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As New York Embraces HIV-Preventing Pill, Some Voice Doubts

NPR Health Blog - Sat, 07/19/2014 - 10:29am
As New York Embraces HIV-Preventing Pill, Some Voice Doubts July 19, 201410:29 AM ET Listen to the Story 4 min 11 sec   i i

Truvada has been around for a decade as a treatment for people who are already HIV-positive. In the last few years, it has also been shown to prevent new infections, and New York officials are embracing the pill as a way to prevent the spread of AIDS.

Justin Sullivan/Getty Images

AIDS researchers and policymakers from around the globe are gathering in Melbourne, Australia, for a major international conference that starts this Monday. They'll be mourning dozens of colleagues who died in the crash of Malaysia Airlines Flight 17.

But the work of the conference will continue, and one of the major topics to be discussed is expanding the use of a pill that prevents HIV.

The drug, Truvada, has been shown to be highly effective at preventing new infections. Public officials in New York are ramping up efforts to distribute the pill widely — but not everyone thinks that's a good idea.

Truvada has been around for a decade as a treatment for people who are already HIV-positive. It's only in the last few years that it's also been approved to prevent transmission of HIV.

That's why Damon Jacobs, an HIV-negative therapist in New York City, is taking it: "I had been newly single after being in a relationship for seven years, and found that people were not using condoms in 2011 the way they had been in 2001," he says.

Jacobs started taking Truvada three years ago for pre-exposure prophylaxis — also known as PREP. Since then, Jacobs says, he no longer uses a condom every time he has sex, but he's not worried about getting HIV.

“ We're trying to do education and give options to people in terms of staying safe. For some people, condoms are that. For some people, monogamy is that. But for some people, the only answer that's going to work right now is PREP.

"I didn't fully understand what it meant to live in fear every time I had sex," Jacobs says. "And it wasn't until about a year after I was using PREP that I had the experience of pleasurable intimacy, and realized: I'm not afraid anymore."

Studies have shown that Truvada can be more than 90-percent effective against the transmission of HIV, as long as it's taken every day. The drug has been approved for PREP by the FDA and endorsed by the Centers for Disease Control and Prevention.

At New York's Gay Pride parade last month, Gov. Andrew Cuomo announced that his state will be the first to make Truvada part of its ambitious plan to cut new HIV infections.

"The state of New York ... in many ways was ground zero of the HIV and AIDS crisis when it first started," Cuomo said. "I think it's fitting that New York should then be the state that is the most aggressive in eradicating this disease, in actually ending this disease."

Michael Weinstein, president of the AIDS Healthcare Foundation and a prominent critic of Truvada, calls this "a very dangerous experiment."

“ If people are taking this medication, they're definitely not going to use condoms. And if they're not taking it regularly, they're not going to be protected when they think they are ... We can do harm by telling people that you can pop this pill.

Weinstein points out that Truvada only works when you take it almost every day. He's worried about what will happen to those who don't.

"If people are taking this medication, they're definitely not going to use condoms. And if they're not taking it regularly, they're not going to be protected when they think they are," Weinstein says. "We would have many, many more infections in this country — particularly among men who have sex with men — if no one was using condoms. And we can do harm by telling people that you can pop this pill."

But public health officials in New York say that pill could be key to cutting the number of new HIV infections — a number that has held roughly steady for the past decade. Daniel O'Connell, who directs the AIDS Institute at the New York State Department of Health, says it's time to consider new approaches.

"We're trying to do education and give options to people in terms of staying safe. So for some people, condoms are that. For some people, monogamy is that," O'Connell says. "But for some people, the only answer that's going to work right now is PREP."

Additional Information: More On Truvada Shots - Health News FDA Approves First Drug To Prevent HIV Infection Shots - Health News Deciding On Truvada: Who Should Take HIV Prevention Pill? Shots - Health News Guideline Is No Guarantee Insurers Will Pay For Pill To Prevent HIV

Truvada is not the cheapest option. The drug costs $1,300 a month, though it is covered by most insurance plans and Medicaid. But those who are most at risk of getting HIV often have limited access to health care.

Perry Halkitis, a professor at New York University, says, "I will believe that PREP is truly going to be effective in the gay community if it gets in the hands of those who need it most in the gay community: young, black, gay men. And I have no evidence to suggest that it's getting there right now."

So far, the number of people anywhere taking Truvada for PREP seems to be small: just a few thousand nationwide. Prominent AIDS activist Larry Kramer, a co-founder of the Gay Men's Health Crisis, has publicly questioned why anyone would want to put "poison" into their body when they could wear a condom instead.

