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How Nursing Homes Failed to Protect Residents From Covid

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The first terrifying wave of Covid-19 caused 60,000 deaths among residents of nursing homes and other long-term care facilities within five months. As the pandemic wore on, medical guidelines called for promptly administering newly approved antiviral treatments to infected patients at high risk of severe illness, hospitalization or death.

Why, then, did fewer than one in five nursing home residents with Covid receive antiviral treatment from May 2021 through December 2022?

It’s hardly the only way that the nation’s nursing homes proved unable to keep patients safe. A series of studies assessing their attempts to protect vulnerable patients and workers from Covid, along with interviews with experts inside and outside the industry, presents a very mixed pandemic report card.

Brian McGarry, a health economist at the University of Rochester, and David Grabowski, a health care policy researcher at Harvard Medical School, both gave the health care system a D grade overall for nursing homes’ pandemic performance.

“I kept waiting for the cavalry to come, and it really hasn’t, even today,” Dr. Grabowski said. “At no time during the pandemic did we prioritize nursing homes.” More than 167,000 residents have died, Medicare reported this month, along with at least 3,100 staff members.

It was Dr. McGarry, Dr. Grabowski and their co-authors who discovered the failure to deliver antiviral medications. Early on, antivirals meant monoclonal antibodies, a difficult treatment. The drugs were in short supply and administered intravenously; patients might need to leave the facility to receive them.

But in December 2021, the Food and Drug Administration granted emergency authorization to Paxlovid, a pill taken for five days. It drastically improves the prognosis for eligible patients who are 65 and older, sick and frail.

Virtually every nursing home resident meets that description. This is “the highest of the high-risk groups,” Dr. McGarry said. Age and chronic illnesses make the residents vulnerable, “and they’re living in an environment that’s perfect for spreading airborne viruses,” he added, with shared rooms, communal spaces and staff moving from one patient to the next.

As the saying went, a nursing home was like a cruise ship that never docked.

But research recently published in JAMA found that only a quarter of infected residents received antivirals, even during the last six weeks of the study — by which time Paxlovid was widely available and free.

About 40 percent of the nation’s approximately 15,000 nursing homes reported no antiviral use at all.

“They’re basically depriving people of treatment,” said Dr. Karl Steinberg, a medical director at three nursing homes in Southern California and former president of AMDA, the medical association representing providers in long-term care. “It’s surprising and disturbing.”

One bright spot, several industry leaders agreed, was the federally coordinated rollout of the Covid vaccine, which sent providers to facilities in late 2020 and early 2021 to vaccinate residents and staff.

“A remarkable achievement, a collaboration between science and government,” said Dr. Noah Marco, chief medical officer of Los Angeles Jewish Health, which cares for about 500 residents in three skilled nursing facilities.

By early 2022, Medicare reported, 87 percent of residents and 83 percent of employees had been vaccinated, though it took a federal mandate to reach that staff rate. Studies have shown that high staff vaccination rates prevent infections and deaths.

But “we totally dropped the ball on boosters,” Dr. McGarry said. “We just left it up to each nursing home.” Medicare reported this month that about 62 percent of residents per facility, and just 26 percent of staff, are up-to-date on Covid vaccinations, including recommended boosters.

“It’s disappointing,” Dr. Steinberg said. But with workers less likely to perceive Covid as a deadly threat, even though hospitalization and death rates recently began climbing again, “people say no, and we cannot force them,” he said.

Other grounds for poor grades: Early federal efforts prioritized hospitals, leaving nursing homes short of critical protective equipment. Even after the federal government began sending point-of-care testing kits to most nursing homes, so they wouldn’t have to send tests off to labs, getting results took too long.

“If we can find and detect people carrying Covid, we’ll keep them out of the building and prevent transmission,” Dr. McGarry explained. That largely meant staff members, since Medicare-mandated lockdowns shut out visitors.

Nursing homes apparently didn’t make much use of the testing kits. By fall 2020, fewer than a fifth had the recommended turnaround of less than 24 hours. “It negates the value of doing the test in the first place,” Dr. McGarry said.

As for those lockdowns, which barred most family members until November 2021, the consensus is that however reasonable the policy initially seemed, it continued for far too long.

“In retrospect, it caused a lot of harm,” Dr. Steinberg said. “We saw so much failure to thrive, people losing weight, delirium, rapid onset of dementia. And it was usually the staff who were bringing in Covid anyway. A big lesson is that family visitors are essential,” assuming those visitors are tested before they enter and that they use protective gear.

Dr. David Gifford, a geriatrician and the chief medical officer of the American Health Care Association, which represents long-term care providers, pointed to a variety of frustrating problems that prevented nursing homes from doing a better job during the pandemic.

Point-of-care kits that required 15 minutes to read each test and thus couldn’t screen workers arriving for a shift. Prescribing information emphasizing such a long list of possible drug interactions with Paxlovid that some doctors were afraid to use it. And the same suspicion and resistance toward boosters and antivirals that now affect the country as a whole.

“Nursing homes did as much as they could with what they had,” he said. “The health care system as a whole sort of ignored them.”

Staffing, already inadequate in many facilities before Covid, took a hit it has yet to recover from. “It’s our No. 1 issue,” Dr. Gifford said. His association has reported that nursing homes lost nearly 245,000 employees during the pandemic and have regained about 55,000.

“The people working in nursing homes certainly get an A for effort” for persevering at their dangerous jobs, Dr. Steinberg said. But so many have left that nursing homes now often restrict new admissions.

Some long-proposed changes could help protect residents and staff from future pandemics.

Facilities could improve their ventilation systems. They could abandon “semiprivate” rooms for private ones. Dividing buildings into smaller units with consistently assigned staff — an approach pioneered by the Green House Project — would both bolster relationships and reduce residents’ exposure to infection from workers coming and going.

All those changes would require more investment, however, principally from Medicaid, which underwrites most nursing home care. And with more money would come increased federal oversight, which the industry rarely welcomes.

