nancygduarteus

[nancygduarteus]

Everything Is a Subscription Now

I’m a person with a toilet-paper subscription. I bought it through my Amazon Prime subscription: Every few months, an embarrassing box of toilet paper arrives at my apartment, at which point I’m charged around $30, which includes the 5 percent savings the retailer awarded me to secure my toilet-paper business in perpetuity.

The same thing happens when the pet-supply company sends me two bags of dog food every six weeks, or when Adobe lets me use Photoshop for another month. Instead of CDs and DVDs, Netflix and Apple Music grant me access to movies and music on a rolling basis. A cosmetics retailer sends me beauty-product samples every month. I never use them, but still pay $10 each time.

For most of American consumer history, subscriptions were the province of magazines, cable, and other media: You paid an annual fee, and news and entertainment organizations gave you their new work as it became available. But as digital payment technology has improved and people look for ways to navigate stress, stagnant wages, and online shopping’s near-infinite purchase choices, the value proposition of subscriptions have changed. So too have the kinds of products people can subscribe to.

Today, things that can routinely show up to your doorstep include: misshapen vegetables, personalized vitamin cocktails, dog toys, a vast wardrobe of clothing and accessories, and even a sofa. In a consumer market of disposable fast fashion and cheap assemble-at-home furniture, the idea of wasting less while getting to use nicer, higher-quality things for a monthly fee is a compelling sell. But what’s harder to predict is what might be lost when the effort to buy less stuff turns into renting huge swathes of your daily life.

A subscription, at its base, is simply a schedule of recurring fees that gives consumers continual access to a good or service. A car lease is a subscription, but so is your gym membership and the way you use Microsoft Office. Subscription creep dates to at least 2007, when Amazon launched Subscribe & Save, a service that lets shoppers pre-authorize periodic charges for thousands of consumable goods like sandwich bags or face wash (or toilet paper), usually at a slight discount over individual purchases. Then came Birchbox in 2010, which provides women with miniature portions of beauty products on a monthly basis for $15. At its peak, the company was valued at more than $500 million.

Both Amazon’s and Birchbox’s models have been widely copied, and their success underscores subscriptions’ appeal to businesses and consumers alike, according to Uptal Dholakia, a marketing professor at Rice University. “The pain of payment and the friction of how a person is going to pay is totally gone,” he says. Consumers receive things they need or want without having to make any decisions, and that creates more stable and predictable revenue streams for the businesses they patronize.

The pitch for Feather, a two-year-old startup that lets consumers borrow suites of furniture for their apartments, sounds a little dystopian. “We don’t own our apartments. We don’t own our cars. We don't even own movies anymore. So why own your furniture?” the company asks on its website. It isn’t that Feather is wrong; Millennials are less likely to own homes and cars than their parents were at the same age, and streaming services dominate entertainment so thoroughly that Best Buy has largely phased out CDs in its stores. But in the face of all that instability, don’t you at least want your sofa to be yours? Feather says the new normal is “defined by freedom and flexibility.” But generational precarity is hardly an exciting lifestyle.

Jay Reno, Feather’s founder and CEO, is realistic about the frequently less-exciting circumstances of sofa rental; he’s moved almost a dozen times himself. “Most people in our consumer demographic are looking for disposable furniture,” he explains. “Your life is changing constantly, you’re moving apartments, you have a different layout in each apartment and different furniture needs.” The company currently operates in New York and San Francisco, two hyper-expensive cities where young, often affluent people tend to bounce between apartments and roommate configurations. The furniture they need might change pretty quickly, along with the rest of their lives. Although Feather offers terms as short as three months, Reno says that most of its customers rent for a full year—the length of an apartment lease.

Rent-to-own businesses have a notoriously predatory history with America’s working poor, but But Reno claims Feather is trying to apply a less vampiric approach to what can be a practical service for apartment-dwellers in unpredictable stages of their lives. Traditional rent-to-own models have been accused of profiting off of their customers’ desperation, not their desire for flexibility. According to Reno, Feather is targeting educated, middle-class consumers who can probably qualify for in-store financing at West Elm—the same type of people who might have been proudly buying a new dinette set for their young family at Havertys in the 1980s. But back then, those shoppers could expect their dining area to be the same size for the foreseeable future.

If furniture subscriptions might help consumers delay a purchase decision that feels too permanent to handle, Rent The Runway might help shoppers stop making purchases that have gotten too easy. The dizzying variety offered by online shopping and the pressure to look great on social media create an intense incentive for women to continually expand their wardrobes, which can strain both budgets and the physical limits of one’s closet. Rent The Runway opened in 2009 to rent special-occasion dresses, but in 2015, it launched a $159-per-month service that gives subscribers access to a rotating array of everyday clothing. Users can swap out for new pieces when they’re done or keep them for an extra fee.

The same year Rent The Runway’s subscription service launched, the average American consumer purchased 65 pieces of clothing, even though most people use relatively little of their wardrobe. Surveys estimate that only 20 percent of people’s clothing sees the light of day with any regularity. Most individual pieces are only worn a handful of times before being discarded, usually into landfills. At the same time, super-cheap clothing is more omnipresent than ever, which can make it seem like a smart, budget-conscious choice for refreshing a seasonal wardrobe or flexing on Instagram.

In theory, a wardrobe subscription gives people access to the variety that modern life demands, in addition to the kind of high-end clothing that it would be impossible for most people to wear every day. “We used to be a business that was more about the cherry on top of the sundae because it was something super special,” says Anushka Salinas, Rent The Runway’s chief revenue officer. “Now people are using us as a utility.”

But along with the advantages of variety or quality comes a downside. Whether or not a subscription to breakfast smoothies or Reformation dresses or mattresses makes sense depends on individual consumer circumstances, which Dholakia says people are bad at evaluating on their own. “You tend to overestimate how much you will consume,” he explains. When signing up for meal kit delivery, you might tell yourself you’ll cook three times a week, when actually once or twice is more realistic. In the case of durable goods, Dholakia says, the tradeoff is in the long game: “The consumer pays less, but they don’t get to own the asset and benefit from it.”

Spending $150 per month to lease three different sets of bedroom furniture in three different apartments might give you flexibility, but at the end of those three years, you’ve spent $5,400 and still don’t own any bedroom furniture.

Consumers also seem to be bad at estimating how much they spend on subscriptions. One survey found that when asked to guess their monthly spend on subscription services, Americans’ first guess was around one third of their actual output. Because people aren’t continuously asked to opt in, it can be easy for those who don’t have to pay stringent attention to their monthly budgets to lose track of what’s being siphoned off. Dholakia says that businesses profit from this disregard. “You have to go and revisit all your subscriptions as a consumer every month, or at least every quarter at a minimum,” he explains. He also urges consumers to look carefully at what companies require to cancel service. If a particular program’s terms make it onerous to opt out, that’s a red flag that subscribing may be a bad deal in general.

Dholakia is careful to point out that in companies where subscriptions work, it’s generally because they’re providing a service that people actually want or need, not because the revenue model itself is a golden ticket. Birchbox, one of the early darlings of the subscription economy, has had some well-publicized growth and revenue struggles in recent years as people tired of paying to receive a different mini mascara every month. Blue Apron, which has had its subscription meal kits copied by numerous competitors, had more than a million subscribers in early 2017; by 2018, that number had dropped to fewer than 800,000.

Both Feather and Rent The Runway Unlimited think they have identified places in which the things people are supposed to own don’t really line up with the ways they have to live their lives: A lot of people rent their homes for a lot longer now, and the internet speeds up trend cycles and keeps permanent records of every outfit you’ve ever been photographed in. Owning things is great, but the constant pressure to shop and acquire—and especially to do so beyond one’s means as a signal of success—is wasteful of both material resources and money. For some, buying flexibility and novelty without commitment or unnecessary waste might be worth more than an IKEA sofa or a bunch of Zara clothes.

Rental furniture and wardrobing services remain a bandage on a bullet wound; they can’t address the reasons that so many people who might have lived comfortable, middle-class lives a few decades ago now don’t know where they’ll be living next year. Still, if you’re one of the many people who find themselves squeezed by circumstance, at least there’s probably a company out there willing to meet you where you are.

“Every business owner in every industry has thought about or is thinking about if subscription makes sense for their products and services,” says Dholakia. “We’re going to see subscription in pretty much everything.”

from Health News And Updates https://www.theatlantic.com/health/archive/2019/05/how-amazon-helped-turn-daily-life-subscription/588526/?utm_source=feed

[nancygduarteus]

Do Married Millennials Cheat on Each Other?

Millennials have killed malls, cheese, and bar soap. Their thirst for blood unslaked, they’re now coming for good, old-fashioned cheating.

At least, that’s according to an analysis the sociologist Nicholas Wolfinger published in 2017 on the Institute for Family Studies website. When asked the survey question “Have you ever had sex with someone other than your husband or wife while you were married?” Americans older than 55 turned out to be more adulterous than people younger than 55. In fact, people born between 1940 and 1959—i.e., people currently between 79 and 60 years old—were the ones who report the highest rates of extramarital sex.

Americans have been asked the infidelity question in every iteration of the General Social Survey, a broad questionnaire about cultural attitudes, since 1991. Wolfinger’s analysis found that in the early 2000s, 18-to-55 year olds were more likely have extramarital affairs than older people were. But right around 2004, the lines cross, and younger people became more chaste than their parents:

Wolfinger takes this data to mean that Ashley Madison’s days might be numbered. Today, the hot new thing for married couples, apparently, is having sex (albeit rarely) with each other until they die. “Barring any unforeseen developments,” Wolfinger writes, “we should anticipate a future of more monogamous marriage.”

Whether or not Millennials are doing marriage differently, they’re certainly changing other parts of courtship. Unmarried couples are more likely to cohabitate than they were a decade ago, and the once-fringe online dating scene has become as mainstream as dinner and a movie. Some people engage in polyamory, while others have open relationships, and more people are talking about those arrangements openly. Both marriage and divorce have become more rare since the 1980s. Between it all are an array of “fuckboys,” ghosts, and friends with benefits.

All these factors together complicate Wolfinger’s claim that marriages of the future will be monogamous. Other researchers I spoke with say it’s not possible to know yet whether Millennials are actually going to have more faithful marriages than Boomers. Several pointed out to me that it the Institute for Family Studies is a blog attached to a think tank dedicated to marriage and family, not a peer-reviewed academic journal.

Wendy Manning, a sociologist at Bowling Green State University, told me there’s no evidence that young adults who are between the ages of 24 and 32 today are more likely to be faithful than the same age group was in 1980. The difference Wolfinger is picking up on, she says, seems to be just that people over 50 are simply older and possibly have been married longer, so they’ve had more opportunities to cheat. We’d have to wait until Millennials get older before determining whether they are, truly, the faithful generation.

There is some limited data to bolster Wolfinger’s point, however. In 2017, Lindsay Labrecque and Mark A. Whisman at the University of Colorado Boulder found that even though the percentage of Americans who think extramarital sex is “always wrong” significantly declined between 2000 to 2016, there was a small but statistically significant decline in the lifetime prevalence of extramarital sex in the same time period. That could mean that the people who were eligible to participate in the survey in 2016 but not 2000, including Millennials, are more open to cheating philosophically, but still less likely to do it.

It’s hard to draw firm conclusions about generations, but Wolfinger’s analysis might be pointing to changing behavior among the subset of Millennials who do choose to get married. To get a sense of how married Millennials think about commitment, I reached out to married Millennials and Gen Xers through Twitter to ask those who are convinced they would never cheat on their spouse: why? Dozens replied via email and direct message. Twitter, obviously, is not a representative sample of the U.S.; its users tend to be more liberal and educated. However, even among this relatively left-leaning group, many people said they knew of very few cheaters in their social circle, and those who did cheat were looked down upon by their friends.

Junie Gray, a woman from Austin, Texas, told me she doubts she could find someone who “understands, supports, and loves” her like her husband does. Since people today wait longer than previous generations to get married, many simply might be selecting the actual right person for them. There’s no need to cheat when your spouse is your best friend, your soulmate, your “everything.” There’s no “one that got away”; you caught him. It just took you until you were 36 to do so.

As the Johns Hopkins University sociologist Andrew Cherlin put it to me, “over the past few decades, marriage has become more selective.” Today, the people most likely to have lasting marriages are those who have gone to college. And college graduates seem “more committed to each other and to the marriage,” Cherlin says. He points out that the divorce rate has gone down significantly for college-educated couples, but not for couples in which neither person has a college education.

I heard from a lot of people who prudently dated their partners for several years before getting married, then waited still more years before having children, just in case. There’s less societal browbeating these days to move faster. “There isn’t pressure to be in relationships like there used to be, so people are less likely to settle for a bad partner,” says Skylar Dallmeyer-Drennen, an energy consultant in Washington D.C. “Why put up with a cheater if no one needs you to be dating?”

This phenomenon is intertwined with what my colleague Kate Julian described as “the sex recession.” Young people today have less sex in general, so it follows that they are likely having less of it extramaritally, too. “We’re living in an astonishingly sexlessless age,” Wolfinger told me.

Of course, we are also living in the midst of a sexual-harassment crisis. But a number of #metoo offenses seem to be perpetrated by older men, some of whom blame changing mores for their alleged transgressions. Though there are also stories of young men who don’t know where to draw the line between friendship and romance, experts say that in general, younger people tend to be more supportive of gender equality. Cheating, meanwhile, can feel deeply inequitable. Infidelity sometimes gets lumped in with other types of harm against women: Several of the entries on the “shitty media men” list that was circulated a few years ago involved allegations of affairs.

Or maybe it’s something about being Millennial, rather than a married Millennial, that deters two-timing. A few people who responded to my Twitter inquiry suggested that maybe Millennials in general are still young and idealistic. My generation wants jobs with a purpose, and we want relationships that feel purposeful, too. Or, as a Gen X friend of mine speculated, perhaps Millennials are terrified of breaking rules. We’re so preoccupied with getting recommendation letters and maintaining our brands that we would never sully ourselves with something so carnal and impulsive as infidelity. (My friend asked to remain nameless because he didn’t want to seem like he was justifying adultery.)

In line with this moral-Millennial hypothesis, many young, married people told me it feels less honorable to leave your spouse for someone else. That would imply there was “emotional cheating” going on while the relationship was in progress—another taboo. “You need to spend some time mourning the end of what had become a formative part of your identity,” says Kae Lani Palmisano, a writer and editor in Philadelphia.

There’s also the usual explanation behind the “Millennials are killing …” trend stories: It’s that Millennials are broke, and they simply can’t afford to buy whatever it is that’s being killed. In this case, some Millennials are still traumatized by the recession and struggling to launch their careers. They can’t afford to buy a house without a second, steady partner. When so much of your life is in flux and unstable, it’s nice to have one person who will definitely be there for you. Why screw it up?

Beyond lingering economic worries, many Millennials and Gen Xers are scarred by their parents’ divorces. The peak in the divorce rate was in 1979, right as the oldest Millennials were being born and younger Gen Xers were reaching their tender grade-school years. Millennials were much more likely to be the children of divorce than their children will be, if current trends continue. “The specter of divorce looms large,” says Manning from Bowling Green State University. “And it seems like it’s a big reason why a lot of young adults want to live with someone first. They want to divorce-proof their marriage.”

For some young people, fidelity is a way of vowing to do better than your own parents did. A few people told me they had been so rattled by their parents’ divorce that they resolved never to do the same thing to their kids. “My parents divorced when I was 2,” says Cole Novak, a pastor in Texas. “My entire life has been marked by the effects of my parents’ divorce. And I never wanted my kids to grow up the way that I did.” When women send him flirtatious texts, Novak says he responds by adding his wife to the thread.

Even as Millennials murder America’s cultural standbys, they continue to be somewhat inscrutable. For now, it does seem like their marriages, when they do happen, are more faithful than those of their elders, but it’s just too soon to know for sure whether that will continue. In fact, Wolfinger accepts some of the alternate explanations for what’s going on here. “Do people in their fifties and sixties have the most extramarital sex because they’re in midlife and have been married for 20-30 years, or because they came of age at a time that fostered greater sexual exploration?” he writes. “The answer is probably ‘both.’”

In other words, yes, it might simply be the case that people over 55 are getting older, growing disinterested, and applying the looser sexual mores they grew up in to sex lives that have grown a little stale. “Being married for a long time means a couple of things: Your kids might be out of the house, you might be bored having sex with your partner,” Wolfinger told me.

Or as a Boomer might say, it might just be that Millennials will understand when we’re older.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/05/millennials-are-less-likely-cheat-boomers/588286/?utm_source=feed

[nancygduarteus]

Pete Buttigieg’s Foreign-Language Count Is Only Going Up

Peter Buttigieg, the mayor of South Bend, Indiana, and a Democratic presidential candidate, has become famous for speaking lots of languages. Depending on the day and the media outlet, the number rises and falls. He’s been granted six languages, seven languages, and eight languages. After the fire at Paris’s Notre-Dame cathedral, he dipped into French to answer questions from French media. He fielded questions from Norwegian journalists in Norwegian, which he’s said to have taught himself in order to read novels in the language.

While speaking so many languages may be rare among the American public, Buttigieg’s ascent is a textbook polyglot path to fame. An aura tends to grow around multilinguists—and often beyond their control. Their fame can be immediately disqualifying if the stories seem too fantastic to be true. It can also set polyglots up for failure and embarrassment if they rely on their myths for attention and livelihood. Either way, the embellishment of their abilities says more about the era in which they live and the culture that surrounds them than the possibility of speaking a lot of languages in any objective sense.

Hyperpolyglots—the world’s best language learners—can perform some prodigious linguistic feats. Early in the 20th century, a German diplomat named Emil Krebs, stationed in Beijing, was a favored interlocutor of the Empress Dowager Cixi and could translate 32 languages into and out of German. In 1990, the Scotsman Derick Herning was crowned the most multilingual person in Europe for having 10-minute conversations in 22 languages in a row with native speakers. Hyperpolyglots like these two men must put in tremendous amounts of time and effort. But even in cases of genuine talent, some recurrent factors contribute to things getting exaggerated.

One important key to the myth that tends to be built up around polyglots is the vaporous quality of numbers of languages. How many languages can Buttigieg actually speak? His campaign confirmed eight when I reached out: English, Norwegian, Spanish, French, Italian, Maltese, Arabic, and Dari. A specific count of languages, though, can also be an unreliable credential for any polyglot, because a language isn’t a defined unit of measure.

[Read: For a better brain, learn another language]

At a certain point, it’s pegged more to people’s fascination than to actual language abilities. In my 2012 book, Babel No More: The Search for the World’s Most Extraordinary Language Learners, one hyperpolyglot I profiled wouldn’t tell me how many languages he could speak because he knew he’d lose control. “I would walk in the party and say I spoke nine languages,” he said, “and by the end of the night I would hear that I spoke 24.”