But public health officials like O'Connell say the side effects are minor — especially compared to the potential benefits.

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Health Safety Experts Call For Public Reporting Of Medical Harms

NPR Health Blog - Fri, 07/18/2014 - 12:20pm
Health Safety Experts Call For Public Reporting Of Medical Harms July 18, 201412:20 PM ET i i

"We can't continue to have unsafe medical care be a regular part of the way we do business in health care," said Harvard School of Public Health's Dr. Ashish Jha at a Senate hearing Thursday.

AP Shots - Health News Independent Grades For Hospitals Show Quality Could Be Better Shots - Health News Online Doctor Ratings About As Useful As Those For Restaurants

The health care community is not doing enough to track and prevent widespread harm to patients, and preventable deaths and injuries in hospitals and other settings will continue unless Congress takes action, medical experts said Thursday on Capitol Hill.

"Our collective action in patient safety pales in comparison to the magnitude of the problem," said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine. "We need to say that harm is preventable and not tolerable."

Dr. Ashish Jha, a professor at the Harvard School of Public Health, said patients are no better protected now than they were 15 years ago, when a landmark Institute of Medicine report set off alarms about deaths caused by medical errors and prompted calls for reform.

"We can't continue to have unsafe medical care be a regular part of the way we do business in health care," Jha said.

One of the biggest problems, the experts told the Senate Subcommittee on Primary Health and Aging, is that providers and public health agencies still are not accurately measuring the harm.

Sen. Bernie Sanders, I-Vt., the panel's chairman, said afterward that most patients probably don't know that preventable patient harm is the third-leading cause of death in America. He said the problem hasn't received the attention it deserves in the public arena or from lawmakers.

Jha said it is crucial to develop better metrics to produce credible data about harm that is valid and credible. Without data, providers don't know how they're doing or if quality improvement efforts are working, he said.

Pronovost and Jha called for requiring the Centers for Disease Control and Prevention, which already collects data about hospital-acquired infections, to begin tracking other patient harms.

Dr. Tejal Gandhi, president of the National Patient Safety Foundation, said studies show that medication errors, adverse drug events and injuries due to drugs occur in up to 25 percent of patients within 30 days of being prescribed a drug.

Missed and delayed diagnosis is also a problem, and a primary cause of malpractice lawsuits in the outpatient setting, she said. Systems need to be put in place to monitor patient care instead of simply relying on doctors to get it right, Gandhi said.

"We cannot just tell clinicians to try harder and think better," Gandhi said.

The title of the hearing, "More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety," was inspired by a study by John James, a scientist and patient advocate whose son died because of a string of medical errors.

James' recently published study estimated that preventable harm in hospitals contributes to as many as 400,000 deaths a year.

James suggested that lawmakers establish a National Patient Safety Board — similar to the National Transportation Safety Board — to investigate patient harm. He also proposed a national patients' bill of rights that would contain protections similar to those for workers and minority groups.

Lisa McGiffert, director of the Consumers Union Safe Patient Project, urged the legislators to ensure there is more meaningful public reporting of the harm to patients, so consumers can make informed choices and providers will be motivated to improve.

Like this story? ProPublica's ongoing investigation into patient safety has highlighted many of the issues. Check out ProPublica's Facebook group and online questionnaires for patients and providers.

Copyright 2014 NPR. To see more, visit
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Half Of Texas Abortion Clinics Close After Restrictions Enacted

NPR Health Blog - Fri, 07/18/2014 - 11:01am
Half Of Texas Abortion Clinics Close After Restrictions Enacted July 18, 201411:01 AM ET


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Texas gubernatorial hopeful and state Sen. Wendy Davis came to prominence when she opposed legislation restricting abortions. The bill eventually became law and is now blamed for the closure of abortion clinics across the state.

LM Otero/AP

In a little over a year, the number of clinics that provide abortions in Texas fell to 20 from 41, and watchdogs say that as few as six may be left by September.

Many clinics closed because of a requirement that doctors at those clinics obtain hospital admitting privileges within a certain radius of the clinic, and many doctors couldn't comply. The requirement took effect last November. This week marks the first anniversary of the state law that started it all.

Bitter fighting over the law last summer propelled state senator Wendy Davis into the national spotlight, and she is now running for Texas governor on the Democratic ticket.

"We're seeing delays," said Heather Busby, executive director of NARAL Pro-Choice Texas. "We're seeing people being pushed further into pregnancy, having to leave the state, having to drive and sleep in their cars in parking lots because of these barriers to access."

The last restriction under the law goes into effect Sept. 1. All clinics that provide abortions at that point must have upgraded their facilities to ambulatory surgery centers. Busby says many can't afford it and more will close.

