One Health In A Fractured World: Why Global Health Governance Must Adapt To Geopolitical Fragmentation

BY CLAIRE J. STANDLEY AND ERIN M. SORRELL

The COVID-19 pandemic exposed weaknesses in global health systems and underscored how interconnected drivers such as changes in land usage, urbanization, and climate amplify zoonotic disease threats. One Health, an integrated approach linking human, animal, and ecosystem health, has gained institutional traction via global governance approaches, yet faces persistent structural challenges, including siloed mandates, funding misalignment, and limited enforcement. We argue for pragmatic, polycentric governance—local leadership supported by regional mini-lateral coalitions and existing bi- and multilateral regimes—to operationalize One Health sustainably and equitably.

Introduction

In early 2020, the COVID-19 pandemic revealed the weaknesses of global health systems to infectious diseases. However, less recognized was how the emergence of this novel virus highlighted the global changes converging to heighten outbreak risks: increased human-animal contact and agricultural intensification, accelerated population growth and urbanization, and changing weather and climatic patterns. These dynamics are playing out repeatedly, from the devastation to the poultry industry—where migratory birds and marine mammals suffer from rampant H5N1 influenza—to surges in mosquito-borne virus infections like chikungunya and Oropouche across the Americas. While these examples demonstrate that health threats are increasingly transboundary, global governance mechanisms are at risk of fragmentation amid political instability and declining trust in multilateral institutions. This article argues that given current geopolitical fragmentation, One Health governance must evolve from idealistic coordination, toward pragmatic, resilient, and multi-level cooperation.

 
What is One Health?

The term “One Health” first emerged in the early 21st century due to growing scientific recognition that infectious diseases of wildlife and livestock could negatively impact humans, and vice versa. Since then, the most widely adopted definition is that of the One Health High Level Expert Panel:

“One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems.”

Early origins of One Health focused on operational collaboration to contain specific infectious disease outbreaks. Yet, the field has grown considerably, benefitting from formalized, interdisciplinary frameworks and governance systems. The most prominent of these is the Quadripartite, established in 2010 between the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (WOAH; formerly OIE), and subsequently joined by the United Nations Environment Programme (UNEP) in 2022. The Quadripartite led the development of the One Health Joint Plan of Action (2022-2026) (OHJPA), providing a blueprint for how these organizations would coordinate to sustainably advance One Health collaboration and implementation, prevent pandemics, and contribute to enhancing resilient health systems.

Since its inception, the Quadripartite has successfully raised the profile of One Health, earning commitments from the G7, G20 and numerous individual countries to adopt the approach in addressing global health threats, particularly for pandemic preparedness and response. The establishment of the One Health High-Level Expert Panel brought geographically and culturally diverse interdisciplinary expertise to the Quadripartite, facilitating better navigation of policy processes and anticipation of implementation barriers. Workshops in different WHO regions further advocated for adoption of One Health strategies, enhanced regional and national coordination, and resulted in the creation of country roadmaps. Yet ultimately, such efforts are limited by the resources of the Quadripartite and critically rely on national ownership, financing mechanisms, and momentum to move from strategy to operationalization.

 
Intrinsic Challenges with One Health Governance

The effort to coordinate sectors with responsibilities in One Health policy and implementation may appear straightforward in theory, but faces persistent structural problems as well as legal and normative weaknesses in practice.

While broad support for One Health exists across the various sectors involved, they often operate with different mandates, budgets, and data systems, making coordination difficult or ad hoc rather than automatic. Though these operational difficulties are being addressed in some settings through multisectoral national and regional strategies, integration is unlikely to ever be fully equitable. One Health has traditionally been promoted with a human health focus by the Global North, marginalizing local and Indigenous knowledge of the cultural and environmental drivers of emergence. This imbalance is mirrored in funding: expecting the environment, veterinary, and agriculture sectors to contribute personnel, knowledge, and consumables to a human health-centric preparedness and response cycle—without acknowledging fundamental discrepancies in resources and mandates—will not resolve the problem.

Government funding is also often reactive—focused on crisis response—whereas One Health approaches to epidemic preparedness depend on sustained investment in prevention. It promotes monitoring ecosystems, conducting surveillance across animal reservoirs, and detecting early spillover. While One Health encompasses far more than just infectious diseases, this remains its most widely applied use case and the one that has gained the most political traction to date. As such, it has become difficult to advocate for One Health multisectoral funding without a looming global health security threat, resulting in trade-offs between sectors.

Finally, One Health as a global initiative lacks a central governing body with real power. While WHO, WOAH, UNEP, and FAO collaborate via the Quadripartite, no one organization can enforce policy across sectors or countries. Similarly, although OHJPA provides a comprehensive framework for advancing One Health and offers technical assistance to support national implementation targets, its initiatives are non-binding and completely voluntary.

The Added Negative Impact of Global Fragmentation

Global fragmentation is increasingly undermining One Health governance. The shift away from Pax Americana and a US-led world order towards a multipolar system has eroded trust in multilateral institutions, including those of the Quadripartite. The WHO has been most dramatically affected, with the US withdrawal prompting a comprehensive review of its core functions and strategic streamlining in response to new fiscal constraints. There have been knock-on effects across other global bodies: the US presidency of the Group of Twenty (G20) in 2026 has refocused its efforts towards economic growth and prosperity, moving away from prior high-level priorities—such as the Sustainable Development Goals (South Africa) and renewable energy (Brazil)—that were more closely aligned with One Health objectives.

This geopolitical fragmentation has been shaped by the prioritization of national interests, the politicization of global health, and international conflicts. Vaccine nationalism during COVID-19, whereby high-income countries disproportionately over-purchased limited supplies of life-saving vaccines, hampered efforts of multilateral initiatives to provide vaccines to countries unable to afford them directly from pharmaceutical companies, further demonstrating the limitations of global cooperation when it is most needed. The politicization of the origins of the pandemic not only directly influenced the US decision to withdraw from the WHO, but also cast a pall over scientific efforts related to zoonotic diseases. Global health and foreign assistance budgets are easy targets in this period of fragmentation when defense budgets are on the rise, as was the case when NATO members agreed to increase their defense spending to support Ukraine. While defense stakeholders increasingly recognize the value of a One Health approach, their integration into One Health governance needs careful consideration.

 
Rethinking One Health Governance: From Idealism to Pragmatism

Moving from idealism to pragmatism requires confronting structural, political, and operational realities. One Health, at its core, is aspirational, requiring efficient collaboration, shared priorities, and sustained funding across a variety of sectors. The stark reality is that international governance systems are, as aforementioned, fragmented and unlikely to be sufficient; a polycentric model provides an alternative approach. Referred to as polycentric governance, this model involves systems in which authority is distributed across levels rather than centralized. Each center operates semi-independently, interacting through cooperation, competition, and coordination, while adapting to local contexts and contributing to broader system goals.

For One Health, centers of authority span communities, governments, and international organizations. The approach emphasizes local actors taking the lead, with higher levels providing support and coordination, leveraging existing and functional structures rather than creating new ones. Local communities are on the front lines of spillover—they are often the first to observe emerging risks but may lack the necessary resources to report these events or respond effectively. Governments are the seat of policy and regulation, housing national surveillance systems and allocating budgets for preparedness and response, but, as noted earlier, lack of coordination and siloed reporting systems prevent effective response. Thus, intergovernmental organizations such as the African Union or the Association of Southeast Asian Nations (ASEAN) can come into play and facilitate coordination between borders. For example, the African Union has a One Health Data Alliance Africa Project, which seeks to “enhance digitalized One Health governance” across the continent. As such, polycentric governance does not replace centralized authority, rather it complements it through a “system of systems.”

