State officials said the company, Blue Flame Medical, failed to deliver masks and ventilators as promised and that the matter has been referred to Maryland Attorney General Brian Frosh, a Democrat, for review.

Blue Flame received a nearly $6.3 million down payment from Maryland in early April – after promising to provide within weeks desperately needed personal protective equipment for front-line medical personnel dealing with the novel coronavirus.

Ethan Bearman, the Los Angeles attorney for Blue Flame Medical, said Saturday he was unaware the state was unhappy with the firm.

“This comes as a surprise,” Bearman said when told that the attorney general had confirmed receiving a referral about the company from the state General Services Department. “This does not comport with what I know of Blue Flame Medical.”

However, a letter sent to the firm Thursday by Danny Mays, Maryland’s director of procurement, revealed deep frustration.

“Despite numerous requests for information and order status, Blue Flame Medical has yet to deliver any items under this order, or provide any pertinent data as to a pending shipment,” Mays wrote. “As Blue Flame Medical LLC has failed to honor its delivery commitment under the terms and conditions, [the Department of General Services] is now formally requiring Blue Flame Medical to cure this deficiency.”

Bearman acknowledged that delays had occurred in filling the order but said such problems have become commonplace this spring during the chaotic rush to locate masks and other protective equipment.

The Wall Street Journal first reported the contract’s cancellation Saturday.

Blue Flame was started in late March by Michael Gula, a Republican fundraising and lobbying consultant in Washington, and John Thomas, a California political consultant.

Before moving in to the medical supply business, Gula was known in GOP circles for his political fundraising prowess. His firm has raised campaign funds for Sens. Patrick Toomey of Pennsylvania, Steve Daines of Montana, Ron Johnson of Wisconsin and dozens of other influential Republicans. He startled some longtime clients in March when he announced he was quitting the fundraising world during an election year to start the medical supply business with Thomas.

Thomas recently worked as a strategist and fundraiser for Republican Don Sedgwick, who sought to run against Rep. Katie Porter, D-Calif., but lost in the March primary.

The two Republican consultants incorporated their firm in Delaware on March 23 and a week later received the contract from Maryland.

Gula used a connection to a staffer in the administration of Gov. Larry Hogan, a Republican, to initially make a pitch for the sale, according to a Maryland official who spoke on the condition of anonymity to discuss a sensitive legal matter. After Gula started using that staffer’s name on a reference sheet to seek contracts with other states, the official said, the staffer referred the matter to the chief legal counsel for Hogan, Mike Pedone.

Pedone then referred the matter on April 9 to Frosh’s office, the official said.

Gula and Thomas did not respond to requests for comment.

The April 1 purchase order, which was obtained by The Washington Post, identifies June 30 as the delivery deadline. But the Maryland official said that is only because June 30 is the end of the current fiscal year. The agreed upon shipping date for the masks and ventilators was April 14, this person said. Bearman did not respond to a request for comment on this complaint.

The order shows that Blue Flame agreed to provide 1.5 million N95 masks and 110 ventilators, and that the state wired the company nearly $6.3 million as a deposit.

Michael Ricci, a spokesman for Hogan, said in an interview Friday that none of the masks and ventilators had arrived.

“We placed this order on April 1, and we haven’t gotten anything,” Ricci said. “We received no shipping confirmation. Obviously, that’s a concern. That’s not been the case with any of our other vendors.”

The price Blue Flame was charging at the time for N95 masks – $4.52 each – was much higher than the list price provided by manufacturers.

Frosh confirmed Saturday the matter had been referred to his office.

Frosh would not comment on the contract, the investigation or what precipitated the referral.

Asked about the delays in fulfilling the contract, Bearman said: “I know Blue Flame Medical wanted to deliver the shipment [masks and ventilators] in April. I know, too, of actions by the Chinese government. Their supplier in China wrote a letter to Blue Flame Medical informing them that the Chinese government interfered with the supplier’s ability to ship.”

Bearman said his client “has done everything in its power to fulfill, and has alternate suppliers to fulfill the order as written. And they so informed the state of Maryland.”

The Hogan administration has been aggressively working to shore up the state’s supplies of equipment needed to fight the pandemic, including the purchase of 500,000 coronavirus tests from South Korea last month.

Local officials in Maryland were frustrated that those tests were not made available for their use, in part because of a lack of swabs, reagents and other testing supplies.

The last time the government tried that, it was a total fiasco.

Gerald Ford was president. It was 1976. Early that year, a mysterious new strain of swine flu turned up at Fort Dix, New Jersey. One Army private died. Many others became severely ill. The nation’s top infectious disease doctors were shaken.

“They were well aware of the ravages of the 1918 flu, and this virus appeared to be closely related,” political scientist Max Skidmore wrote in his book, “Presidents, Pandemics, and Politics.” “The officials were concerned about a repetition of the tragedy, or the threat of perhaps an even more virulent pandemic.”

Ford raced to come up with a response, consulting with Jonas Salk and Alfred Sabin, the scientists behind the polio vaccine, and in late March he announced an audacious plan for the federal government to both produce the vaccine and organize its distribution.

