BUFFALO, N.Y. (AP) — The white 18-year-old who shot and killed 10 people at a Buffalo supermarket had researched the local demographics while looking for places with a high concentration of Black residents, arriving there at least a day in advance to conduct reconnaissance, law enforcement officials said Sunday.

Authorities said the gunman shot, in total, 11 Black people and two white people Saturday in a rampage motivated by racial hatred that he broadcast live.

Buffalo mass shooter’s alleged manifesto leaves no doubt attack was white supremacist terrorism

“This individual came here with the express purpose of taking as many Black lives as he could,” Buffalo Mayor Byron Brown said at a news conference Sunday.

The shooter, identified as Payton Gendron, had previously threatened a shooting at his high school last June, a law enforcement official told The Associated Press. Buffalo Police Commissioner Joseph Gramaglia said the then-17-year-old was brought in for a mental health evaluation afterward.

Meanwhile, federal authorities were still working to confirm the authenticity of a racist 180-page manifesto that detailed the plot and identified Gendron by name as the gunman, the law enforcement official told the AP. But the shooting — the latest act of mass violence in a country unsettled by racial tensions, gun violence and a recent spate of hate crimes — left local residents shattered.

32-year-old Roberta Drury killed in Tops Markets mass shooting

A preliminary investigation found Gendron had repeatedly visited sites espousing white supremacist ideologies and race-based conspiracy theories and extensively researched the 2019 mosque shootings in Christchurch, New Zealand, and the man who killed dozens at a summer camp in Norway in 2011, the law enforcement official, who spoke on condition of anonymity, told AP.

The manifesto posted online and purportedly written by Gendron, outlined a racist ideology rooted in a belief that the United States should belong only to white people. All others, the document said, were “replacers” who should be eliminated by force or terror. The attack was intended to intimidate all non-white, non-Christian people and get them to leave the country, it said.

Gendron had appeared on the radar of police last year after he threatened to carry out a shooting at Susquehanna High School around the time of graduation, the official said. New York State Police said troopers were called to the Conklin school on June 8, 2021, for a report that a 17-year-old student had made threatening statements.

The law enforcement official was not authorized to speak publicly on the investigation and did so on the condition of anonymity.

Gendron, confronted by police in the store’s vestibule, put a rifle to his neck but was convinced to drop it. He was arraigned later Saturday on a murder charge, appearing before a judge in a paper gown.

• The Tops Market shooter arraigned in Buffalo City Court on a charge a first-degree murder. He was put into an anti-suicide gown. (WIVB Photo/Kelsey Anderson)
• People gather outside a supermarket where several people were killed in a shooting, Saturday, May 14, 2022 in Buffalo, N.Y. Officials said the gunman entered the supermarket with a rifle and opened fire. Investigators believe the man may have been livestreaming the shooting and were looking into whether he had posted a manifesto online (Derek Gee/The Buffalo News via AP)
• Payton Gendron talks with his attorney during his arraignment in Buffalo City Court, Saturday, May 14, 2022, in Buffalo, N.Y. Gendron was arraigned on first-degree murder charges and ordered detained without bail. Police officials said the 18-year-old was wearing body armor and military-style clothing when he pulled up and opened fire at people at a Tops Friendly Market. (Mark Mulville/The Buffalo News via AP)
• (WIVB Photo/Hope Winter)
• Police walk along the perimeter of the scene after a shooting at a supermarket on Saturday, May 14, 2022, in Buffalo, N.Y. Officials said the gunman entered the supermarket with a rifle and opened fire. Investigators believe the man may have been livestreaming the shooting and were looking into whether he had posted a manifesto online. (AP Photo/Joshua Bessex)
• Flowers and candles lay outside the scene of a shooting at a supermarket, in Buffalo, N.Y., Sunday, May 15, 2022. (AP Photo/Matt Rourke)

Federal agents interviewed Gendron’s parents and served multiple search warrants, the law enforcement official told the AP. Gendron’s parents were cooperating with investigators, the official said.

It wasn’t immediately clear why Gendron had traveled about 200 miles from his Conklin, New York, home to Buffalo and that particular grocery store, but investigators believe Gendron had specifically researched the demographics of the population around the Tops Friendly Market, the official said. The alleged manifesto claims to have targeted the zip code with the highest percentage of Black people nearby.

In a Sunday press conference, Gramaglia said that Gendron had been in town “at least the day before.”

“It seems that he had come here to scope out the area, to do a little reconnaissance work on the area before he carried out his just evil, sickening act,” Gramaglia said.

