Category: Health & Fitness

LONDON — Piece by piece, the Covid-19 sanctuary was born on a hilltop in the town of Bedworth in central England. The process was meant to be a metaphor for a human life. Like bones fused over time, it grew taller as the memorial’s creators spent months joining intricate pieces of wood into a skeletal structure that finally stood on its own, 65 feet high.

Then they burned it all down.

There have always been monuments to commemorate the loss of life from calamitous events, such as the thousands of memorials dedicated to world wars, the Sept. 11 attacks, the Holocaust.

But the Covid-19 pandemic, now in its third year, has presented a unique challenge for grieving families. It is not a singular event, in one location. As the death toll of more than six million worldwide continues to rise, communities and families are trying to keep up, building memorials as the tragedy is still unfolding, its end not yet written.

New monuments are being installed. Old projects are expanding. Photographs and biographies of Covid-19 victims in Malaysia and South Africa are updated online. Landscapes in villages and cities are transformed by remembrance, from a waist-high structure in Rajannapet, India, to spinning pinwheels fixed along a walkway in São Paulo, Brazil.

Names are painted on a wall along the River Thames in London and on rocks arrayed in hearts on a farm in New Jersey. Thousands of fluttering flags were planted at the Rhode Island State House. Ribbons are tied to a church fence in South Africa.

“People died alone in hospitals, or their loved ones could not even see them or hold their hands, so maybe some of these memorials have to do with a better send-off,” said Erika Doss, a University of Notre Dame professor who studies how Americans use memorials.

“We really do need to remember, and we need to do it now,” Dr. Doss said. “Covid isn’t over. These are kind of odd memorials in that names are being added. They are kind of fluid. They are timeless.”

It is not easy for the builders of these memorials to capture death. It is elusive and vast, like the airborne virus that claimed lives and left the question of how to make a physical manifestation out of a void.

For the builders of the sanctuary in Bedworth, a former coal mining town, the answer was to turn away from their communal artistry of nearly 1,000 carvings of pine and birch arches, spires and cornices, and to reduce it to ash at sunset on May 28.

What the moment needed, one organizer said, was an event of catharsis and rebirth, in which people who had seen the sanctuary standing can now go back and see it gone.

“It will still be there in their mind,” Helen Marriage, a producer of the project, said. “Feel the emptiness, which is the same way you feel with this dead, loved person.”

Wall of Hearts

Over a year after it started, new names are still being added to the thousands scrawled on hearts painted on a wall along the River Thames in London.

A walk along its nearly half-mile stretch shows how death gutted generations and left few countries untouched. Arabic, Portuguese, Spanish and Urdu are among the languages in messages to “Grandpa,” “Mum,” “Daddy,” “Nana.”

Uncle Joshua. My brother. My first friend.

Their authors tried to understand death. “Angel wings gained too soon” was how someone described Sandra Otter’s death on Jan. 30, 2021. “Keep on Rocking” was the message to Big Pete.

The virus claimed neighbors, comedians and drinking buddies, their stories told in marker on the wall. Dr. Sanjay Wadhawan “gave his life saving others.” Cookie is “still remembered at the post office.” To all London “cabbies, RIP.”

Some tried to make sense of loss. Angela Powell was “not just a number.” One person wrote, “This was murder,” and another said, “They failed them all.” A woman named Sonia addressed Jemal Hussein: “Sorry you died alone.”

The wall’s founders were citizens and activists, who started painting the empty hearts last year toward the end of one of Britain’s lockdowns to represent the more than 150,000 people who had Covid-19 on their death certificates in Britain.

Soon, the hearts held countless names.

“We have no control over it,” said Fran Hall, a volunteer who regularly paints new hearts and covers up any abusive graffiti that appears.

“We could be painting one section, and people are adding hearts further down,” she said. “It is still happening. It is really organic.”

Shared Grief

Dacia Viejo-Rose, who researches society’s use of memorials at the University of Cambridge, said the “coming out” of grief over Covid-19 was compelling because so many suffered in isolation.

“It became so much about what are the statistics of people dying, that we lost track of individual suffering,” she said. “We lost track of the individual stories.”

People who are grieving will often seek solace at a memorial that is unrelated, she said.

One day in June, Du Chen, a student from China who is studying at Manchester University, knelt to write in Mandarin on one of the painted hearts in London, to “wish everybody well.”

“People are not just commemorating the people they have lost, but also the way of life before the pandemic,” he said.

