CHARLESTON, S.C. • It's one of the stranger, lesser-known aspects of U.S. health care — the striking, milky-blue blood of horseshoe crabs is a critical component of tests to ensure injectable medications such as coronavirus vaccines aren't contaminated.
To obtain it, harvesters bring many thousands of the creatures to laboratories to be bled each year, and then return them to the sea — a practice that has drawn criticism from conservationists because some don't survive the process.
The blood, which is blue due to its copper content, is coveted for proteins used to create the LAL test, a process used to screen medical products for bacteria. Synthetic alternatives aren't widely accepted by the health care industry and haven't been approved federally, leaving the crabs as the only domestic source of this key ingredient.
Many of these crabs are harvested along the coast of South Carolina, where Gov. Henry McMaster promoted the niche industry as key to the development of a domestic medical supply chain, while also noting that environmental concerns should be explored.
"We don't want to have to depend on foreign countries for a lot of reasons, including national security, so it's good to see this company thriving in the United States," McMaster told The Associated Press this month during a visit to Charles River Laboratories at its Charleston facilities, to which AP was granted rare access. "We want to do everything we can to onshore all of these critical operations."
Horseshoe crabs — aquatic arthropods shaped like helmets with long tails — are more akin to scorpions than crabs, and older than dinosaurs. They've been scurrying along the brackish floors of coastal waters for hundreds of millions of years. Their eggs are considered a primary fat source for more than a dozen species of migratory shore birds, according to South Carolina's Department of Natural Resources.
Their value to avoiding infection emerged after scientists researching their immune response injected bacteria into horseshoe crabs in the 1950s. They ultimately developed the LAL test, and the technique has been used since the 1970s to keep medical materials and supplies free of bacteria.
Their biomedical use has been on the rise, with 464,482 crabs brought to biomedical facilities in 2018, according to the Atlantic States Marine Fisheries Commission.
In South Carolina, that's done only by Charles River, a Massachusetts-based company that tests 55% of world's injectables and medical devices — like IV bags, dialysis solutions and even surgical cleaning wipes, according to company officials.
"We are almost the last line of defense before these drugs leave the manufacturing area and make it to a patient," senior vice president Foster Jordan told McMaster. "If it touches your blood, it's been tested by LAL. And, more than likely, it's been tested by us."
Charles River employs local fishermen to harvest the crabs by hand, a process governed by wildlife officials that can only happen during a small annual window, when the creatures come ashore to spawn.
Contractors bring them to the company's bleeding facilities, then return them to the waters from which they came. During a year, Jordan said his harvesters can bring in 100,000 to 150,000 horseshoe crabs, and still can't satisfy the growing demand.
"We need more, though," Jordan told McMaster, adding that his company is working with the state to open up more harvesting areas. "The population's steady. ... We need access to more beaches, to get more crabs."
The practice is not without its critics, some of whom have argued that bleeding the crabs and hauling them back and forth is harmful. According to the National Oceanic and Atmospheric Administration, 10% to 15% of harvested crabs die during the process.
The International Union for Conservation of Nature listed the species overall as "vulnerable," noting decreasing numbers as of a 2016 assessment. The Atlantic States Marine Fisheries Commission listed 2019 stock as "good" in the Southeast, but "poor" in areas around New York.
Conservationists sued last year, accusing the U.S. Fish and Wildlife Service of shirking its duty to protect areas including South Carolina's Cape Romain National Wildlife Refuge by allowing horseshoe crab harvesting. They argued that taking out the crabs affects other species in the protected area. A federal judge temporarily halted the harvest, but was reversed following Charles River's appeal.
The environmental groups asked to withdraw their complaint this month after federal officials imposed a permitting process for any commercial activity in the refuge, including horseshoe harvesting, beginning Aug. 15. Even if such permits are denied, Jordan told McMaster that only 20% of its harvest came from the refuge, with most coming from further down the South Carolina coast.
There is a synthetic alternative to the horseshoe crab blood, but it hasn't been widely accepted in the U.S., and meanwhile, Charles River's international competitors are making synthetics and also pressing for U.S. Food and Drug Administration approval, which Jordan said could hamper domestic efforts like his own.
"My mission is to make sure that any competitor that comes into the United States, from China or any of these other producers, has to go through the same regulatory process that we had to go through, to make sure that it's safe," Jordan said. "If all these synthetics start coming in from other countries, we're going to lose the protection that we've had for all these years, and the safety, and the control of the drug supply."
