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Virtual Reality Aimed At The Elderly Finds New Fans

NPR Health Blog - 1 hour 41 min ago

Virginia Anderlini (right) was the first private client to try out Dr. Sonya Kim's new virtual reality program for the elderly, and says she's eager to see more. Kim's handful of programs are still at the demo stage.

Kara Platoni/KQED

Virginia Anderlini is 103 years old, and she is about to take her sixth trip into virtual reality.

In real life, she is sitting on the sofa in the bay window of her San Francisco assisted-living facility. Next to her, Dr. Sonya Kim gently tugs the straps that anchor the headset over Anderlini's eyes.

But in the virtual world, Anderlini is on a Hawaiian beach, and it's sunset, and she is surrounded by a glistening sea and a molten, purple-red sky. If she looks up, she sees the fronds of an enormous palm tree, and falling rainbow specks that dance in the air like the light from a disco ball.

"Hello, it's so nice to see you again," comes Kim's pre-recorded voice from inside the headset. "It's such a beautiful day today, isn't it?"

"Oh my goodness!" says Anderlini, sounding delighted. She turns her head slowly from side to side, taking in the details of the virtual landscape: little grass shacks, twists of driftwood, outcroppings of volcanic rock. "Hey, that's really pretty!"

Aloha VR combines images of beaches with music, brief text and an audio introduction and welcome from the physician who helped create the program.

Courtesy of One Caring Team

"In the back, look at this," she continues, wriggling around to see the imaginary world behind her. "Terry, you've got to see this, too!" she calls to her son, who is watching nearby.

For a virtual reality entrepreneur, Kim has an unusual target audience: the elderly. Anderlini is the first private client for Kim's Aloha VR program, which Kim envisions as a way to help people relax, an alternative to endlessly watching TV and a change of scenery for those who can't get out much.

And for those unhappy in the present day, virtual reality might provide an escape into an immersive other world that "allows them to forget their chronic pain, anxiety, the fact that they are alone," Kim says. In VR, she says, her company has found "a new care modality to bring to a senior care setting like this, to inspire them to live another day, where they're happy."

'No One Cares About Me'

A former emergency room doctor, Kim found her way to virtual reality through a series of tough requests. A few years ago, she was running a house-call practice when she received a call for help from a woman whose 88-year-old mother had stopped eating and drinking. As a result, she'd made three trips to the ER in a month, racking up more than $50,000 in medical bills.

Kim knew that seniors often end up in the hospital for preventable conditions — like dehydration, malnutrition and electrolyte imbalances — exacerbated by loneliness and lack of self-care. And when she asked the older woman why she'd stopped eating, Kim recalls, her patient replied: " 'No one loves me. No one cares about me. I don't matter anymore. Why should I eat, why should I drink, why should I live? I just want to die today.' "

"When I was driving back home from that visit, I couldn't stop sobbing," Kim says. "As a single woman without any kids, I thought, when I'm her age, who's going to call me? Who's going to take care of me?"

That interaction led Kim to found One Caring Team, in 2014. Staffers regularly phone seniors at home to check on their mood, medications and appointments, and prompt them to chat about positive subjects, like what makes them happy or what they could do bring joy to someone else.

But then one day, as Kim was giving a talk about her service, a man in the audience asked: "What about my mom?" His mother has dementia, he said, and couldn't have a coherent phone conversation. Finding a solution for his mom, Kim says, became her "new homework assignment."

By chance, Kim had been reading about virtual reality and decided to attend a VR mixer in San Francisco; someone let her use an Oculus headset to walk through a virtual garden, and she "totally fell in love" with the medium. Convinced the older patients would like it, too, she borrowed a friend's headset and took it to a preventive care conference. By the time she was done, she already had directors of assisted-living facilities asking about pricing.

That convinced her that the concept could sell, but she wanted to make sure VR could actually make people feel better.

Easing Chronic Pain, Anxiety and Depression

"There are over 100 clinical research papers that are already published that show proven positive clinical outcomes using VR in managing chronic pain, anxiety and depression," she says. "And in dementia patients, all those three elements are very common."

These images from an fMRI scan show areas of the brain affected by pain, and how those activated areas quieted down for one test patient who donned a headset that immersed the patient in a virtual reality world.

Courtesy of Dr. Sam Sharar/University of Washington

For example, in the 1990s, pioneering researchers at the University of Washington developed SnowWorld, an icy virtual environment that reduced pain for burn victims during wound treatment. More recently, Dr. Albert Rizzo's lab at the University of Southern California has helped military veterans who have post-traumatic stress disorder, by offering exposure therapy in virtual environments. The Veterans United Foundation has created virtual reality experiences of veterans' memorials, for vets who can't travel to see them. And scientists at the Chronic Pain Research Institute have tested a virtual meditative walk meant to help users manage pain and stress.

VR is typically formulated for younger users, and often asks them to play games, solve puzzles, master new information and move around energetically. But many of Kim's clients are wheelchair-bound; those with advanced dementia cannot read or follow verbal commands. Nearly all of them are unfamiliar with the conventions of virtual reality devices, which assume that the user knows to swivel his or her head to take in the 360-degree view, to move around to make the landscape scroll, or to tap objects to interact with them. Instead, many of Kim's clients go through entire sessions seated, heads cast down, hands folded in their laps. Sometimes her staff has to gently pivot clients' chins to help them look to the side.

But exploration and beating puzzles aren't the point of this kind of VR: The environments have no story-line, just scenery. Kim says the name Aloha VR is a nod to her experiences working in a Hawaiian emergency room, where she came to admire the state's "ohana spirit," a concept that encompasses love for extended family and respect for elders.

In the version of the VR program Anderlini is watching, Kim's voice offers a friendly welcome and reminds her to take her medication to stay healthy. As she speaks, the brief text pops up in little orange bubbles that burst pleasingly at the end of each sentence. Versions for the cognitively impaired have no words at all; just music and the sounds of waves.

"If there are too many words, if there are too many things we're asking, they're going to get frustrated," said Kim.

Instead, the point is to make users feel safe and welcome. "Dementia patients often feel lost, because they feel that they don't belong anywhere," says Kim — they may be confused about their surroundings or who they are, or estranged from family members overwhelmed by their care. By giving them a beautiful beach, Kim said, "I want them to feel found again."

In addition to having private clients, Kim conducts group therapy sessions at Bay Area assisted-living centers, where a dozen or so people take turns with the goggles. Although some of her clients struggle with verbal communication, they seem to have found other ways to express enjoyment. One client, Kim said, simply blew kisses. Another hummed happily. A third stole 40 minutes in the headset, repeatedly asking for "Just a little more, hon." A few just go to sleep.

The Challenge: Heavy And Expensive Headsets

There are still challenges for the company to work out. The headsets can be heavy; it can take seniors a while to warm up to trying them. And while prices for mobile VR equipment have come down, it still costs about $850 for each Samsung Gear VR headset plus the Galaxy smartphone that slides into it – costly enough that the firm doesn't have a rig for each client.

Kim's company has created a handful of virtual environments for demonstration purposes, but it will take time and money to build more. So, for now, they also buy off-the-shelf programs to give the clients a little variety. (They recently teamed with the Virtual World Society, a group that intends to use VR to promote social good. The group's founder, the University of Washington's virtual interface pioneer Dr. Tom Furness, is now One Caring Team's acting chief technology officer.)

So far, Virginia Anderlini has taken virtual visits to Venice and Africa and, after her brief trip to the beach, spent some time in an autumn-themed meditation session watching leaves fall. But she's seen it before, and soon asks for something different. What virtual world would she like to try next? "Just something I haven't seen before," she says.

But that could be tougher than it sounds.

"You know, when you get to this age, I think you've seen everything," Anderlini says, and laughs.

This story was produced by KQED's health and technology blog, Future of You.

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
Categories: NPR Blogs

Industry Finds Receptive Doctors At For-Profit, Southern Hospitals

NPR Health Blog - 4 hours 11 min ago

Massachusetts General Hospital in Boston was among the institutions with lower rates of doctors accepting payments from industry.

Elise Amendola/AP

Where a hospital is located and who owns it make a big difference in how many of its doctors take meals, consulting and promotional payments from pharmaceutical and medical device companies, a ProPublica analysis shows.

A higher percentage of doctors affiliated with hospitals in the South have received such payments than doctors in other regions of the country, our analysis found. And a greater share of doctors at for-profit hospitals have taken them than at nonprofit and government facilities.

Doctors in New Jersey, home to many of the largest drug companies, led the country in industry interactions: Nearly 8 in 10 doctors working at New Jersey hospitals took payments in 2014, the most recent year for which data is available. Nationally, the rate was 66 percent. (Look up your hospital using ProPublica's new tool.)

For the past six years, ProPublica has tracked industry payments to doctors, finding that some earn hundreds of thousands of dollars or more each year working with drug and device companies. We've reported how the drugs most aggressively promoted to doctors typically aren't cures or even big medical breakthroughs.

And we recently found an association between payments and higher rates of brand-name prescribing, on average. Accepting even one inexpensive meal from a company was associated with a higher rate of prescribing the product to which the meal was linked, another study showed.

This analysis shows profound differences among hospitals, but it's uncertain why that is. It could be that hospitals play a role in shaping affiliated doctors' acceptance of payments or that like-minded physicians congregate at particular hospitals.

Shots - Health News Drug-Company Payments Mirror Doctors' Brand-Name Prescribing

Those who support limits on such payments say patients may want to know how prevalent industry money is at a hospital before choosing it for care. "Maybe they're prescribing or treating you as a patient not based on evidence but rather based on markets or industry gain or personal gain," said Dr. Kelly Thibert, president of the American Medical Student Association, which grades medical schools and teaching hospitals on their conflict-of-interest policies. Patients, she said, "need to be aware that this could potentially be an issue and they need to speak up for themselves and their loved ones who may be in those hospitals."

ProPublica matched data on company payments to physicians in 2014 with data kept by Medicare on the hospitals with which physicians were affiliated at the time. We only looked at each doctor's primary hospital affiliation and only at doctors eligible to receive payments in the 100 most common medical specialties. The payments included speaking, consulting, meals, travel, gifts and royalties, but not research.

To be sure, the data aren't perfect. Companies must report their payments to the federal government, and some doctors have found errors in what's been attributed to them. Companies can face fines for errors, and doctors have a chance each year to contest information reported about them. Also, Medicare's physician data may not capture doctors who don't participate in the program and it may not accurately reflect the status of doctors who have moved. (Read more about how we conducted our analysis.)

As might be expected, hospitals with tougher rules, such as banning industry reps from walking their halls and bringing lunch, tended to have lower payments rates. For example, at Kaiser Permanente, a giant California-based health insurer that runs 38 hospitals, fewer than 3 in 10 doctors took a payment in 2014. Since 2004, the system has banned staff from taking anything of value from a vendor.

"Our intent was to disrupt the strategy of using what industry calls 'food, friendship and flattery' to develop relationships with prescribers and influence the choice of drugs, the choice of devices, implants, things like that," said Dr. Sharon Levine, an executive vice president of the Permanente Federation, which represents the doctor arm of Kaiser Permanente. "Passing a policy alone doesn't make anything happen. There's a fair amount of surround-sound in the organization around reminding people about this and reminding them why we took this step."

Levine said she believes many of the payments attributed to Kaiser doctors were for meals and snacks at professional meetings, even if they didn't eat them.

ProPublica's analysis found distinct regional differences in comparing where industry payments were most concentrated.

After New Jersey, the states with the highest rates of hospital-affiliated doctors taking payments were all in the South: Louisiana, Mississippi, Florida, South Carolina and Alabama had rates above 76 percent. At the other end of the spectrum, Vermont had the lowest rate of industry interactions (19 percent), followed by Minnesota (30 percent). Maine, Wisconsin and Massachusetts had rates below 46 percent. Some of these states had laws requiring public disclosure of payments to doctors that predated the federal government's.

There were also major differences between hospitals based upon who owned them. For-profit hospitals had the highest rate of payments to doctors, 75 percent, followed by nonprofit hospitals at 66 percent. Federally owned hospitals had the lowest rates at 29 percent, followed by other government hospitals at 61 percent. Hospitals operated by the U.S. Department of Veterans Affairs weren't included in our analysis.

Among hospitals with at least 50 affiliated doctors, the one with the highest proportion of doctors taking payments was St. Francis Bartlett Medical Center, a relatively small hospital outside Memphis that is owned by Tenet Healthcare Corp. Fifty-nine of the 62 doctors for which Medicare listed St. Francis as their primary affiliation took payments in 2014, a rate of 95 percent.

In a statement, the hospital said it supported disclosure and transparency: "Patients should have the ability to access information about any relationship that might exist between their doctor and the companies that make the products that might be recommended for their care, so that they can discuss that information directly with their physician." Spokesman Derek Venckus declined to answer other questions about the hospital's rate or its policies.

Overall, our analysis showed, the percentage of doctors taking payments at a given hospital wasn't correlated with the share of its doctors receiving larger payments, those totaling $5,000 or more. (In part that may be because so few doctors received more than $5,000.)