“Investment in our industry, in order for us to provide the highest-quality care, is absolutely necessary,” Dr. Marco said. “But where is the government and public will to do that? I personally don’t see a lot of encouragement right now.”

West Virginia University Slashes Its Budget, Plans to Drop Languages

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Christian Adams wants to be an immigration or labor lawyer, so he planned to major in Chinese studies at West Virginia University, with an emphasis on the Mandarin language.

But as his sophomore year begins, he has learned that, as part of a plan to close a $45 million budget deficit through faculty layoffs and academic program consolidation, the university has proposed eliminating its world languages department, gutting his major.

He will have to pivot to accounting, he says, and probably spend an extra year in college, taking out more student loans.

“A lot of students are really worried,” said Mr. Adams, 18. “Some are considering transferring. But a lot of students are stuck with the hand they’ve been given.”

In a move that shocked the faculty, students and their families, West Virginia University announced last week that it was proposing laying off 169 faculty members, or 7 percent of the faculty on its main campus in Morgantown.

Thirty-two of the university’s 338 majors would be shut down, and some other programs would be consolidated, like those dealing with the state’s historically important but declining mining industry, which will probably be converted into an “energy” program, officials said. The cuts will affect 147 undergraduates and 287 graduate students, or less than 2 percent of student enrollment.

The administration is calling the plan a “transformation.” Some professors are calling it a “blood bath.”

The budget cuts have ignited debate about some of the biggest issues facing higher education. As students flee the humanities — interest in English and world languages is declining nationally — how much money should universities continue to put into them? Is it time to make tough choices about what students really need in order to be educated?

And what should be done about declining public trust in the value of higher education? “We simply have lost the support of the American public,” said E. Gordon Gee, the president of West Virginia University.

Dr. Gee contends that his school is a canary in the coal mine, and is being candid about its financial problems. Other public universities, he said, confront similar challenges. Penn State, for instance, faces a $63 million deficit this year, despite a hiring freeze and other savings. Rutgers University in New Jersey has been slashing budgets and raising tuition to help close a $77 million deficit.

“A lot of higher education institutions in the country have had a deficit in some form or other — ours is sort of in the middle,” Dr. Gee said in an interview.

Some faculty members in Morgantown lament that the state’s flagship university, a respected research institution, is turning its back on the liberal arts by closing programs like creative writing. They say that it is a low blow to a state known for Appalachian poverty and lack of opportunity, one that will accelerate the brain drain that drives many of its most talented young people out of the state.

The cuts, they say, will have ripple effects that will give students fewer course options and larger classes. And, they say, students will lose a precious commodity: the ability to try Russian or fiction writing, even if they are not majoring in the subjects.

The university’s problems, they say, stem from fiscal mismanagement. Over the last decade, the university has invested in projects like new buildings for agriculture, engineering, student health, student housing and recreation, conferences and labs, and it has renovated its athletic facilities. Faculty member say that capital spending was imprudent when West Virginia’s population was declining.

“I think there was clearly bad management here,” said Scott Crichlow, a professor of political science, a department unaffected by the cuts.

They argue that the $45 million deficit, equal to less than 3.5 percent of the university’s $1.3 billion budget, would be manageable if the State Legislature and the governor would step in with a bailout. But Dr. Gee said he has not asked for that, because it would amount to “kicking the ball down the road.”

The university has answered critics of the capital spending by saying that it was needed to maintain the campus and to attract students and faculty members, and that the university’s bond rating is good. The athletic department must raise money and “is expected to carry its own weight,” according to April Kaull, a university spokeswoman.

Dr. Gee said that pandemic aid had provided a false sense of security. “We were given a lot of relief during the pandemic, and some of that free money sometimes doesn’t bring about the best results,” Dr. Gee said. “But the real issue is the fact that there’s a post-pandemic world that we’re dealing with, which is dramatically different.”

As it did at many universities, the pandemic accelerated enrollment declines at the Morgantown campus, where the number of students has fallen by 2,101 students, or almost 8 percent, since August 2020.

One budget analysis said a long-term decline in state support was to blame for much of the university’s financial trouble. Higher education funding in West Virginia has dropped by about 24 percent, or $146 million, over the past decade, adjusted for inflation, according to the analysis by Kelly Allen, executive director of the West Virginia Center on Budget and Policy.

Nationally, public colleges and universities have doubled their reliance on tuition since 1980, but in West Virginia, the figure has nearly tripled, according to the analysis. More than half — 56 percent — of total revenue for the state’s public colleges and universities now comes from tuition; in 1980, the figure was 19 percent. If West Virginia lawmakers had maintained education funding at the level of a decade ago, most of the current deficit would be erased, the report said.

W.V.U.’s tuition and fees for in-state undergraduates this academic year is $9,648, which is steep for many families. The state’s median household income was a little more than $50,000 in 2021.

Dr. Gee, whose contract was recently renewed for one year, until 2025, is known for his charm, outspokenness and fund-raising skills, qualities that have propelled him to lead five universities: Ohio State (twice), Vanderbilt, Brown, West Virginia (twice) and Colorado.

But he has also made unpopular decisions. He said he had been involved in making budget cuts at all three of the public universities where he has served. At Ohio State, he restricted enrollment, merged departments and cut jobs through attrition, while beginning a fund-raising campaign. He once joked that he wore his trademark bow tie because “it’s much more difficult to be hung by the faculty with a bow tie than with a long tie.”

At West Virginia University, professors complain that the proposed changes will be more destructive than Dr. Gee makes them out to be.

“Other universities have closed particular languages,” said Lisa Di Bartolomeo, a professor of Russian, Slavic and East European Studies. “But nobody has closed an entire department of world languages that we know of. The word that we’re hearing over and over again is ‘unprecedented.’”

But the university says the student body has changed, as it has elsewhere. The number of bachelor’s degrees in world languages, literature and linguistics awarded annually fell by 25 percent nationally and by 30 percent in the states where W.V.U. focuses on recruiting students between 2010 and 2021, the university said.