A family of tourists from Spain paused, saying their people suffered, too. Alba Prego, 10, ran her fingers along photographs attached to a heart mourning a California man, Gerald Leon Washington, who died at 72 in March.

“The people who wrote that loved him very much,” she said.

Around her, unmarked hearts awaited new names.

With the death toll climbing, there will be more.

White Ribbons

Space is also being found for remembrance on a fence at St. James Presbyterian Church in Bedfordview, a suburb on the edge of Johannesburg. In early 2020, caretakers began tying white satin ribbons on the fence for people who died of Covid-19.

By June 25, 2020, about three months after Covid-19 was declared a pandemic, they tied the 2,205th ribbon. By December, there were 23,827.

In January 2021, the month with the highest average deaths in South Africa, the church said it would tie one ribbon for every 10 people who died.

More than 102,000 people have died from Covid-19 in South Africa, although the rate has slowed, the latest figures show. In early July, the fence had 46,200 ribbons tied to it, said the Rev. Gavin Lock.

Families “suffered huge trauma in not being able to visit loved ones in hospital, nor view the deceased, and in some cases not able to follow customary rites,” he said.

White Flags

In Washington, D.C., more than 700,000 white flags, one for each person lost to Covid, were planted on 20 acres of federal land. From Sept. 17 through Oct. 3, 2021, mourners wandered through the rustling field, writing messages and names on the flags.

“I miss you every day, baby,” a woman whispered as she planted a flag, in a moment captured in a documentary published by The New York Times.

By May 12 this year, when the death toll in the United States reached one million, President Biden ordered flags to be flown at half-staff for four days at the White House and in public areas.

The white flags have kept going up.

Suzanne Brennan Firstenberg, the artist behind the installation, “In America: Remember,” said a memorial using new flags was being planned for New Mexico in October. In June, thousands were planted at the State House lawn in Providence, R.I., to commemorate the 3,000 people who died of Covid-19 there.

“What we are seeing is this push for handling it at the state and local level, because no one sees it happening at the national level,” Ms. Firstenberg said.

“The plane is still crashing,” she said. “And it is super hurtful to families to not somehow acknowledge that the pain is still there.”

The 21-year-old woman gasped as she read the headline: “The 16-Year-Old Girl Who Walks and Eats Tacos While on Life Support.” She scanned the article about a girl who had a mysterious illness that destroyed her lungs and who now needed a machine to breathe for her. “I need to do something,” she told herself once she finished the article. She believed she knew what was killing this young girl, because the story could have been her own, six years earlier.

Back then, she was a high school junior on the starting lineup of the girls’ volleyball team. Just days into the new school year, she developed a 103-degree fever and sore throat. Her doctor, in tiny Thief River Falls, Minn., figured she had some type of viral infection and predicted she would feel better after a few days of rest. He was wrong. The fever resolved but was replaced with the most profound fatigue the girl had ever known. Just getting out of bed left her breathless. Her mother took her to the nearest emergency room, 25 miles away.

As the nurse checked the young woman’s vital signs, she looked alarmed. The patient’s oxygen saturation, which would normally be well over 90 percent, was in the 60s, dangerously low. The nurse slapped an oxygen mask over her nose and mouth and reached out to the doctor in charge. A chest X-ray showed a gray cloud invading her lungs. Minutes later she was in an ambulance headed for the Sanford Medical Center in Fargo, N.D., the closest hospital with a pediatric intensive-care unit.

In Fargo she was started on several broad-spectrum antibiotics. The doctors there didn’t know which bug was causing this pneumonia, but until they did, they figured these antibiotics should protect her. But she continued to worsen, and within days needed to be put on a ventilator.

When even that wasn’t enough, the doctors at Sanford contacted the Mayo Clinic in Rochester, Minn. Eight days after she walked into the E.R., the patient’s lungs were hardly working at all. The next step was an artificial-heart-and-lung machine known familiarly as ECMO — short for extracorporeal membrane oxygenation. This device, about the size of a refrigerator, acts as a lung to remove the carbon-dioxide waste product from the blood and replace it with oxygen and then as a heart to recirculate the oxygenated blood back through the body. The ECMO team from the Mayo Clinic flew out to Fargo with their machine, attached the young woman to the device and flew back with her to the Mayo Clinic Hospital. That machine breathed for her for the next 116 days.

Months on the Transplant List

Like the girl in the article, she, too, had walked while connected to the massive machine. She, too, had eaten while on the machine, though not tacos. The first thing to pass her lips was a communion wafer when she finally felt well enough to walk at least part of the way to the hospital chapel surrounded by a squad of doctors, nurses and technicians. They never figured out why her lungs failed. She spent months on the transplant list, waiting for a new heart and lungs to replace the ones her doctors thought would never recover. But they did. And finally, after seven months in the hospital, she was able to go home.