In the media glare, this fraught metric becomes even more unstable. Buttigieg’s linguistic repertoire could continue to swell or diversify, not because he claims more languages but because others do it for him. As soon as Buttigieg popped up on political media, anecdotes poured in about his swooping out of nowhere with his exotic languages. Last month, the writer Anand Giridharadas tweeted that Buttigieg’s Norwegian appeared “like a magic trick.” A South Bend emergency-room doctor sent a message on Twitter to the BuzzFeed writer Ashley C. Ford about the time the mayor materialized in a local hospital and translated in Arabic for a patient. According to the message, Buttigieg had been listening to the police scanner and had heard that an Arabic translator was needed.

The Onion has already joked that Buttigieg “stunned a campaign crowd Wednesday by speaking to manufacturing robots in fluent binary.” (This seems to be an allusion to the most famous movie hyperpolyglot, C-3PO, who is “fluent in over 6 million forms of communication”—or so he claims.)

No matter the historical period, polyglot mythmaking has thrived on anecdotes of isolated encounters and mini-spectacles. In 1820, a Hungarian named Baron Franz Xaver von Zach visited an Italian cardinal, Giuseppe Mezzofanti, who by that point was a world-famous hyperpolyglot. Von Zach reported that Mezzofanti first addressed him in Hungarian, next in several dialects of German, and then spoke English to an Englishman and Russian and Polish to a visiting Russian prince. Mezzofanti’s reputation as “a monster of languages, the Briareus of parts of speech, a walking polyglott,” as Lord Byron enthused about him, was a litany of such instances.

Modern academic linguists have traded similar stories about Ken Hale, an MIT professor who was said to speak 50 languages. They retell how a clerk at an Irish embassy once begged Hale to switch to English because his Irish was better than hers, and how Hale showed up in an Australian aboriginal village at 10 a.m. to begin fieldwork and was conversing fluently by lunchtime. (Hale died in 2001.)

The polyglot myth can further expand based on how commentators, journalists, and bystanders loosely apply terms like “fluency,” “proficient,” “speaks,” or “knows.” Heavy.com, for instance, claimed that Buttigieg “is proficient in seven languages other than English: Norwegian, French, Spanish, Italian, Maltese, Arabic, and Dari.” But what does “proficiency” mean? Is it the same as “mastery”? (When I asked Buttigieg’s campaign about his languages, I received his list with no verb like “speaks” or “knows”; I asked about his criteria for grouping them but have not heard anything back.) Corporations, universities, and governments have developed fine-grained scales of people’s abilities to read, write, speak, listen, and translate in languages because they need objective measures of those abilities. In the vernacular, those distinctions get flattened.

[Read: The bitter fight over the benefits of bilingualism]

MIT’s Hale tried to counter this by distinguishing between “speaking” a language and “talking in” one, in order to combat the myth he felt forming around him. He could speak only three languages, English, Warlpiri, and Spanish, he would say, but could talk in the rest. His admirers weren’t always convinced. In an interview, he once tried to explain that he doesn’t deserve his reputation as a gifted language learner. It didn’t work. “That is not true,” the interviewer told him.

None of this is meant to cast doubt on or give credence to Buttigieg’s actual language abilities. But the contours of polyglot mythmaking underscore a deep, tenacious belief in language as a form of magic. Somehow, words do things. They reveal, and they hide. Witnessing a conversation in a language you don’t understand confirms words esoteric power. In that light, someone who speaks lots of languages can’t avoid being regarded as a prodigious magician.

Monolinguals aren’t the only ones with this belief. Even in communities where being multilingual is completely ordinary, individuals who know many unusual languages or know them at a very young age are often regarded with awe. So Americans could be forgiven for their fascination with Mayor Pete’s languages, whether his viral moments are embellished sleights of hand or true magic.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/pete-buttigiegs-polygot-magic/588169/?utm_source=feed

[nancygduarteus]

The Hack That Created an Underground Market for Old Medical Devices

One day last June, Doug Boss pulled into a police station parking lot to meet a stranger from Craigslist. His purpose: to buy used insulin pumps. Boss has type 1 diabetes, and he relies on a small pump attached to his body to deliver continuous doses of insulin that keep him alive.

To be clear, he didn’t need to buy used medical equipment on Craigslist. Boss, who is 55 and works in IT in Texas, has health insurance. He even has a new, in-warranty pump sitting at home. But he was thrilled to find on Craigslist a coveted old model made by the medical-device company Medtronic and discontinued years ago. What makes these outdated Medtronic pumps so desirable is, ironically, a security flaw. Boss was looking for a pump or two he could hack.

He’s not the only one. In 2014, a few hackers realized that the security flaw in certain Medtronic pumps could be exploited for a DIY revolution. Type 1 diabetes is a disease where the pancreas is unable to produce insulin to control blood sugar. For years, Boss had counted, down to the gram, the carbohydrates in every meal and told his pump how much insulin to dispense. Every cup of coffee (more insulin), every brisk walk (less insulin) turned into a math problem with serious consequences: Extremely high or low blood sugar can both be fatal. The healthy pancreas does these “calculations” to adjust insulin automatically, and for decades researchers have worked toward creating an artificial pancreas that can do the same.

By 2014, the hardware components of a DIY artificial pancreas—a small insulin pump that attaches via thin disposable tubing to the body and a continuous sensor for glucose, or sugar, that slips just under the skin—were available, but it was impossible to connect the two. That’s where the security flaw came in. The hackers realized they could use it to override old Medtronic pumps with their own algorithm that automatically calculates insulin doses based on real-time glucose data. It closed the feedback loop.

They shared this code online as OpenAPS, and “looping,” as it’s called, began to catch on. Instead of micromanaging their blood sugar, people with diabetes could offload that work to an algorithm. In addition to OpenAPS, another system called Loop is now available. Dozens, then hundreds, and now thousands of people are experimenting with DIY artificial-pancreas systems—none of which the Food and Drug Administration has officially approved. And they’ve had to track down discontinued Medtronic pumps. It can sometimes take months to find one.

Obviously, you can’t just call up Medtronic to order a discontinued pump with a security flaw. “It’s eBay, Craigslist, Facebook. It’s like this underground market for these pumps,” says Aaron Kowalski, CEO of JDRF, a nonprofit that funds type 1 diabetes research. This is not exactly how a market for lifesaving medical devices is supposed to work. And yet, this is the only way it can work—for now.

By the time Boss decided to try looping, he had not gotten a good night’s sleep in a decade. Every night, the alarm on his glucose monitor would go off when his blood sugar dipped too low or climbed too high. He’d wake up, do math with a sleep-fogged brain, and either eat a snack or give himself extra insulin. Like many patients with type 1 diabetes, he was sacrificing sleep to stay alive.

OpenAPS changed that. To start looping with OpenAPS, Boss did also need to buy a mini computer called Edison. The Edison receives data wirelessly from his continuous glucose monitor, runs an algorithm to predict future blood sugar, and tells the insulin pump how much to dispense every five minutes to prevent highs and lows. Boss could choose to monitor everything through his phone. But at night, he simply slept. “The sheer idea that I have a chance to sleep through the night ... ” he marveled to me. So many other loopers I spoke with echoed the sentiment. Jeremy Pettus, another looper, used to keep apple juice by his bed to guard against perilously low blood sugar. “One day my wife was like, ‘We haven’t bought you apple juice in a long time,’” he says. “That burden of having a dangerous low in the middle of my night completely disappeared.”

The looping algorithm makes these corrections throughout the day, too. Laura Nally, another looper, described to me how she had always planned out her life hours in advance: Would she be walking a lot at work that day? Eating a meal in a couple hours? Taking a hot shower that could affect insulin absorption? “You’re always thinking, ‘What is the next thing I’m going to be doing?’” she says. With Loop, she still uses an app on her phone to tell the algorithm when she’s eating. (Same with OpenAPS, which is why both systems are technically “hybrid” closed systems rather than fully closed.) But if she is off by a few grams of carbohydrates or walks a little bit more than she expects, Loop can easily make real-time corrections. “Every decision we make we’re trying to hit a bullseye. With Loop, all I’m trying to do is get the dart on the board,” explains Erik Douds, who also uses Loop to manage his type 1 diabetes.

Users of Loop have to carry around an extra device called the RileyLink (in white) that translates the iPhone’s signals to the Medtronic insulin pump and vice versa. To make she didn’t lose it, Laura Nally decided to attach her RileyLink directly to her phone case. (Laura Nally)

Loop and OpenAPS users tend to be a pretty self-selecting bunch, as the systems require buying your own equipment out of pocket and following detailed set-up instructions. It also comes with a bit of a learning curve. But according to one small study and many, many anecdotes, looping is, when done properly, both safe and better than a human brain at managing blood sugar. As the good word about looping spread, demand for the few compatible models of Medtronic pumps has swelled.

Early on, loopers were often able to find old, compatible Medtronic pumps sitting unused in their own closets or a friend’s. Boss had actually gotten his first Medtronic pump from a cousin’s daughter before upgrading to a bigger version he found on Craigslist. Pettus, himself an endocrinologist, got his from a young woman who was his patient. “I have a cute little purple pump,” he says. Douds got his from a friend and looping evangelist who he stayed with while traveling across the country. But when Nally wanted to start looping last year, she was living in the Bay Area, full of tech-savvy early adopters, and everyone she knew with a compatible Medtronic pump was already a looper. She was wary of buying one from a stranger online. Luckily, she ended up winning one of the periodic raffles for a loopable Medtronic pump in an online diabetes group. That’s how coveted the pumps have become.

[Read: ]My pacemaker is tracking me from inside my body

An underlying security flaw is still the reason looping is possible with Medtronic pumps. (Would-be loopers are even told to watch out for old pumps whose software have been upgraded to fix the flaw.) The security issue doesn’t bother Boss, whose day job is in IT. There’s a tiny, theoretical risk that someone who knows his pump’s serial number and gets physically close can take over. But, he says, “If I drink coffee in the morning and forget to enter it into my phone, my blood sugar is going to be higher than normal.” The everyday risk of making such a mistake outweighs the remote risk of someone else hacking his pump.

A spokesperson for Medtronic wrote in a statement, “Patient safety is our first priority, and intentional device modifications can adversely impact device performance and put patient safety at risk. Medtronic strongly discourages intentional device modification of our insulin-pump systems.”

In the absence of official customer support, loopers have come to rely on each other. Rebecca Vitale told me the only reason she hasn’t quit Facebook is because she uses a group for Loop tech help. (Vitale is also friends with my partner.) From the group, she learned to cover her Medtronic pump in packing tape. The compatible Medtronic pumps, unlike newer models, are not waterproof, and their buttons are especially finicky around moisture. The packing tape keeps it just a bit more sweat and waterproof. It’s a hack around a hack.

Like many loopers, Rebecca Vitale put packing tape on her Medtronic pump to protect it from moisture. (Rebecca Vitale)

The looping community is so tight-knit that the person who wrote the code is sometimes the person answering questions. Hilary Koch, whose son loops, remembers spending two hours on the phone with one of the creators of OpenAPS. She tries to do her part, too. “How you give back is, if you see somebody ask a question you know you can answer, you answer it,” she says. Boss also scours eBay for Edisons, which have since been discontinued, and has given a few to people who want to loop, in return for a small donation to Nightscout, another open-source project used with OpenAPS to remotely access glucose data.

When the creators of OpenAPS, Dana Lewis and Scott Leibrand, shared their code back in 2015, they did so for free. They weren’t in it for money, and that ethos is still very much alive in the looping community today. And so, despite all the people clamoring for loopable Medtronic pumps, attempts to sell one to the highest bidder are met with swift backlash in the online community. The going price is usually around $500. “You’ll see posts for $1,000 to $3,000—and community members are like, ‘Haha no,’” says Lewis. (The sticker price of new Medtronic pumps runs over $7,000.)

Since OpenAPS first became available, looping options have slowly expanded. Another group developed Loop for iPhone, which is more user-friendly in some ways but still requires an extra piece of hardware called a RileyLink.

A couple other new options don’t even require Medtronic pumps—but they are currently limited in other ways. AndroidAPS, for example, runs on Accu-Chek or Dana pumps, which are approved in Europe and elsewhere, but not yet in the U.S. The system also goes straight to an Android phone, eliminating the need for an extra device like a RileyLink or Edison. The manufacturer of Dana pumps consulted with the DIY looping community in developing its latest version.

[Read: ]How do you regulate a self-improving algorithm?

Erica Potter liked the fact that her eight-year-old daughter would not need to carry around another part with AndroidAPS. But her family lives in the U.S., where no compatible pumps are sold. Through a contact in the diabetes community, Potter managed to find a medical-supply company in north Africa that would ship a Dana pump overseas. It came out to $2,000 with supplies and shipping.  The set-up has worked so well that Potter has ordered a second pump for her six-year-old, who was recently diagnosed with type 1 diabetes. “I’m aiming for perfection because these are my kid’s organs,” she says. She is waiting for that second pump to ship right now.

More recently, loopers have started testing a hacked version of another pump called Omnipod, which is available in-warranty and tubeless. (Think about the convenience of AirPods versus regular earbuds, except for something that goes under your skin.) Public testing of the Loop-Omnipod system began just last week. Kate Farnsworth, who runs a Facebook group about looping and whose own daughter loops, saw her group gain 1,000 new members in just a few days, buoyed by interest in Omnipod. “I think we’ll have a lot of new loopers,” she says.

Even with these new options, DIY looping is still on the margins of the official health-care system: It’s going overseas to buy pumps not yet approved in the United States. It’s testing an experimental version with Omnipod. And in most cases in the United States, it’s been finding old, out-of-warranty Medtronic pumps. Loopers with Medtronic pumps told me they worried their decade-old devices might break, and they’d have no way to fix it. Boss has a couple backup pumps stockpiled. Kowalski, of the nonprofit JDRF, told me that he once saw his brother, who is also a looper, watching soldering videos on YouTube when something broke. “People are doing wacky stuff,” he says. “We don’t want wacky. We want them to use things like they normally would.” JDRF, which is a major funder of artificial-pancreas research, has been working to make the technology mainstream.  

In fact, the FDA approved a looping system from Medtronic called the Minimed 670G in 2016, after the first people started using OpenAPS. The DIY loopers I spoke to had various reasons for sticking with their DIY setup, though: It gave them more flexibility in setting their target blood sugar. It allowed them to use their preferred glucose monitor rather than Medtronic’s.

A nonprofit called Tidepool is now running a clinical trial to get Loop approved by the FDA.  It’s also partnered with the company behind Omnipod to make the next version of its pods officially Loop-compatible—a more formalized version of the DIY Loop-Omnipod system that hackers just made available for public testing.

JDRF, which is a funder of Tidepool, has put forth a vision of a “plug and play” artificial pancreas. Currently, Medtronic’s MiniMed 670G locks the patient into a Medtronic pump, Medtronic glucose sensor, and Medtronic software. The idea, says Kowalski of JDRF, is to have multiple compatible pumps and glucose sensors and algorithms, so that patients can mix and match what they prefer. Looping, in whatever form, is almost certainly the future for type 1 diabetes. It might be all that kids today ever know.

Koch’s son is almost 13 now, old enough to start learning how to manage diabetes on his own. She reflected on the years of interrupted sleep, of weighing the carbs in every meal he brought to school, of ticking off minutes for his blood sugar to drop before he could eat a snack. He’s been looping for over two years now, and some of those memories are starting to fade. “He will never know it like we did,” she says. “And I think that’s a wonderful thing.”

from Health News And Updates https://www.theatlantic.com/science/archive/2019/04/looping-created-insulin-pump-underground-market/588091/?utm_source=feed

[nancygduarteus]

A Defeated Disease Is Now at Its Highest Level in 20 Years

Students are currently being quarantined in Los Angeles. Mandatory vaccination policies have been implemented in Brooklyn. Even President Trump, contrary to prior assertions, today urged people to get children vaccinated.

All for a disease that was declared eliminated in the U.S. two decades ago.

This week, the the Centers for Disease Control and Prevention announced that measles outbreaks have led to the highest number of cases reported in the country since that declaration in 2000.

The overall number of cases—695 so far—is not a significant portion of the millions annually around the world. But it’s the pattern and direction that are striking to global officials, as well as America’s unpreparedness to address the actual source. Among wealthy countries, the United States has, by far, the highest number of children who did not receive the first two measles vaccination doses over the past several years. The American outbreaks are described by officials as multiple and “unrelated,” stretched across 22 states, meaning each has potential to spread further. But the unifying forces behind them are clear.

As the number of cases has risen in the U.S.—which has historically been at the fore of global-health campaigns—it has also risen around the world. By 2017, the disease that killed half a million people annually at the turn of the century was down to 110,000. Now, the first three months of the year saw a 300 percent increase from the same period a year ago, according to a report from UNICEF.

The Global Vaccine Alliance ties the issue together, citing a storm of seemingly disparate factors: disinformation campaigns in Europe, a collapsing health system in Venezuela, and pockets of low immunization in Africa. In South Sudan, where hundreds of measles cases have been reported in recent months, efforts to vaccinate people after the country’s civil war appear to have been thwarted because of difficulty keeping vaccines cool—not because people are refusing them.

Though the U.S.’s own outbreaks are unrelated in a physical sense, they are linked to a growing online disinformation movement. In a statement on Thursday, the CDC said the outbreak in New York is significant part due to “misinformation in the communities about the safety of the measles/mumps/rubella vaccine. Some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines.”

The overall effect is a single, global dilemma. There is no opting out. The death toll will go up or down; the choice is between doing what’s possible to contain the virus and enabling its spread. Media ecosystems have evolved and siloed people in ways familiar to political discourse, but they remain poorly addressed in public health.

In a statement this week, U.S. Secretary of Health and Human Services Alex Azar reiterated a tactic that has proven ineffective at reaching skeptical populations in recent years: telling them what to do. “Vaccines are a safe, highly effective public health solution that can prevent this disease,” he said. “The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken.”

Earlier this month, CNN asked 10 current and former liaison members of the CDCs Advisory Committee on Immunization Practice about the agency’s plans for countering anti-vaccination disinformation online. The response of senior director of infection control at the Minnesota Children’s Hospital Patricia Stanfield was emblematic: “I feel like on social media, the anti-vaxers are very sophisticated and active and way ahead of us.” Another official, who declined an interview, issued a statement that included: “It is critical that parents and anyone seeking information about vaccines have access to credible information.”