Language requirements for graduation, it says, have been eliminated at Amherst College, the University of Alabama, Johns Hopkins, George Washington University and Duquesne University, among others, as students have shifted to fields like computer science.

For West Virginia students who are still interested in learning French or Mandarin, the university has a possible solution: taking language courses online.

Susan C. Beachy contributed research.

Crews draining manmade lake at apartment after father claimed 2-year-old was kidnapped

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Police are now draining a public manmade lake near an East Point apartment complex after a 2-year-old boy’s father reported that he had been kidnapped in DeKalb County earlier this week.

The child’s father, 23-year-old Artravious North, has since been arrested.

North reported that his son, J’Asiah Deon Mitchell, was kidnapped at gunpoint at an apartment complex on Flat Shoals Road in DeKalb County around 11:23 p.m. Wednesday. North told police that the child was taken while he was stopped at a stop sign.

[DOWNLOAD: Free WSB-TV News app for alerts as news breaks].

Just after 8:15 p.m. Thursday, DeKalb police said they found no signs of an armed robbery or kidnapping and determined that it was a false report.

Channel 2′s Audrey Washington was at the Lakeview Place apartments in East Point Friday, where crews worked all afternoon to drain the large manmade lake while family members of the toddler looked on.

“It’s really critical. This is a 2-year-old boy,” Ischa Njoku with the East Point Police Department said. “We have to find this boy.”

TRENDING STORIES:

North was arrested by DeKalb County police and charged with false statements and false reports of a crime. He was already in jail on an unrelated crime at the time of his arrest.

Channel 2 Action News obtained North’s booking photo from a previous arrest in Gwinnett County unrelated to his son’s disappearance.

Authorities added that the last place J’Asiah Mitchell was seen was in the same apartment complex in East Point where crews are draining the pond. DeKalb County police said East Point police have taken over the search.

“Right now, we have detectives out there looking through video and putting out flyers and speaking with the community,” Njoku said.

Njoku said police are not looking at anyone else as a suspect in the child’s disappearance.

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Anyone with information regarding his whereabouts is asked to call 911 or 770-724-7850. The investigation remains ongoing.

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Flesh-Eating Bacteria at the Beach? What You Need to Know.

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It’s not clear whether the appearance of these cases farther north than usual may be a result of better diagnosis or to warming waters associated with climate change.

The illness, technically called vibriosis, may be caused by infection with several related bacteria. Among the worst is V. vulnificus, which is relatively rare but can be deadly for those who are vulnerable, with survival rates as low as 33 percent, according to one scientific paper.

The bacterium spreads most commonly in two ways.

When people swim in waters contaminated with V. vulnificus, an open sore or cut can provide an entry point for the organism. From there it spreads, becoming a so-called flesh-eating infection that extends quickly beyond the wound into healthy tissue. Then it may spill over into the bloodstream, causing a life-threatening condition called sepsis.

The bacterium also spreads when people who are immunocompromised or have liver disease eat raw oysters that are contaminated. Physicians warn patients with these conditions against eating raw oysters, which become infected by seawater they filter for food.

Older people are generally at greater risk. The three patients who fell ill in Connecticut were all over age 60. People who take medications to reduce stomach acid may also be more likely to get infected or to develop complications following infection.

If you’re among the vulnerable, wear shoes that protect against cuts and scrapes when you’re in salty or brackish water. Wear protective gloves when handling raw seafood. Avoid swimming in the ocean if you have a cut, scrape or other abrasion that might let in the bacterium.

Vibriosis causes a wide range of symptoms, including diarrhea and stomach cramps, vomiting, fever, chills, ear infections and wound infections.

The intestinal problems occur more quickly in people who have ingested the bacterium, usually by eating raw oysters. Ear and wound infections will become red, swollen and extremely painful over a bit more time. Blisters filled with clear liquid may appear on the skin.

Symptoms usually appear within 12 to 24 hours of exposure, and people should seek medical care as soon as possible. Tell doctors about the exposure: The infection can spread quickly if left untreated.

“If the wound starts to look red, puffy and painful, or has a discharge, or redness spreading beyond the edges of the wound, you need to get medical attention right away,” Dr. Schaffner said. “Don’t try to tough it out and wait to see if it gets worse tomorrow.”

A lab test is needed to make the diagnosis. Treatment involves antibiotics and supportive care, but surgery may be required to clean out an infected wound and stop the spread of the infection.

Consider avoiding the water, and not even walking on the beach or wading, if you have an open wound, including one from a recent surgical operation or piercing or tattoo. An open wound means any cut, scrape or other abrasion that might allow the bacterium into your body.

If there is a chance your wound could come into contact with saltwater or brackish water, marine life, or raw or undercooked seafood while you’re cooking, swimming, fishing, boating or walking on the beach, cover the open wound with a waterproof bandage.

If a wound or cut does comes into contact with brackish water or saltwater, raw seafood or its juices, wash it thoroughly with soap and water. If you develop a skin infection, let your health provider know quickly — this is an infection that can spread rapidly.

Climate change will test all of us in unexpected ways. Vibrio infection is something Americans living in the Northeast may need to watch for now.

If you have cancer, are immunocompromised, have liver disease or take drugs to lower stomach acid, doctors say you should not eat raw or undercooked oysters or other raw or undercooked shellfish. (Of course, the same is true for pregnant women.)

If you’re handling raw shellfish, wash your hands thoroughly with soap and water afterward.

Jerome Hauer, 71, Manager of Catastrophes and Other Crises, Dies

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Jerome M. Hauer, who as the first director of the mayor’s Office of Emergency Management oversaw New York City’s response to floods, manhole explosions, mold outbreaks, building collapses, water main breaks, blackouts, hurricanes, sink holes, downed trees, terrorist threats, vermin and the uncertain digital impact on computer networks of Y2K, the turn of the millennium, died on Aug. 11 at his home in Alexandria, Va. He was 71.