For a few years afterward she returned to Mayo every six months for a checkup. During those visits, she always stopped by the pediatric intensive-care unit to see the nurses who had become a second family to her in the months she hovered near death. At one visit, two years after her own time in the hospital, several nurses told her about a child whose illness seemed remarkably like her own.

Hours later she and her parents met with this child’s parents, who told the story of their daughter, just 12 years old, whose lungs had simply stopped working after what looked like a viral illness. The families compared notes to see if there were any similarities between the two children’s lives and exposures. They lived in different environments — one rural, one urban — in different parts of the state. Nothing seemed to match, until finally the child’s parents reported that in the weeks before coming to the hospital, their daughter had been taking an antibiotic: trimethoprim-sulfamethoxazole (TMP-SMX), known under the brand name Bactrim. The young woman gasped. She had been taking this antibiotic (in her case to treat acne) — right up to the day she went to the E.R.

Since then, another family contacted her with a familiar story: A healthy, active adolescent gets desperately sick, with lungs so damaged that he needed life support. She asked these parents if their son was taking TMP-SMX when he got sick. Yes, came the amazed reply. That made a total of three cases. Maybe she had found a real connection.

And now there was this young woman in the news. Her name was Zei Uwadia. The article named Dr. Jenna Miller as the pediatric I.C.U. specialist at Children’s Mercy Hospital in Kansas City, Mo., who was taking care of Uwadia. The young woman found an email address for the doctor and immediately sent her a note. “I began taking Bactrim for acne about 3-4 weeks prior to [my] acute lung failure,” she wrote. “This happened to at least 3 children between 12-20 years [old]. … The similarities between our cases are uncanny.” She asked if Uwadia had been taking TMP-SMX too.

The Same Unusual Pattern

Miller was astonished. Indeed, the girl was taking TMP-SMX when she got sick. Could there be a link? Miller reached out to a friend, Dr. Jennifer Goldman, who was a pediatrician trained in infectious disease and clinical pharmacology. She had been doing research on adverse reactions to this drug for years. TMP-SMX is an effective, safe and inexpensive drug and, because of that, is the sixth-most-prescribed antibiotic in the country. It could be a coincidence that these four people, a tiny fraction of the millions on this medicine on any given day, got sick. Still, the doctors agreed that they should investigate. The two pediatricians collected the medical records of the patient who sent the email and the other cases she had found. All were healthy young people who developed a devastating lung injury after a brief flulike illness often with a fever, sore throat or cough. And all had taken TMP-SMX.

What convinced the doctors that there was a link were the biopsies of the affected lungs. Each showed the same unusual pattern of focused destruction: The only cells within the lung that were affected were those in which carbon dioxide was taken up and oxygen supplied — the cells that do the most important work of breathing. In two, including the patient who first noted the connection between her illness and the drug, these essential cells eventually grew back, allowing them to once again breathe on their own. Others whose lung tissue did not recover needed a lung transplant. Of those first cases, two died: the 12-year-old that the young woman met at Mayo and Uwadia, the girl in the news story.

In the four years since Miller received the patient’s email, she and Goldman have identified a total of 19 patients, most under age 20, who had this reaction after being treated with TMP-SMX. Six died. It is still unclear how the antibiotic triggers this rare but devastating destruction. Goldman thinks it is probably some kind of allergic reaction. But they still cannot predict who is at risk, or why.

As an I.C.U. doctor, Miller tells me, she uses this drug frequently. And although these cases are rare, the devastation caused is terrible. “Most of these people,” she says, referring to the 19 cases, “were not getting treated for a life-threatening illness, and yet they were given this ordinary drug — and it ended their life or changed it forever.”

This original patient shares Miller’s mixed feelings. She is 26 now and is a nurse who cares for patients who have just had a heart-and-lung transplant. She regularly gives her patients TMP-SMX. And they need it — to treat diseases they have and to prevent diseases they might get. Yet she knows that, because of her reaction to that drug, her lungs will never be the same. She can play a friendly game of volleyball but gets winded after climbing a couple flights of stairs. Still, she has a good life. And she is proud to have made a contribution to the science that she hopes will, one day, prevent this from happening to anyone else.

Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at Lisa.Sandersmdnyt@gmail.com.