Research suggests that the reason informed people to fall into conspiracy-theory mindsets often has less to do with lack of information than with social and emotional alignment. Facts are necessary, but not at all sufficient. Websites and  YouTube videos where a federal employee in a suit states various statistics are unlikely to be effective against targeted disinformation campaigns that only need to plant the seed of doubt in the minds of people already skeptical of the medical establishment. The work of global inoculation requires first rebuilding a social contract, which means meeting people on the platforms where they now get their information, in the ways they now consume it.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/measles-media/588130/?utm_source=feed

[nancygduarteus]

AirPods Are the New Cubicles

Once upon a time, offices had walls inside them. They weren’t glass, like the conference rooms of 2019, but made of drywall and usually painted a neutral color, like many of the walls you know and love. Over time, office walls gave way to cubicles. Now, for many office workers, the cubicles are also gone. There are only desks.

If you’re under 40, you might have never experienced the joy of walls at work. In the late 1990s, open offices started to catch on among influential employers—especially those in the booming tech industry. The pitch from designers was twofold: Physically separating employees wasted space (and therefore money), and keeping workers apart was bad for collaboration. Other companies emulated the early adopters. In 2017, a survey estimated that 68 percent of American offices had low or no separation between workers.

Now that open offices are the norm, their limitations have become clear. Research indicates that removing partitions is actually much worse for collaborative work and productivity than closed offices ever were. But something as expensive and logistically complicated as an office design is difficult to walk back, so as Jeff Goldblum wisely intones in Jurassic Park, life finds a way. In offices where there are no walls, millions of workers have embraced a workaround to reclaim a little bit of privacy: wireless headphones.

The arrival of these now-ubiquitous devices has ushered in a new era of office etiquette—and created a whole new set of problems.

Beyond their tethered forebears, Bluetooth wireless headphones are convenient because they allow workers to forget they’re wearing a device and leave their desks without yanking their laptops onto the floor. In open offices, people commonly wander around with their headphones on all day, into bathrooms and kitchens, sometimes listen to nothing at all in order to avoid the constant distraction of compulsory social interaction.

We have Apple to thank for wireless headphones’ proliferation. The tech giant launched its tiny, white AirPods in late 2016 to accompany new iPhones that lacked a traditional headphone jack. Despite initial concern that having two plastic sticks poking out of your ears might look insurmountably lame, AirPods have avoided the demise of other wearable tech like Google Glass by being immediately useful. Industry analysts estimate that tens of millions of pairs of AirPods have been sold already, accounting for as much as 85 percent of the wireless-headphone market. The earbuds even star in ultra-viral videos and TikTok memes as a joke-y symbol of wealth among teens.

For Americans who have already joined the office workforce, AirPods serve a different purpose: tuning out your coworkers without looking excessively hostile. In that capacity, they’ve become indispensable to lots of people, because the hard surfaces, high ceilings, and empty spaces common in open offices help sounds carry. There’s rarely any soft surfaces to dampen them. Jerrick Haddad, a 35-year-old social media strategist in Brooklyn, won’t go to his open office without them. “We moved from offices to an open plan two years ago, and wireless headphones are why I haven’t quit,” he says. “One day I forgot them, and I got up and walked straight to the Apple store to buy a pair of AirPods.”

The same is true for Antigua Samuelson, a 29-year-old Los Angeles resident who works for a medical-marijuana wholesaler. She watches Netflix or Hulu at her desk during slow periods, and without her AirPods, she’d have to find another way to fill significant amounts of idle time. “If I forget to bring them with me, I will go back home and get them,” she says.

According to Ethan Bernstein, a professor at Harvard Business School who studies organizational behavior, it makes sense that this subtle tactic for avoiding constant interaction has seeped into office environments. “People are very good at creating spaces for themselves, and these days you look at everybody, and almost without exception, they’re on their phones with headphones in their ears,” he says. In a 2018 study, Bernstein and his team found that open offices decrease face-to-face interactions among coworkers by as much as 70 percent, in stark contrast to designers’ stated goals of collaborative teamwork.

The proliferation of small, wireless headphones may exacerbate that effect. Since you don’t have to remove AirPods to wander around the office, it can be hard for your coworkers to tell if you’re listening to music or on a conference call, or if you’ve simply forgotten to take them out. For Samuelson, sometimes that’s the point. “Once in a while, I’ll pretend to have them on just so I can eavesdrop on what people are saying,” she admits. And for people who find music as distracting as they find their coworkers, putting on their quiet headphones can be as much of a visual signal as it is an attempt to dampen ambient noise.

It’s not a perfect system. David Grilli, a 33-year-old IT professional, uses his headphones to signal that he wants to be left alone, but the message doesn’t always translate. His coworkers “stand in your field of vision until you take notice and ask what they need, or they start talking immediately as if you're not wearing headphones,” he says. Grilli’s coworkers might just need his attention at inopportune moments, but could also be true that office workers are becoming so used to seeing each other in headphones that they barely register them.

For women, there’s often an extra wrinkle: Wireless earbuds are often so small that they’re entirely invisible under long hair. Bernstein suggests that to send a clearer do-not-disturb signal to colleagues, people might consider larger, over-ear models.

Employers can do some things to help with the confusion, like retrofitting a space with small, private phone booths to give employees somewhere to escape. That solves another headphone problem, too: Even when people can see your AirPods, they still don’t know what you’re doing with them. A person quietly sitting in on a conference call looks pretty similar to a person who’s focused on work while listening to soothing nature sounds or who’s checking Facebook while listening to nothing at all. This ambiguity has prompted a whole new visual language meant to mime the difference to unsuspecting desk-mates. To perform its most common gesture, which indicates that you are on a call, you dramatically motion to your ears while making a face that communicates a sense of semi-smug capitulation: You, too, are currently being inconvenienced by your own importance.

“I do a lot of strategic hair-tucking, gesturing at my ears, and phone-pointing,” says Lisa Derus, a 31-year-old publicist who frequently uses her AirPods for calls both on her long commute between Connecticut and New York City and in her open-plan office. “I learned the hard way that the same ear-tapping motion I'd historically used to signal ‘I'm on the phone’ is the exact same gesture that ends phone calls on my AirPods.”

According to the design psychologist Sally Augustin, all of this irritation has come about because open offices ignore some essential elements of human psychological development. “We get revved up just being around other people, so in a workplace you’ve always got that force energizing you,” she says. “When you’re doing intellectual work, you’ll do it better in an environment that’s generally less energizing.” Although headphones can help filter auditory interruptions, they can’t block visual ones, which Augustin says can be just as disruptive to performance and focus.

AirPods also can’t change the fact that you’re just sitting in the middle of an open room, which Augustin notes is stressful no matter what you’re doing. “When you can be approached from the rear, a little part of your brain is always vigilant,” she says. “It’s not about what you’re looking at on your screen or anything. It’s much more fundamental than that.”

The good news is that trends are already turning away from open offices in favor of designs that have a range of space types, including those that allow workers privacy and relief from constant stimulation. “This is how humans work,” Augustin explains. Evolutionarily, our open-plan stress response goes back to a time long before office politics. “We like to think we’ve come so far from our days on the savanna, but maybe not.”

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/airpods-open-plan-offices/588112/?utm_source=feed

[nancygduarteus]

The Tragic Consequences of the NHL’s Science Denial

Todd Ewen, a former professional hockey player, took his own life in September 2015 in the basement of his St. Louis home. Ewen had been suffering from depression and memory loss since his retirement from the NHL, in 1998. Before his death, he confided in his wife, Kelli, that he feared he may have chronic traumatic encephalopathy, or CTE—a neurodegenerative disease that most experts agree is linked to repetitive head trauma.

After a grueling decade-plus career in the NHL, Ewen exhibited all the tell-tale symptoms. Kelli sent his brain to the neuropathologist Lili-Naz Hazrati to be analyzed for signs of CTE. Six months later, Hazrati called with shocking results: Ewen did not have CTE. The NHL seized on these results in its defense against a class-action suit brought by former players for the league’s negligence regarding head injuries. Hazrati went on to act as an expert witness for the NHL and pointed to Ewen’s case as an example of the inconsistency in CTE pathology. In her expert report and a subsequent deposition, she claimed that there was no link between CTE and head trauma and that CTE was not a disease at all.

Despite Hazrati’s diagnosis, Kelli was convinced that her husband had had CTE. She had sections of Ewen’s brain sent from the Canadian Concussion Centre to Boston, so a world-leading expert on CTE, Ann McKee, could retest them. In late 2018, McKee announced her own conclusions from the tests: Todd had, in fact, had CTE.

In this short documentary from The Atlantic, Kelli Ewen recounts the role her late husband played in the sport of hockey before and after his death.

from Health News And Updates https://www.theatlantic.com/video/index/587839/nhl-todd-ewen/?utm_source=feed

[nancygduarteus]

The Tragic Post-Hockey Life of an NHL ‘Enforcer’

On January 24, 1987, Todd Ewen, a young right-winger for the St. Louis Blues, knocked the Detroit Red Wings’ notorious tough guy, Bob Probert, unconscious with one bare-knuckled punch to the head. Ewen was a new recruit, just 21 years old, and the punch immediately solidified his place in the Blues’ lineup—as well as his role in the National Hockey League as one of the many players who regularly fought members of the opposing team.

Later that same game, Ewen and Probert fought again, despite Probert having been out cold on the ice less than an hour before. This frequency of violence was typical. Ewen would go on to play 11 seasons, a soldier in the vast army of so-called “enforcers” in that era of the NHL. He would fight almost every game, mashing his fists into a pulp that doctors were forced to reconstruct with wire and screws.

Ewen and Probert’s destinies intertwined after they first met on the ice. Probert was just a year older than Ewen, and he had a similarly grueling decade-plus career. After the two men retired from hockey—in 1998 and 2002, respectively—both started to forget things. They angered quickly. Each would be dead before his 50th birthday.

Their deaths were among the earliest to fan the flames of a national debate about the lasting effects of hockey's brutality on its players' brains. But through a twist, Ewen would become a key figure in the NHL's controversial defense of the sport.

[Read: Does the NHL take concussions seriously?]

During his playing days, Ewen was a gentle renaissance man when he wasn’t on the ice. He wrote children’s books and crafted models out of hockey tape for his young fans. In 1998, Ewen retired from professional hockey and returned to the St. Louis suburbs to live with his wife, Kelli Ewen. After retiring, Kelli noticed changes in Todd. “We just saw some aggression that we hadn't previously seen,” she says. “Mood swings, irritability, and not sleeping. Just a pattern of things that was alarming to me.”

Todd’s behavior only became more erratic. During one episode, he choked Kelli and the police had to intervene. In time, depression and reclusiveness replaced Todd’s anger. He routinely became lost and disoriented in the streets around his own home.

Todd confided in Kelli that he feared he may have Chronic Traumatic Encephalopathy, or CTE—a neurodegenerative disease that most experts agree is linked to repetitive head trauma. Research on the disease has largely focused on former professional football players, but it has also been discovered in former NHL players. In 2010, Probert, the Red Wings’ bruiser, became the second NHL player to be diagnosed with CTE. His death was followed in quick succession by the deaths of four other former players’, all under the age of 40, all diagnosed with CTE.

In 2013, 10 former players launched a class-action suit against the NHL for their negligence regarding head injuries. Todd was aware of the suit but declined to participate. He ended his life in the basement of his home on the afternoon of September 19, 2015.

Damage to the brain caused by hits to the head has been observed for nearly a century. CTE was originally studied in boxers in the 1920s as dementia pugilistica. In the early 2000s, the Nigerian-American neuropathologist Bennet Omalu described the pathology of CTE following research on former pro football players. Since then, CTE has been found in the brains of hundreds of athletes across a wide range of sports. It manifests as small lesions of a protein called tau, which kill the surrounding neurons. The consequences are devastating. Anger, personality changes, and memory loss are common.

After Todd’s death, Kelli and many others were convinced he had CTE. Kelli had Todd’s brain sent to the Canadian Concussion Centre to be analyzed. Six months later, the center’s neuropathologist, Lili-Naz Hazrati, called with shocking results: Todd did not have the disease.

The NHL seized on Hazrati’s negative diagnosis in its defense of the player’s ongoing head-injury class-action suit and in public statements by the league’s commissioner. The NHL’s attorneys argued that Todd Ewen died by suicide because he believed he had CTE, therefore it would be dangerous for the league to warn players about the disease because they might kill themselves in fear. The NHL contracted 19 expert witnesses, including Hazrati, who in their testimonies injected doubt into the science of CTE. (The NHL did not respond to multiple requests for interviews.)

In April 2017, Hazrati invoiced the NHL $25,000 for her work on the trial. In her expert report and in a subsequent deposition on March 2, 2018, she claimed there was no link between CTE and head trauma and that CTE was not a disease at all. In an email response to my repeated requests for an interview, however, a representative provided a statement that appeared to conflict with this claim, saying that “Dr. Hazrati does not deny that concussions can cause damage to the brain, potentially resulting in a progressive neurodegenerative disease.” (Hazrati declined multiple interview requests.)

[Read: How athletic culture still suppresses concussion research]

The science of CTE in inherently contentious. Currently the disease can only be diagnosed posthumously, and since it appears to present itself most commonly in professional athletes, researchers are forced to navigate a complicated web of relationships with athletes, sports leagues, and fellow scientists. The very existence of the disease poses an existential threat to certain sports leagues. While most researchers agree on the basic premise that CTE is a neurodegenerative disease linked to head injury, a cottage industry of CTE deniers has nevertheless sprung up. Hazrati’s research features heavily in the former pro-footballer turned commentator Merril Hodge’s 2018 book, Brainwashed: The Bad Science of CTE and The Plot to Destroy Football.

Image courtesy of Kelli Ewen

In 2014, Arland Bruce III, a retired Canadian Football League player accused The Canadian Concussion Centre, citing Hazrati’s research, of obfuscating the science of CTE in a lawsuit against the CFL and the Concussion Centre’s parent company. The case went to the Supreme Court of Canada, who declined to hear it. Kelli, too, held onto her doubts. She says she repeatedly asked Hazrati to retest Todd’s brain but Hazrati declined. Eventually Kelli had sections of Todd’s brain sent from the Canadian Centre to Boston, where a world-leading expert on CTE, Ann McKee, could retest them. In late 2018, McKee announced her own conclusions from the tests: Todd did in fact have CTE.

By 2018, over 140 former players had joined the class-action suit against the NHL. In July of that year, they were denied class-action status due to conflicts between applicable state laws. The NHL offered a settlement to players in the suit which amounted to roughly $22,000 per player with up to $75,000 in medical treatment. According to a lawyer representing players in the case, most involved are expected to take the settlement.

In November, Hazrati told the Canadian sports network TSN that she does not dispute McKee’s findings, but noted that she was “surprised to see that Todd had so very little [of the] disease for an enforcer.”

Meanwhile, McKee’s positive diagnosis relieved any doubts Kelli had about her husband’s condition. But the results were only partial vindication. The NHL so far has not acknowledged any link between head injuries sustained during the game and CTE. Hockey players still slam into each other day after day. The NHL has taken incremental steps to limit fighting and hits to the head, but as CTE is being found in growing number of hockey players, there’s arguably far more the league could do to save future players from Todd’s path.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/hockey-cte-todd-ewen-brain-injury/587818/?utm_source=feed

[nancygduarteus]

Trump’s Policies Are Scaring Immigrants Away From Essential Health Programs

Lourdes Juarez has lived in North Carolina since 2000, working part-time to help children with disabilities improve their motor skills. Originally from Mexico, she is now a lawful permanent resident of the U.S. with plans to apply for citizenship.

After bouts of pancreatic and liver cancer left her struggling with medical debt, she learned she qualified for Medicaid, the government health program for low-income people. But she had a nagging concern that accepting government benefits would affect her chances of gaining citizenship. She had heard rumors to that effect among her friends and in the news.

Juarez’s fear reflects the growing sense among immigrants that they should avoid public programs, which also include food stamps and certain housing programs, in case it counts against their ability to stay in the country permanently. This past December, Juarez called the Charlotte Center for Legal Advocacy, which reassured her that her citizenship would not be affected if she enrolled in Medicaid. Only then did Jaurez relax and sign up. “I’m now more at ease, but there are other people who are confused and need true information,” she told me through an interpreter.

Last October, the Trump administration released a proposed rule that, if finalized, would affect a part of immigration policy known as “public charge.” Since the founding of the country, several American states had long expelled immigrants who were deemed too poor or otherwise “undesirable.” The U.S. government formally codified the practice in the form of the Immigration Act of 1882. The term public charge has, in past decades, been applied loosely, as PRI reported. In 1911, for example, a 15-year-old Italian immigrant was turned back at Ellis Island because his genitals were too small: “Persons so affected are liable, owing to inability to satisfactorily perform sexual congress, to become addicted to unnatural practices,” a public-health officer wrote at the time.

More recently, the provision has applied to foreigners who hoped to immigrate and non-citizens already in the U.S. who are likely to need long-term institutional care or government cash assistance. The government might consider those factors when it comes time to decide who should be allowed to obtain visas or green cards. With the Trump administration’s new proposed rule, though, the U.S. government would broaden the definition of a public charge, examining whether immigrants have used public-health programs such as food stamps or Medicaid during their time in the U.S. Immigration officials could then look less favorably on legal immigrants who used those benefits when they sought to obtain green cards or extend their immigration status.

Though the number of immigrants this new public-charge determination applies to is much smaller, the consulting firm Manatt estimates that as many as 41.1 million non-citizens and their families, or 12.7 percent of the U.S. population, could be deterred from using public benefits because of a chilling effect resulting from this proposed change.

The proposal was just one in a slew of policies backing up the president’s assertion that America is “full” and should admit fewer immigrants. This month, the Trump administration announced it wants to close a loophole and evict undocumented immigrants from public housing.

In addition to the proposed public-charge rule change, in January 2018, the State Department gave embassies and consulates wider leeway to consider the likelihood that a visa applicant would become a public charge when determining whom to let into the country. Consular officers are now allowed to take into account the past or current use of government programs by the visa applicant’s family when deciding whether to grant the applicant entry. Subsequently, State Department data revealed that visa denials on public-charge grounds rose three-fold between 2017 and 2018.

“What the State Department data show is that anyone sponsoring an immigrant is having a tougher time already,” says Stuart Anderson, a former Immigration and Naturalization Service official under George W. Bush who is now executive director of the National Foundation for American Policy, an organization that analyzed the visa data.

Immigrants became nervous about using public benefits almost immediately after Trump’s election, perhaps due to the president’s inflammatory rhetoric about foreigners. But emerging data from around the country suggests these and other recent proposals have heightened this fear. Though some of the rules haven’t been implemented yet, the mere discussion of these changes has been enough to scare many immigrant families away from health services to which they or their children are legally eligible. “They’re hearing all about all sorts of changes,” says Sonya Schwartz, a senior policy attorney from the National Immigration Law Center. “It all fits together, like, ‘I have to keep a low profile, my life is very risky.’”