One Health events often require decisive action at local or regional levels without waiting for global alignment. Mini-lateral cooperation—small coalitions of middle-powered willing states—help narrow the focus on polycentric governance. It can translate One Health from broad visions into tangible outcomes. Cooperation like this can prove to be quite effective, as One Health challenges are typically geographically and ecologically focused, making global agreements inefficient. Mini-lateral groups are politically aligned sufficiently to cooperate effectively and capable of acting quickly on a shared problem, focusing on specific outcomes rather than broad mandates. One Health mini-lateralism can therefore leverage a variety of platforms including regional networks that share cross-border surveillance data, functional coalitions established for specific technical issues like vaccine research and development, antimicrobial resistance monitoring or climate-health data sharing, or public-private partnerships linking policy to operational action. One example is the newly launched WOAH-PREZODE Working Group, which is convening experts across diverse One Health fields to bridge gaps between scientific evidence and policy formulation. While not automatically resolving the structural challenges highlighted above, such efforts provide stronger opportunities to set shared objectives that rebalance sectoral inequities and prioritize local knowledge while supporting regional priorities.

When pursuing intergovernmental cooperation on One Health—be it at the mini-lateral or multilateral level) —rather than creating new frameworks or initiating new agreements, a more effective strategy may be to mainstream One Health into existing regimes that have authority, financing, and compliance mechanisms, notably climate, trade, and pandemic governance. The goal, then, is to incorporate human–animal–ecosystems linkages where decisions are already being made. Climate agreements and trade frameworks provide clear future opportunities to integrate One Health principles. However, lessons from the 2025 Pandemic Treaty should be taken to heart: while One Health was formally recognized in the Treaty as central to pandemic preparedness, important points related to implementation and funding, especially for lower- and middle-income countries, were pushed to subsequent deliberations and left unanswered.

Finally, these examples underscore the importance of aligning incentives for One Health, both between participating sectors and across levels of polycentric governance. As major powers pivot to bilateral approaches to foreign assistance and health funding, countries must react by identifying areas of convergence with One Health structures and programs. Mini-lateral coalitions can expand through inclusion of emerging economies—providing opportunities to center new voices and advance equity—as well as through the engagement of non-governmental actors: philanthropic entities, industry, and civil society organizations can all play important roles and, in turn, benefit from greater One Health integration.

 
Conclusion

Experts suggest that there is approximately a 50/50 chance of another deadly pandemic before 2050, and the likelihood is that it will be zoonotic in origin. While the benefits of One Health encompass far more than infectious diseases, the reality is that pandemic preparedness offers a critical incentive for the levels of political and operational commitment needed for establishing sustainable and effective One Health governance. Though some may argue that geopolitical fragmentation makes cooperation needed for a global One Health approach unrealistic, we suggest that flexible, networked governance can replace, and even outperform, simplistic visions of top-down oversight. Global change is accelerating biological and environmental risks faster than our current systems can respond: One Health is the only framework designed to manage these interconnected threats. With appropriate and effective governance to guide implementation, it can provide practical, risk-reducing strategies to strengthen ecosystem health, support productive economies, and bolster national and regional security.

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FDA Limits Access To COVID-19 Vaccine To Older Adults And Other High-Risk Groups – A Public Health Expert Explains The New Rules

BY LIBBY RICHARDS

PROFESSOR OF NURSING,

PURDUE UNIVERSITY

On May 20, 2025, the Food and Drug Administration announced a new stance on who should receive the COVID-19 vaccine.

The agency said it would approve new versions of the vaccine only for adults 65 years of age and older as well as for people with one or more risk factors for severe COVID-19 outcomes. These risk factors include medical conditions such as asthma, cancer, chronic kidney disease, heart disease and diabetes.

However, healthy younger adults and children who fall outside of these groups may not be eligible to receive the COVID-19 shot this fall. Vaccine manufacturers will have to conduct clinical trials to demonstrate that the vaccine benefits low-risk groups.

FDA Commissioner Martin Makary and the agency’s head of vaccines, Vinay Prasad, described the new framework in an article published in the New England Journal of Medicine and in a public webcast.

The Conversation U.S. asked Libby Richards, a nursing professor involved in public health promotion, to explain why the changes were made and what they mean for the general public.
Why did the FDA diverge from past practice?

Until the May 20 announcement, getting a yearly COVID-19 vaccine was recommended for everyone ages 6 months and older, regardless of their health risk.

According to Makary and Prasad, the Food and Drug Administration is moving away from these universal recommendations and instead taking a risk-based approach based on its interpretation of public health trends – specifically, the declining COVID-19 booster uptake, a lack of strong evidence that repeated boosters improve health outcomes for healthy people and the fact that natural immunity from past COVID-19 infections is widespread.

The FDA states it wants to ensure the vaccine is backed by solid clinical trial data, especially for low-risk groups.

Was this a controversial decision or a clear consensus?

The FDA’s decision to adopt a risk-based framework for the COVID-19 vaccine aligns with the expected recommendations from the Advisory Committee on Immunization Practices, an advisory group of vaccine experts offering expert guidance to the Centers for Disease Control and Prevention on vaccine policy, which is scheduled to meet in June 2025. But while this advisory committee was also expected to recommend allowing low-risk people to get annual COVID-19 vaccines if they want to, the FDA’s policy will likely make that difficult.

Although the FDA states that its new policy aims to promote greater transparency and evidenced-based decision-making, the change is controversial – in part because it circumvents the usual process for evaluating vaccine recommendations. The FDA is enacting this policy change by limiting its approval of the vaccine to high-risk groups, and it is doing so without any new data supporting its decision. Usually, however, the FDA broadly approves a vaccine based on whether it is safe and effective, and decisions on who should be eligible to receive it are left to the CDC, which receives research-based guidance from the Advisory Committee on Immunization Practices.

Additionally, FDA officials point to Canada, Australia and some European countries that limit vaccine recommendations to older adults and other high-risk people as a model for its revised framework. But vaccine strategies vary widely, and this more conservative approach has not necessarily proven superior. Also, those countries have universal health care systems and have a track record of more equitable access to COVID-19 care and better COVID-19 outcomes.

Another question is how health officials’ positions on COVID-19 vaccines affect public perception. Makary and Prasad noted that COVID-19 vaccination campaigns may have actually eroded public trust in vaccination. But some vaccine experts have expressed concerns that limiting COVID-19 vaccine access might further fuel vaccine hesitancy because any barrier to vaccine access can reduce uptake and hinder efforts to achieve widespread immunity.

What conditions count as risk factors?

The New England Journal of Medicine article includes a lengthy list of conditions that increase the risk of severe COVID-19 and notes that about 100 million to 200 million people will fall into this category and will thus be eligible to get the vaccine.

Pregnancy is included. Some items on the list, however, are unclear. For example, the list includes asthma, but the data that asthma is a risk factor for severe COVID-19 is scant.

Also on the list is physical inactivity, which likely applies to a vast swath of Americans and is difficult to define. Studies have found links between regular physical activity and reduced risk of severe COVID-19 infection, but it’s unclear how health care providers will define and measure physical inactivity when assessing a patient’s eligibility for COVID-19 vaccines.

Most importantly, the list leaves out an important group – caregivers and household members of people at high risk of severe illness from COVID-19 infection. This omission leaves high-risk people more vulnerable to exposure to COVID-19 from healthy people they regularly interact with. Multiple countries the new framework refers to do include this group.

Why is the FDA requiring new clinical trials?

According to the FDA, the benefits of multiple doses of COVID-19 vaccines for healthy adults are currently unproven. It’s true that studies beyond the fourth vaccine dose are scarce. However, multiple studies have demonstrated that the vaccine is effective at preventing the risk of severe COVID-19 infection, hospitalization and death in low-risk adults and children. Receiving multiple doses of COVID-19 vaccines has also been shown to reduce the risk of long COVID.