Some hospitals had a relatively low proportion of doctors taking payments but a relatively high share of doctors taking substantial amounts of money. In these cases, experts say, the hospitals are probably banning meals and gifts while permitting or encouraging deeper relationships, often with oversight.

At Karmanos Cancer Center in Detroit, more than a quarter of doctors took more than $5,000 from industry in 2014, the highest rate in the nation. Spokeswoman Patricia Ellis said in an email that the hospital has conflict-of-interest policies in place and is comfortable with its level of physician interactions.

"Our cancer experts are committed to providing exceptional care and work tirelessly to find/discover/advance innovative treatments that can help patients survive their cancer," she wrote. "I lost both my parents and several other loved ones to cancer. ... I know our experts at Karmanos Cancer Institute are doing everything they can to help other cancer patients have more time with their loved ones. And they're doing that with the highest integrity and commitment."

Many cancer hospitals and specialty hospitals, including heart and orthopedic facilities, had among the highest rates of doctors receiving high-dollar payments.

Researchers as well as officials at the Association of American Medical Colleges, a trade group for medical schools and teaching hospitals, said they hadn't analyzed the data the way ProPublica has. But officials said members do track payments made to doctors at their own institutions.

Across the country, hospital and medical school leaders are divided about what constitutes an appropriate payment. "There is a range of opinions between those people who believe that industry payments should be cut out vs. those who believe that there's a way to carefully monitor them," said Dr. Janis Orlowski, the association's chief health care officer.

ProPublica found differences in the payment rates at teaching hospitals based on the grades assigned to them by the American Medical Student Association, which reviewed their conflict-of-interest policies in 2014.

At the A hospitals we analyzed, 46 percent of doctors took a payment, compared to 48 percent at B hospitals, 58 percent at C hospitals and 63 percent at hospitals rated as incomplete because their policies were "insufficient for evaluation." By comparison, 69 percent of doctors at unrated hospitals took payments. Of the 204 hospitals graded, about 150 were in ProPublica's data (hospitals run by the U.S. Department of Veterans Affairs were not).

"I think that's significant," said Thibert, the group's president. "That's still a lot of docs receiving money unfortunately. That's something we're continuing to work on."

The University of Iowa Hospitals and Clinics earned a high grade on ProPublica's payment scorecard.

Susan McClellen/Courtesy of University of Iowa Hospitals and Clinics

The University of Iowa Hospital and Clinics received an A on the scorecard. Its rate of doctors taking payments, less than 27 percent, is among the lowest in the country. Less than 3 percent of its doctors took payments worth at least $5,000, also below average. Its policy, in place since 2009, bans drug companies from providing gifts and meals in almost all circumstances, bans doctors from giving promotional talks and requires consulting arrangements be signed off on by officials.

"We really have had great success in getting [physicians] to comply with it," said Denise Krutzfeldt, manager of the health system's conflict of interest office.

Other hospitals with below-average rates, including Massachusetts General Hospital and Stanford Hospital, limit interactions between doctors and pharmaceutical representatives and monitor doctor interactions with industry closely, officials said. Some post details of their doctors' commercial relationships on their websites.

In interviews, some said they double-checked their physicians' disclosures against the data reported by the companies.

"It's like stop signs. Everybody knows they're supposed to stop at stop signs but as you and I both know, people seem to cruise through them from time to time," said Dr. Harry Greenberg, senior associate dean for research at Stanford University School of Medicine. "That's just human nature. We have a system we try to pick it up and do corrective action."

Deputy data editor Olga Pierce contributed to this report.

Copyright 2016 ProPublica. To see more, visit ProPublica.
Categories: NPR Blogs

'Nobody Is Immune': Bracing For Zika's First Summer In The U.S.

NPR Health Blog - Tue, 06/28/2016 - 1:49pm
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June 28, 20161:49 PM ET Heard on Fresh Air

Aedes aegypti mosquitoes, which have been known to carry the Zika virus, buzz in a laboratory in Cucuta, Colombia.

Ricardo Mazalan/AP

The mosquito-borne Zika epidemic is headed for its first summer in the United States. New York Times reporter Donald G. McNeil Jr. tells Fresh Air's Terry Gross that if the virus is ever going to hit hard in the U.S., 2016 will be the year.

"No one in the population has had the disease before, so nobody is immune to it, nobody has antibodies to it," McNeil says. "After this year, a fair number of people will be immune, and each year immunity will grow."

In his new book, Zika: The Emerging Epidemic, McNeil explores the origins of the Zika virus, as well as how it spreads and the best means of protecting ourselves from it.

When it comes to the virus' transmission in the continental U.S., McNeil notes the Aedes aegypti mosquitoes, which carry the Zika virus, are mostly concentrated in Florida and the Gulf Coast. But, he adds, the fact that the virus can be transmitted sexually means that Zika has the potential to spread more broadly.

"Scientists are just gobsmacked" by the virus' sexual transmission, McNeil says. "Viruses mutate like crazy, but one thing they don't normally change is how they're transmitted. ... You don't expect a mosquito-borne virus to become something that can be transmitted through an act of unprotected sex. But this one is."

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On where the Aedes aegypti (Zika-carrying) mosquitoes are now, in relation to the U.S.

They're all over Puerto Rico and the U.S. Virgin Islands and American Samoa. The mosquitoes that can transmit Zika are the Aedes aegypti mosquito, the yellow fever mosquito, is strong or numerous all over Florida and the Gulf Coast, and there have been previous small outbreaks of dengue virus and chikungunya virus in Key West and Marin County, Fla., and Texas and in a few places like that.

The mosquitoes in very hot, wet summers can range as far as New York City and a touch north. It's not like they're very numerous up here and it's not like they're here every month, and it's not even like they're here every summer. But they have been found up this far north, so the potential for transmission is there, although it's low outside of the tropical Southeast.

On whether mosquitoes can fly long distances

There is no mosquito that typically flies far distances. They're really inefficient fliers, and one of the best ways to keep mosquitoes off you if you're having a barbecue is to keep a fan blowing on everybody, because most mosquitoes are lucky if they make it a mile in their lives. I mean, once in a while they fly onto a jet and they make it from Africa to Paris, and that's why you have occasional cases of airport malaria in Paris, but most of the time mosquitoes only get a few blocks.

On the World Health Organization's recommendation to not cancel the Olympics

The World Health Organization is not paying attention to the polluted bays, and not paying attention to the crime rate or anything like that, they're paying attention only to Zika. And their decision — it's only a recommendation on their part — but what they're saying is they don't think that [the threat of] Zika is so great that anybody ought to avoid going to the Olympics, or that the Olympics ought to be canceled, unless you're a pregnant woman, in which case pregnant women should avoid that, or unless you're somebody who is having sex with a pregnant woman or a woman who wants to get pregnant. ...

The basis for this is that August is winter in Rio and even though winter in Rio means temperatures of 70 to 80 degrees, it is the low mosquito season. If you look at the transmission of dengue or chikungunya in Rio, you see that it's roughly 5 percent of what it is at its height in January and February and March. So they figure the risk is fairly low, and the Brazilians have convinced them that they're going to do everything they can to empty standing water. ... I think fogging is mostly a semi-useless exercise, but they're going to do what they can. The recommendation is that it's OK to go unless you're pregnant or having sex with somebody pregnant.

Donald G. McNeil Jr. is a global health reporter for The New York Times.

W. W. Norton & Company

On how Zika is mostly a mild disease

Zika is a mild disease in 99.9 percent of cases, so it's not as bad as dengue or chikungunya, for example. It's not nearly as bad as malaria. It's one that if you're an otherwise healthy person, you shouldn't worry about. There's about 1 in 4,000 to 5,000 chance that somebody will get Guillain-Barre syndrome.

On seeing Zika cases pop up in the U.S. from being sexually transmitted

We don't have to wait for the Olympics for that to happen, it's happening right now. It happened in Texas in January. The virus can be transmitted sexually. That's a game-changer.

It's not clear how often it happens, but it happens often enough so that it's the second most common form of transmission. Right now, in New York City, despite all those subway posters saying "watch out for mosquitoes," frankly, those subway posters ought to have good-looking guys on them, because good-looking guys who have just come back from Puerto Rico or Brazil or the Virgin Islands or any place else are a bigger risk factor for Zika in New York City than mosquitoes are right now. There are no Aedes aegypti mosquitoes here, but there are good-looking Puerto Rican guys who might, in remote chances, be carrying the virus.

On how Zika can be sexually transmitted

We know it can be transmitted through vaginal sex. We also know it can be transmitted through anal sex. ... There is some suspicion that it can be transmitted through oral sex, because there's one case of a couple in France and it looks like she was infected through oral sex, so that may be a possibility, too. So basically any sex involving mucus membranes is dangerous. ...

It's only transmitted from men to women, or from men to other men. There is no known instance of a woman transmitting the disease to a man or a woman. The assumption is that the virus gets into either the prostate or the testes and sets up an infection there, and it can persist for a long time. We learned this with Ebola, that once a virus breaks into the immunologically privileged parts of the body, which are separate from the rest of the body and have their own sort of fluids — the eyes are immunologically privileged and the testes are immunologically privileged — once a virus gets in there, it's hard for it to break in, but once it gets in, it's hard for the body to get rid of it, because antibodies and white blood cells can't get in there to kill it.

Additional Information: Related NPR Stories Shots - Health News Mosquito Hunters Set Traps Across Houston, Search for Signs of Zika Shots - Health News Florida Governor Ramps Up Mosquito Fight To Stay Ahead Of Zika Goats and Soda What's The Best Way To Keep Mosquitoes From Biting?

On microcephaly, a birth defect caused by the Zika virus

It means a tiny head and generally a very underdeveloped brain. The babies have tiny, smooth brains and there are varying degrees of microcephaly. In the most severe, the baby dies or the baby is born unable to swallow, may have repeated seizures, and may die from those seizures and may never learn to walk, never learn to talk, never learn to control his or her bowels.

There's a whole range of ills that come out of it, and also along with that comes, since it's a virus that attacks the growing brain, things like the nerves that connect the eyes to the brain or the ears to the brain are often damaged along the way, so the baby will end up blind or deaf, but you may not know that when the baby is born, the eyes will look normal, but you suddenly realize they're not following objects or they're not hearing noises.

On the development of a Zika vaccine

It'll probably be two, three, four years until there's a vaccine. Most scientists who know vaccines say this is a disease that will be relatively easy to make a vaccine for because we have one for yellow fever, we have one for Japanese encephalitis, there's a new one for dengue. These are all related viruses. You could literally take the spines of those vaccine viruses and snip out the genes that code for the outside of the yellow fever virus and attach with DNA technology, the genes for the outside of the Zika virus, and make a pretty good vaccine. Some of those vaccines have already been made, but now the testing process begins, and testing takes pretty close to two years at the minimum.

On the Roman Catholic Church's position on contraception because of Zika

The church isn't speaking with one voice entirely on this issue. ... We have to draw a distinction between abortion and contraception here. No Catholic bishop and the pope ... are [ever] going to come out in favor of abortion, and their argument would be it's better to suffer from raising a child with severe handicaps than it is to take an innocent life.

On the other hand, there's been a fair amount of disparate statements within the church about contraception, in this case. The archbishop of Puerto Rico quickly spoke out against contraception when the health secretary of Puerto Rico suggested that women might want to delay pregnancy and say women should practice self-discipline. ...

But the pope, in a conversation with reporters ... was asked a question about Zika and said that under the doctrine of the lesser of two evils, it might be possible that contraception could be acceptable in a case like this, because it would prevent a great evil, like deformity and suffering of a child. He drew the parallel to Pope Paul VI allowing the use of contraceptives by Belgian nuns in the Belgian Congo, because so many of them were being raped during the liberation struggle of the 1960s. ... It was kind of shocking, but it opened the door to the possibility that contraception might be OK in what would be considered an extreme case like this.

Copyright 2016 Fresh Air. To see more, visit Fresh Air.
Categories: NPR Blogs

Teen Bullies And Their Victims Both Face A Higher Risk Of Suicide

NPR Health Blog - Tue, 06/28/2016 - 12:39pm

Suicidal thoughts are common in teenagers, and suicide is the second highest cause of death, after car crashes and other unintentional injuries.

Diverse Images/UIG/Getty Images

Bullying and cyberbullying are major risk factors for teen suicide. And both the bullies and their victims are at risk.

That's according to a report from the American Academy of Pediatrics that urges pediatricians and family doctors to routinely screen teenagers for suicide risks.

"Pediatricians need to be aware of the problem overall," says Benjamin Shain, a child and adolescent psychiatrist and lead author of the report published online Monday in the journal Pediatrics. "They should be screening for things like mood disorders, substance abuse as well as bullying."

Suicide is the number two cause of death of teenagers, after accidents including car crashes and accidental overdoses. The leading methods of suicide were suffocation and guns.

A CDC survey last year found that 17 percent of teens in high school said they had seriously considered suicide in the previous 12 months, and 2.7 percent had made an attempt that resulted in an injury.

Shain calls those numbers "phenomenal."

The AAP report says there is a clear relationship between bullying and suicide thoughts and attempts.