The cause was prostate cancer, his wife, Traci L. Hauer, said.

Working under Mayor Rudolph W. Giuliani from 1996 to 2000, Mr. Hauer “won widespread cooperation” from other city agencies and from the state and federal governments, the urban historian Fred Siegel wrote in “The Prince of the City: Giuliani, New York and the Genius of American Life,” published in 2005. He was “a big, plain-spoken and knowledgeable man,” added Mr. Siegel, who died in May.

Mr. Hauer developed an early and comprehensive response to the threat of a bioterrorism attack and to the proliferation of the West Nile virus in the city, rallying relevant agencies to the cause. He later took what he had learned working for the city and applied it to emergency and risk management jobs for New York State and for the federal government, both during and after major crises, including the terrorist attack on the World Trade Center on Sept. 11, 2001, the subsequent anthrax threat and Hurricane Sandy in 2012.

“He was a unicorn, a truly singular individual, a man for crises in all seasons,” said William J. Bratton, who as New York’s police commissioner worked with Mr. Brauer in city government.

Hurricane Hilary: What Travelers Need to Know

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As Hurricane Hilary, a Category 4 storm, headed toward the Baja California Peninsula and the Southwestern United States on Friday, sandbags were piling up on beaches in Los Cabos in Mexico and meteorologists forecast the possibility of heavy rain in California as soon as Saturday. On Friday morning, Southern California was placed under its first ever tropical storm watch.

While it’s unclear where Hilary will make landfall, this severe weather may disrupt travel and impact flights this weekend, particularly through Los Cabos International Airport in San José del Cabo, Mexico. Here’s what travelers need to know.

On Friday afternoon, Hurricane Hilary was moving north toward the Mexican peninsula with sustained winds of up to 145 miles per hour. The storm is expected to weaken in the coming days as it nears the west coast of the Baja California Peninsula on Saturday, and Southern California by Sunday.

Currently, there is a hurricane watch in effect for most of the northern half of the Baja California Peninsula.

Forecasters anticipate there could be up to 10 inches of rain through Sunday evening across the peninsula. Mexico’s national meteorological service said there could also be intense winds and hail, as well as possible landslides and flooding in low-lying areas. In the United States, the National Weather Service has issued flood watches for Los Angeles and Ventura Counties in effect from Sunday afternoon through Monday evening.

Major carriers are waiving change fees for flights scheduled through this weekend to or from Los Cabos Airport, with varying restrictions. Changes on American Airlines must be booked by Aug. 20 and completed within a year. Delta Air Lines and United Airlines are waiving fare differences for flights on or before Aug. 23. And customers flying on Southwest Airlines can rebook to fly within 14 days of their original date of travel.

JetBlue Airways is offering rebooking for travelers with flights through Aug. 22. Alaska Airlines’s policy to allow no-fee flight changes and cancellations also applies to Loreto Airport, on the east coast of Baja California Sur.

In the United States, Roland Nuñez, a National Weather Service aviation meteorologist, said in a video posted on X, the social platform formerly known as Twitter, that he anticipated airports in Southern California will have “issues with heavy rain” that could trigger some air traffic “disturbances” on Sunday and into early next week.

Air travelers should monitor their flight status using their airline’s website or app. Flightaware.com, a flight-tracking service, also provides timely insight into delays and cancellations at domestic and international airports.

Lilzi Orci, president of the Los Cabos Hotel Association, said that each of the association’s 93 hotels had an “action plan” to keep visitors safe, including a “certified place” to serve as a temporary refuge for guests. She said that hotels are preparing for the storm by taking steps such as clearing lawns of debris, locking down garden furniture and monitoring power regulators.

“We are always in communication with the San José del Cabo International Airport so we can know the status of the flights and to be able to inform the guests. In this way we also prevent them from going outside if their flight is canceled,” she said.

Hilton is waiving cancellation penalties through Aug. 23 at its properties in Baja California Sur, including the Beach and Golf Resort in Los Cabos and the Waldorf Astoria Pedregal, a hotel spokesperson said.

Marriott International is also waiving cancellation fees for guests who have stays booked at its properties “in the path of Hurricane Hilary,” said Kerstin Sachl, a spokeswoman for the hotel brand.

Ms. Orci said that Mexican authorities had already closed the ports and beaches in Los Cabos.

Over the next few days, the coast of southwestern Mexico and the Baja California Peninsula could see large swells “likely to cause life-threatening surf and rip current conditions,” according to an advisory from the National Weather Service in the United States.

A storm surge, accompanied by “destructive waves,” will likely cause coastal flooding along the western Baja California Peninsula, the Weather Service said. On the Baja California Sur coast, these waves could rise to to 22 feet, Mexico’s meteorological service said.

Two Carnival cruise ships, the Radiance and the Panorama, are scheduled to depart in separate sailings from Long Beach, Calif., to Mexico on Friday and Saturday. The cruise line said that while there are currently no changes to the itineraries, the company’s fleet operations center is monitoring the hurricane and its potential impact.

“We are continuing to monitor the storm and factor in guidance from the National Hurricane Center, U.S. Coast Guard and the local port authorities to provide timely updates to our guests as more information becomes available,” Carnival said in a statement. “Based on the current forecast, it may be necessary to make changes to the itineraries.”

Ceylan Yeginsu and Emiliano Rodríguez Mega contributed reporting.

Follow New York Times Travel on Instagram and sign up for our weekly Travel Dispatch newsletter to get expert tips on traveling smarter and inspiration for your next vacation. Dreaming up a future getaway or just armchair traveling? Check out our 52 Places to Go in 2023.

For Spain and England, a Swift Rise Is Also a Warning

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Not long after he had taken up his post as president of the Spanish soccer federation, Luis Rubiales called a meeting with the organization’s head of women’s soccer, Rafael Del Amo. Like his boss, Del Amo was new to his role, but Rubiales wanted to gauge his first impressions. He wanted to know what the Spanish women’s team needed in order to succeed.