The FDA is requiring vaccine manufactures to conduct additional large randomized clinical trials to further evaluate the safety and effectiveness of COVID-19 boosters for healthy adults and children. These trials will primarily test whether the vaccines prevent symptomatic infections, and secondarily whether they prevent hospitalization and death. Such trials are more complex, costly and time-consuming than the more common approach of testing for immunological response.

This requirement will likely delay both the timeliness and the availability of COVID-19 vaccine boosters and slow public health decision-making.

Will low-risk people be able to get a COVID-19 shot?

Not automatically. Under the new FDA framework, healthy adults who wish to receive the fall COVID-19 vaccine will face obstacles. Health care providers can administer vaccines “off-label”, but insurance coverage is widely based on FDA recommendations. The new, narrower FDA approval will likely reduce both access to COVID-19 vaccines for the general public and insurance coverage for COVID-19 vaccines.

The FDA’s focus on individual risks and benefits may overlook broader public health benefits. Communities with higher vaccination rates have fewer opportunities to spread the virus.

What about vaccines for children?

High-risk children age 6 months and older who have conditions that increase the risk of severe COVID-19 are still eligible for the vaccine under the new framework. As of now, healthy children age 6 months and older without underlying medical conditions will not have routine access to COVID-19 vaccines until further clinical trial data is available.

Existing vaccines already on the market will remain available, but it is unclear how long they will stay authorized and how the change will affect childhood vaccination overall.

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Long COVID Inflicts Deep Scars On The Lungs, But Targeting Specific Immune Cells Could Reverse Damage − New Research In Mice

BY HARISH NARASIMHAN

PH.D CANDIDATE IN IMMUNOLOGY

UNIVERSITY OF VIRGINIA

The long-term effects of respiratory viral infections such as COVID-19 are a major public health burden. Some estimates suggest over 65 million people around the world suffer from long COVID-19.

Efforts to better understand this condition, however, have been hampered by its ability to affect multiple organ systems, such as those involving the lungs, brain and heart. This is further complicated by the lack of animal models that can sufficiently mimic the disease.

Animal models, such as mice and rats, are a crucial tool that researchers use to study human diseases and develop treatment strategies. Although there are major differences between humans and animal models, the vast majority of our immune and organs systems function similarly. Such similarities in physiology have made significant health care discoveries, including those related to COVID-19, possible.

I am an immunology researcher in the Sun Lab at the University of Virginia. We study the role the immune system plays in respiratory viral infections such as influenza and COVID-19. In our newly published research, we developed a new mouse model to study long COVID-19 and found that blocking certain overactive immune cells can restore lung function.

New models, new targets

Out team wanted to better understand the long-term effects of COVID-19 on the respiratory system. To do this, we worked to identify key features associated with lung scarring following COVID-19.

First, we examined lung samples from patients with long COVID-19. Although these patients were infected several months to years before the samples were taken, we found evidence of an overactive immune system in their lungs, particularly within areas that failed to fully repair themselves after infection.

Next, we aimed to create a mouse model for long COVID-19 by comparing the pathology of mice infected with four different types of respiratory viral infections. Surprisingly, we found that mice infected with influenza virus, rather than the COVID-19 mouse models scientists currently use, best replicated the physical features of severe chronic lung disease. The reasons why infections from different respiratory viruses affect the lungs in different ways are unclear. But preliminary evidence suggests it may be because each virus targets different types of cells “in humans and mice.”

Additionally, since long COVID-19 is about the damage left behind after infection, it seems less important what virus causes the problem in our animal model than that the damage is similar to what we want to address in human patients.

Using our new mouse model, we were able to identify the presence of an abnormal cluster of cells in mice lungs – made up of the same dysfunctional immune and epithelial, or structural, cells seen in the lungs of long-COVID-19 patients. Additionally, we found that the uncontrolled activity of these immune cells in the lungs impeded structural cells from repairing themselves. It also hindered them from restoring gas exchange, the process of taking in oxygen and releasing carbon dioxide.

Importantly, when we blocked the activity of proteins associated with this overactive immune response, it reduced lung scarring and restored optimal lung function in mice.

Treating respiratory viral infections

Most approaches to addressing long COVID-19 rely on starting treatment early after infection. To the best of our knowledge, our study is the first to identify strategies to treat the respiratory symptoms of long COVID-19 after this chronic disease develops.

The drugs we tested in our study have already been approved by the Food and Drug Administration to treat severe COVID-19 and other inflammatory conditions. We hope our findings can spur further research on using these drugs to treat long COVID-19.

Our work may have applications beyond long COVID-19. Growing evidence suggests that many respiratory viral infections, such as influenza, COVID-19 and respiratory syncytial virus, may result in chronic lung disease. Considering the four pandemics and even more respiratory viral epidemics that have occurred in the past 100 years, studying the cellular and molecular similarities between respiratory viral infections may be critical to how medical practitioners respond to future viral outbreaks.

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Future Pandemics Will Have The Same Human Causes As Ancient Outbreaks − Lessons From Anthropology Can Help Prevent Them

The first emerging infections followed the rise of intensive agriculture. mikroman6/Moment via Getty Images

BY RON BARRETT

ASSOCIATE PROFESSOR OF 

ANTHROPOLOGY, MACALESTER COLLEGE

The last pandemic was bad, but COVID-19 is only one of many infectious diseases that emerged since the turn of this century.

Since 2000, the world has experienced 15 novel Ebola epidemics, the global spread of a 1918-like influenza strain and major outbreaks of three new and unusually deadly coronavirus infections: SARS, MERS and, of course, COVID-19. Every year, researchers discover two or three entirely new pathogens: the viruses, bacteria and microparasites that sicken and kill people.

While some of these discoveries reflect better detection methods, genetic studies confirm that most of these pathogens are indeed new to the human species. Even more troubling, these diseases are appearing at an increasing rate.

Despite the novelty of these particular infections, the primary factors that led to their emergence are quite ancient. Working in the field of anthropology, I have found that these are primarily human factors: the ways we feed ourselves, the ways we live together, and the ways we treat one another. In a forthcoming book, “Emerging Infections: Three Epidemiological Transitions from Prehistory to the Present,” my colleagues and I examine how these same elements have influenced disease dynamics for thousands of years. Twenty-first century technologies have served only to magnify ancient challenges.

Neolithic infections

The first major wave of newly emerging infections occurred with the start of the Neolithic revolution about 12,000 years ago, when people began shifting from foraging to farming as their primary means of subsistence.

Before then, human infections tended to be mild and chronic in nature, manageable burdens of long-term parasites that people carried around from place to place. But full-time agrarian living brought the kinds of acute and virulent infections that we are familiar with today. This global shift was humanity’s first epidemiological transition.

Farming itself was not the cause. Rather, it was the major lifestyle changes associated with this new enterprise. Agriculture supplied people with high-calorie grains, but often did so at the expense of dietary diversity, resulting in compromised immunity from nutritional deficiencies.

The human population increased dramatically, and so did the number of large and densely settled communities that could sustain the transmission of deadlier pathogens.

Our ancient ancestors domesticated animals for food and labor, and their proximity to one another created opportunities for livestock diseases to evolve into human diseases.

Finally, the social hierarchies of newly agrarian societies led to disparities in the distribution of essential resources for healthy living.

These challenges of subsistence, settlement and social organization were the root causes of humanity’s first major disease transition.

Declining infections

For a dozen millennia, these patterns spread across the world like a plague of plagues. They persisted until the 19th and 20th centuries, when life expectancy rose with the precipitous decline of infectious diseases in high- and middle-income countries.

Remarkably, the greatest proportion of this decline occurred before the discovery of effective antibiotics and most of the vaccines we use today. Health improvements were mainly due to nonmedicinal factors such as better farming and food distribution methods, major sanitation projects and housing reforms in poor urban areas.