Suicidal ideation and behavior were increased in victims and bullies and were highest in people who were both bullies and victims of bullying, the report says.

And cyberbullying increased suicide attempts as much as face-to-face bullying.

Shain tells Shots that online bullying is particularly damaging because it's hard for the victim to get away from it.

"It's in black and white, you can see it, everyone else can see it, it doesn't go away," he says. "You're not safe in your own house."

The report recommends doctors talk with teens directly about suicide risk factors, including bullying, drug and alcohol abuse, mood disorders and physical or sexual abuse.

The report includes suggested dialog and questions for doctors to ask their teenage patients and said the children should be interviewed alone, away from their parents.

"Physicians, including pediatricians, can play a critical role in identifying mental health conditions and in preventing suicide," Dr. Christine Moutier, chief medical officer at the American Foundation for Suicide Prevention, said in a statement.

She recommends that doctors get training in how to identify teens who may be thinking of killing themselves.

Beyond bullying, the effect of the Internet on suicide risk was mixed. The report found that teenagers who spend more than five hours a day online are a greater risk of trying to kill themselves.

But the the Web provides a cushion of sorts, too.

Teens who search the term "suicide" online are much more likely to find information on suicide prevention, help lines and other support than web sites that support or describe suicide, the report found.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

States Offer Privacy Protection For Young Adults On Parents' Health Plan

NPR Health Blog - Tue, 06/28/2016 - 10:59am

How do you stay on the family health plan without your parents finding out about your health issues?

Alex Williamson/Ikon Images/Getty Images

The Affordable Care Act opened the door for millions of young adults to stay on their parents' health insurance until they turn 26.

But there's a downside to remaining on the family plan.

Chances are that Mom or Dad, as policyholder, will get a notice from the insurer every time the grown-up kid gets medical care, a breach of privacy that many young people may find unwelcome.

With this in mind, in recent years a handful of states have adopted laws or regulations that make it easier for dependents to keep medical communications confidential.

The privacy issue has long been recognized as important, particularly in the case of a woman who might fear reprisal if, for example, her husband learned she was using birth control against his wishes. But now the needs of adult children are also getting attention.

"There's a longstanding awareness that disclosures by insurers could create dangers for individuals," said Abigail English, director of the advocacy group Center for Adolescent Health and the Law, who has examined these laws. "But there was an added impetus to concerns about the confidentiality of insurance information with the dramatic increase in the number of young adults staying on their parents' plan until age 26" under the health law.

Federal law does offer some protections, but they are incomplete, privacy advocates say. The Health Insurance Portability and Accountability Act of 1996 is a key federal privacy law that established rules for when insurers, doctors, hospitals and others may disclose individuals' personal health information. HIPAA contains a privacy rule that allows people to request that their providers or health plan restrict the disclosure of information about their health or treatment. People can ask that their insurer not send to their parents the ubiquitous "explanation of benefits" form describing care received or denied, for example. But an insurer isn't obligated to honor that request.

In addition, HIPAA's privacy rule says that people can ask that their health plan communicate with them at an alternate location or by using a method other than the one it usually employs. Someone might ask that EOBs be sent by email rather than by mail, for example, or to a different address than that of the policyholder. The insurer has to accommodate those requests if the person says that disclosing the information would endanger them.

A number of states, including California, Colorado, Washington, Oregon and Maryland, have taken steps to clarify and strengthen the health insurance confidentiality protections in HIPAA or ensure their implementation.

In California, for example, all insurers have to honor a request by members that their information not be shared with a policyholder if they are receiving sensitive services such as reproductive health or drug treatment or if the patient believes that sharing the health information could lead to harm or harassment.

"There was concern that the lack of detail in HIPAA inhibited its use," said Rebecca Gudeman, senior attorney at the National Center for Youth Law, a California nonprofit group that helps provide resources to attorneys and groups representing the legal interests of poor children. She noted that HIPAA doesn't define endangerment, for example, and doesn't include details about how to implement confidentiality requests.

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Concerns by young people that their parents may find out about their medical care leads some to forgo the care altogether, while others go to free or low-cost clinics for reproductive and sexual health services, for example, and skip using their insurance. In 2014, 14 percent of people who received family planning services funded under the federal government's Title X program for low-income individuals had private health insurance coverage, according to the National Family Planning and Reproductive Health Association.

Even though most states don't require it, some insurers may accommodate confidentiality requests, said Dania Palanker, senior counsel for health and reproductive rights at the National Women's Law Center, a research and advocacy group.

"Inquire whether there will be information sent and whether there's a way to have it sent elsewhere," Palanker said. "It may be possible that the insurer has a process even if the state doesn't have a law."

Insurers' perspective on these types of rules vary. In California, after some initial concerns about how the law would be administered, insurers in the state worked with advocates on the bill, Gudeman said. "I give them a lot of credit," she said.

Restricting access to EOBs can be challenging to administer, said Clare Krusing, a spokesperson for America's Health Insurance Plans, a trade group. A health plan may mask or filter out a diagnosis or service code on the EOB, but provider credentials or pharmacy information may still hint at the services provided.

There's also good reason in many instances for insurers and policyholders to know the details about when a policy is used, experts say. Policyholders also may have difficulty tracking cost-sharing details such as how much remains on the deductible for their plan.

In addition, "if a consumer receives a filtered or masked EOB, he or she has no way of knowing whether their account has been compromised or used as part of fraudulent activity," Krusing said.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter:@mandrews110.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Does Your Body Really Refresh Itself Every 7 Years?

NPR Health Blog - Tue, 06/28/2016 - 5:00am
NPR's Skunk Bear YouTube

The latest episode of the podcast Invisibilia explores the idea that personality — something a lot of us think of as immutable — can change over time.

That got Invisibilia co-host Lulu Miller wondering if anything about us stays the same. Do all the cells in our body turn over every seven years as is sometimes claimed, with new cells replacing old ones? Or is there something that we hang on to for life?

Additional Information: The Personality Myth

We like to think of our own personalities, and those of our family and friends, as predictable, constant over time. But what if they aren't? What if nothing stays constant over a lifetime? Explore that enigma in the latest episode of the NPR podcast Invisibilia.

NPR's Skunk Bear crew decided to answer that question with a video.

Subscribe to Invisibilia!

It turns out that each body part has its own very distinct lifespan. The lining of the stomach, constantly under assault by digestive acid, is renewed every few days. But bones are refreshed once a decade. And there are a few parts of you that stay with you from birth to death.

Listen to the latest episode of Invisibilia and all the others here, and see what else Skunk Bear has been up to here. Would you like Skunk Bear to answer your science question in a future video? Post your question in Skunk Bear's YouTube comments and it might get picked!

Skunk Bear/NPR Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

How FluMist Slipped From Preferred To Passe

NPR Health Blog - Mon, 06/27/2016 - 4:21pm

Back in 2009, Ella Curry, 6, received a spritz of FluMist at Northwood High School in Silver Spring, Md.

Jacquelyn Martin/AP

What led to the abrupt fall of FluMist — the nasal spray version of influenza vaccine — which until recently was considered the first choice for younger children?

On Wednesday, an advisory panel to the Centers for Disease Control and Prevention concluded that the spray version was so ineffective, it shouldn't be used by anyone during the 2016-2017 flu season.

Just two years ago, that same Advisory Committee on Immunization Practices recommended FluMist as the preferred alternative for most kids ages 2-8, after reviewing several studies from 2006-2007 that suggested the spray was more effective in kids than the injectable forms of the vaccine.

What changed to make the spray so much less effective than studies had shown it to be in the past?

The bottom line is that right now "we don't understand what it is," said David Kimberlin, a professor of pediatrics at the University of Alabama, Birmingham, who said academic researchers and those at MedImmune, the subsidiary of Astra Zeneca that makes FluMist, are working to get answers.

Finding trouble spots in the timeline

FluMist is a live attenuated vaccine, meaning it contains a weakened version of the influenza virus but doesn't give the recipient the flu. Instead, the spray sparks the body's immune system to create antibodies to the virus. The injectable forms of the vaccine contain killed versions of the virus.

Among several studies the panel considered when it made its July 2014 preferential recommendation for FluMist was a 2004 randomized controlled trial — considered the best type of study — that found a 55 percent reduction in the number of flu cases among children who received the nasal spray compared with those who got the shot. Results were reported in the New England Journal of Medicine in 2007.

Three months after it made the recommendation, however, the CDC received some troubling data. During the 2013-2014 flu season, the nasal spray showed no measurable effectiveness against the pandemic H1N1 virus in kids ages 2 to 8. That was the predominant type of influenza virus circulating that year.

As a result, the panel in February 2015 didn't renew its preference for FluMist for the next flu season, although it was still considered a viable option.

At that meeting, the panel also heard that the spray had performed poorly in the 2014-2015 season.

Because vaccine makers have to guess months ahead of time what the predominant strains of the virus will be, designing the correct combination is always a gamble.

That time, they guessed wrong. More than two-thirds of the H3N2 versions of the virus circulating in the U.S. during the 2014-2015 season were different from the H3N2 versions in both the nasal spray and the injectable vaccines. So all versions of the vaccine — shots and spray — performed poorly.

Now, looking at this winter's flu season, the CDC says data show FluMist's efficacy among children 2-17 was only 3 percent, essentially providing no protective benefit.

For its part, AstraZeneca said the CDC's data for 2015-2016 are in sharp contrast with its own studies as well as preliminary findings by public health officials abroad.

"These findings demonstrate that FluMist ... was 46-58 percent effective overall against the circulating influenza strains during the 2015-2016 season," the firm said in a release Thursday.

U.S. sales of FluMist in 2015 totaled $206 million, about 1 percent of AstraZeneca's revenue.

In search of an explanation

In any given flu season, vaccine effectiveness varies. One factor is how well the vaccines match the virus that is actually prevalent. Other factors influencing effectiveness include the age and general health of the recipient. In the overall population, the CDC says studies show vaccines can reduce the risk of flu by about 50 to 60 percent when the vaccines are well-matched.

Now, researchers are trying to see what — if any — is the common factor behind FluMist's recent poor performance.

There's not a clear answer, said Henry Bernstein, a professor of pediatrics at Hofstra Northwell School of Medicine in New York and an ex officio member of the committee on infectious diseases for the American Academy of Pediatrics.

"We know that the influenza virus itself is totally unpredictable from one year to the next," he said.

Among the questions researchers are considering is why the strain of pandemic H1N1 used in the 2013-2014 flu season didn't perform well. The manufacturer's attempt to fix it in following seasons also did not work.

Several years ago, the vaccine also went from incorporating three flu virus strains to four. Did that somehow reduce its effectiveness? The earlier studies demonstrating that the spray was more effective than the shots were based on the three-virus vaccine, not the four-virus version.

Researchers will investigate whether the vaccine loses effectiveness for some reason when given to children who have had many previous flu vaccinations.

Uncertainty comes along with the territory for researchers.

But it's harder for the general public. Kids are bound to be especially disappointed.

"Once they found out about the nasal vaccine instead of the shot, they strongly, strongly preferred the nasal one," said Elizabeth Howton of Falls Church, Va., who has an 8-year-old and a 10-year-old.

Howton said she fears the uncertainty now surrounding the nasal spray will add to the skepticism some parents have about vaccines in general.

For her kids, there will be no skipping the vaccine. Even though it means a shot. Howton said she expects to offer "copious bribes," to sweeten the deal.

"I know they will be very disappointed, but I will still get them vaccinated," said Howton.

The public should be reassured that recommendation not to offer FluMist shows that public health agencies are watching carefully, said Bernstein.

"People need to recognize and applaud the idea that this type of monitoring and evaluation happens continuously," he said. "The CDC does evaluate the effectiveness of these public health initiatives, including vaccine effectiveness and safety."

While people who don't like needles will be disappointed, FluMist's absence is not likely to lead to an overall shortage, experts say.

The spray made up about 8 percent, according to the CDC, of the total projected supply of 176 million doses of flu vaccine being prepared for the upcoming flu season.

And despite the loss of this form of vaccine, the CDC and other experts continue to strongly recommend that just about everyone 6 months and older get vaccinated because influenza can cause serious illness and is blamed for thousands of deaths each year.

"The importance of preventing flu hasn't changed," Kimberlin said. "What has changed is we have one less tool."

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente. Follow Julie Appleby on Twitter: @Julie_appleby

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Fallout From Supreme Court Ruling Against Texas Law's Abortion Restrictions

NPR Health Blog - Mon, 06/27/2016 - 12:35pm

Abortion rights activists celebrate outside the U.S. Supreme Court Monday for a ruling in a case over a Texas law that places restrictions on abortion clinics.

Pete Marovich/Getty Images

In a decision striking down key aspects of a Texas abortion law Monday, the Supreme Court cast doubt on similar laws in nearly two-dozen states.

At issue in the court's decision were two specific provisions of a sweeping law to restrict abortions passed by the Texas Legislature in 2013. The provisions before the court required doctors who perform abortions to have admitting privileges at a hospital no more than 30 miles from the abortion clinic and required abortion clinics to meet the same health and safety standards as ambulatory surgical centers that perform much more complicated procedures.