WASHINGTON — The shortage of vaccines to combat a fast-growing monkeypox outbreak was caused in part because the Department of Health and Human Services failed early on to ask that bulk stocks of the vaccine it already owned be bottled for distribution, according to multiple administration officials familiar with the matter.

By the time the federal government placed its orders, the vaccine’s Denmark-based manufacturer, Bavarian Nordic, had booked other clients and was unable to do the work for months, officials said — even though the federal government had invested well over $1 billion in the vaccine’s development.

The government is now distributing about 1.1 million doses, less than a third of the 3.5 million that health officials now estimate are needed to fight the outbreak. It does not expect the next delivery, of half a million doses, until October. Most of the other 5.5 million doses the United States has ordered are not scheduled to be delivered until next year, according to the federal health agency.

To speed up deliveries, the government is scrambling to find another firm to take over some of the bottling, capping and labeling of frozen bulk vaccine that is being stored in large plastic bags at Bavarian Nordic’s headquarters outside Copenhagen. Because that final manufacturing phase, known as fill and finish, is highly specialized, experts estimate it will take another company at least three months to gear up. Negotiations are ongoing with Grand River Aseptic Manufacturing, a Michigan factory that has helped produce Covid-19 vaccines, to bottle 2.5 million of the doses now on order, hopefully shaving months off the timetable, according to people familiar with the situation.

Health and Human Services officials so miscalculated the need that on May 23, they allowed Bavarian Nordic to deliver about 215,000 fully finished doses that the federal government had already bought to European countries instead of holding them for the United States.

At the time, the nation had only eight confirmed monkeypox cases, agency officials said. And it could not have used those doses immediately because the Food and Drug Administration had not yet certified the plant where the vaccine, Jynneos, was poured into vials.

But it could now. Some states are trying to stretch out doses by giving recipients only one shot of the two-dose vaccine. California, Illinois and New York have declared public health emergencies. In New York City, every available slot for a monkeypox shot is taken.

Lawrence O. Gostin, a former adviser to the Centers for Disease Control and Prevention who has consulted with the White House about monkeypox, said the government’s response has been hobbled by “the same kinds of bureaucratic delays and forgetfulness and dropping the ball that we did during the Covid pandemic.”

The obstacles to filling and finishing vials follow other missteps that have limited vaccine supply. The United States once had some 20 million doses in a national stockpile but failed to replenish them as they expired, letting the supply dwindle to almost nothing. It had 372,000 doses ready to go in Denmark but waited weeks after the first case was identified in mid-May before requesting the delivery of most of those doses. Another roughly 786,000 doses were held up by an F.D.A. inspection of the manufacturer’s new fill-and-finish plant but have now been shipped.

The government also owns the equivalent of about 16.5 million doses of bulk vaccine produced and stored by Bavarian Nordic. But by the time the health agency ordered 500,000 doses worth to be vialed on June 10, other countries with outbreaks had submitted their own orders and the earliest delivery date was October.

Another order for 110,000 doses for European nations soon followed. When the United States came back with two more orders of 2.5 million doses each — announced July 1 and July 15 — the bulk could only be delivered next year.

Mr. Gostin, who now directs the O’Neill Institute for National and Global Health Law at Georgetown University, predicted that President Biden’s decision to appoint two new monkeypox response coordinators would help “light a fire” under federal health agencies. The White House announced Tuesday that Robert Fenton, an administrator at the Federal Emergency Management Agency, and Dr. Demetre Daskalakis, a C.D.C. official, will lead the response.

Mr. Gostin said the nation’s public health agencies have been “kind of asleep at the wheel on this,” and the new coordinators should help with “unblocking all of the obstacles to procuring and delivering vaccines and drugs, which has been deeply frustrating.”

Two senior federal officials, who requested anonymity in order to speak frankly, said Mr. Biden is upset by the vaccine shortage. His administration has often touted its success delivering hundreds of millions of coronavirus shots to Americans, and is stung by criticism that a lack of foresight and management has left gay men — the prime risk group for monkeypox — unprotected.

Some critics blame a failure of leadership at the Health and Human Services Department, saying the department’s secretary, Xavier Becerra, has taken a hands-off approach to an increasingly serious situation. His department not only oversees both the C.D.C. and the Food and Drug Administration, but also runs the Biomedical Advanced Research and Development Authority, or BARDA, which helps develop and buys vaccines, tests and treatments to protect against highly contagious viruses, bioterrorism and other hazards.