Social-services providers, doctors, and attorneys describe immigrant communities that are rife with misinformation and fear. Their immigrant patients and clients steer clear of even those government programs that won’t count against them, in some cases hurting their health as a result.

“I don’t think I’m exaggerating by saying this affects nearly every single immigrant family that I see,” says Lanre Falusi, a pediatrician at Children's National Health System in Washington, D.C. “I’ll see a mom with a newborn, and sometimes … the mom is having trouble affording formula. I talk about programs that they might be eligible for. More and more, I’m having new parents decline, saying ‘I’m not gonna sign up.’”

According to the National Immigration Law Center, which summarized the impacts of the public-charge proposal in a recent fact sheet, health-care providers and insurers in some states have noticed sizable decreases in enrollment in food stamps and Medicaid. After a decade of increases, participation in the food-stamp program among immigrants fell by 8 percentage points from 2017 to the first half of 2018, even though the employment rates among this group remained the same. Politico cited the National WIC Association, the advocacy arm of the government program that provides food to low-income children and mothers, in saying that “nearly two-thirds of WIC providers, from 18 different states, reported they have noticed a difference in immigrant WIC access in the wake of the news about potential changes in the public-charge rules.”

“When the office reaches out to [immigrants] to inform them that proposed changes to the public charge policy have not taken effect, they respond that it is too risky and their attorneys are advising them against receiving benefits,” says Kurt Larrick, the assistant director of the Arlington County Department of Human Services in Virginia, via email. About 200 families stopped receiving WIC benefits in the county between 2017 and 2018.

WIC is not included in the public-charge proposal, but advocates told me this drop is an indication that immigrant families are afraid to use any benefits at all, out of an overabundance of caution. Rodrigo Aguirre, a case manager with Catholic Charities, has seen the same effect with free and reduced-price school lunches, which are similarly not part of the current proposal.

Many immigrants live in mixed-status families, and some reportedly avoid enrolling even the authorized family members in programs, fearing doing so might alert authorities to the presence of an unauthorized parent or spouse. “We have seen clients afraid to have their U.S.-citizen children continue to receive Medicaid, even though for most people that should be fine,” says Laurie Ball Cooper, the legal director of Ayuda, an immigrant-aid organization in the Washington, D.C. area.

When the Kaiser Family Foundation conducted a focus group with 20 immigrant families in 2018, it found that though some of the families were struggling to afford food, they felt signing up for nutrition programs might put them or their family members at risk of deportation. What’s more, a 2019 poll by KFF and the California Health Care Foundation found that 40 percent of uninsured Californians say they are “worried that if they signed up for health insurance, they would draw attention to their own or a family member’s immigration status.”

Advocates told me word of these changes spread through word of mouth or through scraps of information on Spanish- or English-language news. Because the immigration rules are so complex, the message tends to get distilled down: “If you’re an immigrant, and you’re using federal programs, you’re at risk,” says Felusi, the pediatrician, summarizing the sentiment among her patients. Even for those who likely wouldn’t be affected, she says, “it’s difficult for them to rest assured, given that what we know now might change on a whim.”

Occasionally, the game of telephone yields wild theories about immigrant children being forced to serve in the military or being made to pay back their food-stamp benefits later.

Doctors and immigrant-aid attorneys told me they are conflicted about how to counsel immigrant families about using government programs. They emphasize that the rule has only been proposed. Technically, nothing has changed yet. But many nevertheless feel uneasy assuring immigrants that they won’t be affected. Sometimes, advocates said, it comes down to the individual family’s tolerance for risk.

Lisa David, the CEO of Public Health Solutions, the largest WIC provider in New York state, says she sees spikes of people leaving the WIC program any time there’s news about a Trump-administration crackdown on immigrants. “We’ve had families walk in and say, ‘I don’t want these checks anymore, please take me out of your database,’” she says. “I can’t actually tell them ‘don’t worry about it,’ because I can’t say that truthfully.”

The Trump administration, for its part, has denied that the public-charge change is meant to frighten immigrants into not using benefits. An official from the Department of Homeland Security told Politico that the agency is trying to “better align U.S. immigration policy with federal law.” In an email, a State Department official told me, “Public charge determinations are based on a consular officer’s assessment of the totality of the applicant’s circumstances … age; health; family status; assets, resources and financial status; education and skills; and an affidavit of support from a sponsor if one is required by law.” The White House did not return a request for comment.

Robert Rector, a senior research fellow at the conservative Heritage Foundation, argues that the public-charge rule is valuable because it keeps out low-skill immigrants, who, he says, are likely to take in more government services than they pay for. But, he added, “the proper way to implement this rule in the future would be to place it on people before they come into the country rather than after. Trying to apply it to people after they come into the country isn’t going to save very much money.”

Regardless of whether the goal of these measures was to get legal immigrants to stop using government benefits, that appears to be happening. Many are looking to less-tracked means of getting help. Schwartz, from the National Immigration Law Center, says some food banks are seeing an increase in demand. However, many immigrant families work and therefore don’t have time to wait in line at soup kitchens and food pantries.

With this proposal, many immigrants feel they must choose between protecting their chances of staying in the U.S. and protecting their health. Some, advocates say, are choosing America. The families that are declining to participate in WIC are turning to less-healthy food options, David says, like starches and fast food, that will fill up a hungry child on just a few dollars.

Beyond the nutritional deficits, Falusi says she sees families that are ground down by stress, and kids who report vague symptoms of stomach-aches and headaches. She and others paint a picture of an immigrant community that has added hunger to an already long list of worries.

“One time a family came in, and the kid was unmotivated. He had his head down the entire time,” Aguirre says. “The mom said, ‘we don’t have food stamps … so they didn’t have breakfast today.’”

Ena Alvarado-Esteller contributed reporting.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/trumps-immigration-proposal-hurting-immigrant-health/587908/?utm_source=feed

[nancygduarteus]

Grieving the Future I Imagined for My Daughter

Just after midnight, I felt the first unmistakable contraction. I still had two days until my due date, but I knew it was time to get to the hospital. A bulldozer inside my uterus revved its engine, shifted into high gear, and rammed a baby out into the world less than two hours later. Her name would be Isobel, Izzy for short.

She weighed five pounds, three ounces, below the threshold for “normal.” This was surprising—I’d had an uneventful pregnancy, and in one of my last prenatal checkups, my obstetrician predicted that she’d weigh about seven pounds.

Did the doctor miscalculate my due date? I wondered. Should I have taken more prenatal vitamins? Eaten better, worked less?

There would be no explanation, at least not then. We moved upstairs into a recovery room with a view of the summer sun rising behind the Oakland, California, hills. In those early-morning hours, I cradled Izzy’s warm, powdery body and nestled into a feeling that everything was fine.

Five weeks later my father, a retired pediatrician, put a stethoscope to Izzy’s chest and heard a hissing noise. An echocardiogram two days after that revealed a small hole in the membrane dividing the lower chambers of her heart, causing oxygenated blood to leak back into her lungs. The cardiologist explained that her heart was working harder than it needed to, burning extra calories and keeping her small.

Odds were that over the next few months, new tissue would grow and the hole would “spontaneously” close. Considering how much of human development happens on its own, for a heart to correct itself in this way seemed perfectly plausible. I told myself that’s what would happen. At Christmas and New Year’s Eve gatherings with family and friends, that’s what I told them, too.

But my hope was no match for the eventual and unanimous recommendation from a panel of two dozen cardiologists: open-heart surgery, and soon. A force I could not see was starting to take over.

As Izzy’s surgery date neared, I could feel the panic slowly and steadily growing inside me. I retreated into what could be known: A cardiopulmonary-bypass machine would bring her body to a sub-hypothermic temperature, allowing the heart to stop beating. The surgeon would saw through the sternum, shave a tiny piece of tissue off the heart’s outer membrane, and use it to patch the hole. A resident would sew her back up.

Two conversations helped convince me that after the surgery, Izzy would grow up healthy and things for our family would return to normal. The first was with a couple whose son had the same procedure with the same surgeon. They apologized for having to mute the phone for short stretches to temper their 5-year-old’s rambunctiousness, something I found reassuring.

The second was an email exchange with a woman who underwent a valve replacement in the 1970s, when open-heart surgery on babies was still relatively uncommon. “I was a three-season athlete in high school,” she wrote, “and did all the partying that everyone else did. The only impact on me was a scar that healed well and frankly, made me feel like a bit of a badass.”

Less than 24 hours after doctors had wheeled Izzy into the operating room for surgery, she was guzzling down bottles of high-calorie formula. In 72 hours, her rosiness returned; eight days later, we left the hospital and arrived home to find the first buds on our magnolia tree. Within a few weeks, Izzy had gained enough weight to make her growth-chart debut at the 0.2 percentile. Witnessing her scar heal was like watching a time-lapse movie, only in real time.

I started the process of reeling our ship back to shore—we’d be there soon, I thought. My parents booked their flight back to the East Coast, and my husband started a new job earlier than planned. Disillusioned by my last tech job, I was determined to make a fresh start somewhere else. I could envision the end of Izzy’s recovery period, the loving nanny I’d finally hire, a more deliberate career.

But, no. Just as we’d caught sight of land, we were again suddenly unmoored, pushed by unforgiving hands back out into the dark, open sea.

The cardiologist called on an unseasonably warm afternoon, a Tuesday last April.

Sure, I have a few minutes.

I glanced at Izzy, eight months old, wearing only a diaper. The edges of the five-inch incision line down the middle of her chest were still red and puckered from the suture removal a few days earlier. Her scar served as a visual cue that, surely, the worst was behind us.

The call itself was not a shock. One week before surgery, a neurologist had examined Izzy and noticed abnormalities in her facial features so subtle that I, her mother, could barely see them myself—slightly wide-set eyes, straight eyebrows, a thin upper lip, a tiny hole on the upper ridge of her ear that I’d mistaken for a mole. Genetic testing would be the sensible next step, the neurologist had said. He’d ordered seven vials of Izzy’s blood to be drawn in the OR.

The cardiologist began with a “Well …” followed by a sigh. Then his voice assumed the objectivity of a radio traffic reporter describing a seven-car wreck, and he rattled off the details he knew.

I absorbed only the keywords—“abnormal result … syndrome … genetic material missing …”—and scribbled “1p36” on the back of a stray Home Depot receipt. Anxious for more information, I ended the call and grabbed my laptop.

I steadied my fingers and clicked through to an online forum where parents had celebrated their child’s first step at 3, 4, or 8 years old. They compared devices to help nonverbal children communicate and shared work-arounds to Keppra, an anti-seizure medication that can cause kids to bite themselves or hallucinate.

As I skimmed their posts, my heart pounded and I started to hyperventilate. Air was stuck in my throat; I screamed to let it out, gripping the edge of the kitchen counter so I could scream louder. I felt as if I was suffocating in a room filled with invisible pillows, and the only thing that could cut through it was noise in the form of very loud, guttural, incomprehensible screaming. I slammed a door leading into the bedroom and pounded the walls. I remember thinking, I don’t give a shit if the neighbors hear.

The internet confirmed a truth that up until that moment lay beyond the boundaries of what I’d ever imagined possible for my child’s life or my own. As a mental warm-up before her birth, I’d imagined Izzy in painful situations that were both better (a broken arm, pneumonia, being bullied) and far worse (my death, or hers). I hadn’t imagined a scenario in which she might not walk or talk, or where she’d live with debilitating seizures. I hadn’t imagined that I might be uncertain whether she recognizes me. I hadn’t imagined caring for her for the rest of my life. I now had two children, but was only just beginning to understand what it means to be a parent.

The next day, my husband left early for his third day of work at his new job. In an orientation session about employee volunteering, while the presenter rolled a video about the Make-A-Wish Foundation, he sat in the back row and wept. Meanwhile, after a long, sleepless night, my son watched cartoons as I crawled through Izzy’s morning routine, taking breaks to ice my swollen eyelids. I finally got everyone dressed and dropped him off at preschool a few hours late without the words to explain why.

The day after that, Izzy and I had a geneticist appointment at the medical campus five blocks away. I’d been here before. Almost one year earlier, in my second trimester, I’d sat through the routine prenatal screening for birth defects and Down syndrome. The results had been normal.

The geneticist came in to greet me and Izzy. As I took in her easy, welcoming smile, a wave of relief washed over me. The test was wrong, and this is all a terrible mistake!

This was a delusion. She led us into an examination room, where we were joined by a younger, more clinical assistant. I called my husband and put him on speakerphone—we’d agreed before the appointment that he didn’t need to be there in person, a sign that at some level we had not yet fully grasped the magnitude of Izzy’s diagnosis.

The geneticist told us that my daughter has “the most common of rare syndromes diagnosed after birth.” Her tone remained gentle, but unequivocal.

“The size of her genetic deletion is clinically significant.”

Go on.

“It’s hard to say what that means in terms of how the syndrome will present.”

I recounted some of what the internet had told me. Will she walk? Talk? Hear? Seize? See?

“We just have to wait and see.”

We reviewed three single-spaced pages of test results that looked as though they had come out of a dot-matrix printer. The geneticist was quick to clarify that “terminal deletion” referred to the physical location of Izzy’s 133 missing genes (that is, the terminus of the “p” arm of chromosome 1) and did not suggest that the syndrome itself leads to death, although its complications sometimes can. A second, more user-friendly handout summarized the syndrome’s most common “features” in a tidy, bullet-pointed list: seizures, deafness, blindness, low muscle tone, feeding issues, digestive disorders, heart disease, heart defects, kidney disease, intellectual disability, and behavior problems.

I fixated on the likelihood that Izzy would be nonverbal, feeling gutted by the possibility that she might not talk or even develop the coordination to sign. How would she express herself? How would I know her?

My husband left the appointment by hanging up. The geneticist briefly examined Izzy’s “curly” toes, noting it as a common and typically benign congenital anomaly—connected to her syndrome, perhaps, but no one could know for sure.

I packed up our things and made our way home. The only certainty I left with was that I had a lot more to worry about than a couple of curly toes.

Books, the internet, and friends said I would go through a grieving period. But I am still not entirely sure what I am grieving.

I didn’t lose a child; now a year post-op, Izzy is here and very much alive. She shakes her head vigorously when she’s happy, and grunts indignantly when she’s not. She has gobs of voluminous hair that looks as if it’s been blown out at a salon—a common trait for “1pers,” who bear a strong physical resemblance to one another; many don’t look like their parents. But unlike most “typical” 21-month-old toddlers, she cannot yet sit up by herself (let alone toddle), grab a spoon, or use any words to communicate. A few weeks ago, she started to regularly say “aaaah,” one of the vowel sounds that are the first forms of speech—a milestone that most babies hit at four to five months old.

I spent the months following Izzy’s diagnosis deeply confused about how I should feel. Her heart defect had been an isolated biological issue, and the surgery was a relatively common procedure. The hole is gone. A genetic syndrome is different—uncontained and unfixable. Every cell in Izzy’s body lacks some data, and there’s no way those data can be recovered.

During sleepless nights, I anchored my grief in the heft of Far From the Tree, Andrew Solomon’s profound, 1,000-page book about the challenges parents face in accepting differences in their children. “We depend on the guarantee in our children’s faces that we will not die,” Solomon writes. “Children whose defining quality annihilates that fantasy of immortality are a particular insult; we must love them for themselves, and not for the best of ourselves in them, and that is a great deal harder to do.” The book offered me a crucial mooring. Powerless to change my circumstances, I could at least change my psychology.

I am learning that grief can be complicated and ambiguous—that we hold ideas and expectations of ourselves and loved ones so tightly that we have difficulty seeing them from any distance, and that it’s even harder to let them go.

I can describe what’s gone. I’ve lost the buoyancy I gained from the conversation with the parents of the rambunctious 5-year-old boy. I no longer feel the relief, even joy, of envisioning Izzy as an athletic, partying, badass teenager.

I lost any lightheartedness I had left as the 40-year-old mother of two young children. I lost my faith in statistics. A 99.98 percent chance of something not happening is also a .02 percent chance that it will.

I lost the ability to enjoy the scene of my two kids together without feeling guilty that I’d sold my son short. Instead, it’s a reminder of the responsibility I feel to gently acculturate him to the strange, politicized world of disability rights and rare diseases, and to breed empathy and a respect of difference in him above all else.

I lost the identity, earnings, and lifestyle that came with having an upward career trajectory and being an equal breadwinner to my husband. We now have the sort of traditional arrangement I never thought I’d be in: He makes all the money, and I do most of the emotional, logistical, and physical labor of child-rearing. For Izzy, this includes frequent doctor appointments, three therapy sessions a week, and a lot of open-ended research and worrying.

This laundry list of dreams lost has positive value, Solomon maintains. “While optimism can propel day-to-day life forward, realism allows parents to regain a feeling of control over what is happening and to come to see their trauma as smaller than it first seemed.”

Without crumbly, unreliable hope, what else is there? There’s my child, no less alive or human than any other, and with abilities and inabilities much different than I imagined. And realism, which I’ll use to reassemble a positive, long-term picture of what her life could be. Izzy’s diagnosis wiped my canvas clean. But while the expanse of whiteness is unsettling, it is also temporary. Soon there will be lines, contours, shading—a new and beautiful composition. I will not accept less.

from Health News And Updates https://www.theatlantic.com/family/archive/2019/04/1p36-genetic-disorder-reshaping-my-family/586717/?utm_source=feed

[nancygduarteus]

The Penance of Doc O

Well past seven one evening in 1988, after the nurses and the office manager had gone home, as he prepared to see the last of his patients and return some phone calls, Dr. Lou Ortenzio stopped by the cupboard where the drug samples were kept.

Ortenzio, a 35-year-old family practitioner in Clarksburg, West Virginia, reached for a box of extra-strength Vicodin. The box contained 20 pills, wrapped in foil. Each pill combined 750 milligrams of acetaminophen, the active ingredient in Tylenol, with 7.5 milligrams of hydrocodone, an opioid painkiller.

Ortenzio routinely saw patients long after normal office hours ended. Attempting to keep up with the workload on this day, he had grown weary and was suffering from a tension headache; he needed something to keep him going. He unwrapped a pill, a sample left by a drug-company sales rep, certain that no one would ever know he’d taken it. Ortenzio popped the pill in his mouth.

“It was a feeling like I’d never felt before,” he told me recently. “I’m tense and nervous, and that anxiety is crippling.” The pill took the anxiety away. The sense of well-being lasted for four hours, carrying him through the rest of the night’s work.