These were significant reversals in the same ancient categories – subsistence, settlement and social organization – that led to the rise of infectious diseases in the first place. They resulted in humanity’s second epidemiological transition, a significant but only partial reversal of the changes that first began in the Neolithic period.

This second pattern was not a panacea. Despite overall health improvements, chronic noninfectious conditions such as heart disease and cancer rose to become the primary causes of human mortality.

Most low-income countries experienced a later version of this transition after World War II, but their health gains from declining infections were significantly less than those of their wealthier counterparts. At the same time, their losses to noninfectious diseases rose at comparable rates. These conflicting trends have led to a “worst-of-all-worlds” scenario with respect to the health of poor societies.

It is also worth noting that the declining infections in low-income societies have depended more on affordable antimicrobial drugs. Given the emergence of drug-resistant pathogens, these medicinal buffers are proving to be little more than short-term solutions for the health consequences of poverty.

With the ability of pathogens to move freely across borders and boundaries, these consequences can quickly become everyone’s problems.

Converging infections

In recent decades, humanity’s interconnections have reached the point that nearly everyone now lives within a single global disease environment. Borders and boundaries no longer constrain the spread of distant outbreaks. The COVID-19 pandemic dramatically illustrated this new reality, when the SARS-CoV-2 virus spread around the world in only a few weeks.

The COVID-19 pandemic also highlighted the ways that infectious and noninfectious diseases can interact synergistically with one another to produce even worse outcomes than the simple sum of each disease. This is starkly illustrated by the majority of COVID-19 deaths, which occurred among people with chronic heart, lung and metabolic conditions that are common to a growing proportion of older people in populations both wealthy and poor.

When combined, these challenges have set the stage for the converging disease patterns visible today. This is the third epidemiological transition: the rise of new, virulent and drug-resistant infections occurring in a rapidly aging and highly interconnected world.

Unfortunately, the present pattern entails increasing outbreaks of new and deadly infections. The root causes of these outbreaks are in areas such as commercial agricultural practices, the urbanization of human populations and the challenges of poverty in the face of economic growth.

Despite the magnitude of these determinants, they are essentially the same issues of subsistence, settlement and social organization from 12,000 years ago. Addressing these recurring issues will do more than prepare the world for future pandemics; it will help to prevent them from happening in the first place.

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At 15, He Is Defending His Home – And Struggling To Stay In School

Deneffy Sánchez, 15, rests on a bunk bed he shares with his mother and little sister in a Los Angeles studio apartment, where his family pays $700 a month to a roommate to rent the space. (AP Photo/Jae C. Hong)

BY BIANCA VÁZQUEZ TONESS

LOS ANGELES (ASSOCIATED PRESS) -- This was the summer Deneffy Sánchez was supposed to learn algebra, biology and the other ninth grade classes he failed last year because he was too depressed and overwhelmed. But advancing to 10th grade had to take a back seat for now. He had more pressing concerns.

It was June. Deneffy, 15, lay in the twin bed he shares with his mother and little sister, while their new roommate — a stranger only weeks before — lamented having to live with his family.

“I would never have let them live here if I’d known how they behave,” Fabiola Del Castillo told a reporter in Spanish. Deneffy’s mother, Lilian López, stood next to her in the cramped room where they all ate and slept.

“Saturday is the first. You need to leave by then,” Del Castillo said, turning to López.

Saturday was only three days away. For Deneffy, that meant a ticking clock.

He had to save his apartment.

No one has stopped the clock for Deneffy or other older students who fell behind when the pandemic shuttered classrooms.

Time is running out on high school, yet millions of students aren’t showing up to class every day. When they do make it, untold numbers are so consumed with their troubles that they struggle to learn. Others have disappeared from school altogether.

Each community has its own set of circumstances that have conspired to sabotage young people's dreams during and after COVID-19. In Los Angeles and much of California, housing insecurity has devastated children and teens’ chances at recovery like nothing else.

“Housing is the biggest reason kids aren’t going to school or we can’t find them,” says Elmer Roldan, executive director of Communities in Schools of Los Angeles, an organization that helps dozens of Los Angeles Unified schools follow up with students who are chronically absent.

Last year, two in five Los Angeles Unified School District students missed more than 10% of the school year, according to data supplied by the district.

There's more. By April, the district had lost track of more than 2,500 students — kids who quietly stopped attending school and never appeared to enroll elsewhere, according to preliminary data posted on the district website.

The reasons are varied and, in many cases, entirely unknown. Deneffy’s odyssey is but one example of how the pandemic wrecked the life of a vulnerable teen, and why he's struggled to return to studying.

Before the pandemic, Deneffy didn’t like school. But he rarely missed it.

He spent his afternoons playing soccer or baseball with friends at the park. On the weekends, he trained with the police department’s youth cadet program, advancing his mom’s dream that he become a police officer.

This summer, while more fortunate teens worked their first jobs, flirted at the beach or even attended summer school, Deneffy was inside. He was holding down a spot in an apartment, engaged in a battle of wills with a hostile adult roommate.

On the day a reporter visited his home, he lay in bed, a fuzzy blanket emblazoned with the face of Queen Elsa from “Frozen” pinned to the wall behind him. He pretended to be lost in his phone, but he was secretly recording Del Castillo just in case his family needed it someday.

Just feet away, his mother, a petite 47-year-old who emigrated from Guatemala 22 years ago, stood calm, her 3-year-old daughter at her knee.

“But we paid all of the rent for June since you didn’t have it. And you said that you would pay for July,” she said in Spanish. López had given Del Castillo money orders totaling $1,240, though López doubted the landlords charged that much for the dilapidated 450-square-foot apartment.

“Yes,” said Del Castillo, acknowledging López had paid for both June and July. “But how am I going to have you here two months? I can’t.”

Turning back to the reporter, Del Castillo continued: “They don’t let me sleep. They’re loud and they snore.” She started to cry.

Then she added a new threat. Having spent all the money López gave her, Del Castillo didn’t have July's rent. So she would relinquish the apartment and keys at the end of the month.

They needed to get out.

The majority of students the government considers “homeless” do indeed have a place to sleep, but it's precarious and often shared with roommates, according to federal statistics. In Los Angeles, more than 13,000 students are homeless and 2,000 of them stay in shelters, the city's superintendent said last spring.

López says she was assaulted while the family stayed in a shelter after getting evicted three years ago. That’s why she’s determined to find her own housing.

The scarcity of affordable housing in Los Angeles has given anyone with an apartment lease in their name the power to take advantage of people like López who don’t have the saved cash, references or savvy to compete for their own place and are desperate to avoid shelters.

It was Deneffy’s idea for him to stay in the apartment for weeks on end and physically block Del Castillo from throwing them out. She had once locked out López and Jennifer, his little sister, while he was at school.

“It’s scary that she could do that again and we couldn’t do anything about it,” he said. “I don’t feel safe leaving.”

Without a father at home, Deneffy, in some ways, has filled the gap. He watches Jennifer when his mom has to work. He wants a job to help pay rent. He often thinks about López dying and making him responsible for his little sister.

Jennifer already has a name for her teenage brother. She calls him Papá.

Studies show students who take on parental roles have struggled to stay in school. Family responsibilities or financial obligations have caused 35% of student dropouts since the pandemic, according to a January report from Communities in Schools and MDRC, a think tank focused on poverty and education.

Deneffy began shouldering adult responsibilities at the same time he lost control over his home and school life. He became homeless in September 2020, just a week after his mom gave birth to Jennifer.

School was online that fall and for most of the year. Instead of engaging and supporting him at that difficult moment, school was alienating. When he logged into seventh grade Zoom classes from the chaotic shelter, “I felt like they were judging me,” he says of his classmates. “I couldn’t focus.”

Seventh grade was a total loss academically and socially. Not wanting to explain his living situation, he stopped talking to friends, classmates and teachers.