The answer he received was instructive. There was no effort to sugarcoat it for the new boss. The players, at that stage, did not have jerseys designed to be worn by women, let alone things like elite training facilities or a fully professionalized domestic league. Spain, Del Amo told Rubiales, needed “everything.”

That conversation took place in May 2018. It has taken only five years for Spain’s horizons to change utterly. The fitted jerseys arrived in 2019. The professional domestic league came in 2021. On Sunday, for the first time, Spain will take the field in a Women’s World Cup final, separated from the sport’s ultimate glory only by another debutante on the grandest stage in women’s soccer, England.

In one light, it is perhaps a slightly underwhelming denouement to a World Cup that has acted as a showcase for the breadth of talent now flourishing across the women’s game. The past four weeks have been illuminated, at various times, by Nigeria and Jamaica, Morocco and South Africa, Colombia and Australia.

That the last two teams standing should be wealthy European nations — and traditional soccer powers — is, though, a wholly fitting indication of the sport’s ascendant reality.

The axis of women’s soccer has been tilting inexorably toward western Europe for some time. As Jessica Berman, the commissioner of the National Women’s Soccer League, put it in Sydney on Friday, “The game has leveled up.” The presence of Spain and England in a World Cup final is the culmination of that. It is hard not to read it as some sort of watershed, the moment one era shifted into another.

The finalists’ journeys to this point do not match exactly. The roots of England’s transformation run a little deeper, back to the launch of the Women’s Super League in 2011 and taking in the establishment of a second division (2014), the switch to a winter season (2012) and full professionalization (2018).

That triggered a rush of money into the game: from sponsors, broadcasters and, crucially, the megaliths of the men’s Premier League. That investment is a trickle compared with the sums on offer in the men’s game but a torrent compared with women’s programs elsewhere.

The Women’s Super League attracted a headline sponsor in 2019, in the aftermath of England’s run to the World Cup semifinals, a deal that has subsequently doubled in value. Two years after that, the W.S.L. struck a television deal worth more than $30 million. That money helped establish and finance youth academies, improve coaching and facilities, and attract the imports that have turned the W.S.L. into arguably the strongest domestic competition in the world.

Spain’s rise, by some measures, has been far faster. La Liga Femenino turned professional three years after England, and the national team had never won a World Cup game, let alone reach a final, until 2019. But its team has had the air of a coming force for almost a decade.

The country’s under-17 team reached the final of that age group’s World Cup in 2014; since then, Spain’s record at the youth level has been unmatched. It has won the past two editions of the under-17 World Cup and reached the final of the under-20 competition in both 2018 and 2022, winning the latter.

Most of Coach Jorge Vilda’s squad in Australia and New Zealand took part in one, or more, of those campaigns: Salma Paralluelo, the brilliant forward who ranks as this tournament’s breakout star, scored twice in the final of the under-20 World Cup last year.

It is difficult to trace that success, the emergence of the country’s golden generation, to the work of Spain’s national soccer authorities, given Del Amo’s assessment of what was lacking as recently as 2018. Instead, it tracks much more neatly alongside the growth of Barcelona into Europe’s dominant club team.

Barcelona turned professional in 2015, giving young female players full-time access to the expertise at its prolific youth academy for the first time. In 2019, after losing its first Champions League final to the all-powerful French team Lyon, it set out to ensure its players could compete physically, as well as technically, with any opponent they encountered. It has since won two of the past three editions of the Champions League.

It is not a coincidence that Barcelona should have provided the backbone not only of Vilda’s squad, but of all of those Spain teams that have triumphed at the youth level. Like England, Spain’s success demonstrates not only how central a robust club game is to the health of a national team, but also what great strides can be made in a short space of time in women’s soccer with even a modicum of investment and purpose.

More striking still, though, is how uneven the gains have been. It is only a year since the vast majority of Spain’s squad withdrew from international contention because of a raft of deep-seated, long-running complaints about their treatment by the federation. Their list of grievances included the style and ability of Vilda, the coach; the lack of support staff provided on international duty; and the conditions in which they were expected to work while representing their country.

At the same time, budgets in La Liga Femenino continue to vary wildly: Though Barcelona has invested heavily in its women’s team — though even that, by the standards of the men, is a drop in the ocean — few of its rivals have been prepared to do the same. Real Madrid formed its first women’s team only in 2020.

Meanwhile, a major review of the state of women’s soccer in England — led by the former player Karen Carney and published this summer — found that a “major uplift in investment” was required across the game if it was to “fulfill its potential.”

“Despite the positivity and recent successes, the women’s game still finds itself in a start-up phase and a financially vulnerable position,” Carney wrote.

The report identified a range of issues that, if not addressed, threaten to undermine the progress women’s soccer has made in England. There was, Carney wrote, an urgent need to “fix the talent pathway” for young players who will eventually replenish and replace the current England team, and to introduce “minimum standards,” particularly away from the handful of teams at the top of the W.S.L.

England’s squad still contains players who remember the days, in the early phases of their careers, when they had to work second jobs in order to supplement the meager incomes they earned from soccer.

Their opponents on Sunday are still dealing with the fallout from their own fight to be treated as elite athletes by their own federation. They might not need “everything,” as they did five years ago, but that does not mean those battles are conclusively won. Both England and Spain have proved how quickly success can come, in women’s soccer, simply by doing the bare minimum. That should not disguise, though, how much there is left to do.

After Maui Wildfires, Will Tourism Help or Hurt?

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In the throes of responding to the Maui wildfires that razed the celebrated town of Lahaina and claimed over 110 lives, Hawaii remains mostly open for tourism, despite the misgivings of both residents and tourists.

“Do not come to Maui,” Kate Ducheneau, a Lahaina resident, said in a TikTok video that has been viewed more than two million times since it was posted on Sunday. “Cancel your trip. Now.”

“It’s just kind of a gut-wrenching feeling to see other people enjoying parts of their life that we used to welcome,” she said, adding that her home was severely damaged by fire and her family evacuated with minutes to spare.