“No one knows exactly how serious this threat could be,” Ford said, with Salk and Sabin by his side, a shocking sight given the two scientists had become enemies over who should get credit for the polio vaccine. “Nevertheless we cannot afford to take a chance with the health of our nation.”

Every American, Ford said, would be vaccinated.

The government had never attempted such an endeavor – both in its breadth and speed.

Almost immediately, there was chaos.

According to Skidmore, a professor at the University of Missouri-Kansas City, insurers were concerned about liability and balked at covering the costs. Manufacturers the government wanted to partner with had similar concerns, prompting Congress to pass a law waiving liability.

One manufacturer produced two million doses with the wrong strain. As tests progressed, more scientific problems emerged – even as there were few, if any, signs that a pandemic was materializing. In June, tests showed the vaccine was not effective in children, prompting a public squabble between Salk and Sabin over who should be vaccinated.

But Ford was undeterred. He directed the vaccination program to proceed, announcing plans to inoculate one million people per day by the fall – an unprecedented timeline the government struggled to meet.

By mid-October, vaccinations were underway. Ford was injected by the White House doctor.

And then more problems emerged. There were reports of sporadic deaths possibly connected to the vaccine. Cases of Guillain-Barre syndrome also emerged, and are still cited today by the anti-vaccine movement. Panic emerged, with dozens of states pausing vaccinations.

By December, following 94 reports of paralysis, the entire program was shut down.

Almost immediately, in grand Washington fashion, fingers were pointed. Scientists and government officials turned on each other, with allegations that Ford acted recklessly for political gain without knowing for sure whether a pandemic would emerge – an impossible predictive game, his defenders argued.

The recriminations were fueled by the fact that the swine flu pandemic hadn’t materialized.

“Had it done so,” Skidmore wrote, “the swine flu vaccination program would immediately have been reinstituted.” The risk-benefit analysis – a relatively small number of cases of Guillain-Barre syndrome vs. widespread death from the flu – would have appeared differently.

Despite the problems, Skidmore and other historians have given the program credit for its swiftness in the face of typical government red tape. The infrastructure Ford’s team set up was able to quickly identify the side effects. And in the end, Ford had the backing of the world’s foremost vaccine experts — Salk and Sabin.

The program “appears clearly to have been based on concern for the public good,” Skidmore wrote, “not to achieve political advantage.”

Lorna Breen, chair of the emergency-medicine department at NewYork-Presbyterian Allen Hospital, died of self-inflicted injuries after being transported to UVA Hospital in Charlottesville, Virginia, police said.

Breen’s father, Philip Breen, told the New York Times that she had described coronavirus patients flooding her hospital and sometimes dying before they could be removed from the ambulances. She had no history of mental illness but seemed detached before she died, the Times reported.

“She tried to do her job, and it killed her,” the elder Breen told the newspaper.

He later added: “Make sure she’s praised as a hero, because she was. She’s a casualty just as much as anyone else who has died.”

After she contracted the coronavirus, Lorna Breen, 49, recovered for about a week and a half and then tried to return to work, Philip Breen told the Times. The hospital directed her to go back home, and her family brought her to stay with them in Charlottesville.

The Washington Post could not immediately reach Breen’s family on Tuesday.

Lucky Tran, a spokesperson for Columbia University Irving Medical Center and NewYork-Presbyterian, echoed Philip Breen’s praise of Lorna as a hero.

“Dr. Breen is a hero who brought the highest ideals of medicine to the challenging front lines of the emergency department,” Tran said in a statement.

The Allen campus of NewYork-Presbyterian, located on the north side of Manhattan, serves the region of the United States that has been most devastated by the pandemic. New York state had reported 295,106 cases of the coronavirus and 22,866 deaths as of Tuesday.

Breen’s suicide comes during a global pandemic that increasingly directs health care workers’ attention toward the mental-health risks faced by physicians, who die by suicide at twice the rate of the general population. Among doctors, women are the most vulnerable.

Early research out of Wuhan, China, where the coronavirus outbreak is believed to have originated, indicated that female front-line workers experienced higher rates or more severe symptoms of depression, anxiety, insomnia and distress than health care workers overall.

Suicides are an occupational risk for emergency physicians, and the brutality of a pandemic can make them more common, said Loice Swisher, an emergency-room physician in Philadelphia and member of the American Association of Suicidology.

“I’m afraid we’re going to see more of this. And not just physicians,” Swisher said. “People who are losing their jobs, who think all is lost and just don’t see an end to this.”

While suicide and many of the feelings that precede can be difficult to talk about, Swisher said doctors in particular can struggle within a larger culture that views doctors as steady, competent and driven. Doctors who struggle may be especially reluctant to ask for help from the people best positioned to intervene – their own colleagues.

“We don’t want to be seen as a weak link. We don’t want to be seen as incompetent, or place an extra burden on our colleagues,” Swisher said. “It’s almost like you’re being kicked off the island – you don’t belong anymore – if you admit to [needing help].”