That all caught up to him in ninth grade as classes became harder. He never raised his hand. He didn’t have home internet, making it difficult to complete homework. When the school gave tests, he guessed at the answers.

His school offered homework help after his grades crashed. It was assistance he could use.

But what he really wanted was a therapist.

Deneffy says he asked his school’s “psychiatric social worker” sometime in the fall of ninth grade if she could get him professional mental health counseling. But the demand for such help has skyrocketed. A full 42% of high school students surveyed in 2021 by the Centers for Disease Control said they felt persistently sad or hopeless, compared with 28% a decade before.

Instead of getting him his own therapist, the social worker pulled him out of study hall when she could — about once a month — for “check-ins,” according to Deneffy. District and school representatives said they supported homeless students, but would not comment on Deneffy's situation.

When he visited the social worker, he’d smile at the pictures of her dog, play with the fidget spinners on her desk and update her on his living situation. She’d ask him to rate his stress levels. It was usually a 10 — the highest level.

She’d praise him for recognizing his depression and finding his own coping mechanisms, drawing princesses and people wearing Victorian clothing and repeating positive affirmations to himself. He’d return to class feeling relaxed.

Until the next class started.

The stress started to mount that spring. One of the families they were sharing an apartment with had a daughter in drug rehabilitation. She would come home and suffer from withdrawal, or she would use drugs again. And Deneffy would witness a lot of it.

He spent school days listening to moody electronic music in his earbuds and staring at his phone. ”When is this gonna be over?” he would think to himself. “When will I get my happy ending — an apartment?”

Some days he didn’t show up to school at all, skipping as much as 30 days of school that spring. During year-end finals, two of the women assigned to help him with his homework pulled him out of class and brought him to their office, a former storage space outfitted with desks and a table.

Why hadn’t he done any homework all year? they asked. Why hadn’t he studied?

“I’m sorry,” he remembers telling them. “You should just just give up on me.”

They wouldn’t lose hope, they said. They urged him to go to summer school.

It was a five-week session meant to help him pass his subjects and feel confident going into 10th grade. Without summer school, he might not have enough credits to graduate on time. (Studies show that failing classes increases the likelihood of a student dropping out.)

All of this would make it harder for Deneffy to reach his goal of going to college and becoming a therapist. But any personal goals felt remote as Del Castillo continued to rage against his mother. She regularly fought with López and called her ugly names in front of Deneffy and Jennifer.

“It felt," Deneffy says, “like knives stabbing me in my stomach.”

As Del Castillo hounded them to leave by July 1, López told friends and acquaintances they needed a new place.

That was easier said than done.

She applied for public housing and cobbled together enough cleaning jobs so her family would receive priority status. Los Angeles County prioritizes people who work at least 20 hours a week, veterans, disabled people and full-time college students. Notably, parents with young children are not on the preference list. Even at the front of the line, López was told it would take six years to get an apartment.

The first of July came, and Deneffy and his family stayed in the apartment. Del Castillo didn’t move out either. A few days later, she brought in another roommate — this time a man whom Deneffy had seen sleeping on the street, but who had cash to cover the rent. One day the man crumpled to the floor, started bleeding from the mouth and was taken away in an ambulance.

“I saw this man almost die and I didn’t feel anything,” Deneffy says. “I knew something was wrong with me.”

One day toward the end of July, López came home and told Deneffy they were leaving. Would he help her pack up their things?

Deneffy sat still on the bed. This was the day he’d been waiting for, but he couldn’t move. He couldn’t imagine going out into the world again.

Had he forgotten how to talk to people? He panicked at the thought of anyone seeing him dressed, as he was, in shorts and sandals exposing his toes. Or without the black surgical mask that he'd come to rely on to hide his "lumpy and bumpy” face. He sat on the bed as his mom packed up the things around them and moved them into the hallway.

Del Castillo realized they were leaving, and started tossing their things into the hallway. Once everything was out, Deneffy stepped across the threshold and she latched the door behind him.

López had found the new apartment through old friends. It was on the bottom floor of a two-story complex of studio apartments that opened onto a shared concrete courtyard. She knew many of the families that lived there, but not the man they would end up moving in with — a retiree originally from El Salvador.

It was more comfortable than at Del Castillo’s. There was air conditioning. The new roommate didn’t yell. Jennifer could play with other little kids in the courtyard.

But after a few weeks, signs of trouble started to emerge. For the $900 apartment, the roommate was charging López $700 — and another man who slept in the closet $450.

He demanded total silence. López said he tried to kiss her and make other advances. “I'm not sure how long we’re going to be able to stay here,” López said recently.

When school started during the second week of August, Deneffy was allowed to take 10th grade classes as long as he promised to attend summer school next year.

To mentally prepare himself for school, Deneffy wakes up around 4 a.m. He tells himself: “You got this." He tells himself: “A new day means there are going to be new people to talk to with new, interesting problems.”

Even with this preparation, he is already behind.

He couldn’t do any homework for the first month of school because, again, he lacked home internet. Now, armed with a school laptop with its own wireless Internet connection, he’s wading through the backlog while trying to tackle new assignments. He’s most worried about the essays his English teacher has assigned.

“I hate writing,” he says. “I never know where to put the commas and other punctuation.”

He sees a therapist at school every Wednesday for 50 minutes. Things are looking up, he said, but he realizes his new peace is fragile. Against all odds, his mother has convinced the managers of the apartment building where they live to rent them their own small apartment for $1,250 — more than she brings in each month through government cash assistance and her cleaning jobs. The new place would mean an end to their roommate nightmares. To cover the rent, she'll have to find a full time job.

“She tells me not to worry about it,” says Deneffy. “But I do. What if we don't have money and we get kicked out again?”

The Associated Press education team receives support from the Carnegie Corporation of New York. The AP is solely responsible for all content.

The Pandemic's Missing Students: 

Thousands of kids are missing from school. where did they go?

Millions of kids are missing weeks of school as attendance tanks across the US

Americans Can Now Get An Updated COVID-19 Vaccine

This photo provided by Pfizer in September 2023 shows single-dose vials of the company’s updated COVID vaccine for adults. U.S. regulators have approved updated COVID-19 vaccines from Pfizer and Moderna, shots aimed at revving up protection this fall and winter. The Food and Drug Administration’s decision Monday, Sept. 11, 2023 is part of a shift to treat fall COVID-19 vaccine updates much like getting a yearly flu shot. (Pfizer via AP)

BY MIKE STOBBE AND LAURAN NEERGAARD

Most Americans should get an updated COVID-19 vaccine, health officials said Tuesday.

Advisers to the Centers for Disease Control and Prevention endorsed the new shots for everyone 6 months and older and the agency’s director quickly signed off Tuesday on the panel’s recommendation. That means doses should be available this week, some as early as Wednesday.

The severity of the COVID-19 pandemic has faded, but there are still thousands of hospitalizations and hundreds of deaths in the U.S. each week. Hospitalizations have been increasing since late summer, though the latest data indicate infections may be starting to level off, particularly in the South.

Still, experts worry that immunity from previous vaccinations and infections is fading in many people, and a new shot would save many lives.

According to a survey last month that CDC cited, about 42% said they would definitely or probably get the new vaccine. Yet only about 20% of adults got an updated booster when it was offered a year ago.

Doctors hope enough people get vaccinated to help avert another “tripledemic” like last year when hospitals were overwhelmed with an early flu season, an onslaught of RSV, or respiratory syncytial virus, and yet another winter coronavirus surge.

Here is what you need to know about the new COVID-19 shots:

WHO SHOULD GET THE UPDA

TED VACCINE?