Last week’s tragedy has intensified long-simmering tension over the archipelago’s economic reliance on tourism, a dependency that sparked anti-tourism protests in recent years and brought the state to its knees during the pandemic. Many residents, particularly in Maui, are furious over the uncomfortable, contradictory scenario of visitors frolicking in the state’s lush forests or sunbathing on white-sand beaches while they grieve the immense loss of life, home and culture. Others believe that tourism, while particularly painful now, is vital.

“People forget real quick right now, how many local businesses shut down during Covid,” said Daniel Kalahiki, who operates a food truck in Wailuku on Maui, east of Lahaina. The island needs to heal and the disaster areas are far from recovered, he said, but the tourist-go-home messaging is irresponsible and harmful.

“No matter what, the rest of Maui has to keep going on,” said Mr. Kalahiki, 52. “The island has already been shot in the chest. Are you going to stab us in the heart also?”

The devastating loss of life, and these conflicting messages, are causing travelers to grapple over the propriety of visiting Maui, or anywhere in Hawaii, in the near future, prompting them to ask if their dollars would help or their presence would hamper recovery efforts.

“If we’re in a Vrbo, is that going to take away from a potential person who’s been displaced?” said Stephanie Crow, an Oklahoman traveling to Maui this fall for her wedding.

Official guidance from the Hawaiian government has shifted in past week, first discouraging travelers from visiting the entire island of Maui, and now, from West Maui for the rest of the month. Travel to the other islands, including tourist-draws Kauai, Oahu and the Big Island, remains unaffected.

State tourism groups say that travel is encouraged to support Hawaii’s recovery and to prevent it from plunging into a deeper crisis.

“Tourism is Hawaii’s major economic driver, and we don’t want to compound a horrific natural disaster of the fires with a secondary economic disaster,” said Ilihia Gionson, a spokesman for the Hawaii Tourism Authority.

For those in the tourism industry, the year was off to a promising start. Visitor spending through June was $10.78 billion, a 17 percent increase compared to the same period last year, according to Hawaii’s Department of Business, Economic Development and Tourism. The pandemic’s woes were in the past.

But tension over growing tourist numbers was not. Hawaii has for decades been one of the top destinations for American and international visitors, and has struggled to balance tourism with residents’ demands to acknowledge and protect the islands’ traditional culture. Visitor-reliant countries like Jamaica, Thailand and Mexico navigate similar existential issues.

A year ago, John De Fries, the first Native Hawaiian to lead the Tourism Authority, told The New York Times that “local residents have a responsibility to host visitors in a way that is appropriate. Conversely, visitors have a responsibility to be aware that their destination is someone’s home, someone’s neighborhood, someone’s community.”

In the tourism agency’s most recent resident sentiment survey, issued in July, 67 percent of 1,960 respondents across four islands expressed “favorable” views of tourism in the state. But the same percentage agreed with the assertion: “This island is being run for tourists at the expense of local people.”

In the immediate days after the fires, frustration over visitors in Maui erupted.

“People are preying on trauma,” wrote Kailee Soong, a spiritual mentor who lives on Maui in Waikapu, on a TikTok post.

Tourists are still in stores even though resources are limited, said Ms. Soong, 33, in the video. “They are in the way right now as people mourn the loss of their loved ones, of the places that burned down, of the history that was completely erased.”

“Maui is not the place to have your vacation right now,” said the Oahu-born actor Jason Momoa in an Instagram Story. He posted an infographic that read “stop traveling to Maui,” and included guidance on how to make donations. There was fierce outcry after a Maui-based snorkeling company conducted a charity tour after the wildfires, leading the company to issue an apology and suspend operations.

“To hear that people are snorkeling in the water that people have had traumatic experiences and have died in, it’s hard to justify the reasoning behind why that would be viewed as acceptable,” Ms. Ducheneau, 29, said.

She works in property management and at a Lahaina restaurant, and noted that her family’s income is wholly dependent on tourists. Still, she said, “I just don’t think it’s an appropriate time to welcome tourism back into our area.”

The industry supplies approximately 200,000 jobs across the islands, and last year, a little over 9 million visitors spent $19.29 billion, according to the Tourism Authority. About 3 million visitors went to Maui, where the “visitor industry” accounts for 80 percent of every dollar generated on the island, the Maui Economic Development Board said.

“Just like everybody, we need to work. We just got over Covid. Things are just starting to get better. To think that everything might shut down again,” said Reyna Ochoa, a 46-year-old who lives in Haiku in North Maui and works several jobs outside of the tourism industry. “ The islands need the tourism and the income to rebuild.”

In Wailuku, Mr. Kalahiki said that his food-truck sales have dropped by half. Streets usually “popping” with tourists have been empty, he said, and there have been days when his wife, who has a beach apparel store in town, hasn’t sold a single item.

Then there are the travelers who have saved up for their first vacations in years, many with plans to reunite with family or to celebrate weddings and honeymoons. Many want to be respectful and are searching for clarity on what that looks like, deluging online forums to ask local residents where and when it is acceptable to visit.

Early next month, Danett Williams, 48, will spend her honeymoon on the Big Island, where fires burned in North and South Kohala.

For days, she and her fiancé went back and forth about canceling their trip, considering a road trip from their home in San Francisco instead. Ultimately, they decided their tourism dollars were helpful, as long as they stayed clear of other islands and did not take up necessary space or resources away from displaced residents, she said.

Others, like Ms. Crow, from Oklahoma, say that vendors like her wedding planner are asking her to keep their trip. In early September, Ms. Crow, 47, and her fiancé plan to get married on a beach in Kihei, about 20 miles south of Lahaina. It was supposed to be a wedding in a “happy, blissful paradise” setting, she said.

“These are first-world problems I’m dealing with. They’ve lost life, homes, income, they’ve lost everything,” Ms. Crow said.