There are also professional consequences that can deter doctors from seeking support, said William Jaquis, president of the American College of Emergency Physicians. State medical boards and hospitals often ask doctors seeking hospital credentials whether they have ever been treated for depression.

Those credentialing and licensing boards do not distinguish between whether a depressive episode was 20 years ago or last month, Jaquis said. The risk is the same.

“We need to be able to get treatment for depression without the stigma behind it,” he said, adding that a history of depression or mental illness does not necessarily indicate a risk of suicidal thoughts. “There are ‘happy’ doctors who kill themselves.”

Charlottesville Police Chief RaShall Brackney said Breen’s suicide serves as a reminder that health care workers on the front lines of the pandemic are not immune to its mental or physical effects.

“Personal protective equipment (PPE) can reduce the likelihood of being infected,” she said in a statement. “But what they cannot protect heroes like Dr. Lorna Breen, or our first responders against is the emotional and mental devastation caused by this disease.”

Before working at NewYork-Presbyterian, Breen attended the Medical College of Virginia at Virginia Commonwealth University and completed her residency at Long Island Jewish Medical Center in Queens, New York. She also taught emergency medicine at Columbia University Medical Center, according to her bio on the hospital’s website.

As a longtime member of the American College of Emergency Physicians, Breen spearheaded a point-of-care tool – a research resource that doctors can use while with a patient – for people with autism spectrum disorder, the organization said in a statement.

JoAnne Tarantelli, executive director of the ACEP’s New York chapter, said in the statement that she and Breen often discussed Breen’s travels and snowboarding vacations.

“She was a gentle soul with a kind heart and engaging personality,” Tarantelli said. “Lorna will be remembered for her dedication, devotion and contributions to emergency medicine.”

If you or someone you know needs help, call the National Suicide Prevention Lifeline at 800-273-TALK (8255). You can also text a crisis counselor by messaging the Crisis Text Line at 741741.

The Swiss drugmaker has paused new enrollment in a large U.K. clinical trial called Orion-4 that’s evaluating the experimental heart drug inclisiran, Chief Executive Officer Vas Narasimhan said in a Bloomberg Television interview. The medicine, a potential blockbuster, was central to Novartis’s $9.7 billion takeover of Medicines Co. last year.

Novartis is far from alone as regulators around the world ask researchers to avoid in-person interactions and try to use telephone or video visits instead, and medical centers focus on tackling the coronavirus. Sanofi said it’s seen some slowdowns, without giving examples, while Wolfe Research analysts said the outbreak is probably affecting enrollment for a study of Biogen Inc.’s experimental Alzheimer’s drug aducanumab.

“The real issue for us, and across the sector, has been new clinical trial starts, as well as continuing enrollment of studies that are ongoing,” Novartis’s Narasimhan said in an interview with Anna Edwards. “We’re doing our best to mitigate that.”

Most studies are still on track at Novartis, the CEO said. The company has been able to shift tests to China and other Asian countries. The Orion-4 study, expected to finish in 2024, aims to recruit 15,000 participants from sites in the U.S. and U.K., Novartis said last month. The delay shouldn’t have a long-term impact on the trial if enrollment can resume in coming months.

“There are a few digital technologies we have deployed over the years that are helping us manage this situation,” Narasimhan said on an earlier call with reporters, pointing to the company’s global surveillance hub that monitors its network of hundreds of drug studies and aims to predict potential problems on a minute-by-minute basis.

Covid-19 is having an impact on clinical trials in areas such as respiratory diseases that could divert hospital resources from tackling the crisis, Sanofi said by email. The drugmaker said it’s maintaining progress on key projects.

The U.K. regulator last month cited reports of deviations from clinical-test procedures related to the coronavirus. Patients with health problems may be advised to stay away from hospitals or they may be reluctant to visit them, it said.

Another large pharmaceutical company, Eli Lilly and Co., delayed most new study starts and paused enrollment in most ongoing trials, but will continue tests for patients who are already enrolled. And, Erytech Pharma SA, a small drugmaker, said last week that the pace of recruitment for a pancreatic cancer trial has slowed.

The pandemic so far hasn’t hurt demand for existing Novartis medicines — quite the contrary as patients rushed to buy essential drugs before lockdowns. The company maintained its sales and profit forecast for the year as it reported first-quarter earnings.

The philanthropist and founder of Microsoft said that the Bill & Melinda Gates Foundation, with an endowment exceeding $40 billion, will give “total attention” to the pandemic that has killed more than 200,000 and is roiling economies around the world, he said in an interview with the newspaper.

“You’re going to have economies with greatly reduced activity levels for years,” Gates said. The pandemic could cost the global economy “tens of trillions of dollars,” he said in the interview.

The foundation has contributed $250 million to help counter the coronavirus and is re-purposing units dedicated to fighting other diseases to join in the battle against the pandemic.

“We’ve taken an organization that was focused on HIV and malaria and polio eradication, and almost entirely shifted it to work on this,” he told the FT.

Gates also defended the World Health Organization against accusations from U.S. President Donald Trump that the body had mishandled the virus response.