Back then, Ortenzio was one of Clarksburg’s most beloved physicians, the kind of doctor other doctors sent their own families to see. His patients called him “Doc O.” He made time to listen to them as they poured out the details of their lives. “To me, he wasn’t like a doctor; he was more like a big brother, somebody I could talk to when I couldn’t talk to anybody else,” says Phyllis Mills, whose family was among Ortenzio’s first patients. When Mills’s son was born with a viral brain infection and transferred to a hospital in Morgantown, 40 miles away, Ortenzio called often to check on the infant. Mills never forgot that.

As a physician in a small community with limited resources, Ortenzio did a bit of everything: He made rounds in a hospital intensive-care unit and made house calls; he provided obstetric and hospice care. Ortenzio loved his work. But it never seemed to end. He started missing dinners with his wife and children. The long hours and high stress taxed his own health. He had trouble sleeping, and gained weight. It took many years, but what began with that one Vicodin eventually grew into a crippling addiction that cost Ortenzio everything he held dear: his family, his practice, his reputation.

The United States is in the midst of the deadliest, most widespread drug epidemic in its history. Unlike epidemics of the past, this one did not start with mafias or street dealers. Some people have blamed quack doctors—profiteers running pill mills—but rogue physicians wrote no more than a fraction of the opioid prescriptions in America over the past two decades. In fact, the epidemic began because hundreds of thousands of well-meaning doctors overprescribed narcotic painkillers, thinking they were doing the right thing for suffering patients. They had been influenced by pain specialists who said it was the humane thing to do, encouraged by insurance companies that said it was the most cost-effective thing to do, and cajoled by drug companies that said it was a safe thing to do.

Opioid painkillers were promoted as a boon for doctors, a quick fix for a complicated problem. By the end of the 1990s, Ortenzio was one of his region’s leading prescribers of pain pills. It was a sign of the times that he didn’t think there was anything wrong with that.

Clarksburg sits atop rolling hills in northern West Virginia, halfway between Pittsburgh and Charleston. Lou Ortenzio came here in 1978, a recently married young resident out of the University of Maryland School of Medicine. “Small-town living seemed so much better than suburban life,” he told me as we drove around town one afternoon. “In Clarksburg, every block had something going. We had mom-and-pop grocery stores in every neighborhood. All these houses were occupied by teachers, downtown business owners, and people who worked in glass factories.”

Coal mining was the state’s dominant industry, but in Clarksburg, the glass business boomed. Glass manufacturing had arrived at the turn of the 20th century, drawn by the state’s high-quality river sand and rich fields of natural gas. Pittsburgh Plate Glass opened a factory in Clarksburg in 1915 and for years was one of the world’s leading plate-glass producers. Anchor Hocking employed 800 people making tumblers, bottles, fruit bowls. The city had family-owned factories too: Rolland Glass, Harvey Glass, and others.

Unlike simple resource extraction, glassmaking required sustained technological investment to meet new demands from the marketplace. The mass production of plate glass made skyscrapers possible. Picture windows and sliding-glass doors made small homes look bigger and more luxurious. The industry forged a middle class in Clarksburg and even gave the city a cosmopolitan air. The glass factories attracted artisans from France and Belgium; French was commonly heard on the streets for years.

Glass manufacturing helped forge a middle class in Clarksburg, but by the mid-1980s the industry, and the city, was in decline. Clockwise from top left: Lou Ortenzio; the abandoned Anchor Hocking glass factory; glass collected from the city’s streets; downtown Clarksburg. (Jason Fulford)

Each neighborhood was a self-contained world, with its own churches, grocery stores, and school; many had a swimming pool. High-school sports rivalries were fierce, and football games drew large crowds. When Victory played Roosevelt-Wilson, or Washington Irving went up against Notre Dame, people knew to arrive early to find a seat.

By the late 1970s, Clarksburg’s older physicians were retiring. Like many small towns at the time, it had trouble attracting young professionals. Ortenzio was among the few physicians who moved there to fill the void. He and two other young doctors opened a practice in 1982. Almost immediately, Ortenzio was seeing 40 to 50 patients a day.

The people who came to see him were mostly older; many had served in World War II. They had the aches and pains to show for a lifetime of hard work in the glass factories or at the gas company, but they had retired with something approaching financial security. They owned homes and cars, had pensions and good health insurance.

Ortenzio’s patients suffered from the ailments of the old—arthritis, diabetes, hypertension—and most of them did so stoically. This was partly generational and partly an Appalachian inheritance. One man, Ortenzio remembered, came to him thin and wasted away from cancer. “The disease was advanced, but he put up with it. I said, ‘Why didn’t you come in earlier?’ He said, ‘Well, I wouldn’t want you to think I was complainy.’ That was the Appalachian line—‘I wouldn’t want you to think I was complainy.’ ”

Ortenzio grew into his adopted city. In 1992, he established a free clinic where Clarksburg’s uninsured could get medical care. The county chamber of commerce named him Citizen of the Year for that. He had been trained to treat patients holistically. Most of what a doctor needs to know to make a diagnosis, his professors had taught him, could be learned from taking time to listen to the patient. X-rays and lab tests were mostly to confirm what you gleaned from asking questions and paying attention to the answers. He’d also been trained to help his patients help themselves. Part of his job was to teach them how to take care of their bodies. Pills were a last resort. This careful approach endeared him to his patients, but it lengthened his day. “He would have office hours until 11:30 at night,” says Jim Harris, a friend and the director of the free clinic. “People waited until then because he was worth the wait.”

Drug salesmen visited him weekly. It was a stodgy profession back then. Ortenzio remembers the reps as older men who had grown up and lived locally and who cultivated long-term relationships with doctors. One of the reps for Eli Lilly was a deacon in a local Catholic church. Once a week, he would visit Ortenzio’s office in a business suit, with information about the drugs Lilly produced. Like many in his profession in those years, he avoided hard-sell tactics. Ortenzio grew to rely on the salesman’s counsel when it came to pharmaceuticals. Once, when the Food and Drug Administration removed a Lilly drug from the market, the rep dropped by Ortenzio’s office, embarrassed and apologetic.

Before long, Ortenzio and his wife saw Clarksburg as home. They found a two-story, three-bedroom house in the Stealey neighborhood, southwest of downtown and at the foot of a hill. They set off to the bank for a 30-year loan. To their surprise, they were denied. “The house won’t keep its value that long,” the banker told them. “The best we can give you is a 15-year loan.”

The banker was right. It wasn’t yet clear, amid the bustle of Main Street and Friday-night football, but the city’s prospects were fading. Newer glass technologies required large factories, which meant stretches of flat land rare in West Virginia. Mexico and Japan emerged as competition in glass manufacturing, and plastic and aluminum emerged as alternatives to glass. Pittsburgh Plate Glass had closed in 1974. Anchor Hocking left in 1987. Its hulking concrete plant is slated for demolition, but for now it remains, just off Highway 50.

By the mid-1980s, the city was in decline. Glasswork was replaced by telemarketing. Downtown, locally owned stores began to disappear. Homeowners yielded to renters, many relying on Section 8 assistance from the government. The city eventually had to destroy dozens of abandoned homes, leaving streets with toothless gaps. The swimming pools, too, slowly closed; resident associations lacked the money to maintain them.

Ortenzio drove me by the massive Robert C. Byrd High School, home of the Eagles. It was built in 1995 to consolidate two smaller high schools in Clarksburg, whose population had receded. Replacing neighborhood schools with one centralized school allowed for better course offerings. But Byrd is far from any student’s home. School consolidation extinguished the sports rivalries that had brought people together each week. Without local schools, neighborhoods lost their social centers.

When glassmaking departed Clarksburg, locally owned stores began to disappear as well. The city eventually had to destroy dozens of abandoned homes, leaving streets with toothless gaps. (Jason Fulford)

Lou Ortenzio began to see people in economic as well as physical pain. Many were depressed, worn out by work or the fruitless search for it. Obesity became a more common problem. Some patients began to ask whether he could get them on workers’ compensation or disability. Others left to seek job opportunities in New York, North Carolina, Florida. “I was always calling people out of state telling them how sick their parents or grandparents were,” he said.

When Ortenzio had opened his practice, he’d tended to see young people only for pregnancies or the occasional broken leg. By the mid-1980s, younger people were showing up in larger numbers. They were coming in with ailments that their parents and grandparents had borne in silence—headaches, backaches, the common cold. “The new generation that came in the 1980s, those kids began to have the expectation that life should be pain-free,” Ortenzio said. “If you went to your physician and you didn’t come away with a prescription, you did not have a successful visit.”

The shift was not peculiar to Clarksburg. Americans young and old were becoming accustomed to medical miracles that allowed them to avoid the consequences of unhealthy behavior—statins for high cholesterol, beta-blockers and ACE inhibitors for hypertension and heart failure, a variety of new treatments for diabetes. Fewer patients showed up for annual physicals or wanted to hear what they could do to improve their wellness. They wanted to be cured of whatever was ailing them and sent on their way. Usually that involved pills.

The medical establishment, to a large degree, abetted this shift. In the 1980s, a new cadre of pain specialists began to argue that narcotic pain pills, derived from the opium poppy, ought to be used more aggressively. Many had watched terminal cancer patients die in agony because doctors feared giving them regular doses of addictive narcotics. To them, it was inhumane not to use opioid painkillers.

The specialists began to push the idea that the pills were nonaddictive when used to treat pain. Opioids, they said, could be prescribed in large quantities for long periods—not just to terminal patients, but to almost anyone in pain. This idea had no scientific support. One author of an influential paper later acknowledged that the literature pain advocates relied on to make their case lacked real evidence. “Because the primary goal was to destigmatize, we often left evidence behind,” he said.

Nevertheless, an alliance of specialists who saw their medical mission as eradicating pain was soon joined by the pharmaceutical companies that manufactured opioids. Medical institutions—the Department of Veterans Affairs, the Joint Commission on Accreditation of Healthcare Organizations, hospitals and medical schools across the country—bought into this approach as well.

By the late 1990s, medical schools, when they taught pain management at all, focused on narcotics. By the early 2000s, doctors were being urged to prescribe the drugs after almost any routine surgery: appendectomy, ACL repair, wisdom-tooth extraction. They also prescribed them for chronic conditions such as arthritis and back pain. Chronic pain had once been treated with a combination of strategies that only sometimes involved narcotics; now it was treated using opioids almost exclusively, as insurance companies cut back on reimbursing patients for long-term pain therapies that did not call on the drugs.

The U.S. drug industry, meanwhile, was investing heavily in marketing, hiring legions of young salespeople to convince doctors of their drugs’ various miracles. Nationwide, the number of pharmaceutical sales reps ballooned from 38,000 in 1995 to 100,000 a decade later. The old style of drug rep, grounded in medicine or pharmacy, largely passed from the scene.

“It went from a dozen [salesmen] a week to a dozen a day,” Ortenzio remembered. “If you wrote a lot of scrips, you were high on their call list. You would be marketed to several times a day by the same company with different reps.”

Most drug companies in America adopted the new sales approach. Among them was Purdue Pharma, which came out with a timed-release opioid painkiller, OxyContin, in 1996. Purdue paid legendary bonuses—up to $100,000 a quarter, eight times what other companies were paying. To improve their sales numbers, drug reps offered doctors mugs, fishing hats, luggage tags, all-expenses-paid junkets at desirable resorts. They brought lunch for doctors’ staff, knowing that with the staff on their side, the doctors were easier to influence. Once they had the doctor’s ear, reps relied on specious and misinterpreted data to sell their product. Purdue salespeople promoted the claim that their pill was effectively nonaddictive because it gradually released an opioid, oxycodone, into the body and thus did not create the extreme highs and lows that led to addiction.

[From April 2006: The drug pushers]

The reps were selling more than pills. They were selling time-saving solutions for harried doctors who had been told that an epidemic of pain was afoot but who had little time, or training, to address it. For a while, Ortenzio still suggested exercise, a balanced diet, and quitting smoking, all of which can alleviate chronic pain. But his patients, by and large, didn’t want to hear any of this, and he was busy. So he, too, gradually embraced pain pills. Nothing ended an appointment quicker than pulling out a prescription pad.

The number of people on pain pills grew from a tiny fraction of Ortenzio’s practice to well over half of his patients by the end of the 1990s. The shift was gradual enough at first that he didn’t recognize what was happening. Patients with medical problems unrelated to pain migrated to other doctors. Still, Ortenzio was working 16-hour days, seeing patients who had been scheduled for the afternoon at 9 p.m.

The more drugs Ortenzio prescribed, the more he was sought out by patients. Many would use up a month’s supply before the month was out; in need of more pills, they were insistent, wheedling, aggressive. Many lied. Some would curse and scream when Ortenzio told them that he couldn’t write them a new prescription yet, or that he wanted to lower their dosage.

The pills were soon on the streets of Clarksburg as well. They replaced beer and pot at many high-school parties. Phyllis Mills, Ortenzio’s longtime patient, had two daughters who abused the pills. Theirs did not come from Ortenzio, at least not directly, but the supply of pills was exploding, due in large part to doctors like him who were overprescribing them.

Ortenzio should have noticed what the pills were doing, to his patients and his community, but he was less and less himself. After his late-night encounter with Vicodin in 1988, he had begun his own slide into addiction. By the late 1990s, he was using 20 to 30 pills a day, depleting even the plentiful supply of free samples from the ubiquitous sales reps.

Desperate to get his hands on more pills, he found a friend he could trust, a middle-aged accountant and a patient of his. “I’m in some trouble,” Ortenzio told him. “If I write you this prescription, can I ask you to fill it and bring it back to me?”

“Sure thing,” the man said, without asking for an explanation. “If you gotta have it, you gotta have it. You’re the doc.”

Soon a dozen or so trusted patients were helping Ortenzio. He knew he was out of control and needed help—even the amount of acetaminophen he was consuming was toxic—but he feared that seeking treatment for his addiction might cost him his medical license. Around 1999, he found a new way to get his fix. He began writing prescriptions in his children’s names.

Ortenzio could plainly see that the claim that these pills were nonaddictive was untrue. He would try to quit and feel the symptoms of withdrawal. “I couldn’t be away from my supply,” he said. His patients, too, were terrified of going without. One, a nurse at a local hospital suffering from chronic pain as well as depression and anxiety, would approach him in his office parking lot, often bearing gifts of quilts or canned goods, insisting that she needed her pills that morning, that she couldn’t wait for her monthly appointment.

Ortenzio saw no way to break the cycle the pills had created for the people in his care. He never found a way to get his patients down to lower doses of narcotics. They rebelled when he suggested tapering; just cutting people off made them sick. The area didn’t have enough pain clinics or addiction specialists to refer them to, and insurance companies wouldn’t reimburse for many pain treatments that did not involve pills. Without good alternatives for his patients, he kept on writing prescriptions.

Top: A resident of the Mission, a shelter that opened in 1969 with a few beds, for alcoholics and homeless veterans. Today, many of its 120 beds are occupied by opiate addicts. Bottom: A set of house rules. (Jason Fulford)

Addiction and overwork had estranged Ortenzio from his wife and children. As Clarksburg declined, his wife moved the kids to Pittsburgh to find better schools. In 2004, after more than a decade of living in different cities, they divorced. Raised Catholic but without much feeling for the Church, Ortenzio joined a Protestant congregation. Ultimately, he found Jesus in his exam room. During an appointment one day, he and a patient, a Baptist, talked of his search for redemption. The patient knelt with Ortenzio on the linoleum floor and prayed for the doctor. Ortenzio marks that moment as his new beginning. He had advantages many addicts don’t have: a home and a car, financial resources, generous friends and colleagues, and, later, the support of a second wife. He managed to taper off the drugs. A couple of months later, he was baptized in a deep section of Elk Creek, where baptisms have taken place since the early 1800s.

Not long after that, federal agents raided his office. They interrogated his staff and confiscated hundreds of patient records. The investigation dragged on for nearly two years. His children had to testify before a grand jury that they knew nothing about the prescriptions their father had written in their names.

In October 2005, prosecutors charged Ortenzio with health-care fraud and fraudulent prescribing. That year, 314 West Virginians died from opioid overdoses, more than double the number of people five years earlier. By 2006, according to the Centers for Disease Control and Prevention, physicians were writing 130 opioid prescriptions for every 100 West Virginians.

In March 2006, Ortenzio pleaded guilty. His sentencing occurred shortly after a 2005 Supreme Court decision made federal sentencing guidelines nonmandatory and individual sentences up to judges’ discretion. Despite what he’d done, Ortenzio was still beloved in Clarksburg. More than 100 people wrote to the judge on his behalf. He received five years of supervised release plus 1,000 hours of community service, and was ordered to pay $200,000 in restitution. He would serve no prison time, but he did lose his medical license.

At 53, Ortenzio was unemployed. A temp agency offered him a landscaping job at the Stonewall Resort, where, as a doctor, he had taken his family for Sunday brunch. He’d never worked outdoors in his life, but he took the job. It paid $6.50 an hour.

He worked at the resort for a couple of months, then as the janitor at a local community center before returning to Stonewall as a full-time groundskeeper. He also found a night job.

Tom Dyer is one of northern West Virginia’s leading defense attorneys; Ortenzio had been his client. One night in 2006, Dyer ordered a pizza from Fox’s Pizza Den in Bridgeport, a town near Clarksburg. When the doorbell rang, he opened the door and there stood Lou Ortenzio, holding a pie. It took a minute before Dyer realized: Doc O was now a pizza-delivery guy. “I was just speechless,” Dyer told me.

“I made pizza deliveries where I used to make house calls,” Ortenzio said. “I delivered pizzas to people who were former patients. They felt very uncomfortable, felt sorry for me.” But, he said, “it didn’t bother me. I was in a much better place.”

Ortenzio eventually left pizza delivery. But the way he told me the story, the job was an important step in his recovery: Every pie he delivered liberated him. He was free of the lies he’d told his colleagues, his family, and himself to hide his addiction. He liked hearing kids screaming “The pizza guy’s here!” when he knocked on the door. “You make people happy,” he said. “That was what I liked about being a doctor.”

Today, Ortenzio spends his days trying to atone. He does this through constant work. There are places in and around Clarksburg where addicts can get help, and Ortenzio can be found at most of them.

The Mission opened in 1969, in Clarksburg’s Glen Elk neighborhood, at the time a small red-light district with bars and backroom gambling. The shelter started with a few beds, intended for alcoholics and homeless veterans. A neon-blue jesus saves sign outside has remained illuminated for all the years since, as the shelter has expanded. Today, many of its 120 beds are occupied by opioid addicts.