Opponents of the bill argued before the court that if both requirements were to be enforced, only 10 clinics would remain to perform abortions in Texas, compared with more than 40 before the law was passed. Such limited access in a state so large would cause an "undue burden" on a woman's right to obtain an abortion, they said.

The court has said in the past that states can regulate access to abortion but not in a way that causes an undue burden on women.

In a 5-3 ruling, written by Justice Stephen Breyer, the court said that "both the admitting privileges and the surgical-center requirements place a substantial obstacle in the path of women seeking a previability abortion, constitute an undue burden on abortion access, and thus violate the Constitution."

One of the key questions was which side Justice Anthony Kennedy, who has been a swing vote on abortion issues, would join. He signed onto the majority opinion with the four justices who traditionally support abortion rights.The immediate impact of the ruling means that the plaintiff in the case, Whole Women's Health, will not have to close any more of its Texas clinics.

"Every day, Whole Woman's Health treats our patients with compassion, respect and dignity," said Amy Hagstrom Miller, the founder and CEO of the group. "And today the Supreme Court did the same. We're thrilled that today justice was served and our clinics stay open."

Many of the laws were based on models written by Americans United for Life, an anti-abortion legal group. Clarke Forsythe, the group's acting president, said today's decision "endangers women nationwide as health and safety standards are at risk."

The Center for Reproductive Rights, whose lawyers argued the Texas case before the Supreme Court, says the decision could have far-reaching implications. While each individual state law will have to be judged on its own merits, this decision represents "a clear statement by the court about what the standard should be in these types of cases," said Julie Rikelman, the director of litigation for the group. "The benefits of restriction have to outweigh the burden."

According to the Guttmacher Institute, 14 states, including Texas, require physicians that perform abortions to have admitting privileges or some other relationship with a nearby hospital, while 22 states have facility requirements that are very similar or exactly the same as requirements for ambulatory surgical centers.

Rikelman said that in several cases where state laws were blocked pending the outcome of this case, including in Wisconsin, Louisiana and Alabama, "this reinforces" lower court rulings that found those laws "were likely unconstitutional."

The main dissent in the case was written by Justice Samuel Alito, and joined by Chief Justice John Roberts and Justice Clarence Thomas. They argued that the constitutional question shouldn't have been triggered in the case, because part of the law had previously been challenged separately and the plaintiffs lost.

"As we have said, a losing litigant deserves no rematch after a defeat fairly suffered, in adversarial proceedings, on an issue identical in substance to the one he subsequently seeks to raise," the dissent said.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Julie Rovner is on Twitter: @jrovner.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Water Break: Is Your Child Drinking Enough Fluids This Summer?

NPR Health Blog - Mon, 06/27/2016 - 12:06pm

Most children in the U.S. don't drink enough water, and summer heat and outdoor play can increase water needs.

Erica Shires/Getty Images

Most children in the United States do not drink enough water, and when it's hot outside, they may need to drink even more.

But getting children to drink water can be a challenge. We spoke with medical experts, coaches, camp counselors and parents to find out how much water kids should drink in the summer, and how adults can help make sure they're getting enough.

How much water should kids drink on a hot day?

The Institute of Medicine offers recommendations that children ages 4 to 8 should drink about 2 quarts a day. That amount goes up as they get older, with 3.5 quarts a day recommended for teenage boys and 2.4 quarts a day for teenage girls. But that doesn't necessarily apply to a child playing tag on a hot asphalt playground.

"When children are outside and it's hot and humid, they need to drink more," says Stella Volpe, chair of the Department of Nutrition Sciences at Drexel University and member of the panel who set the recommendations. "Their sweating mechanisms aren't as well developed as in adults so they could tend to overheat faster."

Although it may seem to some that parents, teachers and coaches are hyper-conscious about kids' water needs today, research shows that most American children are mildly dehydrated.

There is no exact calculation for figuring out how much water is enough as kids run around faster and the temperature climbs higher. The good news, according to Dr. Kelsey Logan, director of the Division of Sports Medicine at Cincinnati Children's Hospital, is that in most cases kids will drink when they need to if water is available.

That makes sense to Sue DiPietro, a girls field hockey coach based in Westminster, Md. "I honestly have never felt like any of the girls have overexerted themselves to the point of dehydration or exhaustion," she says.

According to DiPietro, the first- through eighth-graders she coaches look forward to the water breaks she schedules roughly every 15 minutes during practices and games.

Still, if children don't have regular water breaks built into the day they can forget to drink, Logan says. "Some kids may get caught up in what they're doing and may exercise for a long time without even thinking to drink."

That's when parents, coaches and camp counselors need to step in and make sure that kids are drinking enough.

Does juice count?

Yes! All liquids in beverages and foods are included in a child's daily fluid intake. "Watermelon, soups, a milkshake, all count toward water needs because there's water in all those foods," says Volpe. "But we do want children to choose healthier beverages."

In most cases, medical experts agree that water is the best drink for hydrating kids. "Many parents think the first thing they should reach for is the sports drinks," says Dr. Patrice Evers, a pediatrician at Tulane University School of Medicine. "But really it should be water, unless your child is in the more elite athlete category."

How can parents tell if kids aren't drinking enough water?

"Decreasing frequency of urination is the first sign that kids could be becoming dehydrated," says Evers. She advises parents to check if their kids are urinating every four to five hours.

She also suggests that parents look for other signs of dehydration like darker urine, dry lips, a headache or a fast heart rate. A kid's demeanor might also be a clue. "A child who was previously happily playing and now just wants to sit down could be dehydrated," she explains.

Logan also adds that parents of athletes may want to consider weighing a child before and after a game to find out how much fluid the child lost and needs to replace. This strategy is especially important for teenagers, who sweat more heavily. "Kids can lose several pounds over the course of a game," she says.

How can adults encourage water breaks for kids?

The No. 1 rule is to always make sure there is plenty of water available. For children and teenagers who need a little extra encouragement, here are some tips:

  • Coaches should remind athletes to drink by scheduling water breaks every 15 to 20 minutes during practices, Logan says.
  • Parents can offer other fluid options in addition to water, Evers says, like homemade ice pops made from fresh fruit or juices.
  • For younger children, it's all about the cup, says Laila Al-Arian, a documentary filmmaker based in McLean, Va., and mother of two boys ages 3 years and 18 months. "My boys have certain preferred sippy cups and I try to put water in the ones they like the most." She also adds that when her boys see other kids on the playground drinking water, they want to drink it, too. "Peer pressure is really huge," she says.
  • Hydration packs can help, too, according to Erin Saunders, the education programs director who helps run Thorne Summer Camp in Boulder and Littleton, Colo. She says that the kids who have water backpacks with straws drink the most water on their own. "It's just more accessible. It's always right there," she says. For others, the counselors check water bottles every hour to make sure the kids are drinking enough.

So parents, take heart. The solution can be as sweet and simple as a strawberry fruit pop or a favorite sippy cup.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Inside A Secret Government Warehouse Prepped For Health Catastrophes

NPR Health Blog - Mon, 06/27/2016 - 4:56am
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June 27, 20164:56 AM ET Heard on Morning Edition

Stacks of boxes containing critical supplies stretch almost as far as the eye can see in this Strategic National Stockpile warehouse.

Courtesy of the CDC

When Greg Burel tells people he's in charge of some secret government warehouses, he often gets asked if they're like the one at the end of Raiders of the Lost Ark, where the Ark of the Covenant gets packed away in a crate and hidden forever.

"Well, no, not really," says Burel, director of a program called the Strategic National Stockpile at the Centers for Disease Control and Prevention.

Thousands of lives might someday depend on this stockpile, which holds all kinds of medical supplies that the officials would need in the wake of a terrorist attack with a chemical, biological or nuclear weapon.

The location of these warehouses is secret. How many there are is secret. (Although a former government official recently said at a public meeting that there are six.) And exactly what's in them is secret.

"If everybody knows exactly what we have, then you know exactly what you can do to us that we can't fix," says Burel. "And we just don't want that to happen."

What he will reveal is how much the stockpile is worth: "We currently value the inventory at a little over $7 billion."

But some public health specialists worry about how all this would actually be deployed in an emergency.

"The warehouse is fine in terms of the management of stuff in there. What gets in the warehouse and where does it go after the warehouse, and how fast does it go to people, is where we have questions," says Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University.

I recently asked to go take a look at one of the warehouses, and was surprised when the answer was yes. I was told I was the first reporter ever to visit a stockpile storage site.

Bob Delaney moved a pallet of surgical masks in Utah in 2009. Like other states, Utah received supplies from the Strategic National Stockpile to prepare for a flu pandemic.

Francisco Kjolseth/The Salt Lake Tribune/AP

Since I had to sign a confidentiality agreement, I can't describe the outside. But the inside is huge.

"If you envision, say, a Super Walmart and stick two of those side by side and take out all the drop ceiling, that's about the same kind of space that we would occupy in one of these storage locations," Burel says.

A big American flag hangs from the ceiling, and shelves packed with stuff stand so tall that looking up makes me dizzy.

"We have the capability, if something bad happens, that we can intervene in a positive way, but then we don't ever want to have to do that. So it's kind of a strange place," says Burel. "But we would be foolish not to prepare for those events that we could predict might happen."

The Strategic National Stockpile got its start back in 1999, with a budget of about $50 million. Since then, even though the details aren't public, it's clear that it has amassed an incredible array of countermeasures against possible security threats.

The inventory includes millions of doses of vaccines against bioterrorism agents like smallpox, antivirals in case of a deadly flu pandemic, medicines used to treat radiation sickness and burns, chemical agent antidotes, wound care supplies, IV fluids and antibiotics.

I notice that one section of the warehouse is caged off and locked. Shirley Mabry, the logistics chief for the stockpile, says that's for medicines like painkillers that could be addictive, "so that there's no pilferage of those items."

As we walk, I hear a loud hum. It's a giant freezer packed with products that have to be kept cold.

Just outside it, there are rows upon rows of ventilators that could keep sick or injured people breathing. Mabry explains that they're kept in a constant state of readiness. "If you look down to the side you'll see there's electrical outlets so they can be charged once a month," she says. Not only that—the ventilators get sent out for yearly maintenance.

In fact, everything here has to be inventoried once a year, and expiration dates have to be checked. Just tending to this vast stash costs a bundle — the stockpile program's budget is more than half a billion dollars a year.

And figuring out what to buy and put in the stockpile is no easy task. The government first has to decide which threats are realistic and then decide what can be done to prepare. "That's where we have a huge, complex bureaucracy trying to sort through that," says Redlener.

The process goes by the clunky acronym PHEMCE and involves agencies from the Department of Defense to the Food and Drug Administration. They're looking to acquire or develop products that can meet the threats.

"A lot of under-the-hood, background work goes into identifying what the size, the scope, the special needs are, and what medical countermeasures exist or need to be made," says George Korch, senior adviser to the assistant secretary for preparedness and response at the Department of Health and Human Services. "That then drives the rest of the process for research, development, procurement, stockpiling, et cetera."

There is often debate, he says, but at the end of the day they have to reach a consensus and move forward.

"We could start stockpiling cobra antivenom if we really wanted to, but should we?" says Rocco Casagrande, who runs a consulting firm called Gryphon Scientific.

The government recently hired Gryphon to do an analysis of how well the stockpile was positioned to respond to a range of scenarios based on intelligence information. "The studies that were done before have all been one-off. They've all been looking at a single type of attack at a time, or a single type of weapon of mass destruction," says Casagrande. "They haven't looked across all threats to make decisions about whether you should buy A versus B."

The results can't be discussed publicly, says Casagrande, but "one thing we can say is that across the variety of threats that we examined, the Strategic National Stockpile has the adequate amount of materials in it and by and large the right type of thing."

The trouble is, increasingly the new medicines chosen for the stockpile have some real limitations.

"These are often very powerful, very exciting and useful new medicines, but they are also very expensive and they expire after a couple years," says Dr. Tara O'Toole, a former homeland security official who is now at In-Q-Tel, a nonprofit that helps bring technological innovation to the U. S. intelligence community.

O'Toole chairs a recently formed committee at the National Academies of Sciences, Engineering and Medicine, which the government asked to study the stockpile program and offer advice. She says as the inventory of the stockpile goes up and up, the budget to maintain that inventory is staying flat.

"This is an unsustainable plan," she says. "And we don't think there's enough money to do what the stockpile says it must do, already."

That's because getting stuff out of the stockpile to the people who would need it is a major challenge. Imagine if there's a major anthrax attack, and there's just 48 hours to get prophylactic antibiotics to more than a million people.

"It is not going to be easy or simple to put medicines in the hand of everybody who wants it," says O'Toole.

Back at the warehouse, Mabry and Burel show me all the ways they're set up to expedite delivery. For example, one of the first things you see when you walk into the warehouse is rows of 130 shipping containers. "This is the 12-hour push package, approximately 50 tons of material," says Mabry.

This collection of stuff could help after a variety of disasters, and it's designed to be delivered to a city or town within hours. Mabry shows me how the outside of each container has a pouch. "That has the information that anyone would need if they were to receive this, so they could very easily identify what is in this," she explains.