“WHO is clearly very, very important and should actually get extra support to perform their role during this epidemic,” Gates said. He said he doesn’t believe Trump will follow through on his threat to withdraw funding for the WHO.

The symptoms, which the CDC reports could appear two to 14 days after exposure to the virus, are:

– Chills

– Repeated shaking with chills

– Muscle pain

– Headache

– Sore throat

– New loss of taste or smell

Previously, the CDC listed just three known symptoms: shortness of breath, cough and fever.

Mario Ramirez, the former acting director of the Office of Pandemic and Emerging Threats under President Barack Obama, told The Washington Post that the frequency of symptoms in new diseases changes with time, even with recurring illnesses like season influenza. The recent additions, he said, reflect the CDC’s confidence in stating: “we can say reliably that these six symptoms go with covid-19.”

Ramirez, who is also an emergency room physician, said that confidence stems in part from the growing number of patients being treated for covid-19 in the United States. Local trends in symptoms, in conjunction with data from other countries, allow the CDC to present information that captures the right segment of the population for testing, he added.

“You don’t want to list twenty-something symptoms, especially if half the population has those symptoms,” Ramirez said. “You’re trying to balance targeting the right people to come in for testing, so it must be specific.”

The additions confirm what patients and doctors have been reporting anecdotally for weeks. In particular, the loss of taste or smell has been known to appear in patients since at least mid-March when a British group of ear, nose and throat doctors published a statement amid growing concern that it could be an early sign someone is infected but otherwise asymptomatic.

A study of European covid-19 patients found between 85.6% and 88% of patients “reported olfactory and gustatory dysfunctions, respectively.” In an Iranian study, 76% of covid-19 patients who reported a loss of smell said it had a sudden onset. In many of the cases, anosmia, as it’s called, appeared before other symptoms.

“It scared the hell out of me,” said Vallery Lomas, a 34-year-old champion baker, who feared she would never get her senses of smell and taste back. “I could smell nothing for probably five days.”

Lomas was presumed positive for covid-19 in the midst of writing a cookbook. Smell and taste are intertwined, so some people who think they have lost both senses may have lost only their sense of smell.

“What happens with loss of the sense of smell is you lose flavor,” but not taste, said Jo Shapiro, a professor of otolaryngology at Harvard Medical School.

Though not listed on the CDC website, fatigue also has been reported in people who have either tested positive or told to assume they have covid-19 when testing was not available.

Hedy Bauman told NBC News the fatigue hit her like a truck. Even reading was exhausting, she said.

“My bathroom is maybe 15 steps from my bed,” Bauman told NBC News. “I wasn’t sure I could get from the bathroom to my bed.”

Bauman told NBC she had chills but no fever.

Early reports of the virus suggested it caused standard respiratory symptoms, though it is extremely contagious and deadly. During the past few weeks, health experts have noted how covid-19 attacks many organs in the body.

In some patients, physicians are reporting a blood-clotting complication that does not respond to anticoagulants. Some patients’ lungs fill with hundreds of microclots, autopsies have shown, and larger clots can break off and travel to the brain or heart, causing a stroke or heart attack.

Evidence from the more than 80,000 coronavirus cases reported in China indicates symptoms in about 80% of patients are mild. The additional symptoms will make it easier for people to know when to ask for a test, Ramirez said, and it could help physicians determine when patients need to be tested or at least be told to assume they have it and self-isolate.

“Anecdotally, we’ve heard about the symptoms – and most physicians were already including it in their decision-making process,” Ramirez said. “But to the extent the U.S. population reads CDC guidelines, this is a much more public-facing document.”

The CDC continues to recommend managing symptoms at home unless they include trouble breathing, persistent pain or pressure on the chest, new confusion or inability to arouse, or bluish lips or face.

https://www.washingtonpost.com/video/c/embed/d12c3fe0-b5a9-4759-9b91-fc3db96af25e

It’s a virus that has the world on its knees, so when Maccabi Healthcare Services recently unveiled what it billed as a simple one-stop testing booth, I was curious.

Could this be the solution to freeing millions of Israelis from a months-long lockdown? If anyone could go to a health clinic for a fast and fairly painless test, confirm whether they have the virus, seek treatment and isolate themselves, then maybe our lives could get back on track.

I decided I had to go see this “roadside” testing booth for myself.

In Israel, which has managed to keep the number of covid-19 cases and related deaths relatively low – as of Friday, there were roughly 14,800 confirmed infections and fewer than 200 deaths – there is still quite strict criteria on who can take a coronavirus test.

Showing no symptoms of the virus, not having traveled overseas lately and not living in a high-risk area, I did not qualify for a test, but when I asked Maccabi if I could try out the new testing booth, it readily agreed – though my results would not be fully processed.

Part of me was relieved. I had already thought about what a positive result might mean for me, my husband and our two teenage daughters, who have all been stuck at home with me since early March. Even if I tested negative, I wasn’t sure I really wanted to appear in Israel’s digitalized medical system as being a suspected carrier.