Determining what to do has been overwhelming and conflicting, she added. And the shifting directives from officials were perplexing, she said.

Marilyn Clark, a travel agent who specializes in trips to Hawaii, said the travel industry was in a “holding pattern” waiting for further government guidance.

Major hotels across Maui have relaxed their cancellation policies through the end of August, she said, but what hotels and vendors will offer beyond that is unclear, compounding the anxiety and confusion among travelers.

And travelers like Ms. Crow are unsure whether their presence will take away from the people who need shelter. In Lahaina alone, one official said that as many as 6,000 people may have lost their homes.

Some hotel operators say that they are offering rooms and other support to emergency responders, displaced residents and hotel staff. The state has secured 1,000 hotel rooms, most of which are north of Lahaina, in Kaanapali, said Kekoa McClellan, a spokesman for the Hawaii Hotel Alliance.

Joe Pluta, a West Maui community leader and real estate broker, is among the homeless. He is staying with his daughter after escaping the flames that destroyed his home and all his possessions.

Describing himself as a “top fan of tourism,” he however suggested that there were other ways to support Maui. The horror and grief is too raw, he said.

“This is not the proper time to come and play,” said Mr. Pluta, 74. “Come again, just give us some time. We just need some time.”

Kirsten Noyes contributed research.

Follow New York Times Travel on Instagram and sign up for our weekly Travel Dispatch newsletter to get expert tips on traveling smarter and inspiration for your next vacation.

Savoring and Saving: Cooking on Vacation

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Matt Tracy, 45, a shoe distributor based in Portland, Maine, loves to cook. On a recent multigenerational trip to Tuscany, he and other family members cooked seven out of 10 nights in a rental villa, preparing dishes like wild boar ragù for 10 people, including his children, 6 and 9.

​ “We save a tremendous amount of money cooking,” he said. “We love going out to dinner, but with two kids and other guests it’s expensive.”

​Whether catering to allergies or other dietary needs, ensuring family harmony or sticking to a budget, cooking on vacation is increasingly popular among travelers choosing short-term rental accommodations.

According to a 2023 travel trend report from the vacation rental platform Vrbo, demand for “foodie-menities” is on the rise. Sixty-five percent of users surveyed said equipment like a barbecue, air fryer and deluxe coffee machine were more important than the destination. Nearly half cook to reduce costs.

At Airbnb, “kitchen” is the third most searched amenity among rentals after pools and Wi-Fi. The rental platform made it easy to find accommodations with “chef’s kitchens” when it introduced various lodging categories in May 2022.

“The kitchen tends to be the heart and soul of vacation homes,” wrote Josh Viner, a regional operations director at the vacation rental home platform Vacasa, in an email. It is in the kitchen, he notes, that “guests gather to not only have a delicious, home-cooked meal, but also connect and relax.”

Travelers who cook do it for many reasons: as a way to explore a place when shopping locally for ingredients; saving money; a family convenience; and more.

​ “Many clients like to have the cooking option,” said Rob Stern, a travel agent based in Raleigh, N.C., who runs RobPlansYourTrip.com, singling out “families on a budget or those who have picky eaters.”

​For others, meal prep brings them closer to their destination.

“When I’m trying to experience a place one of my favorite things to do is visit a grocery store,” said Tanya Churchmuch, 53, who runs a public relations firm in New York City.

​Preparing her own food also allows her to maintain a healthy diet. Even on trips as short as three days, she takes a mini espresso maker and steel cut oats and buys fruit locally to eat at least one meal in, saving, she estimates, between $15 and $30 a couple compared to dining out.

For Ashleigh Butler, the author of the cookbook “The Small Kitchen Cook” who has spent years living out of a camper van in her native Australia as well as North America, patronizing local markets “allows you to absorb the culinary culture whilst supporting local farmers and makers.”

​For frequent travelers, staying somewhere with a kitchen feels less isolating.

“There’s nothing harder than being in a regular hotel room, especially when you’re in places indefinitely,” said Gary Durant, 49, a sports agent from Toronto who is on the road 300 days a year, in an interview from a Level Hotels & Furnished Suites location in Los Angeles.

In the kitchen, he prepares simple dishes like eggs and pasta and entertains clients with delivery meals that he can properly heat and serve. “A kitchen with amenities feels like home away from home,” he said.

Renting a place with a fancy kitchen doesn’t have to cost more. While the “chef’s kitchens” category for Chicago Airbnbs recently had plenty of fancy rentals going for $1,200 and up, there was also a good selection under $200.

For gastronauts, going to places famed for their food makes the cooking not only exciting but cheaper and simpler.

“In Italy, you’re starting off already with great quality ingredients, which makes cooking Italian food so much easier because you don’t have to do so much to the ingredients,” said Jeff Michaud, 46, a Philadelphia-based chef who runs Osteria restaurant. With his wife, Claudia, he also runs the travel company La Via Gaia, which takes small groups to Italy for cooking classes and visits to cheesemakers, truffle hunters and pasta masters.

On average, he estimates he spends about a half to a third of what he would on equivalent ingredients at home, noting a loaf of bread often costs less than a dollar. “In Italy, food is still priced affordably,” he said.

When she travels in Europe, ​Diane Morgan, 68, a food writer and culinary instructor based in Portland, Ore., searches rental listings for appliances like a grill to keep the cleaning to a minimum.

​Three stays in the southern French town of Sablet offered her the chance to patronize local markets and bakeries.​ “It was really simple eating,” she said, describing fresh salads for her lunches. “I wasn’t trying to bake cakes but just be able to utilize the local produce and especially the cheeses.”

​Sampling local food in your rental kitchen doesn’t always require cooking skills.

“My hot French insider tip for travelers with kitchens: frozen food,” wrote Gayle Keck, 62, a writer from California who recently relocated to France, in an email. She recommended the frozen-food chain Picard as a time- and money-saver (four servings of salmon tartare costs 11.70 euros, or about $12.85). It’s also a taste of how the locals cheat with classics like duck confit and quiche Lorraine. “Picard is everyone’s little guilty secret.”