The people who would receive this container — or anything else from the stockpile — are state and local public health workers. They're the ones who have to figure out how get pills into mouths and shots into arms.

But local public health officials have had budget cuts and are drastically underfunded, says Paul Petersen, director of emergency preparedness for Tennessee.

"Many jurisdictions across the U. S. have less staff and less resources available to them to surge up in large-scale events," says Petersen. "I mean, that's a risk."

While they do have plans for emergencies, and lists of volunteers, he says, "they're volunteers. And they're not guaranteed to show up in the time of need."

Over and over, I heard worries about this part of the stockpile system.

"We have drastically decreased the level of state public health resources in the last decade. We've lost 50,000 state and local health officials. That's a huge hit," says O'Toole, who wishes local officials would get more money for things like emergency drills. "The notion that this is all going to be top down, that the feds are in charge and the feds will deliver, is wrong."

She'd also like to see more interest from Congress in all of this — because it's a national security issue. "These will be do-or-die days for America, should they ever come upon us," O'Toole points out.

And having a stockpile in a warehouse will be just the beginning.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

To Help A Criminal Go Straight, Help Him Change How He Thinks

NPR Health Blog - Sun, 06/26/2016 - 7:00am
Lorenzo Gritti for NPR

Hard-core criminals are trapped in a vicious circle of their own thinking. Cognitive treatment of offenders can show them a way out of that trap. With effort and practice, even the most serious offenders can learn to change their thinking about other people and themselves. They can learn to be good citizens, and feel good about it. But in most cases the criminal justice system doesn't present them that opportunity — not in a form that offenders recognize as genuine.

Since 1973, I've been working to develop and deliver cognitive treatment to medium- to high-risk offenders in juvenile and adult detention centers, jails and prisons. The treatment is rooted in cognitive-behavioral therapy, which has proved effective in treating a wide range of mental disorders.

In the 1950s and 1960s, psychiatrist Aaron Beck discovered that his depressed patients had habits of thinking that kept them depressed. ("I'm no good.") At about the same time, Albert Ellis found that patients with a wide range of neuroses held what he called "irrational beliefs." ("Everyone must like me all the time.") Both based their psychotherapy on leading their patients to change that thinking.

Additional Information: The Personality Myth

We like to think of our own personalities, and those of our family and friends, as predictable, constant over time. But what if they aren't? What if nothing stays constant over a lifetime? Explore that enigma in the latest episode of the NPR podcast Invisibilia.

In correctional treatment, cognitive therapy has evolved to include cognitive skills training, like how to solve problems, how to deal with social situations, and how to control your anger.

The idea is to change the thinking that lands offenders in trouble, like "I'll never snitch," "I'll never back down," "I'm going to take what I want," and "If anyone disrespects me, I'm going to attack." Forms of cognitive treatment have become the predominant treatment for offenders in the U.S. and Europe. Underlying it is the realization that criminal behavior is the result of criminal ways of thinking, and that for offenders to change their behavior they must change the way they think.

In the 1990s, Canadian researchers discovered that treatment of offenders is effective, but only if it addresses what they called "criminogenic needs." Chief among these is criminal thinking. More recently, researchers have established that cognitive treatment programs delivered with professional standards can reduce recidivism by 25 to 35 percent. That means saving taxpayer money on incarceration, which costs $31,286 per inmate per year on average. It also means safer communities, more intact families, more people back in the workplace.

This doesn't mean we should replace incarceration with treatment, or let people out of prison early just because they have taken treatment. But adding treatment to incarceration provides hope to offenders now, and benefits to society in the future.

Incarceration is a basic tool of criminal justice, but when the sole purpose is punishment and confinement, offenders respond, in the privacy of their own minds, with resentment and defiance. The thinking that led them to offend is not extinguished by punishment; it is reinforced.

Criminal justice need not be solely punitive. We can enforce the law without compromise and without triggering offenders' resistance. We can offer genuine opportunities to change. And we can acknowledge offenders' innate freedom to choose the attitudes they live by. My colleagues and I call this strategy "supportive authority." It consists of conveying three messages at the same time, spoken with one voice.

  • We are determined to enforce the laws.
  • We offer you a genuine opportunity to change and take part in society.
  • We respect your capacity to make your own choices.

Enforcement of rules and laws is the core, but we don't stop there. Punishment is tempered with the opportunity to join with us in our common society. That invitation must be real, and each offender must be able to recognize it as such. It includes the opportunity to escape the trap of their habits of thinking.

And finally, we acknowledge that each offender will decide whether to take the opportunity to change or to continue to break the law. Offenders know they always retain the power to freely think, the human freedom to choose their own path in life, whether the rest of us like it or not. By acknowledging this freedom, we are giving them nothing they don't already have. We are simply conveying respect for them as human beings. As Viktor Frankl said in Man's Search For Meaning: "Everything can be taken from a man but one thing: the last of the human freedoms — to choose one's attitude in any given set of circumstances, to choose one's own way."

Providing offenders an opportunity to change their thinking, their lives and their place in society is in everyone's interest. It does not compromise our enforcement of the law. But it demands changes in our thinking: to see criminals as fellow human beings and to provide genuine opportunities for ex-offenders to take part in society.

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Time and again I've seen real change happen. Ken had been a criminal all his life. "I wanted to be the baddest criminal anybody had ever seen," he said. In prison he was a convict leader and a strong upholder of the convict code. In spite of his reputation, the administration of Oregon State Penitentiary recognized his potential to change. Ken came to understand the pain he had brought to others and that his hurtful actions came not from what others had done to him but from his own ways of thinking. He developed a new goal: "I want to be an honorable man."

Once he was out of prison, Ken learned and practiced ways to think that allowed him to marry, to hold jobs in drug treatment programs or gas stations or anything he could find to earn an honest living. The 20-plus years since his release from prison have been hard, but he's a taxpaying citizen — and an honorable man.

I've also seen failures. Like many medical treatments, sometimes behavioral treatment works and sometimes it doesn't. People who take statins to lower cholesterol sometimes still have heart attacks, and convicts who have been in treatment programs sometimes re-offend. The question is, how can we maximize the positive results and minimize the failures?

I recently visited Red Onion State Prison in Wise County, Va., a "supermax" facility for "the worst of the worst" that had come under Department of Justice scrutiny for excessive use of solitary confinement. This prison is in the process of changing from what had been a culture of control and punishment into a culture of control and hope. Prison officers and counselors are trained to treat prisoners with respect. They are also trained to support and deliver an array of cognitive treatment programs. Offenders are presented with pathways leading from solitary confinement to lower levels of control and eventually, for most of them, to re-entry and life in the community.

Since 2011, there has been a 68 percent reduction in the number of prisoners at Red Onion confined to solitary; a 78 percent reduction in incident reports; and a 91 percent decrease in inmate grievances, efforts praised in a January report from the Department of Justice.

At Red Onion, cognitive treatment is a key piece of the system, but only a piece. The whole prison is the intervention.

Jack Bush is co-developer of the treatment program Thinking For A Change, published by The National Institute of Corrections, and co-author with Daryl Harris and Richard Parker of Cognitive Self Change: How Offenders Experience the World and What We Can Do About It (Wiley Blackwell, 2016).

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Personality Tests Are Popular, But Do They Capture The Real You?

NPR Health Blog - Sat, 06/25/2016 - 5:18am
Jeannie Phan for NPR

Twelve years ago, I tried to drive a stake into the heart of the personality-testing industry. Personality tests are neither valid nor reliable, I argued, and we should stop using them — especially for making decisions that affect the course of people's lives, like workplace hiring and promotion.

But if I thought that my book, The Cult of Personality Testing, would lead to change in the world, I was keenly mistaken. Personality tests appear to be more popular than ever. I say "appear" because — today as when I wrote the book — verifiable numbers on the use of such tests are hard to come by.

Personality testing is an industry the way astrology or dream analysis is an industry: slippery, often underground, hard to monitor or measure. There are the personality tests administered to job applicants "to determine if you're a good fit for the company"; there are the personality tests imposed on people who are already employed, "in order to facilitate teamwork"; there are the personality tests we take voluntarily, in career counseling offices and on self-improvement retreats and in the back pages of magazines (or, increasingly, online).

I know these tests are popular because after the book was published, most of the people I heard from were personality-test enthusiasts, eager to rebut my critique of the tests that had, they said, changed their lives.

Additional Information: The Personality Myth

We like to think of our own personalities, and those of our family and friends, as predictable, constant over time. But what if they aren't? What if nothing stays constant over a lifetime? Explore that enigma in the latest episode of the NPR podcast Invisibilia.

Actually, it was just one test they were talking about: the Myers-Briggs Type Indicator. If you've ever made a new acquaintance who, after conversing with you for a minute, says, "Are you an INTJ? Because my sister-in-law is an INTJ and you remind me of her, and as an ESFP I'm obviously your opposite, but as long as we know that, we can get along and work together really well," you've met an MBTI convert. The MBTI is a secular religion, and no amount of scientific evidence will dissuade its true believers. I have tried, and have repeatedly been told that it's clearly my fill-in-a-four-letter-personality-type-here nature that makes me so skeptical.

After a number of encounters of this sort, I developed a tolerance and even an affection for type-obsessed fans of the MBTI. Sure, their instrument is a Carl Jung-inspired load of nonsense engineered to make everyone who takes it feel good about themselves. On the other hand, insight often turns up in unlikely places. Wherever you find illumination, I began to tell the type disciples I met, you should seize it.

But the one manifestation of personality testing to which I have never been able to accommodate myself is the administration of tests to captive audiences: students and employees required to place themselves in boxes for an administrator's convenience. If my marshaling of scientific evidence against the test failed to change many minds, I hope that the narrative in which that evidence is embedded makes my larger point: that human beings are far too complex, too mysterious and too interesting to be defined by the banal categories of personality tests.

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Indeed, the creators of major personality tests are themselves a colorful bunch of characters whose tests were largely reflective of their own idiosyncrasies. In researching and writing their life stories, I came to believe that personality tests tell us less about the individuals who take them than about the individuals who devised them:

  • There's Hermann Rorschach, the Swiss psychiatrist who turned a parlor game into the iconic inkblot test — the results of which were for decades taken very seriously in courtrooms and mental hospitals.
  • There's Henry Murray, the patrician (and married) professor who developed the Thematic Apperception Test with the help of his lover, who worked alongside him at his Harvard clinic.
  • There's Starke Hathaway, the Midwestern psychologist who included questions about test-takers' religious beliefs, sex lives and bathroom habits in his influential instrument, the Minnesota Multiphasic Personality Inventory (MMPI).
  • And, of course, there's Isabel Myers, the Pennsylvania housewife who was inspired to turn Jung's cryptic writings into a personality test accessible to all. Her mother, Katharine Briggs, helped with this endeavor, and at first the test was called the Briggs-Myers Type Indicator; the order of the names was reversed starting in 1956.

Myers typed herself as an INFP (that is, introverted-intuitive-feeling-perceiving). Having spent many months poring over her letters and journal entries, reading the recollections of those who knew her and reporting on the way she turned an obscure psychological theory into a personality test that has been taken by millions of people worldwide, I can tell you that a string of four letters doesn't come close to capturing the fascinating complexities of this woman. If Myers imagined that her multitudes could be contained by four pseudo-Jungian descriptors — well, that was her limitation. We don't have to make it ours.

Annie Murphy Paul is a journalist and author of The Cult of Personality Testing.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Minnesota's Largest Health Insurer Will Drop Individual Plans

NPR Health Blog - Fri, 06/24/2016 - 2:24pm

At Blue Cross and Blue Shield headquarters in Eagan, Minn., the losses on the sale of insurance plans to individuals led to a change in course.

Jim Mone/AP

Blue Cross and Blue Shield of Minnesota will retreat from the sale of health plans to individuals and families in the state starting next year. The insurer, Minnesota's largest, said extraordinary financial losses drove the decision.

"Based on current medical claim trends, Blue Cross is projecting a total loss of more than $500 million in the individual [health plan] segment over three years," the insurer said in an emailed statement.

The Blues reported a loss of $265 million on insurance operations from individual market plans in 2015. The insurer said claims for medical care far exceeded premium revenue for those plans.

"The individual market remains in transition and we look forward to working toward a more stable path with policy leaders here in Minnesota and at the national level," the company stated. "Shifts and changes in health plan participation and market segments have contributed to a volatile individual market, where costs and prices have been escalating at unprecedented levels."

The decision will have far-reaching implications.

Blue Cross Blue Shield says the change will affect about "103,000 Minnesotans [who] have purchased Blue Cross coverage on their own, through an agent or broker, or on MNsure," the state's insurance exchange.

"We understand and regret the difficulty we know this causes for some of our members," the insurer wrote. "We will be notifying all of our members individually and work with them to assess and transition to alternative coverage options in 2017."

Cynthia Cox of the Kaiser Family Foundation, who analyzes individual health insurance markets around the country, says what the Blues are doing in Minnesota is similar to a walk back by UnitedHealth Group, the nation's largest health insurance company.