The concept of the testing booth is simple. It is basically a booth that allows the examiner to stand safely inside, eliminating the need for protective personal equipment as they interact with patients from behind a fiberglass screen. They administer the test through oversized rubber gloves that poke out of the booth. Immediately after each test, the examiner presses down on a foot pump that sprays disinfecting soap over the outside of the booth, including on the gloves.

As nervous as I felt, I was so excited to get out of the house after six weeks of lockdown.

I approached the booth awkwardly, hampered by a face mask and a funky GoPro on my head (to film the process). I strained to hear the tester’s instructions, wondering if a face mask hampered one’s hearing too.

“Come closer but don’t touch anything,” he said, directing me to swipe my health insurance card and then, after a quick scan of my details on his computer, ordered me to hold up my ID card.

Israeli law requires citizens to join one of four public health funds, services heavily subsidized by the government to ensure that everyone has access to health care. I am a member of the Maccabi health organization.

I watched as a pair of giant rubber gloves clipped open a test tube and withdrew an extra-long Q-tip-type stick. The tester instructed me to open my mouth wide and poked around inside, reaching the back of my throat, scraping for a few seconds on the top of my tongue. It was very similar to the DNA test I did myself a few years ago, but obviously I was much more gentle. Then came the kicker: He told me to tilt my head back before pushing the same swab up my left nostril.

But it was over in seconds and I felt no lingering pain.

I watched as the tester placed the resealed test tube with my sample inside into a cooler box attached to the booth. Then began the process of sterilizing the outside of the stand.

According to Ran Sa’ar, Maccabi’s chief executive, the development and building of the testing booth took less than a week. The health fund is working to improve and modify the idea.

“The great thing about this testing booth is that it’s not only simple and easy to assemble, it is also very cheap to manufacture,” Sa’ar said in an interview with The Washington Post.

Maccabi has some 2.4 million members and, in regular times, carries out about 25,000 different kinds of medical tests per day. Sa’ar said the plan is to place these booths at each of his organization’s clinics.

There are still some barriers though. At the start of Israel’s outbreak, Magen David Adom, Israeli’s first-aid agency, hurried to take up the challenge of testing for the virus, and the government is still reluctant to open up the process. But Sa’ar, along with the heads of the other public health funds, is pushing to have the testing process transferred to them. This would not only increase the number of tests being carried out – this week Israel reached more than 10,000 tests per day – but it would also enable the virus to be tracked more effectively, Sa’ar said.

As I drove home from Jaffa, I wondered to myself if what I had just experienced could soon become the new norm shaped by the coronavirus crisis. Will we all need to stand in front of a booth like that every time we get a sore throat, or have been near someone who has covid-19, or when we want to travel?

The anonymous tester, the giant gloves, even the cotton swab deep up my nostrils – if that’s what we have to do to reclaim our pre-coronavirus lives, at least until a cure or a vaccine, then I can live with that.

Confirmed cases have surpassed 25,000 among Africa’s 1.3 billion people, and the death toll has exceeded 1,200.

Dozens of nations have “very, very limited” capacity for testing, said John Nkengasong, director of the Africa Centers for Disease Control and Prevention, at a Thursday briefing. The lack of tests could be obscuring a larger danger.

The virus threatens to kill more than 300,000 people in Africa, according to a United Nations estimate, and plunge tens of millions more into poverty.

Leaders can still dodge worst-case scenarios, officials said, with wider testing nets and aggressive contact tracing. Most African countries have sealed or tightened their borders, banned public gatherings and closed schools, among other preventive measures.

“Are you finding the cases?” Nkengasong asked. “Are you isolating and tracking the contacts?”

But doctors, aid workers and residents say the lockdowns are blocking people from food, water and health care. For many, money comes from human interactions: cleaning houses, doing odd jobs, hawking fruit.

“It’s as if we are in a grave,” said Moussa Diallo, 22, who sells milk, sugar and other basics on a street corner in the Senegalese capital, Dakar.

Customers are disappearing, he said. His perishable goods expire in May, and he doesn’t have the cash to restock if they go bad.

“I have nothing to eat – just this milk,” said Diallo, who said social distancing has disastrously slashed incomes. “It’s unthinkable.”

About 135 million people worldwide, mostly in Africa and the Middle East, are already “marching toward the brink of starvation,” David Beasley, executive director of the World Food Program, told reporters this week.

Pandemic-sparked food insecurity could nearly double that total by the end of the year.

Fallout from food scarcity is expected to be most extreme in Yemen, Syria, Congo, South Sudan and Nigeria, the organization said.

“More people will die of hunger than the coronavirus,” said Isa Sanusi, spokesman for Amnesty International in the Nigerian capital, Abuja.

Nigeria’s lockdowns have put an untold number of workers out of jobs, he said. Most people in Africa’s most populous nation can’t afford to eat if they miss a day of paid labor.

The government is passing out bags of rice and other necessities, but people tell him they haven’t received anything.

“They say, ‘We don’t see these things. Where is the food? We only read about it in the news,’ ” he said.