"This would basically force all the clinics to become mini-hospitals," Busby said. "They have to have hallway widths a certain length, and a janitor's closet, male and female locker rooms, which is completely unnecessary — and a bunch of other regulations that are really not appropriate or do anything to increase the safety of one of the safest procedures in the country."

Supporters of the law said it would protect women by making abortion safer. At the time of the law's passage, The Texas Tribune quoted Republican state Sen. Donna Campbell saying, "There's nothing in this legislation that will close a clinic. ... That's up to the clinic. If they want to put profit over a person, that's up to them."

Busby said abortion is already one of the safest office-based medical procedures, with a complication rate of less than .05 percent.

Busby predicted that after September only six or eight places will be left in Texas to get an abortion, unless a lawsuit stops the new requirement from going into effect. Whole Woman's Health is part of that lawsuit. The group previously had six reproductive health clinics in Texas but had to close two of them over the past year, Busby said.

It may have to close an additional three clinics that don't meet the new surgical center specifications, in Fort Worth, Austin and San Antonio. It would be left with just one, in San Antonio, that meets the new requirements.

Busby noted there are now no clinics that provide abortions in all of East Texas or in the Rio Grande Valley. She said the one clinic left in El Paso could close soon.

In Houston, the newly built headquarters of Planned Parenthood Gulf Coast does fulfill the ambulatory surgical center requirements, so it will remain open. But the status of smaller clinics remains unclear.

A call and email to Texas Right to Life for comment was not returned.

This story is part of a reporting partnership including NPR, Houston Public Media and Kaiser Health News.

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Head Scientist At CDC Weighs Costs Of Recent Lab Safety Breaches

NPR Health Blog - Fri, 07/18/2014 - 3:36am
Head Scientist At CDC Weighs Costs Of Recent Lab Safety Breaches July 18, 2014 3:36 AM ET Listen to the Story 5 min 2 sec  

The CDC's director, Tom Frieden, testified before a congressional subcommittee Wednesday regarding a recent anthrax incident and lab safety improvements he is instituting.

AFP/Getty Images

The director of the Centers for Disease Control and Prevention is on the hot seat.

“ We need to take a hard look at the risks and the benefits of the different types of research that are being done and make sure in every case that the benefits justify ... potential risks.

It all started in mid-June, when the CDC announced that dozens of its scientists might have accidentally been exposed to anthrax.

Since then, a number of other security risks in and via national laboratories have come to light: Ordinary flu virus was unknowingly contaminated with the deadly bird flu virus (sent from a CDC lab); vials of smallpox virus were found forgotten in a National Institutes of Health storage room; and just this week the FDA revealed that forgotten vials of other potential bioterrorism agents were discovered in the same storage room where the smallpox samples turned up.

These lapses, occurring in some of the nation's top government-run facilities, left many to wonder whether the CDC, which is charged with protecting the public from natural and man-made health threats, is capable of shielding Americans from the risks posed by its own research.

Under questioning by lawmakers on Wednesday, the CDC's director, Dr. Tom Frieden, testified that these errors represent a larger pattern of unsafe practices in government laboratories that must change.

This week Frieden sat down with NPR's Morning Edition host David Greene to discuss these breaches and what new steps are being taken to ensure the safety of lab workers and the public. Following are highlights of the conversation.

On the CDC's response to the anthrax and bird flu incidents

I've imposed a moratorium on transfer of all infectious or potentially infectious material out of all of our high containment labs until we trust but verify that they're changing their protocols. ... I've closed the individual labs associated with the two incidents and they won't reopen until we are certain that they can reopen safely. I've appointed a senior scientist to be the single point of accountability and we're going to work at every level of CDC to increase the culture of safety here.

On how the CDC is working to improve the safety of its labs

One of the things that we want to ensure in the strengthening of the culture of safety is that people understand that anytime there might be a problem — or there is a problem — report it, rather than try to figure it out first and then report it. CDC scientists are rightly famous around the world for being the top in the world in their field, and that same rigor that we've been applying to finding and stopping outbreaks — that's the rigor we are now applying to improving safety at CDC.

On how the CDC currently regulates labs that work with dangerous pathogens

Scientists don't regulate themselves. We currently have a select agent program run by both a separate division of CDC and the Agriculture Department's Animal and Plant Health Inspection Service. These two agencies ... oversee all entities that work with select agents. We make unannounced site visits; we have detailed reviews. We'll look at whether these incidents suggest that we should do other things in addition at those.