"Right now what it seems like is that insurance companies are really trying to reset their strategy," Cox said. "So they may be pulling out selectively in certain markets to re-evaluate their strategy and participation in the exchanges."

She said the individual markets just aren't turning out as expected. "The hope was that these markets would encourage exchange competition and [get] more insurers to come in. ... I don't know if we're at a point where it's completely worrisome, but I think it does raise some red flags in pointing out that insurance companies need to be able to make a profit or at least cover their costs."

In response to the development in Minnesota, Gov. Mark Dayton, a Democrat, highlighted gains in enrolling more Minnesotans in health insurance plans since the implementation of the Affordable Care Act. But he also acknowledged the insurer's departure reflects the instability in the market for individual and family coverage.

"This creates a serious and unintended challenge for the individual market: the Minnesotans who seek coverage there tend to have greater, more expensive health care needs than the general population," said Dayton. "Blue Cross Blue Shield's decision to leave the individual market is symptomatic of conditions in the national health insurance marketplace.

University of Minnesota health economist Roger Feldman called the Blues' departure a major blow to Minnesota's already troubled individual market.
"What this says about the individual market is that it is very unstable and it has been disrupted by a number of events, and we still don't know whether it will recover or not from those disruptions," he said.

Feldman said lawmakers would be wise to pay attention to the unstable individual markets and to shore them up with a carrot and stick approach.

"To get people to sign up in the exchange we need one or both of those," he said. "The stick could be to raise the penalties on people who don't buy insurance, and the carrot could be to increase the subsidies for people that do. I think that's the only way that we're going to get a decent mix of risks to buy into that exchange."

Although the main Blue Cross Blue Shield unit is leaving Minnesota's individual market, its much smaller subsidiary, Blue Plus, will continue to offer plans on the individual market, according to the company statement. Blue Plus has only about 13,000 members, according to his message.

Kaiser's Cox says that's typical and leaves insurers a re-entrance option.

MNsure spokesman Shane Delaney said about 20,000 Minnesotans purchased Blue Cross and Blue Shield of Minnesota plans through MNsure. He said the vast majority of them qualified for tax credits to help pay premiums. Delaney said all of the Blue Cross and Blue Shield customers losing their coverage next year should look for other options on MNsure, the only place eligible applicants can secure federal tax credits.

This story is part of a reporting partnership with NPR, Minnesota Public Radio and Kaiser Health News. You can follow Mark Zdechlik on Twitter: @MarkZdechlik.

Copyright 2016 Minnesota Public Radio. To see more, visit Minnesota Public Radio.
Categories: NPR Blogs

Changes For Colon Cancer Screening: 5 Things To Know Now

NPR Health Blog - Fri, 06/24/2016 - 12:03pm

Tests you can take at home to check for colorectal cancer are now recommended on par with colonoscopy.

Janis Christie/Getty Images

It's a predictable passage in life: Hit 50, get lots of birthday cards with old-age jokes, a mailbox full of AARP solicitations — and a colonoscopy.

But millions of Americans — about one-third of those in the recommended age range for colon cancer screening — haven't been tested. Some avoid it because they are squeamish about the procedure, or worried about the rare, but potentially serious, complications that can occur during colonoscopies.

Now, an influential panel has added some new choices, aiming to get more Americans screened for colorectal cancer, which is the second leading cause of cancer death in the U.S.

Here are five things to know now:

1) Getting tested — in any of a variety of ways — is a good thing.

Following its review of all the available medical evidence, the U.S. Preventive Services Task Force — an independent blue-ribbon panel of medical experts — updated its colorectal cancer screening guidelines. The panel gave an A rating to screening all adults between ages 50 and 75 years at average risk of the disease, saying the benefits are "substantial." People with a family history or other risk factors might want to start earlier — and those older than 75 should talk with their doctors about whether to continue screening.

Noting that not enough Americans are getting screened, the panel essentially said the best test is the one that patients will take: "The goal is to maximize the total number of persons who are screened because that will have the largest effect on reducing colorectal cancer deaths."

2) Two less-invasive tests may qualify for free preventive screening.

The biggest change from prior guidelines is the panel's inclusion of two more ways to screen for the disease, including virtual colonoscopies, like the one President Obama had in 2010. Also called computed tomography (CT) colonography, the test uses special X-ray machines to examine the colon. The panel also added a $650 home test called Cologuard, which checks stool for elevated levels of altered DNA that could indicate cancer. Those tests join several others that were part of the panel's previous recommendations: the full colon exam called colonoscopy; sigmoidoscopy, which uses a lighted tube and camera to examine just the lower portion of the colon; and two other types of home stool tests, fecal occult-blood tests and fecal immunochemical tests. Because of the task force's A rating for colon cancer preventive screening, these tests generally must be offered to insured patients without a copayment or deductible under the rules put in place by the Affordable Care Act.

3) Don't expect all insurers to drop copays on the new tests right away.

While Medicare already covers Cologuard as a preventive screening tool, many private insurers don't. Of people with private insurance who are in the target age range, about 1 in 4 currently has coverage for the test, said Kevin Conroy, president and CEO of Exact Sciences, which makes the test. "That's going to change," he said, "because health plans have told us that they will follow the task force's guidelines."

When it comes to virtual colonoscopies, some insurers — including Cigna — cover them, but Medicare doesn't. In 2009, Medicare said there was insufficient medical evidence to determine whether such tests should be covered nationally.

Now Medicare will likely be asked by proponents of virtual colonoscopy to revisit that decision.

Under Obamacare, insurers have up to a year to incorporate A- or B-rated screening tests into their benefit packages without a copayment. But there is some ambiguity in this case because the screening itself — not the individual tests — was given the A rating. While many experts believe insurers must offer all the types of tests, that isn't entirely clear. Insurers and patient advocate groups both say they will seek additional clarity from the Obama administration.

4) The task force didn't pick favorites.

The panel did not rank the tests, noting a lack of head-to-head comparisons showing any one method has the most net benefit. All tests have pros and cons. For example, getting a colonoscopy every 10 years has the advantage that, if potentially cancerous polyps are detected, they can be removed during the procedure. But it also carries a small risk of harmful complications, such as anesthesia-related cardiac problems, bowel perforations or abdominal pain. Sigmoidoscopy at five-year intervals has a lower rate of complications, but can miss some cancers because it doesn't reach the entire colon. Annual stool tests, which don't themselves carry any risk, reduce colorectal cancer deaths, the panel noted. The newer FIT immunochemical stool tests are a bit better at spotting cancers than FOBT, which studies show can correctly identify cancers 62 percent to 79 percent of the time. Cologuard — recommended every one to three years — detects existing cancers 92 percent of the time, but has a higher false-positive rate than FIT. Virtual colonoscopies, which expose patients to X-ray radiation, spot existing cancers of 10 millimeters or larger 67 percent to 94 percent of the time. The exam can also lead to additional, sometimes unnecessary testing because it flags potential problems outside the colon 40 percent to 70 percent of the time, with only about 3 percent of those concerns ultimately needing some form of treatment, the panel noted.

5) You might still get hit with a copayment.

Although preventive screening is covered without copayments or deductibles, some patients still end up with a bill. Medicare, most notably, requires a 20 percent copay if a polyp is found during a screening colonoscopy and removed. That payment averages $272, although advocates say they have seen far higher bills. Most private insurers do not charge patients if a polyp is found during a preventive screening, following Obama administration clarifications on the topic.

Two bills in Congress aim to apply those same rules to Medicare.

Another way consumers can get hit with a copayment is if a stool test, sigmoidoscopy or other exam indicates cancer might exist. A colonoscopy is then performed and some insurers consider that test a diagnostic exam, rather than a preventive screening. The American Cancer Society Cancer Action Network says it has asked the administration to clarify what happens in such a case. "If a patient has a positive test, the next step is colonoscopy, and therefore should be covered without cost-sharing," said Caroline Powers, director of federal relations with ACSCAN. "We're trying to get more people screened."

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente. Follow Julie Appleby on Twitter: @Julie_appleby.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Are Your Pipes Made Of Lead? Here's A Quick Way To Find Out

NPR Health Blog - Fri, 06/24/2016 - 5:00am

Lead pipes like this one still bring water into many U.S. homes.

Seth Perlman/AP

All the bad news around lead and water has people worried. So we decided to create a step-by-step guide to help find out if the pipe bringing water into your home is made of lead. Get started here.

Until the 1970s, lead was a common additive in gasoline and household paints. But now, scientists agree that no amount of lead in a child's blood is considered safe.

In kids, even low levels of lead exposure can cause behavior and learning problems. In adults, it's associated with high blood pressure and kidney problems. And there's evidence it can affect a developing fetus.

Corrosive water running through lead pipes in Flint, Mich., led to a public health crisis — signaled in part by a rise in the amount of lead in children's blood. Conditions in Flint were particularly disastrous, but lead pipes continue to bring water to homes in much of the country. And wherever lead plumbing is in place, there is a risk that small amounts of the metal could leach into drinking water.

What are your pipes made of? Click here to find out. All you need is a key and a magnet.

The main source of lead in domestic drinking water is the service line. It's like a straw that carries water to the house from the main, and it can be pure lead. (If it isn't made of lead, it might be soldered together with lead or connected to brass fixtures containing lead.) And in many cities, most of the service line is considered private property – the homeowner's responsibility.

Anti-corrosive chemicals can reduce the amount of lead leaching into the water, but they can't stop it entirely. Lead can still flake off from pipes or soldering in tiny pieces and end up in drinking water, especially when it sits in pipes for more than a few hours. Other things can shake lead free, like construction or heavy trucks driving down the road.

And if you do find lead, the online guide can show you what you can do. Comment below to let us know what you think.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Invisibilia: Is Your Personality Fixed, Or Can You Change Who You Are?

NPR Health Blog - Fri, 06/24/2016 - 3:00am
Kristen Uroda for NPR

Editor's note: This is an excerpt from the latest episode of the Invisibilia podcast and program, which is broadcast on participating public radio stations. This story contains language that some may find offensive.

Additional Information: Listen To The Episode

This is the story of a prisoner who committed a horrible crime and says he's no longer the same person who did it. It's also the story of why it's so hard for us to believe him.

In the early 1960s, a young psychologist at Harvard University was assigned to teach a class on personality. Though Walter Mischel was excited to prove himself as a teacher, there was one small problem: He didn't happen to know very much about personality.

"So, realizing I had to teach this stuff, I decided to look at the literature," says Mischel, who now works at Columbia University. "And I found myself enormously puzzled."

Mischel, like pretty much every other psychologist at the time, had some basic assumptions about personality. The first was that people had different personalities, and that those personalities could be defined by certain traits, such as extroversion, conscientiousness, sociability.

At the time, personality researchers liked to argue about which traits were most important. But they never argued about the underlying premise of their field — that whatever traits you had were stable throughout your life and consistent across different situations.

"For example, a friendly person is someone who should be friendly over time," Mischel says. "So if he's friendly at 20, he should be friendly at 25. And if he's friendly, he should be friendly across most situations in which friendliness is a reasonable and accepted possible way of being."

Thus an honest person would behave like an honest person no matter where they went or how much time passed, and a criminal would remain a criminal.

But when Walter Mischel sat down to do his literature review, he didn't find much support for the idea that personality is stable. "I expected to find that the assumptions would be justified," he says, "and then I started reading study after study that found that actually the data didn't support it."

Psychologist Walter Mischel says that if you think his famous marshmallow test means that people's traits are fixed from birth, you're wrong.

David Dini/Courtesy of Columbia University

One enormous study on honesty in children was done way back in 1928. The researchers, Hugh Hartshorne and Mark May, had put thousands of children in different settings where they had the opportunity to cheat or steal.

"And it came out with results that were shocking at the time," Mischel says. The same child who cheated in math class could be honorable in a different class — no cheating. "They were not consistently anything," he says. "They were inconsistent in their honesty."

The studies Mischel was reviewing were all looking for consistency in personality across situations — and none of them were finding it.

And researchers seemed to be ignoring this, dismissing the fact that study after study was finding no consistency in personality.

Mischel ended up writing a book called Personality and Assessment in 1968 that challenged some of the most basic ideas we have about the role personality plays in our lives. He said that the idea that our personality traits are consistent is pretty much a mirage.

But that idea was so hard for people to wrap their heads around. Mischel tried in many ways to make it stick, but never did. In fact, the irony of Walter Mischel's career is that he himself is remembered as proving the very opposite of what he actually believes.

It has to do with Mischel's most famous experiment, called the marshmallow test, which he first conducted in 1960. You can still find videos of it on YouTube. Mischel would give a small child a marshmallow, a cookie or a pretzel, telling her or him that they could eat it now — or if they could wait for a few minutes, they'd get two marshmallows or cookies. Then he left the room. Given that the children in the study were 4 to 6 years old, the marshmallow often got gobbled up.

But sometimes Mischel told the child ahead of time that she could just pretend that the marshmallow was not really there. Then "the same child waits 15 minutes," he says now. "It's a very small change that's been made in how the child is representing the object — is it real or is it a picture? And by changing the representation, you dramatically change her behavior."