The struggle to find clean water also hinders the fight against covid-19, said Canisius Kanangire, executive secretary of the African Ministers’ Council on Water in Abuja.

In densely packed urban neighborhoods, where police and soldiers enforce stay-at-home orders, poorer residents routinely lack running water at home.

“The lockdown cannot work because people have to go out for water,” Kanangire said. “They have little to drink or for hand-washing.”

Another effect of travel restrictions: Medical deliveries are stalled, health-care workers say, and people battling illnesses other than the coronavirus face longer waits.

A shift in efforts away from malaria control could fuel another fatal outbreak, a new WHO report cautioned Thursday.

Sub-Saharan Africa accounts for 94% of all malaria deaths, and the victims are usually younger than 5. If prevention services, such as the distribution of mosquito nets, decline during the pandemic, the number of casualties this year could double.

“Even in times of lockdown, these essential services must be continued,” Matshidiso Moeti, WHO’s Africa director, said Thursday.

Breakdowns in some services are already happening, said Nicolas Mouly, program manager for emergency response at the Alliance for International Medical Action, an aid group that ships health-care supplies across West Africa.

Roughly two-thirds of the continent’s airports are closed, and lifesaving drugs are sitting in storage. Finding flights for them is an increasingly strenuous task.

“It’s a daily fight,” he said.

A “deeply concerning picture” is emerging about residents of homes for the elderly, Hans Kluge, the WHO’s top official for Europe, told reporters at a news conference Thursday. According to countries’ estimates, he said, “up to half of those who have died from covid-19 were resident in long-term care facilities. This is an unimaginable human tragedy.”

Kluge’s warning focused on Europe, but the United States has also struggled with the pandemic at homes for the elderly. A Washington Post analysis this week found that nearly 1 in 10 nursing homes in the United States have reported cases of the coronavirus, with a death count that has reached the thousands.

Many countries in Europe have banned family visits to nursing homes, an attempt to shelter the facilities from the spread of the disease, since it is far more fatal among older people and those with pre-existing conditions. Those bans, though well-intentioned, may have deprived the elderly of advocates as conditions swiftly deteriorated.

“This pandemic has shown a spotlight on the overlooked and undervalued corners of our society,” Kluge said.

He and other WHO officials who spoke Thursday said they did not have enough data to say conclusively that people in nursing homes were being transferred to hospitals less often than they should be, or that they were being discharged from hospitals prematurely – fears raised by advocates in Britain and elsewhere. But the WHO officials hinted strongly that those factors might be contributing to the high death rates.

“It is important that the decisions, the very tough decisions that have to be made, are not based on a single criteria like age,” said Manfred Huber, a WHO long-term care specialist.

Measuring and comparing coronavirus death rates can be difficult, since some nations are testing more suspected coronvirus cases than others are and each country is using different accounting methods as they record cases and deaths.

Many countries in Europe have essentially ignored coronavirus testing in nursing homes to focus their testing capacity on hospital patients and hospital staffers. In Italy, for instance, a recent national health service report indicated that people dying in nursing homes were overwhelmingly unlikely to have been tested for the virus.

And many countries have not been carefully tracking deaths outside of hospitals.

“The challenge is we don’t have very good information for people in care homes,” said Adelina Comas-Herrera, a researcher at the London School of Economics.

Comas-Herrera and colleagues reported last week that coronavirus deaths in nursing facilities in Belgium, Canada, France, Ireland and Norway might account for half of those countries’ deaths from covid-19, the disease caused by the novel coronavirus.

She noted that most elderly care homes were never designed to serve as acute care hospitals. Many do not even have a nurse on duty.

A first grim glimpse of Europe’s nursing home situation came on March 23, when soldiers sent to disinfect nursing homes in Madrid discovered dozens of elderly people dead in their beds. Spain’s defense minister pledged that the government would be “unrelenting and forceful” in finding those responsible. As of this week, public prosecutors are investigating some 86 nursing homes throughout Spain for hundreds of elderly deaths, including 40 facilities in the region of Madrid, which has outpaced the rest of the country in death toll.

Spain has not included deaths in nursing homes in its official counts, although authorities say 10% to 20% of residents might be infected.

British Health Secretary Matt Hancock on Wednesday told Parliament that nursing home residents might represent 20% of all deaths in that country. That corresponds to an estimate by the nonprofit National Care Forum, which says elderly and disabled people in residential and nursing homes account for 4,000 of Britain’s nearly 19,000 coronavirus-related deaths. But some researchers in Britain have put the number as high as 40% for deaths in care homes – a staggering number, considering that such facilities house less than 1% of the country’s population.

In Belgium, where officials have included suspected cases in their overall death count since early this month, more than half of the 6,450 recorded deaths were in long-term care facilities, not hospitals. And of those nursing-home deaths, 95% are “suspected” cases, meaning that patients displayed some of the symptoms of covid-19 but were never tested for the disease.

“We have not had enough testing capacity in the past to confirm all of them in the laboratory,” said Steven van Gucht, the head of viral diseases at Belgium’s public health institute, at a news conference this week. “But that does not mean that those cases are less real.”