One afternoon, I met Ortenzio in a small, windowless office at the Mission. Now 66, he is thin, gray-haired, and bespectacled; he dresses in a hoodie, blue jeans, and sneakers. He does a bit of everything at the Mission, from helping the addicted find treatment to helping them find a coat, or shoes for their children, or a ride to the probation department. He is a volunteer adviser there, too, and at the county’s drug court, where he guides addicts through the criminal-justice system.

Ortenzio is also involved with two newer initiatives, which suggest the challenges of repairing the damage done by opioids. A wood-beamed downtown church is home to Celebrate Recovery, a Christian ministry founded in Orange County, California. Celebrate Recovery has grown nationwide due in large part to the opioid epidemic. On the cold Tuesday night I visited, the service featured an electric band singing the kind of fervid new gospel music that is common to nondenominational Christianity: “You are perfect in all of your ways …”

Ortenzio is Celebrate Recovery’s lay pastor in Clarksburg, running its weekly services. The flock is about 100 or so strong. One evening, a young mother named Sarah stood before the congregation to give her testimony. Sarah’s story started with parents who married too young and divorced before she was 3. It featured father figures who were coal miners and truck drivers and a stepfather who molested her repeatedly, beginning when she was 8. Then a life of illicit drugs, marriage, divorce, and addiction to prescription pain pills.

Clarksburg’s traditional congregations have dwindled along with the city’s population; many rely on support from former residents who commute in from elsewhere on Sundays. The place these churches once held in this community has been taken by new churches proclaiming a gospel of prosperity, insisting that God wants us all to be rich. And by ministries such as Celebrate Recovery.

A regular devotional service held in the Mission’s cafeteria (Jason Fulford)

Ortenzio coordinates the training of recovery coaches at the church, people who can help addicts as they try to wean themselves from narcotics. Addiction, however, seems as present as ever in Clarksburg. At the Mission one day, I met a group of recovering young drug users. Several of them had started out on heroin but then turned to meth. In Clarksburg and many other parts of the country, meth is coming on strong, poised to be the fourth stage in an epidemic that began with prescribed pills, then moved to heroin, and then to fentanyl. Meth seems to reduce the symptoms of withdrawal from opioids, or maybe it’s just a way to get high when anything will do. Whatever the case, like the various forms of opioids before it, meth is now in plentiful supply in Clarksburg.

A couple of years ago, Ortenzio decided to open a sober-living house downtown, where recovering addicts could spend six months or more stabilizing their lives. He said God had instructed him to undertake the project, and had told him, in fact, where to do it—in a house right around the corner from the duplex where Clarksburg’s first resident overdosed on fentanyl. In 2017, more than two West Virginians a day were being claimed by opioids. Recovering addicts needed places where they could maintain sobriety. “We thought, This is going to be great. They’ll throw a parade for us,” says Ben Randolph, a businessman whom Ortenzio helped recover from pill addiction.

Instead, the idea of a sober-living house outraged many in town. The principals of two local schools were concerned that the house was too close to their campuses. Owners of local businesses worried that the house might further tarnish the city’s image. “The property value of the homes around it are going to plummet. You’re going to have both drug dealers and recovering addicts in one area, so they’ll have a captive market,” one resident told The Exponent Telegram.

But Ortenzio persisted, and a bank eventually granted him a mortgage. Since July 2017, he has run a six-bed home for men, with daily supervision and no problems—no spike in crime nearby, no complaints of loitering—reported so far. A similar home for women opened last May. Nevertheless, the episode showed where the city, perhaps even the country, was when it came to addiction: afflicted mightily and wanting it to go away, but not knowing how to make that happen.

Lou Ortenzio was the first Clarksburg doctor prosecuted for improperly prescribing pain pills. He was the first person most residents I talked with recall as putting a different face on addiction. He was the first to show that this was a new kind of drug plague, and the first to puncture the idea that the supply came from street dealers. He was also the first to publicly work at his own recovery without shame.

He was not, however, alone. In 2005, another local doctor, Brad Hall, gathered with members of the West Virginia State Medical Association concerned about addiction among physicians in a state that cannot afford to lose them. They started the Physician Health Program, which has helped some 230 West Virginia doctors with substance-abuse problems get confidential treatment and retain their license to practice. Many are overworked, as Ortenzio had been. Some were self-treating emotional and physical problems. About a quarter abused opioids.

Left: Lou Ortenzio beside one of Clarksburg’s abandoned neighborhood pools. Ortenzio managed to overcome his own addiction to narcotic painkillers and today spends his time helping other addicts recover, at the Mission (right) and elsewhere. (Jason Fulford)

Ortenzio managed to escape drugs, but he’s still living with the effects of his addiction. He is working to repair his relationship with his youngest son; Ortenzio didn’t attend his wedding and has yet to meet a young grandson. He leans on his faith to keep him going. Many of his encounters with addicts prompt sudden, public prayers, Ortenzio bowing his head as he clasps the person’s shoulder. His faith has humbled him, relieving him of a sense of hubris that got him into trouble as a doctor: the idea that he could heal an entire community, if he just kept the office open a few hours longer.

Doc O will never practice medicine again. Yet his work at the Mission doesn’t seem so different from his routine as a family physician, tending to the needs of one person after another. One morning, he took a resident to a clinic, then talked on the phone with an addicted doctor living in a halfway house. A pastor from the coalfields of southern West Virginia called to ask how to set up a Celebrate Recovery ministry in his large but dying church. A 24-year-old mother of four from a West Virginia mountain town was looking for $225 to pay the utilities for an apartment she was trying to rent. Ortenzio promised to reach out to the Mission’s supporters for a donation.

As the morning wore on, a gaunt 26-year-old man from North Carolina, a construction worker addicted to heroin and meth, showed up to report that he’d had five of his teeth pulled. The dentist had prescribed a dozen hydrocodone pills. The construction worker couldn’t fill the scrip without proper ID, which he didn’t possess. Ortenzio sat and listened as the young man, slumped beneath a baseball cap, stared at the floor and insisted on his need for the painkiller.

The dentist had probably figured that the fellow had lost a lot of teeth, that a dozen pills weren’t many. If that were the case, it would mark a change. Not that long ago, the dentist might have prescribed 20 to 40 pills.

Ortenzio offered the construction worker a prayer. The man clearly still wanted the drugs. Ortenzio, who as a doctor had prescribed pills by the hundreds each day, could only give him packets of ibuprofen.

“You want to stay away from hydrocodone,” he said.

This article appears in the May 2019 print edition with the headline “The Penance of Doc O.”

from Health News And Updates https://www.theatlantic.com/magazine/archive/2019/05/opioid-epidemic-west-virginia-doctor/586036/?utm_source=feed

[nancygduarteus]

Silicon Valley Has Invented Shoes

The first time I tried on a pair of Allbirds sneakers, I was in the brand’s San Francisco boutique, sitting on a gently curved wooden stool designed to tip forward in aid of shoe-changing. The stool was created by the same people who design the start-up’s shoes, and it made me feel the same combination of familiarity and irritation: Do we really need tech to disrupt the established technology of stools and sneakers?

My answer, after sitting on the stool and trying the shoes, is a begrudging, contemptuous “sometimes.” The tip forward helped. And the shoes, I silently admitted to myself, were astonishingly comfortable.

Allbirds has been selling sneakers made from environmentally friendly materials since 2016. The brand’s most recognizable style is its Runner, which looks a lot like a logo-free, work-appropriate version of Nike’s popular Roshe One. It’s what a running shoe needs to be in order to fly under the radar in an office.

In theory, I should be the brand’s ideal customer: I hate uncomfortable shoes, I work in an office with a vaguely casual dress code, and I’ve owned several pairs of Roshe Ones. I’m a member of the digital creative class in which Allbirds has found its most dedicated market, which includes the Silicon Valley tech workers often characterized as the brand’s biggest fans. When I look around at work or in my neighborhood in New York City, I often spot a pair.

Instead, for Allbirds’ entire three-year existence, I’ve hated what I believed the company was pushing. I spent a decade covering the fashion industry, and the “noise” the company cut through with its super-simple shoes, I told myself, was actually a vibrant, imaginative world of glow-in-the-dark high tops and snakeskin stilettos. Allbirds seemed like a way for men to intellectualize their way out of personal taste in favor of start-up culture’s efficient sameness. I had, on more than one occasion, referred to the shoes derisively as “Yeezys for software developers.”

Press coverage of the company is divided along similar lines: Some writers praise the brand’s style and functionality, others lament its popularity as proof that the algorithms are winning. Much of the fashion industry is firmly in the latter camp.

Structurally and philosophically, the fashion industry isn’t great at dealing with change. American life has been casualizing since the 1990s, and nowhere is that clearer than in offices. The trend has left both designers and shoppers confused about what people should be wearing for jobs that were much different (or entirely non-existent) before the advent of the cell phone.

Now, Silicon Valley is stepping into the rift it helped create. Start-ups want to help people get dressed—and they might beat fashion at its own game.

In another time, developing manufacturing or textile technologies and licensing them to existing brands might have been the whole story of these new companies. But the upheaval in the American wardrobe has let outsiders into fashion’s territory, according to the fashion historian Nancy Deihl. “The idea of ‘careerwear’ is so dispersed and a little less determined,” says Deihl, a professor at New York University. “The career office [at NYU] has these little workshops on what to wear to interviews and things because there isn’t this kind of monolithic style guidance out there.”

Not only has the American office gone more casual, but work itself has changed since Dockers started pushing business-casual dressing in 1992. More women than ever before are living full professional lives, and they need shoes that do much more than just look appropriately conservative with a skirt suit.  “It isn’t like, ‘Oh, I wear sneakers while I commute and then I put my heels on in the office,’” says Kerry Cooper, the president and chief operating officer of Rothy’s, a start-up that specializes in women’s shoes and rivals Allbirds in newfound prominence. “That’s just sort of a silly, non-modern way of thinking.”

Six months ago, I bought a pair of Rothy’s. Nothing about start-up shoes had changed, but my job had: When The Atlantic hired me, I left the fashion world and found myself in a realm of indeterminate business-casualness. In spite of years spent writing about how people shop, I had no idea what I was supposed to wear. The harder I looked for an answer, the clearer it became that no one else did, either.

Rothy’s is a 3-year-old start-up that makes women’s flats from recycled plastic. The shoes are bright and feminine, which has made them common in the aesthetically pleasing environs of Instagram, where women post about their colorful collections. Instead of the leathers or textiles common in footwear manufacturing, Rothy’s knits its uppers (the part of the shoe that covers the foot) from soft, durable thread made from recycled plastic bottles.

Allbirds and Rothy’s have charted remarkably similar paths: Both companies started selling their shoes in 2016, and they say they’ve each pulled in more than $100 million in revenue and sold more than a million pairs of shoes. Both brands emphasize their sustainable materials and manufacturing practices. Although the companies are based on the same street in San Francisco, they do their biggest sales numbers on the East Coast: Allbirds sells better in New York City than anywhere else, while Rothy’s colorful flats are a hit in D.C.

In charting a way forward in textiles and manufacturing, both Rothy’s and Allbirds offer something valuable to fashion that the industry itself has repeatedly declined to pursue. For traditional fashion brands, which usually use third-party textiles and factories, designers have to start guessing what shoppers might want as much as a year in advance. Rothy’s says that their three-dimensional knitting process dramatically shrinks both the amount of material waste from manufacturing and the timeline between when the company places an order and when those shoes can be put up for sale.

“If there’s something bananas that no one could have predicted, we’d rather not overproduce colors we have to bet on. It’s such a waste,” says Erin Lowenberg, the Rothy’s creative director.

Allbirds, for its part, uses wool and eucalyptus textiles for its sneakers, and it worked with a Brazilian chemical company to develop foam soles made from the waste of sugarcane processing. In conventional sneakers, that foam is made with fossil fuels.

For any of the existing players in the fashion supply chain, there’s little incentive to invest in new materials or techniques. If a textile company develops a waste-reducing product, there’s no promise that brands will order it or their factories will be able to process it. If no one ever develops or orders new textiles, factories won’t shift to accommodate them. It’s a standoff, and it makes fashion allergic to innovation on a structural level. Manufacturing waste, combined with the overproduction that happens when designers inevitably make a wrong guess about consumers’ future whims, account for a huge portion of the fashion industry’s well-documented harm to the environment.

As I tried on sneakers in the San Francisco Allbirds shop, I found myself in the middle of an existential crisis. I looked around for the sense of aesthetic doom that critics assured me the shoes’ popularity promised. Instead of the suffocating sameness or joyless efficiency that critics have ascribed to the shoes, I saw just a small, conventional boutique in which a handful of customers ranging from teen boys to female retirees were trying on sneakers.

Tim Brown, Allbirds’ cofounder, seems aware of—and chafed by—the insinuation that his shoes are boring, or only for tech bros. “I actually think there is excitement in the simplicity and calmness, which belies an enormous amount of work,” he says of the design. He also says women have always made up the majority of Allbirds’ customers.

I was having trouble remembering what so many fashion people found threatening. Upstairs from the shop, in an impromptu studio, some Allbirds employees were photographing the simple sneakers against an Instagram-friendly peachy background with giant Monstera leaves as props. On the feet of the young women who worked in the office, the shoes were free of the jarring, swagless business-athlesiure aesthetic I’d always associated them with.

Like Uggs, Birkenstocks, Crocs, and Tevas before them, it started to feel like fashion’s Allbirds acceptance was both inevitable and, at worst, completely fine. All it takes for any particular shoe to make the crossover is for some already-cool people to decide it should. (Case in point: New Balance sneakers are currently having a moment.)

Silicon Valley has done more than enough to earn knee-jerk skepticism. For all the middle-class conveniences its new technologies and platforms have offered us, its tools have also been used for disseminating propaganda, inciting genocide, and destabilizing whatever notions of privacy most Americans might have had in the 1990s. Allbirds found its first audience on the crowdfunding platform Kickstarter, so the associations between the brand and internet behemoths were probably unavoidable, even if improving fashion manufacturing isn’t quite as questionable as anything Facebook might be up to on a given day. The fashion industry has long been selling vaguely harmful cultural influence, too, but it benefits from how much people want to be cool, and how well it has managed to be a gatekeeper to the designation.

If you don’t like the idea of wearing the same shoe for all occasions, Allbirds’ Zwillinger says that you can blame a familiar modern villain: your smartphone. “Everyone works on their phones now, and maybe in different chunks of the day and over the weekend,” he says. “It’s a different experience, and you’d expect the wardrobe to evolve so it can float in and out of those activities more fluidly.” For a certain chunk of the population, there isn’t an opportunity to go home and change into a dinner outfit after work, or a clear border between work and not-work at all. If your head’s always in the office, maybe you feel like your feet should be, too. And if that’s the case, the shoe isn’t the problem.

On the subway home from work recently, I looked around at my fellow riders’ feet, as I had been for weeks while thinking about this story. I spotted a pair of Allbirds on an unfashionable millennial man in dress pants, sure, but there were also two identical pairs of Gucci loafers on women wearing post-gym mixtures of athleisure and work clothing. Another rider was wearing a pair of Adidas Superstar sneakers exactly like my own. In San Francisco, I had seen plenty of Superstars while I was getting to the bottom of whether or not new start-ups were conspiring to make us all wear the same shoes.

I no longer have much of a grasp on what made the ubiquity of my sneakers or those Gucci loafers shoes less troubling than the ubiquity of Allbirds or Rothy’s, which now mostly just seem like a comfortable, useful tool to have in a busy person’s wardrobe, even if they don’t really meet my personal definition of “cool.” It all suddenly feels a bit Chicken Little. Maybe the sky wasn’t really falling. But if there’s one thing the fashion industry loves more than uncomfortable shoes, it’s a bit of drama.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/allbirds-rothys-silicon-valley-shoe-fashion/587428/?utm_source=feed

[nancygduarteus]

Under the Depression Helmet

The last two weeks have been frenetic for Bre Hushaw, who is now known to millions of people as the girl in the depression helmet.

Hushaw has been hearing from people all around the world who want to try it, or at least to know how it works. Her life as a meme began when she agreed to an on-camera interview with the local-news site AZfamily.com for a story headlined “Helmet Approved by FDA to Treat Depression Available in Arizona.” The feel-good tale of Hushaw’s miraculous recovery from severe depression was tossed into the decontextualizing maw of the internet and distilled down to a screenshot of a young woman looking like a listless stormtrooper.

Jokes poured in. Some of the most popular, each with more than 100,000 likes on Twitter, include: “If u see me with this ugly ass helmet mind ur business.” “Friend: hey everything alright? Me, wearing depression helmet: yeah I’m just tired.” “The depression helmet STAYS ON during sex.”

Hushaw has been tracking the virality, sometimes cringing and sometimes laughing. She replies to as many serious inquiries as she can, while finishing up her senior year at the University of Northern Arizona before starting a job in marketing. A year ago, she didn’t think she was going to live to graduation. Back when she was 10 years old, her mother died. Her depression symptoms waxed and waned from then on, and they waxed especially when she heard the gunshots on her campus during a shooting at the school in 2015. She tried many medications over the years—14, by her count.

“From age 15 until I was 20, I was extremely suicidal, and I was self-harming,” she told me last week. She recounted multiple related hospitalizations, and a gradual loss of faith in the medical system.

So last year, when Hushaw learned of a helmet that promised to magnetically rewire her brain, she saw this as an obvious yes. The helmet contains magnets that exert energy on the electrical functioning of the brain, a process known as transcranial magnetic stimulation, or TMS. Hushaw went to a clinic and absorbed electrical impulses for 20 minutes every (business) day for six weeks.

[Read: Why a ‘lifesaving’ depression treatment didn't pass clinical trials]

Though Hushaw likens the feeling to being “tapped” by a pencil, the chin strap makes it appear as if the helmet is going to blast her with energy. This didn’t help with the jokes. I retweeted the news story with, “After wearing it you feel like a weight has been lifted off you.” That made me feel clever until I actually read the story and saw that Hushaw said almost exactly the same thing—“I felt like there was a huge blanket that was lifted off my shoulders and I felt completely free”—referring to suicidal depression.

Hushaw is okay with it. Despite the mockery, she’s overall thrilled by the attention given to the helmet. The image above is a recreation—she went back to the clinic to take the photo, and she sent it to me. I didn’t ask her to do this. But she is passionate: “I just want to make sure that people are getting help,” she said. “I had a friend commit suicide on my campus and I just never want that to happen again.”

As she put it multiple times, “It actually, really saved my life.”

The attention Hushaw’s story received is testament to how few people know what to make of TMS. Even when I surveyed physician friends about it, several hadn’t heard of it, and no one had seen it used in more than a rare case. It is certainly not woven into typical treatment plans.