The vast majority of children in Mischel's study were able to delay gratification when they reframed their interpretations of the situation in front of them.

The point of the marshmallow test was to show how flexible people are — how easily changed if they simply reinterpret the way they frame the situation around them. But that's not the moral that our culture drew from the marshmallow study. We decided that those traits in the preschoolers were fixed — that their self-control at age 4 determined their success throughout life. They're happier, have better relationships, do better at school and at work.

LATorontoBlog YouTube

The marshmallow test became the poster child for the idea that there are specific personality traits that are stable and consistent. And this drives Walter Mischel crazy.

"That iconic story is upside-down wrong," Mischel says. "That your future is in a marshmallow. Because it isn't."

So how did we get it so wrong? Psychologists have come up with all sorts of theories. One is that the consistency we see in people's personalities is an illusion that we create. No matter how people behave, we shoehorn them into the idea we already have of them.

Lee Ross, a psychologist at Stanford University, has another intriguing idea. He had read Mischel's book on personality when it came out in the 1960s and immediately understood the profound puzzle it presented. He thinks we actually are seeing consistency in human behavior, but we're getting the reason for it wrong. "We see consistency in everyday life because of the power of the situation," he says.

Most of us are usually living in situations that are pretty much the same from day to day, Ross says. And since the circumstances are consistent, our behavior is, too.

But sometimes the dynamics at work and home ask us to be different people. The violent gangster at work may be the kind father at home. In the 1960s and 1970s, a number of experiments were done where the researchers put people in an extreme situation to see if it would change their behavior.

One of the most infamous is the obedience experiment done in the 1960s, by Stanley Milgram, a social psychologist at Yale University who was intrigued by the concepts of conformity and authority. In the experiment, a "learner" was wired with electrodes, and a "teacher" was told to give the learner an electric shock every time they got an answer wrong. The learner wasn't actually getting shocked; the part was played by actors who pretended to be hurt. But the teachers didn't know that, and they kept administering what they thought were stronger and stronger shocks, even as it made them very uncomfortable, because they were in a situation that required them to do it.

The point, Ross says, is that ultimately it's the situation, not the person, that determines things. "People are predictable, that's true," he says. "But they're predictable because we see them in situations where their behavior is constrained by that situation and the roles they're occupying and the relationships they have with us."

Even though these experiments were done almost 50 years ago, we're still struggling with the notion that human personality and behavior isn't a constant. Consider the story of Delia Cohen. Like most of us, she believed in a core consistency in humans; she'd seen it in people her whole life. The good people were good; the bad, bad.

Cohen had been doing some work for the TED organization, the one that does TED talks, and had heard about a TEDx event that was put on in a prison, by prisoners. So she went to Marion Correctional Institution in Marion, Ohio, to see it.

Dancers at the Marion Correctional Center in Marion, Ohio, top, perform onstage at a TEDx event in 2015. Attendees and speakers at the event included prison inmates and visitors.

Courtesy of Tessa Potts/Healing Broken Circles

One of the first prisoners she met was a man named Dan. He had the word "hatred" tattooed on the back of his neck.

But as soon as she started talking to Dan, Cohen completely forgot about the tattoo. His personality didn't seem to have anything to do with hatred.

The prisoners' presentation included poetry and music. Cohen liked it so much that she told Dan she wanted to work with him to re-create it in prisons across the country. Then a friend of hers Googled Dan and started reading descriptions of his crime to Delia. It turned out that Dan was a sexual predator who had raped a woman at knife point. Cohen says: "I was absolutely horrified."

She went home and tried to figure out how she should think about Dan (the prison asked us not to use his full name so it would be less difficult for his victim). Was he the kind, creative, competent person she had met, or the brutal, sadistic personality who had committed the crime?

To find out, she decided to ask him. She sent him an email.

"I've had a lot of people contact me," Dan says. "I don't know if they see some of my poetry online or they see something about me and they write me." Then at some point those correspondents Google Dan like Cohen's friend did, and they vanish. "So I'm kind of used to people having adverse reactions."

Dan emailed Cohen back, saying he was willing to talk with her about his crime. But the conversation didn't go well. "It was an incredibly awkward conversation," Cohen says. "Basically he said he was a horrible, horrible person."

After talking for almost an hour, Cohen didn't feel like she was any closer to answering the question that plagued her: Was there something in Dan's personality that caused the crime, and did that thing still exist?

We decided to ask Dan ourselves.

When he committed the crime, Dan says, "I was a real live piece of s***." But he says that person has ceased to exist.

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It happened six or seven years into prison, Dan says. His best friend in prison had stolen something from another inmate, and Dan, who had a reputation for being violent, told the other inmate to back off. Then he went back to his best friend and beat him up.

"I remember while I was doing it, he was asking me to stop, and I was like, 'How could you be so stupid? I'm going to beat the stupid out of you.' "

Dan remembers looking down at the man he was beating, and thinking, "Whoa, what am I doing? This is someone I say I love. This is someone I care about. This is someone I say I treat like family. And this is how you treat family?"

Dan says that's the last time he was physically violent. He decided to quit the group of guys he hung out with in prison. He physically isolated himself. It was hard. "It was easier to be a no-good m*****-f***** than it was to be alone."

Dan says it took him about two years to reconfigure his personality. He wanted to be less aggressive, less impulsive, more conscientious. He says he's now a different person. But he knows most people won't see him that way.

"I'm forever going to be a criminal," he says, "which I'm not. I've become a completely different human being at this point."

Delia Cohen had a hard time accepting that Dan had changed; you hear those words so often from people, and they're often not true. But she decided to suspend her disbelief and work with him on the TEDx project. They started exchanging emails.

Cohen knew that there are people whose horrible crimes really do emanate from their personalities, such as psychopaths. But after more than a year of working with Dan, Cohen felt sure he wasn't a psychopath.

As she tried to figure out if something rotten remained in Dan and the other prisoners she worked with, she decided to reject the frame of reference she used to think about people. "All these people I've met that have done really horrible things are not horrible people," Cohen says. "They're not bad people. Which was shocking to me."

She's still working with prisoners on the TEDx project, and she says she no longer even thinks about their crimes. "I'm more curious about who they are now."

Even though Dan says he's no longer the man who committed the crime, he knows why he's in prison. "I have to atone for my crime. But I realize now I'm just paying for someone else's debt. The person who committed the crime no longer exists."

There's something more than a little disturbing about that sentence — being in prison now for someone else's crime. But just because it's disturbing doesn't mean it can't be true.

"Maybe we're not thinking right about who we are and what we could be," says Walter Mischel.

It's no wonder, Mischel says, that we're drawn to this idea that personality is important and stable. It makes us feel better. "I mean, how can you marry anybody unless you believe that they are basically going to stay the way that you have them pictured now?" he asks. "We like to feel like we're living in a stable world."

We realize the outside world can change in a heartbeat, "but when it comes to human beings, we really don't have tolerance for realizing that there is an enormous amount of instability."

Still, we're not slaves to that instability. Traits and life situations both affect our behavior, Mischel says. But so do our minds.

The beliefs, assumptions, expectations that you've gotten from your friends, family, culture — those things, Mischel explains, are the filter through which you see the world. Your mind stands between who you are, your personality and whatever situation you are in. It interprets the world around it, and how it feels about what it sees. And so when the stuff inside the mind changes, the person changes.

"People can use their wonderful brains to think differently about situations," Milgram says. "To reframe them. To reconstruct them. To even reconstruct themselves."

Copyright 2016 NPR. To see more, visit NPR.
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Depressed Teen's Struggle To Find Mental Health Care In Rural California

NPR Health Blog - Thu, 06/23/2016 - 5:36pm
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June 23, 20165:36 PM ET Heard on All Things Considered

From

Doctors who diagnosed Shariah Vroman-Nagy with bipolar disorder wanted to keep her in the hospital for treatment, but her insurance company wouldn't cover the stay.

Andreas Fuhrmann for KQED

There's a hot pink suitcase on the floor of Shariah Vroman-Nagy's bedroom. The 18-year-old is packing for a trip to Disneyland, one of several she takes with her family every year.

"Let's see, I need a hairbrush," she says, moving past the collection of Mickey Mouse ears on her dresser and glancing at the inspirational quotes from Marilyn Monroe on the wall.

The lyrics to a song called "Smile" hang in a frame over her bed.

"My mom made me that when I was struggling," says Vroman-Nagy, "because that's the song that I would listen to. Michael Jackson did a version of it, which I love."

When she feels her depression creeping in, she sings it to herself.

Smile, though your heart is aching
Smile, even though it's breaking
If you smile through your tears and sorrow
Smile and maybe tomorrow
You'll see the sun come shining through, for you.

Three years ago, it was in this room, filled with porcelain dolls and stuffed animals, that Vroman-Nagy tried to kill herself. She was 15, a freshman in high school.

"Everything piled up, piled up, piled up until I just couldn't handle it anymore," she says. "So I had my antidepressants and I took a handful of those. But then I thought better of it, and I told my mom. She took me to the emergency room."

There's no psychiatric hospital that specializes in adolescents in Redding, the small city in far Northern California where Vroman-Nagy lives. So she was taken from the local ER to a hospital in Sacramento, an hour and a half drive to the south. She was there for eight days.

The doctors diagnosed her with bipolar disorder. They wanted to keep her longer, but they told her the insurance company wouldn't cover it.

"I didn't feel like I was ready because I had just been put on new medications," she says. "In the past I've had reactions to medications, and some have not worked. So I wanted to wait and stay for observation a little bit longer."

Vroman-Nagy wasn't alone in feeling that she was sent home too soon. Since 2010, the state has received almost 900 appeals from patients saying their insurer unfairly denied inpatient mental health treatment, according to data from the Department of Managed Health Care, the main health insurance regulator in the state. The department overturned 47 percent of those decisions.

Insurers are allowed to deny coverage for certain treatments, if they determine that the care is not "medically necessary." This determination is based on evidence-based clinical standards in both mental and medical care, but it has become a key battleground for mental health advocates.

They say insurers are able to deny mental health treatments more often than other medical treatments, because it's harder to prove when mental health care is medically necessary.

Determining the best treatment for depression, bipolar disorder, or anxiety disorders relies heavily on the subjective report of the patient, so it can be difficult to demonstrate how ill a person is.

"There aren't blood tests in mental health, there aren't X-rays in mental health," says Keith Humphreys, a Stanford psychiatrist and former White House adviser on mental health policy. "So it's easier to deny care for mental health than it is for things we've got physical evidence for."

Outside the hospital, care still difficult to find

After Vroman-Nagy went home, the hospital helped her find a therapist to continue the work she had begun in the inpatient unit. But the insurance company, Anthem Blue Cross, said no to that, too. It said the therapist wasn't part of its network.

"We spent quite a long time with the insurance company battling them trying to get them to cover visits," Vroman-Nagy says.

Shariah Vroman-Nagy talks to her father, Tom Nagy, about a Mother's Day gift for her mom.

Andreas Fuhrmann for KQED

Anthem wanted her to see someone on its list of approved in-network providers, Vroman-Nagy says. At the time, that list was just six people, a common problem in rural parts of the country. When Vroman-Nagy started calling them, she says they either told her their schedules were full or they were retired. So she decided to stick with the out-of-network therapist.

Her father, Tom Nagy, supported the decision. "Because at that point, I mean, you're talking possible life and death issues," he says. "That was my approach, to pay for it. Run up the charge cards."

He ended up paying thousands of dollars. Nagy is a teacher, and his wife is a nurse. They couldn't afford to keep doing that.

By law in California, insurers are required to make special arrangements for patients to see an outside therapist if there are none in the plan, and they have to provide the care at the same copay or coinsurance as an in-network clinician. They can't charge extra.

It's unclear why Nagy didn't get that help at first. He says he had to fight and fight with the insurance company until he was finally reimbursed.

"It was literally a yearlong process," he says. "As a parent, it's hard enough to deal with these situations and be supportive, but then you get the whole financial thing, it just adds a whole other layer. It's frustrating."

In a statement, Anthem Blue Cross said it is "committed to providing access to high quality and affordable health care, including mental healthcare." It has a variety of resources to help people find the best provider for them, the statement continues, including an online listing of available mental health providers, and customer service staff who can help with a search.

The company also launched an online psychology service earlier this year, called LiveHealth Online Psychology, so patients who live in rural areas where it can sometimes be hard to find a clinician can "talk face-to-face with a licensed therapist or psychologist through high-definition video on your smartphone, tablet or computer with a webcam."

Looking toward the future

It's Vroman-Nagy's spring break from college, and the preparations for the family trip to Disneyland continue. She says she really needs the vacation.

"They call it the happiest place on earth, and I really do feel that it makes me happy when I go," Vroman-Nagy says. "I'm glad we get to go this week because I have been having a little depression going on."

She and her parents run some errands before they leave town, including a stop at Wal-Mart to stock up on snacks for the nine-hour drive.

"I have a question," Vroman-Nagy says to the cashier. "You used to have Mickey Mouse-shaped cheese. Do you not carry it anymore?"