Kluge and others say now is the time to pour resources into nursing homes – to provide more testing of staff and residents, to supply caregivers with proper protective gowns and visors, to give them quick training to protect themselves and residents.

Some employees have complained that they have been offered little or no equipment. Many facilities are staffed by people with scant medical training or none at all.

Despite the vulnerability of most residents of the facilities, Kluge said, good medical care ought to be able to prevent many deaths.

“Even among very old people who are frail and live with multiple chronic conditions, many have a good chance of recovery if they are well-cared for,” he said.

Italian authorities have said some of the worst outbreaks at nursing homes might have been preventable, and they have launched investigations into malpractice at a series of facilities, including one of the largest in the country: the 1,000-bed Pio Albergo Trivulzio in Milan. Italy’s ANSA news service reported that 200 elderly residents had died at that facility.

In France, one of the earliest coronavirus restrictions was an urging by President Emmanuel Macron that people stop visiting elderly relatives in assisted-living centers.

But as the French government began to give daily briefings on the rising death toll and number of confirmed infections, figures from assisted-living centers and care homes were initially excluded from the tally, and only included starting April 1. The numbers are still reported irregularly, largely because it takes public health authorities longer to collate data from centers spread across the country.

The plight of the elderly isolated in homes away from their families has gained increasing traction in France.

Jeanne Pault, 96, lamented in a televised interview this week that she hasn’t been able to eat properly, and that she said she is no longer able to converse with her neighbor, much less her family.

“Is this a life, at age 96?” Pault said.

Macron responded to her directly on Twitter.

“Madame, your grief overwhelms us all,” he wrote. “For you, for all our seniors in retirement homes or institutions, visits from loved ones are now authorized.”

In Germany – where about one-third of the country’s 5,000 deaths have been among residents of care centers, according to data from the Robert Koch Institute – Chancellor Angela Merkel on Thursday said she was particularly “burdened” by what those in nursing and assisted-living facilities “have to endure.”

“It’s cruel that, aside from the staff doing their best, no one can be there for those nearing the end of their lives, their strength ebbing,” she said. “We will not forget these people and the isolation they now have to live,” she said.

The next morning, Trump cracked down with a Twitter edict: Redfield had been totally misquoted in a cable news story summarizing the interview, he claimed, and would be putting out a statement shortly.

By Wednesday evening, Redfield appeared at the daily White House briefing – saying he had been accurately quoted after all, while also trying to soften his words as the president glowered next to him.

“I didn’t say that this was going to be worse,” Redfield said. “I said it was going to be more difficult and potentially complicated ’cause we’ll have flu and coronavirus circulating at the same time.”

He added: ” ‘It’s more difficult’ doesn’t mean it’s going to be more impossible.”

The remarkable spectacle provided another illustration of the president’s tenuous relationship with his own administration’s scientific and public health experts, where the unofficial message from the Oval Office is an unmistakable warning: Those who challenge the president’s erratic and often inaccurate coronavirus views will be punished – or made to atone.

In a statement Wednesday, for example, Rick Bright – who until recently led the agency working on a coronavirus vaccine – said he was removed from his post for resisting efforts to “provide an unproven drug on demand to the American public.”

The result is a culture in which public health officials find themselves scrambling to appease and placate Trump, a mercurial boss who is focused as much on political and economic considerations as scientific ones.

An internal White House “Covid Mail” email address, for instance, exists to receive queries and suggestions from “friends and family” as well as random individuals – including doctors and business owners – from around the country who have reached out to White House officials. Those emails then get farmed out to the appropriate agencies – from the Food and Drug Administration to the Health and Human Services Department – but some officials have privately worried that these missives receive priority and distract from more crucial scientific pursuits.

In another instance, Nancy Messonier, the CDC’s director of the National Center for Immunization and Respiratory Diseases, was removed from her post as her agency’s coronavirus response head after sounding early alarms that Americans should begin preparing for “significant disruption” to their lives from a “severe illness.” The CDC held its last daily briefing on March 9 – a forum through which the nation would normally receive critical public health information – in part out of a desire to not provoke the president.

“I think the main media briefing has been the task force briefing,” Redfield said in his interview with The Post on Tuesday, asked about the now-defunct CDC briefing. “A lot of the flow of the briefings probably had to do with where the response was grounded.”

And Surgeon General Jerome Adams seemed to go out of his way to lavish praise on Trump in an interview on CNN last month, claiming the 73-year-old president was “healthier than what I am” – a comment the 45-year-old physician later walked back in a series of tweets.

“We hope that science and the public health experts are leading the politicians, that their voices are in the foreground, and that the politicians follow their advice,” said Matt Seeger, who has researched crisis and emergency risk communication for the past 35 years at Wayne State University. “But in this case, the political agenda seems to be setting the agenda for the subject matter experts, which is exactly the opposite of the way we would expect to have this happen.”