Researchers at some academic institutions are taking the technology seriously. Yale has a Transcranial Magnetic Stimulation Research Clinic, and the service is offered at Johns Hopkins. There have been numerous studies suggesting promising clinical uses, including one this week in the journal Neurology. But the mechanisms proposed are vague. TMS may be beneficial in treating addiction, according to a 2017 paper in Nature Neuroscience Reviews, by “influencing neural activity ... throughout the brain.” According to the Mayo Clinic: “Though the biology of why TMS works isn’t completely understood, the stimulation appears to impact how the brain is working, which in turn seems to ease depression symptoms and improve mood.”

Yes, TMS seems to impact how the brain is working. These statements are not abdications of explanatory burden, but come close to the extent of what is known. Serenity Mental Health Centers, the Arizona clinic that provided Hushaw with the electromagnetic treatment, claim that “people with depression often have areas of their brain with decreased activity, and people with [obsessive-compulsive disorder] often have overactive areas of their brain, so TMS stimulates and resets those regions of the brain.”

The notion that the device has dramatic effects on the structure or function of the brain is at odds, though, with the U.S. Food and Drug Administration’s classification. In March, the regulatory agency issued a rule deeming them Class II medical devices, along with electric wheelchairs and pregnancy tests, which means that they are presumed to be safe. Most therapeutic devices that affect human physiology are Class III, which would certainly be the case with anything that “resets the brain.” The FDA argued that a Class II designation would “enhance patients’ access to beneficial innovation, in part by reducing regulatory burdens by placing the device into a lower device class than the automatic Class III assignment.”

BRE HUSHAW

The first TMS helmet approved by the FDA, Neurostar, was for treatment of major depressive disorder, in 2008. Others have been since, as the market began to boom. On Tuesday, Brainsway, the company that made the helmet used by Hushaw, announced its initial public offering. Brainsway was also approved for obsessive-compulsive disorder in August of 2018, and the publicity efforts around this approval were what eventually led to Hushaw’s news fame, according to the marketing director of the clinic that provides the helmet, Sunrise Mental Health Centers.

This marketing director, Candise Miller, has her own miraculous personal story of recovery via TMS. “My life is forever changed. I’m a completely different person,” she told me. She asked me to include a link to the clinic’s home page, which features her testimonial but does not mention that she is director of marketing.

Until the FDA’s new classification this year, the agency had reigned in marketing of such health claims by requiring pre-market approval for TMS devices. Manufacturers had to submit evidence that the devices had no immediately obvious adverse effects and at least a small amount effectiveness. For instance, the FDA said it based approval of Brainsway for OCD on a single study of 100 people, which showed improvements in some patients. A control group wore actual TMS helmets that secretly weren’t turned on. Presumably due to placebo effect, this group also saw an 11 percent decrease in symptoms.

Like most treatments in psychiatry, there is value in showing up, and in believing you are being treated. These and other mechanisms are mysterious, and the effects are unreliable—attesting to the complexity of mental illness, and the many factors that go into causing and treating it.

The basic idea of shocking the system into compliance has deep roots. Since electroconvulsive therapy was introduced almost a century ago, the approach has been shown to unreliably but sometimes dramatically effective for treatment of severe depression. At least partly due to its barbaric connotations and the uncertainty of the outcomes, electroconvulsive therapy remains one of the most controversial treatments in medicine. It isn’t practiced by most psychiatrists.

The electrical charges delivered by TMS are meant to be more focused, but still very powerful. Inside the helmet, a series of looped wires are connected to capacitors that pass electrical currents through them in bursts. Pulses generate a secondary electric current that alters the electric fields in the brain, depolarizing neurons and causing them to fire. The scalp and skull do not shield the electrical processes in the brain from such a force any more than a cubicle wall shields your ears from a colleague who is incapable of keeping their phone on silent.

Whether or how TMS would cause lasting change in brain function is not entirely clear. The concept was introduced in 1985 at the University of Sheffield, in England, as a diagnostic and mapping tool for the motor cortex. The technology can reliably be used to make a person’s legs jerk, but the ostensible aim of the current treatments is to reach beyond transient cortical activity and fundamentally alter the brain’s circuitry. And unlike the invasive neurological procedure of deep-brain stimulation, which has proven useful in treating OCD as well as Parkinson’s disease and other conditions, the helmet doesn’t require any holes in the skull and electrodes planted in the brain.

But TMS’s marketing claims raise questions about how the helmet’s electrical currents could reach the brain’s emotion-driving portions without causing any unwanted cortical activity or serious adverse effects. In electroconvulsive therapy, a person must be anesthetized and made to convulse, and this was always seen as an unfortunate byproduct of the attempt to reset deeper parts of the nervous system. TMS requires no sedation, and only rarely causes seizures. (The sessions are still supposed to be closely monitored by a licensed technician—and the helmet is not supposed to be worn in public, as was implied in most of the jokes that hit the internet last week.)

The only people who claim to know precisely how these helmets treat such complex sociocultural-behavioral conditions as depression and anxiety are the ones selling treatment with the machine, or machines themselves. As TeeJay Tripp, the medical director of Arizona’s Sunrise Mental Health Centers who treated Hushaw, understands it, TMS activates the prefrontal cortex, which can lead to downstream effects that ultimately impact the amygdala or other deep structures tied to emotion.

The lack of understanding about what might be happening in those deep structures is paired with uncertainty about what parts of the cortex should be stimulated in the first place. The common wisdom among TMS practitioners is that depression occurs in the right side of the brain and anxiety on the left. Depending on which you have, the energy needs to be focused on one side. But this two-sided model of the brain is not supported by any neuroscience text I can find.

In addition to treatments for depression and anxiety, Sunrise Mental Health Centers also offers to provide TMS for: “ADD/ADHD, addiction, Alzheimer’s disease, anxiety, autism, bipolar disorder, chronic pain, eating disorders, multiple sclerosis, schizophrenia, stroke rehabilitation, and substance abuse.” The FDA has only approved TMS for depression and OCD, but the approach can still legally be used “off-label.” When asked where in the brain electricity should be applied for these various conditions, Tripp says he bases his treatment on a mix of trial and error, along with whatever small studies have been done on any particular condition. Most notably among these uses, he and other practitioners have begun putting the helmets on children with autism.

I asked Tripp if he was concerned about potential long-term repercussions, or simply about rewiring the wrong area. He cited the fact that the FDA had approved the helmet 10 years ago (for use in depression), and there has been no research showing long-term harm yet. Miller, Sunrise’s marketing director, believes that TMS’s overhead so far has prevented it from being more widely known and used; she put the ballpark cost of a Brainsway at $200,000. She also contends that uptake has been slow because of “Western medicine’s reliance on pharmaceuticals,” and the insurance companies’ unwillingness to pay for it.

Insurance companies are increasingly covering the treatment, though. Direct-to-consumer marketing has increased demand in recent years, practitioners tell me, and many plans will cover the $10,000 to $12,000 treatment for people who haven’t responded to trials of medications and therapy.

This is how LeeAnn Tucker afforded six weeks in the helmet. A 47-year-old former elementary school teacher in the Houston Area, she spent two decades “on and off of every antidepressant,” she says. She has been diagnosed with bipolar II, and she also has generalized anxiety disorder, PTSD, and panic attacks. The anxiety has led her to develop agoraphobia. “I don’t leave my house unless I absolutely have to. It’s just bad,” she says. “Sometimes if I’m in the grocery store I will have to leave my cart and just go home.”

Tucker has also been suicidal. “The suicidal thoughts were so severe that I never told anyone,” she told me, “not my doctor, not my husband. Because when you tell someone, then they’ll try to save you.”

A few years ago, she began seeing a new psychiatrist who had a video commercial for the Neurostar TMS helmet playing on a loop in his waiting room. (Neurostar provides all marketing material for patients. Clinicians buy the machine, and they also pay for each use of it.) She was convinced to try it. She was “tapped,” as they call it, “on the left side for depression, and on the right side for anxiety.” She sent me a video from her phone of her undergoing treatment. Her face is expressionless, and the piercing blasts sound like laser guns.

After six weeks of daily treatment, Tucker saw no improvement. “I would love to say it worked, but I felt no different when it was over,” she says. “I’m still depressed as fuck.”

One thing that did help, though, was that Tucker made friends with her technician, Allison Rose Zartier, over the course of weeks of treatment. “Having someone like Allison administer TMS was actually the best part for me,” Tucker says. Zartier, who is now the TMS coordinator at a business called Elite Medical Wellness in Lake Charles, Louisiana, says she finds it unbelievable that some practitioners leave people alone during the 20-to-30-minute treatments. Some of the biggest benefits she has seen have come through talking to people while the magnets are firing. She says that a recently retired CEO needed to find a way to have purpose with all of his free time. Another extremely isolated person felt better after Zartier recommended a dog.

Advocates of the depression helmet consider the treatment great if it ends up actually helping even a small number (and harming fewer than it helps). For ECT and TMS, and anything that proposes to offer a hard restart to your central nervous system, the health risks cannot be zero—and should be expected to be significant. TMS and other high-tech, high-cost treatments also have the potential to divert focus from social, structural, and preventive support—the basic elements of health that, when ignored, often manifest as depressive symptoms.

[Read: The diet that might cure depression]

The medical model of depression tends to offer treatments that imply they can fix emotions that may actually be related to a need to feel valued and secure. Addressing these and other basic imperatives—to sleep and eat well, and be physically active and socially connected—is the first priority for treating and preventing most illnesses, mental and otherwise. This emphasis can be lost when an expensive magnetic helmet that promises to make the feelings somehow simply go away is seen as anything other than a last resort.

Zartier went through TMS herself, and told me she was able to stop taking antidepressants shortly after. She now runs a Facebook support group for TMS patients, in which Hushaw is also active. Zartier says the shared experience of having gone through this process fosters a sense of community. It’s also a tool for recruiting prospective patients. Zartier says the $12,000 cost can be well worth it. She tells people it’s like “going to the gym, but for your brain.”

That community is growing. “It keeps climbing faster, especially in the last four months. The word is finally getting out there,” Zartier says, which she believes is partly because Neurostar is now running television commercials. And she’s seeing ever more parents in the concerned Facebook community bringing in children.

“I had a 10th grader who was suicidal, and I saw the pain in her eyes,” she says. “The younger you are, the more the brain can be affected—their brains seem to want to change.”

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/depression-helmet/587242/?utm_source=feed

[nancygduarteus]

The 'Love Hormone' Could Be Used for Weight Loss

Scientists suspect that one element of the obesity epidemic is that the brains of obese people respond differently to images of delicious, calorically dense foods. Obese individuals’ brains seem to light up at the sight of donuts, pizza, and other calorie bombs, even when they’re no longer hungry.

Some studies have suggested that this heightened activity might predispose people to overeating. Today, nearly 40 percent of American adults are obese, and obesity is predicted to become the leading cause of cancer among Americans, replacing smoking, within five or 10 years. (Though it’s still not clear yet which comes first—the obesity or the overactive brain activity.) “Part of the reason for the obesity epidemic is that people eat when they’re not hungry,” says Elizabeth Lawson, an associate professor of medicine at Harvard Medical School and a neuroendocrinologist at Massachusetts General Hospital.

[Read: How therapy can cure overeating]

A remedy for this over-activation in the brain might come from an unexpected source: oxytocin, the brain chemical often associated with love and social relationships. Oxytocin is sometimes called the “cuddle hormone” because it’s released during sex, childbirth, and breastfeeding. People who are in the early stages of falling in love have higher levels of oxytocin than normal. The drug ecstasy also increases concentrations of the hormone in the blood.

Oxytocin has a variety of other surprising functions. A form of the chemical, Pitocin, induces labor, and another form might help treat stomach pain. Early studies have suggested the hormone might boost social skills among kids with autism. Now, Lawson and other researchers are investigating whether oxytocin might also prevent overeating.

Lawson and her colleagues recently showed images of high-calorie foods to 10 overweight and obese men. She found that the regions of the brain involved in eating for pleasure lit up when the men viewed the images. A dose of oxytocin, compared to a placebo, weakened the activity in those regions, and it also reduced the activity between them. Meanwhile, oxytocin didn’t have that effect when the men viewed images of low-calorie foods or household items. Lawson’s colleagues presented the research, which has not yet been published in a peer-reviewed journal, last month at Endo 2019, the Endocrine Society’s annual meeting.

“One of the key ways oxytocin works in limiting the amount of food that we eat is that it speeds up the satiety process, or reaching fullness,” says Pawel Olszewski, an associate professor of physiology at the University of Waikato in New Zealand who was not involved with Lawson’s study. “Then, oxytocin works through brain areas that are associated with the pleasure of eating, and it decreases our eating for pleasure.”

[Read: Why comfort food comforts ]

That’s just one of the ways oxytocin shows potential as an obesity treatment. Previously, Lawson and her colleagues found that the hormone improves insulin sensitivity and encourages the body to use of fat as a fuel for the body. Lawson’s other studies have shown that oxytocin reduces activation in the hypothalamus, an area of the brain that controls hunger, and increases activation in areas of the brain associated with impulse control. To Lawson, the results together suggest that the hormone creates less of a need to eat, reduces the compulsion to eat for fun, and improves impulse control when it comes to actually reaching for that second slice of cake. Oxytocin, in other words, appears to make food seem less rewarding.

Other researchers have found that oxytocin might weaken alcoholics’ dependence on alcohol, drawing parallels to the hormone’s effects on how some obese people’s brains perceive food. A study published in the journal PLoS this month showed that oxytocin cut the desire to drink among alcohol-dependent rats. It’s not clear what this anti-drinking element of oxytocin has to do with its love-hormone properties, if anything.

So why can’t we just pick up bottles of oxytocin at CVS? For one thing, most of these studies have been very small; 10 is a minuscule sample size. They’ve been largely conducted on men, so future research would need to be expanded to women. The entire mechanism behind oxytocin’s effects on eating behavior and metabolism needs to be firmed up, and the safety of using the hormone over the long term needs to be established.

The way Lawson’s and many other studies have been conducted is by putting oxytocin in a nasal spray and attempting to shoot it directly toward the brain. But it’s not clear how much of the drug the person is actually getting through this kind of application, and researchers are still working on making it more precise. To answer some of these questions, Lawson is currently conducting an NIH-funded randomized, controlled trial that will administer oxytocin to obese men and women for eight weeks.

Finally, even if all of these studies are successful, it’s important to remember that there are myriad reasons—social, economic, biological, cultural—that people become obese, addicted to food, or addicted to other substances. An oxytocin treatment might only work for some of them, and even if it did, not all obese people desire to lose weight. “Its effectiveness may depend on the reason for why the obese individual is obese,” Olszewski says.

Still, a drug that helped even a fraction of America’s 93 million obese people would be a major breakthrough. If all of this research bears results, many years from now, there may be another reason to love the love hormone.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/oxytocin-obesity-treatment/587533/?utm_source=feed

[nancygduarteus]

The Trouble With Dentistry

In the early 2000s Terry Mitchell’s dentist retired. For a while, Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient 10-minute walk from Mitchell’s home, in San Jose, California. Lund’s practice was situated in a one-story building with clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows, round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars.

To hear more feature stories, see our full list or get the Audm iPhone app.

Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell’s insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and cost of the treatments did not trouble him. He had no idea that it was unusual to undergo so many root canals—he thought they were just as common as fillings. The payments were spread out over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he might as well get them before things grew worse.

Meanwhile, another of Lund’s patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s, had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly healthy, although she’d had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and telling her she needed root canals and crowns.

Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a doctor’s daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent, so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the work cost her about $70,000.

In early 2012, Lund retired. Brendon Zeidler, a young dentist looking to expand his business, bought Lund’s practice and assumed responsibility for his patients. Within a few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly successful, but Zeidler was making only 10 to 25 percent of Lund’s reported earnings each month. As Zeidler met more of Lund’s former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work—a much larger proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn’t need any additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he checked thoroughly?

In the summer, Zeidler decided to take a closer look at Lund’s career. He gathered years’ worth of dental records and bills for Lund’s patients and began to scrutinize them, one by one. The process took him months to complete. What he uncovered was appalling.

We have a fraught relationship with dentists as authority figures. In casual conversation we often dismiss them as “not real doctors,” regarding them more as mechanics for the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are so anxious that they avoid the dentist almost entirely, and a smaller percentage have a genuine phobia requiring psychiatric intervention.

When you’re in the dentist’s chair, the power imbalance between practitioner and patient becomes palpable. A masked figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like a personal failure. When a dentist declares that there is a problem, that something must be done before it’s too late, who has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what’s true? In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist’s office—perhaps because we both dread dental procedures and belittle their medical significance—the impulse is to comply without much consideration, to get the whole thing over with as quickly as possible.

The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. “We are isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of the equation,” says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the American Dental Association’s Center for Evidence-Based Dentistry, which was established in 2007. “We’re kind of behind the times, but increasingly we are trying to move the needle forward.”

Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such a young age, that we’ve internalized it as truth. But this supposed commandment of oral health has no scientific grounding. Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.

Many standard dental treatments—to say nothing of all the recent innovations and cosmetic extravagances—are likewise not well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available are not always reassuring.

The Cochrane organization, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure. For example, dental sealants—liquid plastics painted onto the pits and grooves of teeth like nail polish—reduce tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but there is only “weak, very unreliable” evidence that it combats plaque. As for common but invasive dental procedures, an increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don’t clearly indicate whether it’s better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.

“The body of evidence for dentistry is disappointing,” says Derek Richards, the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland. “Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don’t test them properly in a good-quality trial.”

The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients. Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she would probably not find much to help her. When we submit to a dentist’s examination, we are putting a great deal of trust in that dentist’s experience and intuition—and, of course, integrity.

When Zeidler purchased Lund’s practice, in February 2012, he inherited a massive collection of patients’ dental histories and bills, a mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain the alarmingly abundant dental work in the mouths of Lund’s patients, he would find it in those records. He spent every weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical analyses.

The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates. Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly, and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it.

Dental crowns were one of Lund’s most frequent treatments. A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so its new shell will fit. Crowns typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace them every five years—the minimum interval of time before insurance companies will cover the procedure again.

More than 50 of Lund’s patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has 32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that a root canal is a “quick, comfortable procedure” that is “very similar to a routine filling.” In truth, a root canal is a much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple trips to a dentist or specialist. It’s also much more costly.

[Read: Americans are going to Juarez for cheap dental care]

Root canals are typically used to treat infections of the pulp—the soft living core of a tooth. A dentist drills a hole through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery.

Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage, known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections, which occur in a minority of cases. Yet they were extremely common in Lund’s practice. In 2009, for example, Lund billed his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would almost certainly have been a memorable experience.