Instead, she got Frozen-themed cheese sticks, with characters from the hit Disney film on the package. The radio in her car is primed with a series of Disney soundtracks, from Tarzan to Beauty and the Beast, songs Vroman-Nagy knows well from her days singing with a show choir in high school.

Overall, Vroman-Nagy is doing much better. She works part time at the local In-N-Out Burger, and she is training to volunteer for a suicide hotline. She is also studying psychology and music at the local junior college.

She plans to become an adolescent therapist one day. But first, she'd like to be a character singer at Disneyland.

"I would love to be in their entertainment," she says, and imagines herself in a princess costume singing and dancing in the park's stage shows or parades. "That would be my dream."

This story is part of a partnership with NPR, KQED and Kaiser Health News.

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
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A Protein That Moves From Muscle To Brain May Tie Exercise To Memory

NPR Health Blog - Thu, 06/23/2016 - 1:33pm
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June 23, 20161:33 PM ET Heard on All Things Considered

Researchers have identified a substance in muscles that helps explain the connection between a fit body and a sharp mind.

When muscles work, they release a protein that appears to generate new cells and connections in a part of the brain that is critical to memory, a team reports Thursday in the journal Cell Metabolism.

The finding "provides another piece to the puzzle," says Henriette van Praag, an author of the study and an investigator in brain science at the National Institute on Aging. Previous research, she says, had revealed factors in the brain itself that responded to exercise.

The discovery came after van Praag and a team of researchers decided to "cast a wide net" in searching for factors that could explain the well-known link between fitness and memory.

They began by looking for substances produced by muscle cells in response to exercise. That search turned up cathepsin B, a protein best known for its association with cell death and some diseases.

Experiments showed that blood levels of cathepsin B rose in mice that spent a lot of time on their exercise wheels. What's more, as levels of the protein rose, the mice did better on a memory test in which they had to swim to a platform hidden just beneath the surface of a small pool.

The team also found evidence that, in mice, cathepsin B was causing the growth of new cells and connections in the hippocampus, an area of the brain that is central to memory.

But the researchers needed to know whether the substance worked the same way in other species. So they tested monkeys, and found that exercise did, indeed, raise circulating levels of cathepsin in the blood.

Next, they studied 43 people who hadn't been getting much exercise.

"The people were university students that were couch potatoes — they didn't exercise much," says Dr. Emrah Duzel, a neurologist and team member from the German Center for Neurodegenerative Diseases.

Half the students remained sedentary. The other half began a regimen of tough treadmill workouts several times a week.

"Within four months, we really made them fit," Duzel says.

And, just like mice, the students who exercised saw their cathepsin B levels rise as their fitness improved. They also got better at a memory task: reproducing a geometric pattern they'd seen several minutes earlier.

But the clincher was the link between memory improvement and cathepsin levels, Duzel says.

"Those individuals that showed the largest gains in memory also were those that had the largest increase in cathepsin," he says.

Of course, cathepsin is probably just one of several factors linking exercise and brain function, van Praag says.

"I don't think we have fully explained how exercise improves memory," she says, "but I think we've made a significant step forward."

Also, cathepsin has a dark side. It's produced by tumor cells and has been linked to the brain plaques associated with Alzheimer's. So, trying to artificially raise levels might not be a good idea, van Praag says.

However, van Praag says she's trying to keep her own cathepsin levels up naturally by jogging — when she can.

"It takes a lot of time and effort to do all this research," she says. "So sometimes the exercise regimen suffers a little bit."

Copyright 2016 NPR. To see more, visit NPR.
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Bad News For Kids Who Don't Like Flu Shots

NPR Health Blog - Thu, 06/23/2016 - 12:43pm

It's time to brace the kids who don't like getting their flu shots for some disappointing news.

A panel of vaccination experts advising the Centers for Disease Control and Prevention made the surprising recommendation late Wednesday that FluMist Quadrivalent, the nasal spray vaccine that protects against influenza, should no longer be used.

It turns out that the spray — which is particularly popular among kids, pediatricians and parents who don't like seeing their little ones cringe at the sight of a needle — hasn't worked as well as the old-fashioned shot during the past few flu seasons.

Before then, FluMist protected against influenza as well as, or even better than, the flu shot. The panel's recommendation against the spray was informed by data collected for children ages 2 through 17 that showed no evidence the nasal spray vaccine offered protection during last year's flu season. Data also showed that FluMist performed poorly in the prior two flu seasons.

The recommendation by the Advisory Committee on Immunization Practices has to be reviewed and approved by the CDC director before it becomes official policy, but that's usually a formality.

Scientists don't know why the nasal spray vaccine isn't working anymore, says Dr. William Schaffner, an infectious disease specialist at the Vanderbilt University School of Medicine and longtime member of the Influenza Vaccine Working Group that offers guidance to the CDC's panel of vaccination experts.

"The company [that manufactures FluMist], the FDA, and other investigators still haven't been able to put their scientific finger on the exact reason, but there are several studies that have indicated that in the United States the vaccine has underperformed in a very substantial way," he says.

Schaffner did note, however, that the spray began performing poorly when all flu vaccines were adjusted to protect against four influenza strains instead of three.

Flu vaccine manufacturers had planned to supply as many as 176 million doses of vaccines for this upcoming season. MedImmune, a subsidiary of AstraZeneca and the maker of FluMist, planned to provide about 8 percent of this total.

In response to the recommendation against FluMist, AstraZeneca said in a statement that it "is working with the CDC to better understand its data to help ensure eligible patients continue to receive the vaccine in future seasons in the U.S."

According to Schaffner, companies that offer flu vaccine in shot form say they'll be able to produce enough to cover kids who would have opted for the nasal spray version.

Schaffner understands that the decision to recommend against the nasal spray will be disappointing for many. "There will be grumbling among children, parents and pediatricians," he says. "This was a sad, very discomforting decision, but I fully believe it was the correct decision."

And for the truly shot averse, he offers some hope. "There is a lot of work being done to try to develop methods to deliver vaccines different from the traditional needle and syringe method. For example, a patch with many microneedles that doesn't hurt — that would be nice," he says.

Until an effective needle-free flu vaccine arrives, the CDC still recommends the injectable vaccine for just about everyone 6 months and older. Shots are no fun. But neither — most of us agree — is the flu.

Copyright 2016 NPR. To see more, visit NPR.
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The Challenge Of Taking Health Apps Beyond The Well-Heeled

NPR Health Blog - Thu, 06/23/2016 - 8:58am

The Text4Baby app sends free, periodic text messages in Spanish or English to pregnant women and new moms about prenatal care, labor and delivery, breastfeeding, developmental milestones and immunizations.

Kristin Adair/NPR

When you hear the phrase "digital health," you might think about a Fitbit, the healthy eating app on your smartphone, or maybe a new way to email the doctor.

But Fitbits aren't particularly useful if you're homeless, and the nutrition app won't mean much to someone who struggles to pay for groceries. Same for emailing your doctor if you don't have a doctor or reliable Internet access.

"There is a disconnect between the problems of those who need the most help and the tech solutions they are being offered," said Veenu Aulakh, executive director of the Center for Care Innovations, an Oakland, Calif.-based nonprofit that works to improve health care for underserved patients.

At most digital health "pitchfests," it's pretty much white millennials hawking their technology to potential investors. "It's about the shiny new object that really is targeted at solving problems for wealthy individuals, the 'quantified-self' people who already track their health," Aulakh said. "Yet ....What if we could harness the energy of the larger innovation sector for some of these really critical issues facing vulnerable populations in this country?"

A small but growing effort is underway to do just that. It's aimed at using digital technologies – particularly cellphones – to improve the health of Americans who live on the margins. They may be poor, homeless or have trouble getting or paying for medical care even when they have insurance.

The initiatives are gaining traction partly because of the growing use of mobile phones, particularly by lower-income people who may have little other access to the Internet.

The Affordable Care Act and the expansion of Medicaid have added millions of previously uninsured people to the nation's health care system, including community health clinics that serve poor and largely minority populations, according to a California Health Care Foundation report. (California Healthline is an editorially independent publication of the California Health Care Foundation.)

In California alone, the number of people on Medi-Cal, the state's version of the Medicaid program for the poor, rose from 7.5 million in 2010 to 12.4 million by early 2015. Many Americans remain uninsured, however, because they live in states that have declined to expand Medicaid eligibility.

Health advocates say it's important to tailor digital health technologies to lower-income people not only to be fair, but because they're more likely to have chronic illnesses, like diabetes, that are expensive to treat.

Health-care providers have incentives as well. They are being rewarded financially under the Affordable Care Act, Medicare and Medicaid for keeping patients healthy, and this goes beyond simply performing medical procedures and prescribing drugs.

For now, experiments targeting low-income people are a tiny part of the digital health industry, which racked up an estimated $4.5 billion in venture funding in 2015 alone. Entrepreneurs are still trying to figure out how they're going to get paid by serving this population, and government health programs like Medicaid and Medicare are taking a while to figure out how they're going to pay providers for approaches that don't involve a doctors' visit.

But Jane Sarasohn-Kahn, author of the California Health Care Foundation report, says investors are getting more interested in digital health initiatives for low-income patients simply because there are so many of them.

Investors are eyeing the "fortune at the bottom of the pyramid," she said, much as Walmart profits from selling low-priced items to millions.

"It's now sexy to scale," she says. "If you can have impact [on many people], inexpensively, you can make a lot of money. If we get it right, we can do well and do good."

Some initiatives are simple and cheap, like Text4Baby. The free text-messaging service for pregnant women and new moms offers information in English and Spanish about prenatal care, labor and delivery, breastfeeding, developmental milestones, and immunizations. The specific texts are timed to the baby's due date.

Operated by the nonprofit ZERO TO THREE and the mobile health company Voxiva, Inc., Text4Baby has reached nearly 1 million women since starting in 2010. In one survey, more than half of them reported yearly incomes of less than $16,000.

Other experiments are far more elaborate. In California and Washington state, San Francisco-based Omada Health is testing a version of Prevent, a diabetes and heart disease prevention program that's been modified for "underserved" populations – basically people on Medicaid or who are uninsured. The free program offers patients a digital scale as well as behavior counseling and education, access to a personal health coach and an online peer network.

To adapt the program, the company made it available in Spanish and English and lowered its reading level from ninth grade to fifth grade. Bilingual health coaches were hired, and the educational materials now acknowledge potential food access, neighborhood safety and economic issues that participants may face, said Eliza Gibson, Omada's director of Medicaid and safety-net commercial development.

The scale doesn't require a wireless connection, and the patient just needs to be able to access the Internet for one hour each week, Gibson said.

Omada is enrolling 300 community clinic patients in Southern California and rural Washington in a year-long clinical trial of Prevent, in hopes that the program can demonstrably slow the progress of diabetes.

Patients at other community clinics in California will try out the program but won't be included in the clinical trial, Gibson said. Omada Health is also offering a version called Prevent for Underserved Populations that specifically targets low-income community clinic patients.

Among the people trying out the program is Susy Navarro, an elementary school substitute teacher who lives in the Spring Valley community east of San Diego. After being diagnosed with prediabetes, Navarro, 28, set an ambitious goal to lose 100 pounds. In the meantime, she is taking medication to stave off Type 2 diabetes.

"You name it, I've probably tried it – Weight Watchers, low-fat, low carb, pills, injections, acupuncture," Navarro said. "The first time I try things it goes very well, I feel like I'm very successful, then I wean off and I'm not successful. This program focuses more on life choices that are going to help us out long-term, not just for a little bit."

Navarro described the scale she was given as "sophisticated looking – all black, flat, digital." It has been programmed to her weight profile (she is considered obese), and transmits her weight every morning to the program's counselors.

The program, with its daily weigh-ins, helps her pay attention to what she eats, and her blood sugar levels are declining, Navarro said. She also appreciates the ability to connect online with fellow patients on her "team." "It's very awesome – you get to know the other members and feel like it's a team effort."

As they continue to explore digital health possibilities for underserved patients, developers are learning more about what works and what doesn't, says Sarasohn-Kahn. For example, apps chew up a lot of cellphone data, so many community clinic patients prefer lower-cost text messaging.

At the Petaluma Health Center, a network of community clinics in Sonoma County, Calif., staffers offered free, simplified "loaner" digital devices to patients after a hospital stay to help them avoid complications that could land them back in the hospital.

They first offered an Android tablet to allow for a video visit with a health professional, but patients were reluctant to take it, saying it was hard to hide and could be stolen, said Dr. Danielle Oryn, the network's chief medical information officer.

Then they tried iPhones, in which everything was locked down except the ability to call 911 and a single button triggering the video visit. Those were more acceptable. Still, there were challenges. Would patients, some recuperating at homeless shelters, have access to electricity to charge their phones? Oryn said they had to learn by trial and error. She was surprised and pleased to see seniors accepting the technology. Every loaner iPhone was returned to the clinic.

Oryn's advice to the captains of the digital health industry?

They should "not necessarily come in with too many assumptions. They should come with an open mind and a willingness to listen," Oryn said. "Safety-net people are very excited to have these companies interested in them and to share their experiences."

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation. Follow Barbara Feder Ostrov on Twitter: @barbfederostrov.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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