The Food and Drug Administration approved the updated shot s from Pfizer and Moderna for adults and children as young as age 6 months. FDA said starting at age 5, most people can get a single dose even if they’ve never had a prior COVID-19 shot. Younger children might need additional doses depending on their history of COVID-19 infections and vaccinations.

The CDC decides how best to use vaccines and makes recommendations for U.S. doctors and the general public. The agency’s panel of outside exerts recommended the updated COVID-19 shots by a vote of 13-1. The no vote came from a panel member who had argued that the new shots should initially be recommended only for older people and others at greatest risk of severe illness. But other panel members said all ages could — and should — benefit.

“We need to make vaccination recommendations as clear as possible,” said one panel member, Dr. Camille Kotton, an infectious diseases doctor at Massachusetts General Hospital.

WHERE CAN I GET A SHOT?

The new vaccine will be available at pharmacies, health centers and some doctor offices. Locations will be listed on the government’s vaccines.gov website. The list price of a dose of each shot is $120 to $130, according to the manufacturers. But federal officials said the new COVID-19 shots still will be free to most Americans through private insurance, Medicare or Medicaid. For the uninsured or underinsured, the CDC is working with health departments, clinics and certain pharmacies to temporarily provide free shots.

On Tuesday, a Pfizer official said his company expected to have doses available at some U.S. locations as early as Wednesday.

WHY MORE COVID-19 SHOTS?

Similar to how flu shots are updated each year, the FDA gave COVID-19 vaccine makers a new recipe for this fall. The updated shots have a single target, an omicron descendant named XBB.1.5. It’s a big change. The COVID-19 vaccines offered since last year are combination shots targeting the original coronavirus strain and a much earlier omicron version, making them very outdated.

Pfizer, Moderna and Novavax all have brewed new supplies, and the FDA on Monday approved shots from Pfizer and Moderna. Novavax’s updated vaccine is still under review.

WILL THEY BE EFFECTIVE ENOUGH?

Health officials are optimistic, barring a new mutant. As expected, XBB.1.5 has faded away in the months it took to tweak the vaccine. Today, there is a soup of different coronavirus variants causing illness and the most common ones are fairly close relatives. Recent lab testing from vaccine makers and other research groups suggest the updated shots will offer crossover protection.

Earlier vaccinations or infections have continued to help prevent severe disease and death but protection wanes over time, especially against milder infections as the virus continually evolves. The FDA did allow seniors and others at high risk to get an extra booster dose last spring. But most Americans haven’t had a vaccination in about a year.

CAN I GET A FLU SHOT AND COVID-19 SHOT AT THE SAME TIME?

Yes. The CDC says there is no difference in effectiveness or side effects if people get those vaccines simultaneously, although one in each arm might be more comfortable. The CDC urges a yearly flu shot for pretty much everyone ages 6 months and up. The best time is by the end of October.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

New COVID-19 Variant Sends Cases Climbing As School Year Begins

The concentration of SARS-CoV-2​ detected in the county's wastewater has doubled since July 19. Image via Patch

Cases have been climbing for weeks fueled by the now dominant EG.5 variant. Here's what parents should know about COVID and the school year.

BY PAIGE AUSTIN

LOS ANGELES, CA (PATCH) — A new coronavirus subvariant is now dominant in California, sending new cases climbing as half a million students prepare for the new school year in the Los Angeles Unified School District.

Compared to the annual winter surge, COVID-19 cases in Los Angeles and across the state remain low. However, cases have been climbing for four weeks fueled by the EG.5 variant, which now makes up a dominant 16.2 percent of cases across the West, according to the Centers for Disease Control and Prevention.

In Los Angeles County, the transmission rate remains low — wastewater samples show a SARS-CoV-2 concentration rate at just 19 percent of the totals during last winter's surge, according to the Los Angeles County Department of Public Health. Still, the concentration of SARS-CoV-2 detected in the county's wastewater has doubled since July 19. That mirrors a small spike in the number of cases reported in the county, averaging 333 new cases per day compared to 202 cases per day in mid-July.

Similarly, California Walgreens stores confirmed a sharp uptick in positive COVID-19 test results with a positivity rate of 48.3 percent, the highest it's been since January, the San Francisco Chronicle reported.

The uptick comes just a day before Los Angeles County rescinds an order requiring employees in healthcare facilities to wear masks when providing care or when in patient care areas. Healthcare workers will still be urged to wear masks while providing care to vulnerable patients and to stay up to date on COVID-19 vaccines.

COVID-19 strains currently circulating descend from Omicron XBB, and county health officials expect that current protections will remain effective to prevent severe illness or death.

As students head back to the classroom next week, county healthy officials urged coronavirus testing to reduce the risk of outbreaks.

"Even when rates of COVID-19 are low, the back-to-school season can bring greater risk of COVID-19 spread," health officials warned in a written statement. "Last August and September, TK-12 schools reported more than 1,100 COVID-19 clusters, groups of potentially connected cases, over an eight-week period. To help reduce transmission among students and staff, Public Health is working with schools to distribute COVID-19 tests and...encourages staff and students, especially those with recent exposures, travel or any symptoms, to take an at-home antigen test the night before or the morning they return to school."

The county health department is offering guidance for navigating the new school year as the pandemic nears its fourth full year:

If a student tests positive for COVID-19 and was at school two days prior to a positive test or the start of COVID symptoms, parents should immediately inform school officials.
Students and staff who test positive for COVID-19 must stay home and isolate regardless of symptoms and vaccination status.

While those infected with COVID are required to isolate for a minimum of five days, it is not necessary to stay home away from others after an exposure to COVID unless you have symptoms and/or test positive after an exposure.

Individuals who have been exposed should test as soon as possible after an exposure and again three to five days after exposure.

Masking for 10 days after an exposure when indoors around others remains a best practice.
Those who develop symptoms and test negative should repeat the test after 48 hours and remain away from others while symptomatic.

Children who are sick should not attend school.

Tuberculosis On The Rise For First Time In Decades After COVID-19 Interrupted Public Health Interventions And Increased Inequality

BY CARLOS FRANCO-PAREDES, ASSOCIATE FACULTY MYCOBACTERIA RESEARCH LABORATORIES, COLORADO STATE UNIVERSITY

Before SARS-CoV-2, the virus that causes COVID-19, spread across the world in 2020, tuberculosis was responsible for more deaths globally than any other infectious disease. But thanks to targeted public health efforts in the U.S. and globally, tuberculosis cases had been steadily falling for decades.

I am an infectious disease clinician and public health practitioner who has been caring for underserved communities in the U.S. for more than two decades.

During the pandemic, it at first appeared that, as with many other common illnesses like the flu, COVID-19 prevention efforts reduced tuberculosis cases, too. But tuberculosis numbers have quickly climbed back up to pre-pandemic levels, marking the first time in decades that cases and deaths have risen globally.

The pandemic not only interrupted important health interventions for tuberculosis, it also caused a decrease in social and economic opportunities for marginalized people around the globe. Together, these effects appear to have put a serious dent in the fight against tuberculosis.

Tuberculosis before and during COVID-19

Tuberculosis is a contagious bacterial infection of the lungs that is normally spread through the air. Most tuberculosis infections are asymptomatic and not contagious.

About 5% to 10% of infected individuals develop active tuberculosis, which is characterized by cough, fever, decreased appetite and weight loss. If left untreated, tuberculosis is a very contagious and dangerous disease that can result in death.

Total estimated tuberculosis infections globally have been falling for years. The lowest number, 10.1 million cases, occurred in 2020, according to the World Health Organization. 2021 saw a significant increase in infections, to 10.5 million, the first rise in more than a decade. Global tuberculosis deaths followed a similar pattern, reaching a low point of an estimated 1.4 millions deaths in 2019, then rising to 1.5 million in 2020 and 1.6 million in 2021.