Latest on the Buffalo Supermarket Mass Shooting

Among the dead was security guard Aaron Salter — a retired Buffalo police officer — who fired multiple shots at Gendron, Gramaglia said Saturday. A bullet hit the gunman’s armor, but had no effect. Gendron then killed Salter, before hunting more victims.

“He cared about the community. He looked after the store,” Yvette Mack, who had shopped at Tops earlier Saturday, said of Salter. “He did a good job you know. He was very nice and respectable.”

Also killed was Ruth Whitfield, 86, the mother of retired Buffalo Fire Commissioner Garnell Whitfield.

Buffalo Mayor Byron Brown told churchgoers that he saw the former fire official at the shooting scene Saturday, looking for his mother.

“My mother had just gone to see my father, as she does every day, in the nursing home and stopped at the Tops to buy just a few groceries. And nobody has heard from her,” Whitfield told the mayor then. She was confirmed as a victim later in the day, Brown said.

Police surround home of Buffalo mass shooter

Katherine Massey, who had gone to the store to pick up some groceries, also was killed, according to the Buffalo News. The names of the rest of the victims hadn’t been released.

“We pray for their families. But after we pray — after we get up off of our knees — we’ve got to demand change. We’ve got to demand justice,” state Attorney General Letitia James said an emotional church service in Buffalo on Sunday morning. “This was domestic terrorism, plain and simple.”

The Buffalo attack came just a month after a shooting on a Brooklyn subway wounded 10 and just over a year after 10 were killed in a shooting at a Colorado supermarket.

Associated Press reporter Robert Bumsted contributed reporting from Buffalo, New York. Balsamo reported from Washington.

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David Rosner continually talks to colleagues who are distraught about the American response to the Covid-19 pandemic.

“When you are in a school of public health and a public health environment, people really feel when they are failing,” said Rosner, who studies public health and social history at the Columbia University Mailman School of Public Health.

That defeated feeling is compounded by the fact that 1 million people in the US have died from Covid-19 – the highest Covid death rate among large wealthy countries.

According to public health experts, the virus’s outsized impact on the US can be attributed in part to underinvestment in long-term care, in primary care and in public health departments. As a result, some people were more vulnerable to Covid and had little connection to – or trust in – the healthcare providers who urged them to socially distance, to wear masks and to get vaccinated.

It was a disconnect, they say, that was only exacerbated by misinformation – particularly by Republican leaders’ undermining of scientists’ recommendations.

“This is more than just a failure of a health system,” said Rosner. “It’s a failure of an American ideology.”

A history of poor healthcare quality and access

The problems in US society and healthcare that lead to the high death toll predate the pandemic.

In 2018, the country spent an average of $10,637 on healthcare per person, almost twice as much as other large and wealthy countries, according to data from the Kaiser Family Foundation. And yet, compared with those countries, the US had a significantly lower life expectancy and the worst healthcare quality and access.

Almost $4,000 of that additional spending comes from higher payments to hospitals for inpatient and outpatient hospital care. Meanwhile, over the last decade, US spending for state public and local health departments decreased by 16% and 18% respectively.

“We have really valued the hospital care to the exclusion of public health and community healthcare in this country,” said Sheila Davis, CEO of the non-profit Partners in Health, which tries to bring healthcare to the world’s poorest places.

She argues that reimbursement patterns in the US focus on care delivered at hospitals, “which is the most expensive place to deliver care, with the most expensive providers”, she said.

As an alternative, she points to a comprehensive model, “which has excellent hospital care but also has a strong public health department, as well as community care”, such as federally qualified health centers in underserved communities.

The one health area where the US spends significantly less than other countries is on long-term care, including nursing homes. In 2018, the country spent $516 a person on long-term care, less than half of what comparable countries spent, according to KFF data.

The pandemic exposed these disparities. About three-quarters of Americans who died from Covid were 65 or older – including more than 150,000 nursing home residents, according to Centers for Disease Control and Prevention data.

A majority – more than two-thirds – of nursing homes in the US are for-profit institutions. They often don’t pay their workers much, are understaffed and have high turnover rates: the mean US wage for nursing assistants and orderlies in 2020 was $14.82 an hour, and the mean turnover rate for nurse staff in 2017 and 2018 was 128%, according to a study.

A man talks with his mother through a window at a nursing home in Windsor, Connecticut, in May 2020. Photograph: Chris Ehrmann/AP

That understaffing saw some nursing homes fail to follow best practice for infection control, said Dr Celine Gounder, an epidemiologist at New York University and editor-at-large for Kaiser Health News.

“If you have workers who are paid poorly and have very difficult working conditions, they are not going to trust the employer as much,” Gounder said. “So in a crisis when you have lack of trust, that’s going to create barriers to everyone working in synchronicity to address problems.”