In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical complications, and further operations, Lund had apparently billed patients for treatments he had never administered. Zeidler was alarmed and distressed. “We go into this profession to care for patients,” he told me. “That is why we become doctors. To find, I felt, someone was doing the exact opposite of that—it was very hard, very hard to accept that someone was willing to do that.”

Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell them that the man to whom they had entrusted their care—some of them for two decades—had apparently deceived them for his own profit.

Arsh Raziuddin

The idea of the dentist as potential charlatan has a long and rich history. In medieval Europe, barbers didn’t just trim hair and shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of enemas, and tooth extraction. Barber surgeons, and the more specialized “tooth drawers,” would wrench, smash, and knock teeth out of people’s mouths with an intimidating metal instrument called a dental key: Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s, Thomas Berdmore, King George III’s “Operator for the Teeth,” described one woman who lost “a piece of jawbone as big as a walnut and three neighbouring molars” at the hands of a local barber.

Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies as a trade akin to blacksmithing (Paul Revere was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic, nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen—who genuinely believed in the therapeutic power of bloodsucking worms—were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged them extra to stuff their pitted molars with homemade gunk of dubious benefit.

In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From 1839 to 1840, Horace Hayden and Chapin Harris established dentistry’s first college, scientific journal, and national association. Some historical accounts claim that Hayden and Harris approached the University of Maryland’s School of Medicine about adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry was of little consequence. But no definitive proof of this encounter has ever surfaced.

Whatever happened, from that point on, “the professions of dentistry and medicine would develop along separate paths,” writes Mary Otto, a health journalist, in her recent book, Teeth. Becoming a practicing physician requires four years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When physicians complete their residency, they typically work for a hospital, university, or large health-care organization with substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the nation’s 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically don’t have the same level of oversight.

[Read: Why dentistry is separate from medicine]

Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral health is somehow divorced from one’s overall well-being is absurd; the two are inextricably linked. Oral bacteria and the toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation.

Dentistry’s academic and professional isolation has been especially detrimental to its own scientific inquiry. Most major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the phrase evidence-based medicine was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based medicine, but only a handful devoted to evidence-based dentistry.

In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that curate useful resources. But its adoption “has been a relatively slow process,” as a 2016 commentary in the Contemporary Clinical Dentistry journal put it. Part of the problem is funding: Because dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and industry to tackle these issues. “At a recent conference, very few practitioners were even aware of the existence of evidence-based clinical guidelines,” says Elliot Abt, a professor of oral medicine at the University of Illinois. “You can publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change.”

Among other problems, dentistry’s struggle to embrace scientific inquiry has left dentists with considerable latitude to advise unnecessary procedures—whether intentionally or not. The standard euphemism for this proclivity is overtreatment. Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for “microcavities”—incipient lesions that do not require immediate treatment—and superfluous restorations and replacements, such as swapping old metal fillings for modern resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and misguided treatment, dentistry is lagging behind. It remains “largely focused upon surgical procedures to treat the symptoms of disease,” Mary Otto writes. “America’s dental care system continues to reward those surgical procedures far more than it does prevention.”

“Excessive diagnosis and treatment are endemic,” says Jeffrey H. Camm, a dentist of more than 35 years who wryly described his peers’ penchant for “creative diagnosis” in a 2013 commentary published by the American Dental Association. “I don’t want to be damning. I think the majority of dentists are pretty good.” But many have “this attitude of ‘Oh, here’s a spot, I’ve got to do something.’ I’ve been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or 12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the procedure.”

Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband in Texas, recalls many troubling cases: “We would see patients seeking a second opinion, and they had treatment plans telling them they need eight fillings in virgin teeth. We would look at X-rays and say, ‘You’ve got to be kidding me.’ It was blatantly overtreatment—drilling into teeth that did not need it whatsoever.”

Studies that explicitly focus on overtreatment in dentistry are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180 dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists singled out 13 different teeth for drilling; each advised one to six fillings. Similarly, in an investigation for Reader’s Digest, the writer William Ecenbarger visited 50 dentists in 28 states in the U.S. and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about $500 and going up to nearly $30,000.

A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in dentistry. In addition to dentistry’s seclusion from the greater medical community, its traditional emphasis on procedure rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than $200,000. And then there’s the expense of finding an office, buying new equipment, and hiring staff to set up a private practice. A dentist’s income is entirely dependent on the number and type of procedures he or she performs; a routine cleaning and examination earns only a baseline fee of about $200.

In parallel with the rising cost of dental school, the amount of tooth decay in many countries’ populations has declined dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the 1950s and ’60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts, and veneers. It’s easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and proactive treatments—a small filling here, a new crown there—even when waiting and watching would be better. It’s equally easy to imagine how that behavior might escalate.

“If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward this attitude of ‘I’ve got tools so I’ve got to fix something’ much too often,” says Jeffrey Camm. “Maybe it’s greed, or paying off debt, or maybe it’s someone’s training. It’s easy to lose sight of the fact that even something that seems minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad.”

Arsh Raziuddin

In the summer of 2013, Zeidler asked several other dentists to review Lund’s records. They all agreed with his conclusions. The likelihood that Lund’s patients genuinely needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund’s decisions or to explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I asked Zeidler how those meetings went, he offered a single sentence—“I decided shortly thereafter to take legal action”—and declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither responded.)

One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund’s care, explaining what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his diagnoses and treatments were meant to keep them healthy. Isn’t that what doctors do? “It makes you feel like you have been violated,” Terry Mitchell says—“somebody performing stuff on your body that doesn’t need to be done.” Joyce Cordi recalls a “moment of absolute fury” when she first learned of Lund’s deceit. On top of all the needless operations, “there were all kinds of drains and things that I paid for and the insurance company paid for that never happened,” she says. “But you can’t read the dentalese.”

“A lot of them felt, How can I be so stupid? Or Why didn’t I go elsewhere?” Zeidler says. “But this is not about intellect. It’s about betrayal of trust.”

In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit, Zeidler and his lawyers argued that Lund’s reported practice income of $729,000 to $988,000 a year was “a result of fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never performed.” The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund’s former patients, including Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They collectively reached a nearly $3 million settlement, paid out by Lund’s insurance company. (Lund did not admit to any wrongdoing.)

Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney’s office is prosecuting a criminal case against him based on 26 counts of insurance fraud. At the time of his arraignment, he said he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund’s license, which is currently inactive.

Many of Lund’s former patients worry about their future health. A root canal is not a permanent fix. It requires maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell’s root canals has already failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a crown were fixed in place. “I don’t know how much these root canals are going to cost me down the line,” Mitchell says. “Six thousand dollars a pop for an implant—it adds up pretty quick.”

Joyce Cordi’s new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday chewing. “It hurts like hell,” she says. She has to wear a mouth guard every night.

What some of Lund’s former patients regret most are the psychological repercussions of his alleged duplicity: the erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. “You lose your trust,” Mitchell says. “You become cynical. I have become more that way, and I don’t like it.”

“He damaged the trust I need to have in the people who take care of me,” Cordi says. “He damaged my trust in mankind. That’s an unforgivable crime.”

This article appears in the May 2019 print edition with the headline “The Trouble With Dentistry.”

from Health News And Updates https://www.theatlantic.com/magazine/archive/2019/05/the-trouble-with-dentistry/586039/?utm_source=feed

[nancygduarteus]

When Medical Schools Become Less Diverse

At Texas Tech University’s medical school, just 4 percent of students are black; 13 percent are Hispanic. And those numbers may soon shrink. Research has shown that’s what happens when schools no longer consider race in admissions, and that’s what the school plans to do.

In late February, Texas Tech University reached an agreement with the U.S. Department of Education to end its use of race in admissions to its medical school. The resolution, first reported by the Wall Street Journal, brought to an end a 14-year federal investigation into the school’s affirmative-action practices. The complaint had been filed following the Supreme Court decisions in the Michigan affirmative action cases, Grutter vs. Bollinger and Gratz vs. Bollinger, where the court decided race could be used in admissions but only in a “narrowly tailored” way. Texas Tech had stopped using race in admissions at its pharmacy school in 2008, and for its undergraduate college in 2013, but not at its medical school. There, the school argued, it needed to use race as a factor to ensure a diverse class of future doctors, and there was no other way around it.

The law, as interpreted by the Supreme Court in affirmative action cases over the last 40 years, requires schools to show that they have exhausted all other, race-neutral options to achieve a diverse student body before using race as an admissions criteria. Most schools are able to show that the way they are using race in admissions is in the narrowly-tailored way that the Supreme Court has said, time and again, is legal. But Texas Tech was not periodically reviewing those race-neutral alternatives; or, at least, could not show that it was. That’s why it’s hard to read too much into what this means for the future of affirmative action, Scott Schneider, a higher-education attorney with Husch Blackwell, told me, because the details of the case were specific to Texas Tech.

[Read: The movement to diversify medical schools.]

In a letter to the Department of Education’s Office for Civil Rights, Eric Bentley, the general counsel for the Texas Tech University system, said that the school could prove that it was using race in an constitutionally-accepted way, but that Texas Tech would voluntarily agree to drop the practice anyway. Still, he wrote, the medical “strongly believes that diversity in academic medicine is not only a necessity at the [School of Medicine], but is a necessity nationally as well; therefore, we continuously strive to enhance the diversity of our student body.” But diversity in medical schools, broadly, has been difficult to achieve—especially without the use of race in admissions.

Many minority groups—particularly blacks, Hispanics, and Native Americans—are significantly underrepresented at medical schools, Liliana Garces, an associate professor at the University of Texas who has studied the effects that affirmative-action bans have had on student representation, told me. And according to a recent report from the Association of American Medical Colleges, positive increases in racial diversity are few. For example, the number of black matriculants to medical school rose by 4.6 percent last year to 1,856, and the number of American Indian or Alaska Native matriculants rose by 6.3 percent to 218.

These numbers could yet get smaller. Research shows that banning affirmative action—eliminating the use of race in admissions—leads to a decline in the enrollment of those underrepresented students. This is just as true at medical schools as it is at undergraduate institutions. For example, the number of black and Chicano students enrolled at University of California medical schools between 1996 and 1997 declined by 38 percent and 29 percent, respectively, following the state’s affirmative action ban.

The lack of diversity isn’t merely a problem for young black college graduates hoping to become doctors some day, but for many of their would-be patients. Research has shown that health outcomes are improved when black patients have black doctors; they’re more likely to go to them for treatment, and to be more satisfied with the care they receive. Those facts make the continuing lack of diversity in medical schools even more acute; and the potential for a decline in enrollments more threatening. “For health care and medical schools in particular to be in a situation where we might be likely to have fewer black doctors creates real implications for the type of care and treatment that black patients are likely to receive,” Adia Harvey Wingfield, a professor of sociology at Washington University in St. Louis, told me.

Wingfield’s new book, Flatlining: Race, Work, and Health Care in the New Economy, explores how changes in work affect black medical professionals. Black doctors, she finds, end up doing an extra level of work—the attentiveness to black patients; the added attention to caregiving—that are a part of why black patients have better health outcomes with doctors who look like them.

With fewer black doctors, those who are already doing more work would be stretched more thin. “If we're talking about practitioners who are going to be servicing communities that are only going to become a larger and larger part of our society,” the goal, Wingfield says, should be to boost the ranks of those underrepresented minorities in medical professions.

from Health News And Updates https://www.theatlantic.com/education/archive/2019/04/affirmative-action-medical-school-diversity/587290/?utm_source=feed

[nancygduarteus]

What It Means to Dream of Nothing

Where do our minds go at night? For more than a century, discussions of dreams have tended to revolve around the interpretation of our dreams’ contents. Do they reflect our unconscious anxieties? Are they an attempt to simulate threats, training us to cope with future challenges? Or are they simply the result of our mental housekeeping, as the sleeping brain reactivates our memories and processes them for long-term storage? In each case, the focus has been on the more immersive, surreal flights of fancy that occupy the sleeping brain.

Yet our most puzzling dreams may not have contents at all. Have you ever woken up with the certainty that had just been dreaming, yet you were unable to recall even a single detail of the scene your mind was playing out? Various sleep studies have found that approximately 30 percent of the time, participants wake up with the sensation that they have been dreaming about something, yet when they are asked to describe the experience, they draw a complete blank. This is a distinct experience from waking up and have no sense of having been dreaming at all, which occurs around 20 percent of the time, or the rich narratives found in the other 50 percent.

Sleep researchers refer to that first vague sensation as a “white dream”—and its true nature is a scientific mystery. It’s known that white dreams can occur at any part of the sleep cycle, though they are more likely to occur during non-rapid eye movement, earlier in the night. Sometimes, they are explained as a case of simply forgetting what was being dreamed. But some researchers now believe that something much stranger is going on. Rather than reflecting a memory deficit, white dreams might represent a boundary between sleep states, consisting of a basic form of consciousness without detailed sensual content.

If so, for a large part of the night, we really are dreaming of nothing. And probing that fundamental state of being might help us understand the foundations of all other conscious experiences.

The idea that white dreams are due to some kind of lack of memory dates to at least the time of Sigmund Freud, in the late 19th and early 20th centuries. In The Interpretation of Dreams, the father of psychoanalysis argued that dreams express our subconscious desires and anxieties, as the brain’s repressive instincts are relaxed. On awakening, however, this “psychic censorship” could come into full force again by blotting out any fantasies that would be too shocking for the conscious mind to handle. Contentless dreams—now known as white dreams—were the result of this repression, Freud said, but he believed they could be recovered through analysis.

[Read: The trippy state between wakefulness and sleep]

Freud’s theories of psychic censorship might have fallen out of fashion, but modern neuroscientists have hypothesized that white dreams are rich mental simulations that were indeed simply forgotten, perhaps because the neural activity at night was not sufficient to encode the experience for later recall.

In a 2017 study, Francesca Siclari at the Lausanne University Hospital and colleagues at the University of Wisconsin at Madison invited 32 participants to spend a night in the lab, while EEG electrodes on the scalp recorded their brain activity as they slept. The team woke the participants and asked them to record whether or not they had been dreaming in the moments beforehand—and if so, what they had been dreaming about. When the participants reported white dreams, Siclari and her colleagues found that the front and center of the brain—normally implicated in memory encoding—lacked the characteristic high-frequency activity that was found with remembered dreams.

The brain, in other words, didn’t appear to be running the machinery to create memories in the first place. So why would humans evolve to have these vivid nighttime experiences if so many of them are forgotten? “Maybe forgetting is a natural part of the function of dreaming,” says Tore Nielsen at the University of Montreal, who wasn’t involved in the study. It’s possible that dreaming might play some important role—such as processing the day’s emotions—but the contents are then forgotten to avoid clogging up our memories with fictitious events.

Memory problems alone, however, do not appear to be the whole story. In a new paper for Sleep Medicine Reviews, Peter Fazekas, of the University of Antwerp, and colleagues instead suggest that white dreams are better understood as a diminished form of consciousness. According to this hypothesis, white dreaming is a bit like watching a badly tuned TV, with the volume muted: The sleeper really is dreaming, but the signal is too weak to establish any definite details beyond the vaguest impressions.

Fazekas’s previous research focused on the variations in waking consciousness, such as the vividness of a sensory experience. In so-called masking experiments, for example, researchers quickly flash one image, “the target,” before the participants’ eyes, followed by another picture, “the mask.” Sometimes the participants have a clear impression of the target—a cat, say—while other times its presentation is too quick for conscious perception; they only see the mask.

[Read: A new theory explains how consciousness evolved]

In between those extremes, however, many participants report a vague sense of having seen something, without being able to give the details of what that is. This sense of vividness—or lack of it—usually correlates with activity in the posterior regions at the back of the brain. The greater the high-frequency activity in this area, the richer and more detailed the experience, while muted activity corresponds to the weaker impressions.

Perhaps, Fazekas hypothesized, white dreams are similar to those minimal forms of conscious awareness. Working with Georgina Nemeth at Eotvos University in Hungary and Morten Overgaard at Aarhus University, he took another look at Siclari’s data to see if this were true. They noticed that Siclari’s statistical analysis had unintentionally obscured some potentially important differences in the posterior brain activity between white dreams, remembered dreams, and the sensation of having not dreamed at all. Sure enough, a reanalysis of the raw data suggested that white dreams do indeed reflect a striking reduction in that posterior brain activity, compared to remembered dreams, but still greater activity than when participants report no dreaming experience at all.

The reduced frontal and central activity that Siclari observed would naturally follow from this, Fazekas believes, since those regions would have little information to encode into a memory. “For those areas to ‘turn on,’ so to speak, you need an intense experience, which you don’t have in the white dream,” Fazekas says.

Siclari agrees that Fazekas offers a feasible interpretation of her data, though she believes that the reduced recall is still the primary distinguishing feature of white dreams. When prompted to dig deep into their memories, she says, some participants were later able to draw details from those apparently content-less experiences, which suggests that in at least some cases, it is purely a failure of recall.

Other researchers have responded warmly to Fazekas’s new paper. “I was thrilled to see white dreams, which are an often-neglected topic, get so much attention,” says Jennifer Windt at Monash University in Melbourne, Australia.

One very real possibility—supported by both Siclari and Fazekas—is that white dreams may in fact comprise a whole spectrum of experiences, the nuances of which may have been lost as the scientists averaged the data across participants. Some white dreams may be vivid, cinematic visions that are simply forgotten, as Siclari suggests, while others may be the kind of vague, gist-like experiences proposed by Fazekas. At the extreme, some white dreams may be completely content-less, containing only “the experience of the passage of time, of an indeterminate duration,” according to Windt.

Studying those particular cases could give us a view of the “the simplest forms of subjective experience that exist,” Windt says—something that is “perched on the border between unconscious sleep and more complex and dreamful experiences.” She points out that experienced meditators regularly report a “‘pure,’ non-conceptual awareness” in sleep in which they are conscious of being asleep, but lacking any specific thoughts or images. Further research, she hopes, might help to verify those descriptions and compare the neural activity with other participants’ white dreams to see if there is any overlap with this mysterious state.

The concept of “pure consciousness” can sound like a New-Age buzzword, but philosophers and neuroscientists are coming to view it as an important concept. You could think of consciousness like a Fabergé egg, and once you peel away the outer layers you are left with the most fundamental state of conscious existence—the core of our mental world. Finding ways to strip down our mental activity to this has been incredibly difficult, but this latest research suggests that white dreams could offer one important entry point to explore that state and to understand the starting point of all thought and feeling.

White dreams may appear meaningless, but for scientists probing the mysteries of sleep and consciousness, they are rich with possibility.

from Health News And Updates https://www.theatlantic.com/health/archive/2019/04/white-dreams-pure-consciousness/587293/?utm_source=feed