During a press call on monkeypox last week, Mr. Becerra said his department is doing all it can to ensure that “we not only stay ahead of this virus but that we end this outbreak.” He noted that he had recently elevated the agency’s Office of Strategic Preparedness and Response so it can respond more quickly to public health emergencies.

Sarah Lovenheim, his spokeswoman, said in a statement: “Our response has accelerated to meet evolving needs on the ground, and it will keep accelerating. We will use every lever possible to continue allocating doses ahead of timelines, as possible.”

So far, according to the C.D.C., 6,326 cases of monkeypox have been reported. For now, the virus is spreading almost entirely among gay and bisexual men, and those with multiple or anonymous partners are considered especially at risk. Mr. Becerra noted that while more than a million Americans have died of Covid-19, no one in the United States has died of monkeypox.

The official case count is widely considered an underestimate. Not only is testing limited, but public health officials like Dr. Joseph Kanter, the top medical official in Louisiana, said that monkeypox can be hard to diagnose. “It can be one or two solitary lesions, so if it’s not on a clinician’s radar,” he said, it can be missed.

With too few doses, health officials apparently plan to rely heavily on the “test and trace” strategy that figured heavily in the early stages of the Covid pandemic. As the pandemic escalated, the sheer torrent of cases overwhelmed the ability of health officials to contact people who might have been infected by someone who had tested positive for the coronavirus. Once Covid vaccines became available, they became the cornerstone of the administration’s pandemic response.

Through early June, Health and Human Services officials appeared firmly convinced that the United States had more than enough supply of the monkeypox vaccine, called Jynneos, to handle what appeared to be a handful of cases.

Bavarian Nordic was able to develop the vaccine, which also works against smallpox, largely thanks to the federal government’s backing, which surpassed $1 billion in 2014 and is now edging toward $2 billion. Dawn O’Connell, the federal health agency’s assistant secretary for preparedness and response, told reporters in early June: “The world has Jynneos because we invested in it.”

The company opened a new $75 million fill-and-finish plant in 2021 that is now bottling as many as 200,000 to 300,000 doses a week. At the time, the United States was counting on Jynneos to protect against smallpox, not monkeypox, and the government had a large stockpile of another effective smallpox vaccine. No F.D.A. inspection was scheduled until after the monkeypox outbreak, and it did not conclude until July 27.

In early June, Health and Human Services officials agreed to essentially loan back about 215,000 finished doses of vaccine to Bavarian Nordic so the firm could supply them to European countries that were suffering outbreaks.

“It didn’t make sense while we were waiting for F.D.A. to get the inspection done — which is coming — that we sit on doses that our international colleagues in Europe could actually use,” Ms. O’Connell said on June 10. Now the government is trying to reschedule delivery of those doses for later this year, a company spokesman said.

The final stage of putting the liquid vaccine into vials accounts for a substantial share of the cost of vaccine production. Some federal officials say the health department was slow to submit its orders for that work because officials at BARDA argued they were short on funds.

When the demand for vaccines became an outcry, though, the agency found the money to pay for five million more doses to be vialed. Officials are now contemplating shifting half the work to another firm that may be able to finish and fill doses more than twice as fast.

Some experts say it can take as long as six to nine months for a plant to gear up to handle a vaccine like Jynneos, which contains a live virus in a weakened state. Carlo de Notaristefani, who oversaw coronavirus vaccine manufacturing for the federal government until last year, said that such factories must operate at a high “biological safety level,” including a fully enclosed, segregated manufacturing line.

But he and other experts said it should be possible to streamline the transfer of Bavarian Nordic’s process so another plant could be ready in about three months. A company spokesperson said Bavarian Nordic agreed to pay $10 million of the cost of such a transfer after federal officials said they did not have the budget for it.

Kitty Bennett contributed research.

Teva Pharmaceuticals, one of the country’s biggest manufacturers of generic opioids, announced a settlement in principle with some 2,500 local governments, states and tribes over the company’s role in the deadly, ongoing opioid epidemic.

The deal — worth up to $4.25 billion — came after a series of blistering trials and previous settlements in individual cases across the country over the past year.

Though much lesser-known, Teva, an Israeli company, and its affiliates produced far more prescription opioids during the peak years of the crisis than marquee-name opioid manufacturers such as Johnson & Johnson did. Its production of both generic and branded painkillers dwarfed the output of Purdue Pharma, the maker of OxyContin, the medication most immediately associated with setting off an avalanche of overdoses and deaths.

Under the deal, Teva would make payouts over 13 years, directed to state, local and tribal programs to ease the opioid crisis, which has only deepened during the coronavirus pandemic. The $4.25 billion total included the nearly $550 million in settlements the company had already struck as trials got underway in San Francisco as well as in Florida, West Virginia, Texas, Louisiana and Rhode Island.