The number of confirmed cases of tuberculosis – infections detected through direct testing – tells a different part of the story. As testing efforts have improved, confirmed cases have been rising globally to a peak in 2019. As the coronavirus disrupted lives in 2020, confirmed cases of tuberculosis fell significantly before quickly rising again in 2021.

A similar pattern played out in the U.S. There was a sharp drop in confirmed cases in 2020 – mostly driven by lack of testing – followed by a sharp rise back to pre-pandemic levels.

Tuberculosis is a social disease

Tuberculosis is a preventable disease, thanks to effective vaccines, testing and treatments. But millions of people around the world still suffer from this disease, not because of a lack of medical knowledge, but because of persistent social inequities.

Unequal access to economic opportunities, limited health care, poor sanitation, crowded living conditions, malnutrition and illnesses such as diabetes or HIV are all associated with increased risk of tuberculosis.

In the U.S. in 2021, racial and ethnic minority groups accounted for more than 85% of tuberculosis cases, with 71% of cases occurring in persons born outside the U.S.

Increased inequality causing more tuberculosis

Even as the world witnessed a rapid decline in confirmed cases in 2020, experts were worried that interruption of prevention and treatment efforts might result in a rise in tuberculosis.

These fears were warranted. Many health experts, along with the U.S. Centers for Disease Control and Prevention, have confirmed the pandemic disrupted access to tuberculosis testing and diagnosis. It is likely that many cases were missed because of the interruption of tuberculosis control activities, since funding, resources and staff were reassigned to assist in COVID-19 control efforts. Additionally, during health encounters, similarities in symptoms between COVID-19 and tuberculosis may have led to missed diagnoses.

The drop in confirmed cases seems to be, in large part, driven by a lack of testing. The rapid increase since the pandemic, and especially the rise in deaths, confirms that progress made in tuberculosis control over the past 20 years has stalled, slowed or reversed. These two troubling trends are also almost certainly connected to the increase in inequality brought about by the pandemic.

The existence of multigenerational households, overcrowding in low-income neighborhoods, lack of paid sick leave, inability to shield from the pandemic, use of public transportation and lack of health insurance all converged to heighten the risk of both COVID-19 and tuberculosis among the most vulnerable people.

Of course, the pandemic is not the only factor that has increased human hardship – and therefore, tuberculosis – in recent years. For example, Ukraine now has one of the world’s highest tuberculosis disease burdens as a result of Russia’s invasion and the resulting harm to Ukraine’s medical, social and economic systems. Ongoing conflicts in other parts of the world, energy shortages and the effects of climate change and associated impacts on food security are expected to worsen the broader social and political determinants of tuberculosis.

There are many neglected diseases of poverty, and tuberculosis is a great example of how social forces produce human disease. With an estimated one-third of the world’s population at risk for tuberculosis today, fostering social justice interventions to reduce health inequities is a critically important step to relieving the global medical burden of this relentless disease.

The Great Grift: How Billions In COVID-19 Relief Aid Was Stolen Or Wasted

FILE - President Donald Trump signs the coronavirus stimulus relief package, at the White House in Washington, on March 27, 2020, accompanied by, from left, Treasury Secretary Steven Mnuchin, Senate Majority Leader Mitch McConnell of Ky., House Minority Kevin McCarthy of Calif., and Vice President Mike Pence. An Associated Press analysis published on Monday, June 12, 2023, found that fraudsters potentially stole more than $280 billion in COVID-19 relief funding; another $123 billion was wasted or misspent. Combined, the loss represents a jarring 10 percent of the total $4.2 trillion the U.S. government has so far disbursed in COVID-relief aid. (AP Photo/Evan Vucci, File)

BY RICHARD LARDNER, JENNIFER McDERMOTT AND AARON KESSLER

WASHINGTON (AP) — Much of the theft was brazen, even simple.

Fraudsters used the Social Security numbers of dead people and federal prisoners to get unemployment checks. Cheaters collected those benefits in multiple states. And federal loan applicants weren’t cross-checked against a Treasury Department database that would have raised red flags about sketchy borrowers.

Criminals and gangs grabbed the money. But so did a U.S. soldier in Georgia, the pastors of a defunct church in Texas, a former state lawmaker in Missouri and a roofing contractor in Montana.

All of it led to the greatest grift in U.S. history, with thieves plundering billions of dollars in federal COVID-19 relief aid intended to combat the worst pandemic in a century and to stabilize an economy in free fall.

An Associated Press analysis found that fraudsters potentially stole more than $280 billion in COVID-19 relief funding; another $123 billion was wasted or misspent. Combined, the loss represents 10% of the $4.2 trillion the U.S. government has so far disbursed in COVID relief aid.

That number is certain to grow as investigators dig deeper into thousands of potential schemes.

How could so much be stolen? Investigators and outside experts say the government, in seeking to quickly spend trillions in relief aid, conducted too little oversight during the pandemic’s early stages and instituted too few restrictions on applicants. In short, they say, the grift was just way too easy.

“Here was this sort of endless pot of money that anyone could access,” said Dan Fruchter, chief of the fraud and white-collar crime unit at the U.S. Attorney’s office in the Eastern District of Washington. “Folks kind of fooled themselves into thinking that it was a socially acceptable thing to do, even though it wasn’t legal.”

The U.S. government has charged more than 2,230 defendants with pandemic-related fraud crimes and is conducting thousands of investigations.

Most of the looted money was swiped from three large pandemic-relief initiatives launched during the Trump administration and inherited by President Joe Biden. Those programs were designed to help small businesses and unemployed workers survive the economic upheaval caused by the pandemic.

The pilfering was wide but not always as deep as the eye-catching headlines about cases involving many millions of dollars. But all of the theft, big and small, illustrates an epidemic of scams and swindles at a time America was grappling with overrun hospitals, school closures and shuttered businesses. Since the pandemic began in early 2020, more than 1.13 million people in the U.S. have died from COVID-19, according to the Centers for Disease Control and Prevention.

Michael Horowitz, the U.S. Justice Department inspector general who chairs the federal Pandemic Response Accountability Committee, told Congress the fraud is “clearly in the tens of billions of dollars” and may eventually exceed $100 billion.

Horowitz told the AP he was sticking with that estimate, but won’t be certain about the number until he gets more solid data.

“I’m hesitant to get too far out on how much it is,” he said. “But clearly it’s substantial and the final accounting is still at least a couple of years away.”

Mike Galdo, the U.S. Justice Department’s acting director for COVID-19 Fraud Enforcement, said, “It is an unprecedented amount of fraud.”

Before leaving office, former President Donald Trump approved emergency aid measures totaling $3.2 trillion, according to figures from the Pandemic Response Accountability Committee. Biden’s 2021 American Rescue Plan authorized the spending of another $1.9 trillion. About a fifth of the $5.2 trillion has yet to be paid out, according to the committee’s most recent accounting.

Never has so much federal emergency aid been injected into the U.S. economy so quickly. “The largest rescue package in American history,” U.S. Comptroller General Gene Dodaro told Congress.

The enormous scale of that package has obscured multibillion-dollar mistakes.

An $837 billion IRS program, for example, succeeded 99% of the time in getting economic stimulus checks to the proper taxpayers, according to the tax agency. Nevertheless, that 1% failure rate translated into nearly $8 billion going to “ineligible individuals,” a Treasury Department inspector general told AP.

An IRS spokesman said the agency does not agree with all the figures cited by the watchdog and noted that, even if correct, the loss represented a tiny fraction of the program’s budget.

The health crisis thrust the Small Business Administration, an agency that typically gets little attention, into an unprecedented role. In the seven decades before the pandemic struck, for example, the SBA had doled out $67 billion in disaster loans.