Sizing up a rental’s kitchen can be a hurdle for cooks on the road, resulting in unique packing lists.

Mr. Tracy, the wild boar ragù chef, travels with Better Than Bouillon roasted chicken base, toothpicks for spearing finger food, and a chef’s knife and a paring knife, both wrapped in a towel and stowed in checked baggage.

​In the summers of 2020 and 2021, Ms. Churchmuch and her wife relocated to Iceland to work remotely. “That’s when we started taking things like knives and a microplane,” she said. “No one has a grater in their apartment.”

On a recent trip to Philadelphia, Tara Crowley, 37, a chef based in South Lake Tahoe, Calif., chose the extended-stay hotel AKA University City because its open-plan kitchen allowed her to socialize with friends and family while cooking.

“I always travel with a wine key and bring along flaky Irish salt,” Ms. Crowley wrote in an email. “The salt elevates any dish.”

Eva Sobesky, an architect based in Los Angeles, tried to make it easier for renters to navigate the kitchen at her four-bedroom vacation home in coastal Manzanita, Ore., which she rents on Vrbo. Open shelves allow guests to see where dishes and glasses are. A large central countertop island lets others gather around the cook. An induction cooktop is efficient and easy to clean.

​ “To me, the kitchen is the heart of the house,” Ms. Sobesky said.

R.V.s and rental vans challenge cooks with limited work and storage space. Ms. Butler of the vanlife cookbook embraced the size limitations, which she said encouraged her to “be creative and also more thoughtful” with her recipes, which include pan-fried pizza and steamed cake.

When Covid restrictions limited her travel, Ms. Morgan managed a van trip in remote southeast Oregon by planning out meals like lamb curry ahead of time and washing greens in advance.

​ “We had no food waste on that trip,” she said.

At home or afar, food waste is the pitfall of cooking. The United States Department of Agriculture estimates that 31 percent of food produced each year nationally is wasted at the retail and consumer levels.

That figure may be higher among travelers. In preliminary results, the first phase of a study by the Environmental Protection Agency in Telluride, Colo., over high-season summer and winter time periods found that 70 percent of trash was recoverable, meaning it could have been recycled or composted.

“Sometimes I go into an apartment and the amount of food people have left is incredible,” said Bob Garner, who rents short-term vacation homes in Italy and last year launched EnviroRental, a website for property hosts to learn how to operate more sustainably. “I could live off it for a week.”

Mr. Garner advises guests to shop for half of their stay. “Buy less, don’t over-shop the first day and you’ll save money and won’t worry about food waste,” he said.

While reducing waste is an individual responsibility, the new organization Sustonica certifies short-term rentals based on sustainable practices, including waste reduction among its criteria. The requirements call for at least four recycling bins — glass, paper, plastic and organic — and supplying reusable shopping bags. Sustonica aims to have 70,000 properties vetted by year end.

Earlier this year, Diane Daniel, a short-term rental host in Indian Rocks Beach, Fla., founded the nonprofit Vacation Donations to help visitors and other property managers find ways to donate food and items like books and beach toys.

​In addition to buying less, Ms. Daniel recommends travelers ask short-term rental hosts if they have a system for donating food and other things.

​ “In my wildest dream, keeping things out of the waste bin will be part of what you expect and demand in your rentals,” she said.

Follow New York Times Travel on Instagram and sign up for our weekly Travel Dispatch newsletter to get expert tips on traveling smarter and inspiration for your next vacation. Dreaming up a future getaway or just armchair traveling? Check out our 52 Places to Go in 2023.

Middle-Aged Adults Are Binge Drinking and Using Marijuana at Record Levels

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Binge drinking among adults aged 35 to 50 occurred at record prevalence in 2022, according to research funded by the National Institutes of Health. A new study found that nearly 30 percent of people in this age group reported binge drinking in 2022, continuing a consistent upward trend in the behavior. In 2012, 23 percent of such adults reported binge drinking.

Use of marijuana in this group also reached historical levels, with 28 percent reporting the behavior, up from 13 percent in 2012. In 2022, 4 percent of adults in this group reported using a hallucinogen, double the figure in 2021.

The survey also looked at behavior among adults 19 to 30 years old. For this group, use of marijuana in 2022 was significantly greater, at 44 percent, up from 28 percent in 2012. But their self-reported binge drinking had fallen to 30.5 percent, down from 35.2 percent a decade earlier.

Different generations use different drugs and at different levels. “Drug use trends evolve over decades and across development, from adolescent to adulthood,” said Megan Patrick, a research professor at the University of Michigan and principal investigator on the study, known as Monitoring the Future.

The research has been supported since 1975 by the National Institutes of Drug Abuse, or NIDA, which is a part of the N.I.H. NIDA typically draws attention for its study of behavior and drug use patterns among young people in middle and high school. But the research also follows people throughout their lives, looking at the use of alcohol, marijuana, cigarettes and other substances.

“It’s important to track this so that public health professionals and communities can be prepared to respond,” Dr. Patrick said.

The implications of what drugs a generation tends to use can be significant. For instance, a recent study found that alcohol-related deaths continued to increase among people 65 and older, with deaths among women in this age group rising at a faster rate than among men.

The study suggests that substance-use behavior is heavily influenced by the culture of a generation and the legal status of various drugs at various periods of life. For instance, among the adults aged 35 to 50, the 50-year-olds had tried marijuana the least — only 68 percent of them reported having used it sometime in their life. “These respondents graduated from high school in 1990, when marijuana and other drugs were at or near historical lows across the past four decades, suggesting a cohort effect,” the study noted.

Nora Volkow, the director of NIDA, said in a news release that the data from this study and others like it can inform how health officials and individuals address the risks posed at different life stages. “We want to ensure that people from the earliest to the latest stages in adulthood are equipped with up-to-date knowledge to help inform decisions related to substance abuse,” Dr. Volkow said.

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