Seeger, who has watched the daily White House briefings and said he has seen some of the administration’s health professional speak in other forums, added that “it’s very clear the public health professionals have been self-censoring their statements.” They are, he added, “being very thoughtful and measured and probably adjusting their statements they don’t run the risk of running afoul of the political agenda. That’s very problematic.”

The White House dismissed the idea there was any undue pressure on public health officials from the president.

“Despite the media’s ridiculous efforts to somehow create distance between the president and his top health experts, it is simply fake news,” White House spokesman Judd Deere said in a statement. “President Trump has relied on and consulted with Dr. Adams, Dr. Birx, Dr. Fauci, Dr. Hahn, Dr. Redfield, and many others as he has confronted this unforeseen, unprecedented crisis and put the full power of the federal government to work to slow the spread, save lives, and place this great country on a data-driven path to opening up again.”

One senior administration official said Trump is also more receptive to the scientists and doctors in private than his public statements indicate. He is especially respectful of Deborah Birx, who oversees the administration’s coronavirus response, and has figured out a way to gently push back against the president, the official said.

The president has described Birx in positive terms to other confidants and always wants her at the briefing lectern, even as his opinion wavers on other task force members. She regularly spends several hours a day with the president and top aides, including Trump son-in-law and senior adviser Jared Kushner.

During Tuesday’s coronavirus news conference, Birx seemed hesitant to directly contradict Trump – who has made clear he is eager to see states begin to reopen their economy as quickly as possible – when asked about the plans by Georgia’s governor to reopen places like gyms and nail and hair salons.

“So if there’s a way that people can social distance and do those things, then they can do those things,” Birx said. “I don’t know how, but people are very creative.”

During Wednesday’s task force meeting, a White House official said, the group discussed Georgia’s plans, as well as their concerns that the state’s proposal does not necessarily allow for safe and responsible distances to be maintained, or for good hygiene practices. And during the briefing Wednesday, Trump also addressed his concerns with the plan, claiming he told Georgia Gov. Brian Kemp, a Republican, he strongly disagrees with his decision, which he called “too soon.”

Earlier this month, Anthony Fauci, an infectious disease expert and coronavirus task force member, began a briefing by offering a seeming apology for comments he had made to CNN’s Jake Tapper, in which he said that earlier mitigation efforts “could have saved lives.” Fauci said he had not intended to criticize Trump in responding to a hypothetical question with “the wrong choice of words,” but stressed that his clarification was entirely “voluntary.”

On Wednesday, asked if health professionals are unable to speak freely in Trump’s administration, Fauci dismissed the suggestion, saying, “Here I am.”

Many public health experts, however, say they are frustrated at what they see happening during the daily briefings, with the scientists being sidelined. According to a Post analysis, since the federal guidelines were announced on March 16, Trump has spoken 63 percent of the time, compared with Birx at 10 percent and Fauci at 5 percent.

“For most of us in the field, there’s frustration with the dance that we’re seeing,” said Jeanne Marrazzo, the director of the Division of Infectious Diseases at the University of Alabama at Birmingham School of Medicine. “. . . Most of us in the field are incredibly frustrated that they are being put in that position, but also incredibly grateful that they are willing to do it.”

Trump also regularly tells visitors to the Oval Office that he is in touch with doctors in New York – including his own – and many others he knows personally.

Guidelines that were drafted by the CDC and Federal Emergency Management Agency for safely reopening the country were watered down by White House officials before they were published, officials say. A person involved in the White House revision of the guidelines, however, said the goal was simply to make them understandable to the public.

Bright, the former director of the Biomedical Advanced Research and Development Authority who was moved to a narrower role at NIH this week, had expressed opposition to the way hydroxychloroquine was being politicized by the president and others in the administration, according to two people familiar with the discussions. Two senior administration officials said he repeatedly clashed with his boss, Robert Kadlec, the HHS assistant secretary for preparedness and response.

An adviser familiar with the virus response said the doctors were attempting to communicate with the country and follow crisis management guidelines. The president, on the other hand, this person said, “is trying to win a political battle.”

“He’s broken every rule of maintaining public trust, if you’re trying to do crisis communications for the entire public,” the adviser said, speaking anonymously to share a candid assessment. “I’m not sure that is what he’s trying to do.”

HHS Secretary Alex Azar, who once led the coronavirus response meetings as chairman of the task force, now attends only some in person. Late last month, he called into a meeting after President Trump enacted the Defense Production Act, saying he was unaware and asking for specifics.

The White House also recently installed Michael Caputo, a longtime Trump loyalist, to run communications at HHS.

“Secretary Azar communicates with agency heads constantly and attends Task Force meetings with them daily. Any statement to the contrary is false,” HHS spokeswoman Caitlin Oakley said in a statement.

Within the agencies, less public-facing health officials are also struggling with the requests coming from the White House. Ideas passed along through the internal “Covid Mail” email system are routed largely to the health agencies. There have been messages to the FDA on testing, to the CDC on surveillance and epidemiology; and to NIH on vaccines.

Because the missives are coming from the White House, agency officials imbue them with a sense of urgency. “And then everyone has to drop what they’re doing,” a senior administration official said.