States and communities can choose to accept a portion of their payouts in overdose reversal medications, rather than cash.

The deal was negotiated by representatives for about a dozen state attorneys general. “Today’s announcement once again shows that those responsible for this tragic issue will be held accountable and help will be available to those affected by the opioid epidemic,” Tom Miller, the attorney general of Iowa, whose office was involved in the negotiations, said in a statement.

Teva said in a statement, “While the agreement will include no admission of wrongdoing, it remains in our best interest to put these cases behind us and continue to focus on the patients we serve every day.”

People close to the talks said that about 10 to 12 percent of the money would be allocated for fees to lawyers who, starting in 2013, brought the cases against the company.

In 2016, Teva acquired Actavis, a generics unit of Allergan. For Teva’s deal to be finalized, Allergan also has to reach a settlement with these plaintiffs. Lawyers familiar with negotiations said they expected that announcement to be made soon.

The deal is also contingent upon an overwhelming majority of state, local and tribal governments voting in favor it.

Lawyers on an executive committee negotiating for local governments urged everyone to back the hard-won deal: “We encourage all these groups to sign onto this agreement to allow these resources to get into the hands of those who need them as fast as possible,” they said in a statement.

While that outcome seems likely, one state that participated, among the dozen that negotiated the terms, has not yet signed on: New York, along with Nassau and Suffolk counties, which prevailed against Teva in a civil jury trial last December. Under the shadow of a second phase of that trial to determine financial remedies, New York is still in talks with the company, a spokeswoman for the New York attorney general’s office said.

Eliciting an acceptable offer from Teva has been a particularly protracted battle for the states, tribes and municipalities that brought cases against it. While Purdue Pharma, for example, has often been associated with amped-up and misleading marketing of its branded drugs to doctors, manufacturers of generic drugs do not formally make sales calls to them. Teva maintained that it did not market its opioids to doctors.

One of Teva’s initial settlement offers, in 2019, consisted almost entirely of medications, along with a small amount of cash. While Johnson & Johnson and the three drug distributors that also participated in that early offer went on to strike a deal two years later, Teva continued to litigate.

But in December 2020, the Senate Finance Committee released findings that were particularly critical of Teva, among other manufacturers, for the millions of dollars it paid to tax-exempt groups that lobbied lawmakers and others, pressing for greater patient access to pain medications. At trial, plaintiffs said that Teva, which assumed a dominant position in the generics market by buying smaller companies, had ignored red flags such as outsized pill orders.

Ghana announced the country’s first outbreak of Marburg virus disease after two people who were not related died on June 27 and 28. Word of a new outbreak of a lethal disease caused by viral infections added to the concerns of a public weary from battling the coronavirus pandemic, and recently alarmed by the spread of monkeypox and a new case of polio.

Doctors and public health experts in the country immediately started searching for anyone who had been exposed and investigating the cause of the spread in an effort to contain infection. For now, health researchers in Ghana and in other parts of the world said that there was no indication that the virus had spread further.

What is Marburg virus disease?

Marburg was first detected in 1967, when outbreaks of hemorrhagic fever occurred simultaneously in laboratories in Marburg and Frankfurt in Germany, and in Belgrade, in what is now Serbia — in cases that were linked to African green monkeys imported from Uganda. Other cases have since been found in Angola, the Democratic Republic of Congo, Kenya, South Africa and Uganda, according to the World Health Organization. Last month’s cases in Ghana were the first recorded in that country.

The Marburg virus is the pathogen that causes Marburg virus disease in humans, health experts said.

There are no vaccines or antiviral treatments for the disease, medical experts said, but hydrating patients and treating their specific symptoms can improve their chances of survival.

The disease is clinically similar to Ebola in its spread, symptoms and progression, although it is caused by a different virus, according to the W.H.O. In Marburg’s case, fruit bats are considered to be the hosts of the virus, though researchers say it does not cause them illness. Researchers believe that Ebola is likely carried by bats or by nonhuman primates, according to the Centers for Disease Control and Prevention. Even though it has not spread widely, Marburg has been deadly, with case fatality rates ranging from 24 to 88 percent, depending on which strain people contract and the management of cases, according to the W.H.O. The Ebola case fatality rates are nearly the same.

The Marburg virus can spread through direct contact with blood, secretions or other bodily fluids from infected people, according to the W.H.O. It can also spread through contact with contaminated surfaces and materials like bedding or clothing.