Almost half of the aides and personal care workers, who often make little money, are Black or Hispanic. Nursing homes whose staff come from “less white” neighborhoods saw larger Covid-19 outbreaks, probably because those neighborhoods are also generally denser and have residents who rely more on public transportation, according to a report from a Harvard University economist.

Nursing home residents “were the most vulnerable population – so if Covid made it into the building, bad outcomes were likely to follow shortly thereafter”, said Brian McGarry, a University of Rochester professor who studies long-term care.

In general, life just appeared to be more difficult for seniors in the US than those in similar countries – even before the pandemic. For example, US seniors tend to be more likely to worry about having enough money for meals or medical needs, and to not fill a prescription or skip doses because of the cost, according to a 2017 Health Affairs study.

In the US, 36% of older adults reported having three or more chronic conditions, such as chronic lung diseases and heart conditions, which placed people at greater risk of becoming severely ill from Covid. In New Zealand, Australia, the Netherlands, Norway and Switzerland, the figures were 17% or under. The US also had the highest rate – 55% – of people taking four or more prescriptions regularly.

Gounder’s grandparents lived in Normandy, France, and never had to worry about medical bills or whether they could see a doctor, she said. “There might be a wait to get an appointment, but they could always get the medical care they needed,” she said.

Americans are also less likely to have a primary care provider, which contributed to the high death toll here. In the Netherlands, 71% of adults have had a regular doctor or place of care for five years or more; in the US, the number is 43%, according to a study from the Commonwealth Fund, a non-profit focused on improving the health system.

“It’s especially a factor when it comes to the vaccination campaign,” said Dr David Blumenthal, president of the Commonwealth Fund. “We know from survey data that people like to get vaccinated in their primary care physician’s office, but too few Americans have primary care physicians.”

That shortage is due in part, Blumenthal said, to tuition fees and to the wage gap between primary care doctor and specialists – again, both figures where the US tops the charts.

“Compensation is an important factor: it’s not just how much people are paid but how hard they have to work to get that level of income,” said Blumenthal, who was a primary care physician himself. Without a primary care provider, he said, many sick people end up visiting emergency rooms – or not seeking care at all.

“In the pandemic, when you are going to an emergency room, you are surrounding yourself with tens or hundreds of other people, many of whom will not have been infected until you show up, so it’s not an epidemiologically helpful way to manage sick people,” Blumenthal said.

The approach to the pandemic became enmeshed in people’s party affiliation and in their views towards governmentDr David Blumenthal

Meanwhile, the US counties that were hit hardest after vaccines became available were those in which a majority voted for Donald Trump in 2020, according to a National Public Radio study.

Since vaccines became widely available in May 2021, people in counties where more than 60% of voters supported Trump were 2.73 times as likely to die from Covid than those in counties where that same percentage supported Joe Biden.

The US also trailed other large wealthy countries in its vaccination rate – and a contributor to that was the low vaccination rates among Republicans. As of November 2021, 91% of Democrats had received at least one dose of the vaccine, while only 53% of Republicans had, according to a Kaiser Family Foundation survey.

“You can’t separate our failure in the pandemic from conflicts over ideology and politics,” said Blumenthal. “The approach to the pandemic became enmeshed in people’s party affiliation and in their views towards government.”

People protest against the Covid vaccine in Tallahassee, Florida, in November 2021. Photograph: Rebecca Blackwell/AP

That’s in large part due to Republicans such as Trump, said Rosner. After the then-president contracted Covid in October 2020 and became much sicker than he publicly acknowledged, Trump wrote on Twitter: “Don’t be afraid of Covid. Don’t let it dominate your life.” During a presidential debate, Trump also said of Biden: “I don’t wear masks like him. Every time you see him, he’s got a mask.”

Contrast that with another conservative politician, Boris Johnson, the UK prime minister, Rosner said. After also being hospitalized with Covid, Johnson thanked his nurses and said the National Health Service had saved his life “no question” and that “things could have gone either way”.

“It’s not like [Johnson] is some angel, but he acknowledged something deeper in British culture that in some sense trusted medicine, trusted public health, trusted the health system, in a way that Trump didn’t even feel was necessary,” said Rosner.

Preparing for the next emergency

Despite their dismay over the number of preventable Covid deaths, public health experts say they are encouraged by federal government efforts to make sure the US is better prepared for the next emergency, which they say is inevitable.

For example, the federal Coronavirus Aid, Relief, and Economic Security (Cares) Act included $300m for community health worker services to try to improve, among other things, health and mental health care access.

“We were very pleased with the inclusion of community health workers in a lot of the Biden administration funding during the emergency,” said Davis. “Now the goal – and the hope – is that that will [become] a permanent part of our health structure.”

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