"We want to have as much stuff made here as we can," McMaster said in response.
As for the environmental concerns, the governor said maintaining a healthy balance between scientific demands and the state's ecosystems, which bolster a significant portion of South Carolina's tourism economy, is paramount.
"It's like a house of cards. You pull out one part, and the rest of it will fall," McMaster said. "So I think we have to be very careful, and be sure that any company, any business, any activity, whether it's commercial or otherwise, meets whatever requirements are there to protect the species — birds, horseshoe crabs, any sort of life."
BILOXI, Miss. • Before mass on a recent Tuesday afternoon, about 50 people knelt and said the rosary in the sanctuary of Biloxi's Vietnamese Martyrs Church in Biloxi.
Looking out over the crowd, the Rev. John Thang Pham said all of the worshipers had been vaccinated against COVID-19.
He knows, because he saw many of them get the vaccine right there at the church. He joked with his congregation that he had volunteered to become the first "victim" of the vaccine when he got his first shot in the winter.
"Now, (after) three days, I'm still here, I'm not dying yet, so go ahead and do it," he told parishioners. "I'm a testament to the vaccine."
Among regular Sunday attendees, he estimates that about 70% have been vaccinated.
In Harrison County, where the overall vaccination rate of 31% lags behind the state average, that statistic stands out. It also reflects the higher vaccination rate among Asian residents: about 49% of all Asian residents of Harrison County have been fully vaccinated, according to a Sun Herald analysis of U.S. census and Mississippi health department data.
Across South Mississippi, Asian and Pacific Islander residents have the highest vaccination rates of all racial and ethnic groups, outpacing the state average.
The health department does not release data on national origin for vaccine recipients, so it's not clear exactly how many Coast residents from different Asian communities have been vaccinated. But Daniel Le, head of the Biloxi branch of Boat People SOS, a national nonprofit that serves Vietnamese Americans, estimated about 80% of Vietnamese Americans on the Coast have been vaccinated.
Within the Vietnamese community, the Coast's largest Asian national origin group with an estimated 10,000 residents, advocates and health care workers say the high vaccination rate is a product of trust in science and medical experts.
"When the call came out to say, 'Hey, get the vaccine, it's gonna save your life,' they were the first in line," Le said.
When the vaccine rollout began in January, Xuan Tran, who works in community outreach at the nonprofit Mercy Housing and Human Development, was worried. The website and hotline for eligible seniors to make an appointment to get the shot were not available in Vietnamese. And supply was so limited that even when she helped someone navigate the website, there were often no appointments left by the time they'd completed all the forms.
"I personally was really scared," Tran said. "I was like man, we're gonna be left behind."
Earlier in 2020 and 2021, organizations like Boat People SOS had held workshops to explain how the vaccine worked and why it was safe. When they struggled to make appointments, they reached out to Boat People and Mercy Housing for help.
"They tried to do it themselves, but it was very difficult for them to navigate the portal system," Le said.
Coast community advocates got in touch with the health department, where Selma Alford serves as language access director. The department set up COVID-19 Hispanic and Vietnamese task forces dedicated to providing resources in Spanish and Vietnamese and working with community organizations to promote and distribute vaccines.
Those conversations led to the departments setting aside about 600 doses for a distribution event at the Coast Coliseum in early March.
Ahead of the distribution even in March, Tran and Le helped sign people up for appointments. Demand was so high that Tran had to tell some people it was too late to get a slot.
Six Vietnamese-speaking social workers and nurses were on hand at the Coliseum that day to help people navigate the process.
Chigozie Udemgba, director of the Office of Health Equity at MSDH, said lessons from the Coast Vietnamese community's approach to the COVID-19 vaccine can be applied across the state.
"We involved the community and asked them how the work should be done," he said. "They know best. Inform, consult and involve the community."
TRUSTED ORGANIZATIONS PROMOTING VACCINATION
Angelica Trieu, a pediatric nurse practitioner at Coastal Family Health Center in Biloxi, worked with Father Thang to organize a vaccine drive at Vietnamese Martyrs Church. And outside of formal vaccine distribution events, she serves as a point of contact for Vietnamese speakers in search of a vaccine.
"If the priest comes to me and says hey, I have someone who wants the vaccine, but they don't speak good English, can they come to your clinic?" she said. "I would get them into the clinic here."
What happened in South Mississippi's Vietnamese community reflects a strategy Asian communities have adopted across the country.