What are the symptoms of Marburg virus disease?

Marburg can cause severe viral hemorrhagic fever, which interferes with the blood’s ability to clot. The incubation period ranges from two to 21 days, and symptoms begin abruptly with high fever, severe headache and severe malaise, according to the W.H.O. Other symptoms can include muscle aches, diarrhea, nausea, lethargy and bleeding through vomit, feces and from other body parts.

“Mortality is very high,” said Dr. John Amuasi, who leads the global health and infectious disease research group at the Kumasi Center for Collaborative Research in Tropical Medicine in Kumasi, Ghana. “And there’s no asymptomatic Marburg.”

A patient can confirm their condition is Marburg through antibody, antigen and polymerase chain reaction tests, health organizations said.

How many cases have there been this year?

There have only been two cases of Marburg virus disease this year, both reported in Ghana. The people who contracted the virus were not related and they were in different parts of the Ashanti region of Ghana, Dr. Amuasi said. They both died.

Both patients were men who worked on farms, he said. One was a 26-year-old farmhand who had recently been to a different part of the country for work, and the other was a 56-year-old subsistence farmer. Contact tracing by local authorities led them to conclude that the men had not been in the same places.

Fruit bats, known to be the carriers of the virus, are common in the Ashanti region.

How does the outbreak compare to previous ones?

More than 200 people died in an outbreak in Angola from 2004 to 2005 and more than 100 died of the disease in the Democratic Republic of Congo from 1998 to 2000, according to the C.D.C. Other outbreaks of Marburg have not involved as many cases.

In 2021, there was one case in Guinea, which resulted in that person’s death, and three of four people who had the disease in Uganda in 2017 also died, according to the C.D.C.

Experts want to know how the two people contracted the virus in Ghana, said Dr. Francis Kasolo, the W.H.O. representative to the country.

“The current investigation is not only focusing on contacts,” Dr. Kasolo said. “We are also going back to medical records in these areas to see if there were unusual events in terms of cases that presented with symptoms. That is why we are holding back in saying that this is just a one-off event.”

Should we be worried?

The C.D.C.’s office in Ghana is working with local health authorities to assist with testing and epidemiological investigations, said Dr. Jonathan Towner, who leads the Virus Host Ecology Section at the C.D.C.

People in the United States are not at high risk for exposure, Dr. Towner said.

“It’s a very, very low risk probability at this point that there will be some travelers, for example, coming into the country with Marburg right now,” he said.

So far, Dr. Amuasi said, the public health response has been appropriate and transparent. Contacts of the two infected people were monitored, particularly in the 21 days after the two died.

The pandemic crushed the senior housing market, cutting occupancy rates and stalling construction. Now, as the market begins an uneven rebound, developers are adapting to the coming wave of aging baby boomers with a new crop of living developments.

Specialized housing for older Americans has been around for decades. But shifting demographics are forcing the industry to diversify more rapidly across rates and services, yielding increasingly lavish residences for upper-income Americans as well as a growing number of affordable housing models.

For example, Trillium, a high-rise under construction near Washington, features restaurants, a wellness spa, and other boutique-hotel-style amenities and finishes. And in the Boston area, Opus Newton, a more modest development, will rely on resident volunteers to help reduce costs.

Developers are also experimenting with nontraditional models. In Loveland, Colo., Kallimos Communities is planning a multigenerational development featuring 100 subsidized rental homes clustered around shared green spaces and offering dining, arts and wellness opportunities.

The aging of more and more baby boomers (an estimated 65 million in total) is creating “a big surge,” said Beth Mace, chief economist for the National Investment Center for Seniors Housing & Care, a data service provider for the elder care industry.

Other changes are reshaping housing, from pandemic-fueled safety concerns and labor shortages to trends favoring more personalized and community-based solutions. Housing for older Americans offers three general options: independent living, for active lifestyles; assisted living, which includes some medical care; and memory care. (Nursing homes provide nursing care and typically do not fall under the category of senior housing.)

“Everybody is trying to figure out the secret sauce — what the senior housing consumer wants,” Ms. Mace said. “Bottom line: You’re going to see a lot of options.”

Developers are banking on the fact that if they build enough variety, they will be able to draw the next generation of aging Americans.

“We have to design communities that cater to what boomers want, and that’s a difference between senior housing today and housing developed 10 or 20 years ago,” said Bobby Zeiller, vice chairman and co-chief executive of Silverstone Senior Living, the developer behind the Trillium.