When the pandemic struck, the agency was assigned to manage two massive relief efforts — the COVID-19 Economic Injury Disaster Loan and Paycheck Protection programs, which would swell to more than a trillion dollars. SBA’s workforce had to get money out the door, fast, to help struggling businesses and their employees. COVID-19 pushed SBA’s pace from a walk to an Olympic sprint. Between March 2020 and the end of July 2020, the agency granted 3.2 million COVID-19 economic injury disaster loans totaling $169 billion, according to an SBA inspector general’s report, while at the same time implementing the huge new Paycheck Protection Program.

In the haste, guardrails to protect federal money were dropped. Prospective borrowers were allowed to “self-certify” that their loan applications were true. The CARES Act also barred SBA from looking at tax return transcripts that could have weeded out shady or undeserving applicants, a decision eventually reversed at the end of 2020.

“If you open up the bank window and say, give me your application and just promise me you really are who you say you are, you attract a lot of fraudsters and that’s what happened here,” Horowitz said.

The SBA inspector general’s office has estimated fraud in the COVID-19 economic injury disaster loan program at $86 billion and the Paycheck Protection program at $20 billion. The watchdog is expected in coming weeks to release revised loss figures that are likely to be much higher.

In an interview, SBA Inspector General Hannibal “Mike” Ware declined to say what the new fraud estimate for both programs will be.

“It will be a figure that is fair, that is 1,000% defensible by my office, fully backed by our significant criminal investigative activity that is taking place in this space,” Ware said.

Ware and his staff are overwhelmed with pandemic-related audits and investigations. The office has a backlog of more than 80,000 actionable leads, close to a 100 years’ worth of work.

“Death by a thousand cuts might be death by 80,000 cuts for them,” Horowitz said of Ware’s workload. “It’s just the magnitude of it, the enormity of it.”

A 2022 study from the University of Texas at Austin found almost five times as many suspicious Paycheck Protection loans as the $20 billion SBA’s inspector general has reported so far. The research, led by finance professor John Griffin, found as much as $117 billion in questionable and possibly fraudulent loans, citing indicators such as non-registered businesses and multiple loans to the same address.

Horowitz, the pandemic watchdog chairman, criticized the government’s failure early on to use the “Do Not Pay” Treasury Department database, designed to keep government money from going to debarred contractors, fugitives, felons or people convicted of tax fraud. Those reviews, he said, could have been done quickly.

“It’s a false narrative that has been set out, that there are only two choices,” Horowitz said. “One choice is, get the money out right away. And that the only other choice was to spend weeks and months trying to figure out who was entitled to it.”

In less than a few days, a week at most, Horowitz said, SBA might have discovered thousands of ineligible applicants.

“24 hours? 48 hours? Would that really have upended the program?” Horowitz said. “I don’t think it would have. And it was data sitting there. It didn’t get checked.”

The Biden administration put in place stricter rules to stem pandemic fraud, including use of the “Do Not Pay” database. Biden also recently proposed a $1.6 billion plan to boost law enforcement efforts to go after pandemic relief fraudsters.

“I think the bottom line is regardless of what the number is, it emanates overwhelmingly from three programs that were designed and originated in 2020 with too many large holes that opened the door to criminal fraud,” Gene Sperling, the White House American Rescue Plan coordinator, said in an interview.

“We came into office when the largest amounts of fraud were already out of the barn,” Sperling added.

In a statement, an SBA spokesperson declined to say whether the agency agrees with the figures issued by Ware’s office, saying the federal government has not developed an accepted system for assessing fraud in government programs. Previous analyses have pointed to “potential fraud” or “fraud indicators” in a manner that conveys those numbers as a true fraud estimate when they are not, according to the statement.

Han Nguyen, a spokesman for the SBA, said Monday that “the vast majority of the likely fraud originated in the first nine months of the pandemic programs, under the Trump administration.” For the COVID-19 economic injury disaster loan program, Nguyen said, SBA’s “working estimate” found $28 billion in likely fraud.

The coronavirus pandemic plunged the U.S. economy into a short but devastating recession. Jobless rates soared into double digits and Washington sent hundreds of billions of dollars to states to help the suddenly unemployed.

For crooks, it was like tossing chum into the sea to lure fish. Many of these state unemployment agencies used antiquated computer systems or had too few staff to stop bogus claims from being paid.

“Yes, the states were overwhelmed in terms of demand,” said Brent Parton, acting assistant secretary of the U.S. Labor Department’s Employment and Training Administration. “We had not seen a spike like this ever in a global event like a pandemic. The systems were underfunded. They were not resilient. And I would say, more importantly, were vulnerable to sophisticated attacks by fraudsters.”

Fraud in pandemic unemployment assistance programs stands at $76 billion, according to congressional testimony from Labor Department Inspector General Larry Turner. That’s a conservative estimate. Another $115 billion mistakenly went to people who should not have received the benefits, according to his testimony.

Turner declined AP’s request for an interview.

Turner’s task in identifying all of the pandemic unemployment insurance fraud has been complicated by a lack of cooperation from the federal Bureau of Prisons, according to a September “alert memo” issued by his office. Scam artists used Social Security numbers of federal prisoners to steal millions of dollars in benefits.

His office still doesn’t know exactly how much was swiped that way. The prison bureau had declined to provide current data about federal prisoners. The AP reached out to the bureau several times for comment, starting June 2. Bureau spokesperson Emery Nelson said on Monday the agency had provided in February and March “all the necessary data” to the Pandemic Response Accountability Committee. Turner is a member of the committee.

Ohio State Auditor Keith Faber saw trouble coming when safeguards to ensure the unemployment aid only went to people who legitimately qualified were lowered, making conditions ripe for fraud and waste. The state’s unemployment agency “took controls down because on the one hand, they literally were drinking from a firehose,” Faber said. “They had a year’s worth of claims in a couple of weeks. The second part of the problem was the (federal government) directed them to get the money out the door as quickly as possible and worry less about security. They took that to heart. I think that was a mistake.”

Ohio’s Department of Job and Family Services reported in February $1 billion in fraudulent pandemic unemployment claims and another $4.8 billion in overpayments.

The ubiquitous masks that became a symbol of the COVID-19 pandemic are seen on fewer and fewer faces. Hospitalizations for the virus have steadily declined, according to CDC data, and Biden in April ended the national emergency to respond to the pandemic.

But on politically divided Capitol Hill, lawmakers have not put the pandemic behind them and are engaged in a fierce debate over the success of the relief spending and who’s to blame for the theft.

Too much government money, Republicans argue, breeds fraud, waste and inflation. Democrats have countered that all the financial muscle from Washington saved lives, businesses and jobs.

Republicans and Democrats did, however, find common ground last year on bills to give the federal government more time to catch fraudsters. Biden in August signed legislation to increase the statute of limitations from five to 10 years on crimes involving the two major programs managed by the SBA.

The extra time will help federal prosecutors untangle pandemic fraud cases, which often involve identity theft and crooks overseas. But there’s no guarantee they’ll catch everyone who jumped at the chance for an easy payday. They’re busy, too, with crimes unrelated to pandemic relief funds.

“Do we have enough cases and leads that we could be doing them in 2030? We absolutely could,” said Fruchter, the federal prosecutor in the Eastern District of Washington. “But my experience tells me that likely there will be other priorities that will come up and will need to be addressed. And unfortunately, in our office, we don’t have a dedicated pandemic fraud unit.”

Congress has not yet passed a measure that would give prosecutors the additional five years to go after unemployment fraudsters. That worries Turner, the Labor Department watchdog. Without the extension, he told Congress in a late May report, people who stole the benefits may escape justice.

Sperling, the White House official, said any future crisis that requires government intervention doesn’t have to be a choice between helping people in need and stopping fraudsters.

“The prevention strategy going forward is that in a crisis, you can focus on fast delivery to people in desperate situations without feeling that you can only get that speed by taking down commonsense anti-fraud guardrails,” he said.

McDermott reported from Providence, Rhode Island.