When initial vaccine rollouts were not designed to provide easy access for people with limited English proficiency and inconsistent technology access, advocates with deep ties to their communities stepped up to make appointments and organize distribution events in New York City, Austin, Texas, Greensboro, North Carolina, and many other American cities and towns.
Tran said that when the vaccine arrived, it helped that organizations like hers already had deep roots in the community.
"We're not here because the government paid us to get you vaccinated," she said. "They trust us, and we've been here for a long time."
SHARING COVID VACCINE INFORMATION IN VIETNAMESE
Cynthia Le, a Vietnamese-speaking nurse practitioner at Singing River's Ocean Springs clinic, said that early on, she heard concerns about possible side effects from the vaccine, and fears that it would make people sick.
"I tell them it's probably better to be ill from the vaccine than really ill from being hospitalized, or even death, from COVID," she said.
Le, who grew up in Biloxi, estimates about half of her patients are Vietnamese. When she was a child, parents, grandparents, aunts and uncles frequently took her with them to doctor's appointments so she could translate.
"It was kind of scary," she said. "And not really knowing what they were saying, but trying to make out what they were trying to say and explain it."
She became a nurse practitioner because she wanted to create a space where Vietnamese-speaking patients could come and get information about their health directly, and feel comfortable asking questions.
Le joined Tran and State Health Officer Dr. Thomas Dobbs in a Vietnamese-language virtual town hall in February to provide information about the vaccine.
Le is also a parishioner at Vietnamese Martyrs Church. This past winter, during Mississippi's previous peak in cases, she asked Father Thang if she could have five minutes during mass to talk to the congregation.
"We had to tell them look, it's ok if you have COVID," she said. "But there's medicine out there we can give you — monoclonal antibodies. They weren't aware of that."
Trieu said she felt the vaccine hadn't become a political issue in the Coast's Vietnamese community.
"They believe in medicine," she said, referring to older Vietnamese Mississippians. "They believe in science. A lot of this COVID-19 vaccine, everyone thinks it's a conspiracy or it has something to do political, and we don't — we try not to politicize the COVID-19 vaccine. And I think that's why we have such a high vaccination rate."
Tran said the language barrier that can drive health disparities for the Vietnamese community on the Coast also caused people with limited English to rely heavily on organizations like Boat People and Mercy Housing for information during the pandemic. And all of those organizations were "all in" on promoting the vaccine.
But misinformation still circulates. Buzzfeed News reported that some far-right Vietnamese American YouTubers with large followings have promoted conspiracy theories like the claim that more people have died from the vaccine than from COVID-19.
In Vietnam, where mistrust of China is deeply ingrained, the government recently backed off plans to distribute a Chinese-made vaccine in Ho Chi Minh City after public outcry.
Thang said anxiety about Chinese-made vaccines in Vietnam had made its way to members of his congregation in Mississippi, though Chinese-made vaccines are not approved for distribution in the United States.
"The Vietnamese nowadays with communication, they talk back to Vietnam, and they're afraid the vaccine came from China," he said. "That's all rumor."
YOUNGER PEOPLE MORE WARY OF VACCINE
Trieu said she thinks younger Vietnamese Americans are less likely than their parents and grandparents to get vaccinated, and other community leaders agreed.
"They're more Americanized," she said. "It's just like every other excuse that every other unvaccinated person has."
But Cynthia Le said she had also heard from many parents who were eager to find out when their six- or seven-year-old could get the vaccine.
Health department data does not show the age breakdown of Asian vaccine recipients on the Coast.
"They think they have the immune system and they don't need it," Father Thang said of younger parishioners. "But the elders, I can scare the elders."
And after getting the vaccine himself, explaining the benefits, and organizing vaccination events at church, he has taken a strong stance.
While many other pastors in the Deep South have been "paralyzed or silent" on the vaccine, as one theologian recently told the Associated Press, Father Thang has been clear. When he speaks, his parishioners hear no caveats about personal choice.
"I say: 'You don't get it, it's not right,'" he said. "'You don't get it, you're uncharitable to those that sit next to you.'"
HELENA, Mont. • A Montana school district is dangling $4,000 bonuses and inviting people to test drive big yellow school buses in hopes of enticing them to take a job that schools are struggling to fill as kids return to in-person classes.
A Delaware school district offered to pay parents $700 to take care of their own transportation, and a Pittsburgh district delayed the start of classes and said hundreds more children would have to walk to school. Schools across the U.S. are offering hiring bonuses, providing the training needed to get a commercial driver's license and increasing hourly pay to attract more drivers.