After focusing on suburban-style senior communities, Silverstone is expanding into urban environments, Mr. Zeiller said. The industry, he said, “is evolving very fast.”

The average occupancy rate for the nation’s 31 largest senior housing markets was 81 percent in the first quarter of 2022, up from a low of 78 percent in the first quarter of 2021 but below the prepandemic level of 87 percent in 2020, Ms. Mace said.

The numbers are starting to tick up in select markets, according to data from the National Investment Center. In Miami, for example, construction as a share of inventory amounted to 11 percent in the first quarter of 2022, the second-highest level ever. But at the other end of the spectrum is Sacramento, where construction fell to about 1 percent, down from 17 percent in 2019.

Even before the pandemic, only about 11 percent of Americans over 75 lived in senior housing. Strong preferences for aging in place is one reason for the low rate.

The high cost of housing is another factor, especially for the eight million middle-income Americans who do not qualify for subsidies but cannot afford to pay out of pocket. The national median monthly rate for assisted living was $4,300 in 2021, according to a survey by Genworth, an insurance holding company. And the average monthly cost of memory care is $7,277, according to the National Investment Center.

Developers of luxury projects are betting on larger units, sophisticated design and amenities, and a heightened focus on social engagement and active living.

Coterie Cathedral Hill, a 208-unit development that opened in San Francisco in April, features five restaurants, an outdoor pool, and landscaped courtyards and terraces. Wellness staff receive training through the Mayo Clinic, and an on-site care coordinator helps residents meet a broad range of mental, emotional and physical health goals, including assistance with social and philanthropic objectives.

A joint venture between the real estate developer Related Companies and Atria Senior Living, one of the nation’s largest senior living providers, Coterie focuses on affluent urban dwellers who seek “consistency between the lifestyle they were accustomed to when they were living in a traditional high-rise,” said Joanna Mansfield, general manager of Coterie Hudson Yards, a second development that will open this fall in New York.

At Coterie Cathedral Hill, monthly rental rates range from $7,900 for a studio to $16,660 and up for two-bedroom residences.

A new spate of thrifty business models focus on middle-income Americans. Opus Newton, for example, will require residents to volunteer 10 hours a month, giving them a stronger sense of purpose and community while “meaningfully reducing staff overhead costs,” said Amy Schectman, president and chief executive of 2Life Communities, a nonprofit organization that is developing the project.

Other cost savers include outsourcing care and providing discounted memberships at the nearby Jewish Community Center, eliminating the need for in-house recreational facilities.

Ms. Schectman expressed confidence in the future of congregate senior living, despite lingering pandemic concerns.

“Coronavirus revealed a pandemic of loneliness and isolation,” she said. “Aging in place harms society by presenting the choice to live with others as a failure. We are creatures of community.”

Upfront costs for Opus Newton’s 174 units start at $391,000, a fee that many of the residents will pay by selling their homes.

Repurposing existing buildings is the key to solving the middle-market challenge, said Fee Stubblefield, chief executive of The Springs Living, a developer in Portland, Ore., with 18 properties serving seniors across the income spectrum.

The Springs Living has two luxury projects under construction, including a high-rise on the Columbia River in Vancouver, Wash. The properties will include firewalls to cordon off floors in the event of a disease outbreak, and they will be certified to meet new health and wellness standards regarding design and operations.

Starting rents in the new buildings range from $3,700 to $10,000 per month.

There are two types of senior housing residents, Mr. Stubblefield said: those who want to live there and those who have to. Those who want senior living are “a big portion of our society,” he said. “The social and wellness component is underbuilt for that population.”

Labor shortages add to the economic challenges facing developers of senior housing. Employment in long-term care declined 6.7 percent from February 2020 to December 2021, according to a recent analysis of Bureau of Labor Statistics data.

“Work-force stability is the most important factor in the future of housing and service for older adults,” Mr. Stubblefield said, adding that operators have an “obligation” to create career pathways for the entry-level staff who sustain the industry.

Bill Thomas, a co-founder of Kallimos Communities, offers another solution to the various challenges tied to the future of aging and retirement in the United States. “The very best thing you can have for helping you stay independent is damn good neighbors,” he said.

The first Kallimos community, a partnership with the Loveland Housing Authority, is rooted in the idea that older Americans can be supported in homes designed for elder living in community-oriented mixed-age neighborhoods.

“Young people and elders have been living together and supporting each other for many millennia,” Mr. Thomas said. “The idea that we’ve wandered into a cul-de-sac of history where young people don’t see any merit in being around old people is just wrong.”