatment for substance use disorder is effective, and some evidence that it could even be harmful.

Critics of involuntary commitment have questioned the California Legislature’s objectives. If the ultimate goal of forced treatment is to reduce homelessness — and ease the moral failing of ill people sleeping on the street or using drugs in the open — then lawmakers are writing the wrong prescription, they said.

“The problem of homelessness is that people don’t have housing,” said primary care physician Margot Kushel, director of the University of California-San Francisco’s .

“If you had all the treatment in the world and you didn’t have the housing, we would still have this problem.”

Supporters of involuntary commitments say both are needed. Many of the California lawmakers backing expanded conservatorship and CARE Courts are also backing efforts to increase the housing supply, including for the construction of small, neighborhood-oriented residences for people with mental illness.

Nationwide, rents have than people’s incomes in the past 20 years, particularly impacting people who rely on a fixed income, such as monthly disability payments.

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“My mom’s like my cup of coffee,” Gatchet said, her voice breaking, “to mentally psych myself up for what I’m walking into.” Gatchet’s mother reminds her she is good at what she does and she’s loved. After she walks in and sees her colleagues in the break room, Gatchet said, her panic lifts: “This is my team, and it feels safe again.”

More than 700 days have passed since the first case of covid-19 was confirmed in Oregon. Like the rest of the country, Oregon had far more cases in early 2022’s omicron surge than in any previous peak of the pandemic. New cases have begun to recede, but the sheer volume of infections continues to swamp hospitals nationwide. , where Gatchet works, is adapting, yet again, to accommodate more patients than it is licensed to hold.

Dr. Peter Hakim works alongside Gatchet. Recently, his mother-in-law had a heart attack and was taken to a small, rural hospital. She needed specialty care that wasn’t available there. “They could not find a bed for her anywhere in Washington or Oregon for 24 hours,” Hakim said. “So she was sitting in this small six-bed emergency department and couldn’t get transferred out.”

His mother-in-law eventually got the care she needed. A lot of people, Hakim said, “are not as lucky.”

The Salem Hospital emergency department has 100 beds. To handle the influx of people seeking treatment, hospital staffers have made space by putting dozens of beds in the halls.

By noon, those hall beds are occupied, and ambulances are pulling up to the bay behind the hospital — seven, eight, nine at a time.

The pressure builds through the afternoon as more patients arrive. Three years ago, treating people in the hallways would have been an extraordinary measure. Now Gatchet and Hakim prepare for it every day.

Some of what Hakim does as a physician, like cutting off a patient’s clothing to examine a broken hip, is too sensitive for the hallway. He said he took one patient into the bathroom to complete an exam: “That is the one private space we could find at the time.”

The hospital has been above 100% capacity for months, with patients doubled up — and even occasionally tripled up — in their rooms, according to hospital executives. Salem Health allowed a reporter to shadow Gatchet and other staff members on Jan. 27, which proved to be the day with the highest number of covid patients yet — 122 people, nearly 1 in 4 patients in the hospital had the virus.

About 70% of those covid patients were admitted with respiratory symptoms, while the rest were asymptomatic cases discovered during admissions screening, according to hospital executives.

But those 122 patients were just part of the strain from the pandemic. If the health system were a line of dominoes, emergency medicine would be at one end. But the domino that tipped first and knocked the other parts down is long-term care. Statewide, more than 70% of long-term care facilities had a staff member or resident test positive for covid in January, with many reporting full-blown outbreaks.

Low-paid caregivers are burned out and quitting the long-term care sector in huge numbers — it’s one of many industries competing for workers in a crunched labor market experiencing record resignations and retirements.

The covid outbreaks and staffing shortages mean Salem Hospital can’t discharge patients to nursing homes. Those facilities are closed to new admissions.

It’s also harder to find support for patients who need assistance to return to their homes after an illness or disabling accident. The pandemic has made hospital beds, in-home caregivers, and even wheelchairs all more difficult to get.

Dr. Sarah Webber, a , said that before the pandemic, coming up with a safe discharge plan for patients took her team a few days. “And now sometimes it is taking a week or two. And I do have some patients that have been here for several weeks,” she said. Of the 20 hospital patients she was responsible for the prior week, eight were stable and ready to leave but didn’t have a discharge plan.

Statewide, almost 600 patients are ready to leave the hospital but waiting on a discharge plan. One in 10 patients in an Oregon hospital bed could leave but has .

As in the delta wave, a majority of the covid patients hospitalized at Salem Hospital are people who haven’t been vaccinated.

Patients infected with the omicron variant are, on the whole, requiring less oxygen and less intensive care. “I’m seeing more patients live,” said Jackie Williams, a respiratory therapist who works on every floor of the hospital. “It’s like a little glimmer of hope.”

Many of the less critical covid patients are behind closed doors in the hospital’s medical-surgical unit. Being hospitalized with covid — even a milder variant — is a lonely experience.

In the hallway on Jan. 27, a nurse manager spoke with the wife of a covid patient who had been transferred from the emergency room. The manager was explaining that the patient’s wife needed to leave the unit because she was exposed to covid while caring for her husband and could infect hospital staff members or patients. The wife quietly fought back tears as she handed over a bag with glasses and a clean change of clothes for her husband.

“Does he have a cell phone?” the nurse manager asked. “The nurses, they can help him do FaceTime so you can talk to him, OK?” She added: “I’m sorry.”

An Oregon National Guard member to help the nurses pushed a cart full of supplies down the hall and called out a greeting. The guard members provide a little lift — and a show of solidarity — to staff members who are feeling ground down.

For Webber, it stings that many of her patients don’t take her advice to get vaccinated after they recover. “People come to the hospital sick and they want me to help them, but they won’t trust me over the basics of how to prevent it,” she said.

At home, she has less patience for her children — and they seem to need her more. Her 6-year-old daughter recently asked why Webber couldn’t just stay home with her.

“She asked me, ‘Are the sick people more important than me?’” Webber said.

In recent days, hospitalizations in Oregon appear to have reached their peak and are plateauing. Salem Hospital staff members hope that as the omicron wave subsides, the pressure will ease up a bit.

Even as it does, it’s still flu season, and health issues that have worsened through the pandemic in Oregon will resurface. “It might not be breathing problems, but it’s alcoholism. It’s suicide,” said Williams, the respiratory therapist. “It’s traumas, it’s all these other things that are what the world is dealing with after coming out of two years of a pandemic. And those are critical illnesses too.”

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