The shortage of bus drivers is complicating the start of a school year already besieged by the highly contagious delta variant of COVID-19, contentious disagreement over masking requirements, and the challenge of catching up on educational ground lost as the pandemic raged last year.
The driver shortfall isn't new, but a labor shortage across many sectors and the pandemic's lingering effects have made it worse, since about half the workforce was over 65 and more vulnerable to the virus, said Joanna McFarland, co-founder and CEO of school ride-service company HopSkipDrive, which tracks school bus issues.
Her company conducted a survey in March that found nearly 80% of districts that responded were having trouble finding enough bus drivers.
"It's really at a breaking point," McFarland said.
First Student, a company that contracts bus service for school districts around the county, held test driving events they called "Big Bus, No Big Deal" in Montana and many other states this summer to give people an opportunity to try their hand at driving. The hope was that it could remove a barrier to those who otherwise might be interested in helping get kids safely to and from school, said Dan Redford, with First Student in Helena, Montana.
"We actually set up a closed course at the fairgrounds, and we invited the public to come in and learn that it's not a big deal to drive a big bus," Redford said. "They're actually pretty easy to drive. You sit up high. You've got plenty of view."
In Helena, the company has 50 bus drivers and needs 21 more before classes start on Aug. 30, a shortfall Redford called unprecedented.
Attendance ended up being light at Helena's event, but similar demos, like one held recently in Seattle, led to more applications.
The delta variant also drove the U.S. Centers for Disease Control and Prevention to recommend universal mask wearing in schools, especially for children too young to be vaccinated. But in many areas, there's a wave of fierce anti-mask protest.
First Student lost some Helena drivers to mask requirements on buses, Redford said.
"I know I've had a lot of drivers that don't believe in that and don't want to have to deal with that," Redford said.
For parents, school bus headaches are coming at an especially difficult time.
Monica Huff was at home in quarantine with a likely case of COVID-19 on Wednesday when she learned that her 14-year-old son's school bus didn't show up at his stop in suburban Houston.
"I was worried. I was scared. ... I didn't know where he was," she said. She felt especially helpless because she couldn't leave to get him herself without putting others at risk of infection.
Eventually she learned that the elementary-school bus driver had picked up the older kids and brought them to the high school. She was relieved to know he arrived at school, though his late start time was also a concern since he's still making up some ground in his studies after falling behind during remote learning early last year.
"There's enough to worry about this year with people getting angry about masks," she said.
Republican Gov. Greg Abbott initially prohibited Texas school districts from requiring masks, but successful court challenges led the Texas Education Agency on Thursday to suspend enforcement of his ban while the challenges move through the courts.
In Florida, many of the largest school districts are using managers as drivers and implementing other stop-gap measures to get students to class as the school year begins against a statewide political fight over masks between Republican Gov. Ron DeSantis, who wants to forbid mask mandates, and districts convinced they're needed to keep kids safe.
President Joe Biden on Wednesday ordered his education secretary to explore possible legal action against states that have blocked school mask mandates and other health measures meant to protect students against COVID-19.
Economic forces are also at play in the bus driver shortage. Driving a school bus requires a commercial driver's license that can take weeks to obtain. And people who have them can often find higher-paying work that doesn't require splitting the day for pickup and drop-off. Demand for commercial drivers is only increasing with the pandemic-related surge in online shopping, said McFarland with HopSkipDrive.
But working with kids driving a bus can be a rewarding profession, and the hours work well for stay-at-home parents or retirees seeking to supplement their income, contractors say. There's no requirement to work nights, weekends or holidays. Field trips and sporting events can add more hours for those who want them, said Redford with First Student.
His company allows bus drivers whose children are at least 1 year old to ride on the bus with them while they work, saving on daycare costs, Redford said.
One Michigan school district was able to find enough drivers by guaranteeing they could work enough hours in the district, including as janitors or in food service, to qualify for health insurance coverage, said Dave Meeuwsen, executive director of the Michigan Association of Pupil Transportation.
In suburban Salt Lake City, the Canyons School District was in dire straits about a month ago. It was down about 30 drivers, so its workforce would have been too small to staff all their routes, said spokesman Jeff Haney. Administrators put out the word that office staffers might have to get their commercial driver's licenses just to get all the kids to and from school.
"It was very alarming and very concerning," he said.
The district also increased bus-driver pay and offered a program to help people get their commercial licenses. In the weeks since, it has seen an uptick in applications. If they keep coming in at the same rate, the district should be staffed up for the year, Haney said.