On whether we should establish an independent oversight team to regulate CDC facilities

We're certainly open to anything that will improve lab safety. One of the things that I will be doing this week is inviting an external advisory group that has no prior employment with CDC to ... look at what we are doing on lab safety and biosecurity and suggest any ways that we can improve that process.

One thing that all three of these incidents suggest is that we need to take a hard look at the risks and the benefits of the different types of research that are being done and make sure in every case that the benefits justify ... potential risks.

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Hey, Miss Idaho, Is That An Insulin Pump On Your Bikini?

NPR Health Blog - Thu, 07/17/2014 - 2:49pm
Hey, Miss Idaho, Is That An Insulin Pump On Your Bikini? July 17, 2014 2:49 PM ET i i

Miss Idaho Sierra Sandison, shown here in her home town of Twin Falls, Idaho, decided not to hide the insulin pump she wears to treat Type 1 diabetes during the pageant.

Photo illustration by Drew Nash/Courtesy of Times News i i

"Honestly, it is terrifying walking out on stage in a swimsuit, let alone attached to a medical device," Sandison wrote on Facebook.

Susan Hessing Photography

There she is, Miss Idaho. And there it is, the insulin pump attached to her bikini bottom during the swimsuit competition. Since posting the photo on social media on Monday, Sierra Sandison has become a new hero to the Type 1 diabetes community.

One mother wrote on Facebook, "You changed my 11-year-old daughter's summer! She's been so self-conscious, but since she read about you and saw this photo, she cannot wait to wear a bathing suit tomorrow and show off her insulin [pump] and have me post a photo here!"

And that woman is not alone. As of Thursday afternoon, the photo has received more than 4,000 "likes" and over 2,500 "shares" on Facebook. Twitter users are responding to the hashtag she created, #showmeyourpump, with their own pump photos.

Insulin pumps ease diabetes control in many ways, but wearing one is a personal choice. People with Type 1 diabetes can also use multiple daily injections to control the condition. In her blog, Sandison, 20, of Twin Falls, Idaho, says that she used injections when she began competing in pageants because "I didn't want people to see a weird-tubey-machine-thing attached to me all the time, and could not wrap my head around having a medical device on my body for the rest of my life."

What changed her mind for the Miss Idaho pageant on July 12th? Hearing about Miss America 1999, Nicole Johnson, who also wore an insulin pump during the competition, although not visibly. Sandison writes, "Miss America 1999 has an insulin pump, and it doesn't make her any less beautiful. In fact, in my mind, it enhances her beauty!"

Johnson, who has continued her diabetes advocacy since her reign, tells Shots, "I think diabetes technology has become more socially acceptable because of the dominance of social media and our 'selfie' culture." She adds: "Our culture seems to be more accepting today, as opposed to when I was diagnosed in 1993."

Indeed, medical device-wearing "pride" appears to be a trend. Amputees are increasingly using visible prostheses rather than covering them up. And the ostomy community has its own version of the "show me" campaign.

On Facebook, Ms. Sandison also received thanks from two parents of kids who wear other medical devices: hearing aids and a feeding tube.

As an insulin "pumper" myself, I can attest to the hesitancy to wear a visible medical device – I resisted for years before deciding to use the pump in 2007. But now I wear it proudly. It's really fun for me to randomly run into another "pumper" on the street and strike up a conversation as if we were old friends. And in fact, that happens fairly often.

Johnson agrees. "It seems that insulin pumps and diabetes devices are now a symbol of community," she told me. "It is becoming more and more common to see them widely displayed, because of the opportunity that brings for connection to others. In the diabetes community, we use the visibility of our devices as a badge of courage and a connector. There is a pride in successfully managing the condition and surviving. One hundred years ago there were no survivors of Type 1 diabetes."

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Young Scientists Say They're Sexually Abused In The Field

NPR Health Blog - Thu, 07/17/2014 - 10:26am
Young Scientists Say They're Sexually Abused In The Field July 17, 201410:26 AM ET

Many young scientists dream of their first trip to a remote research site — who wouldn't want to hang out with chimps like Jane Goodall, or sail to the Galapagos like Charles Darwin, exploring the world and advancing science?

But for many scientists, field research can endanger their health and safety.

In a survey of scientists engaged in field research, the majority — 64 percent — said they had personally experienced sexual harassment while at a field site, and 22 percent reported being the victim of sexual assault.

Most of the people reporting harassment or assault were women, and the vast majority were still students or postdocs.

And for female victims, the perpetrator was more likely to be a superior, not a peer. "This is happening to them when they are trainees, when they are most vulnerable within the academic hierarchy," says evolutionary biologist Katie Hinde, an author on the study published Wednesday in PLOS ONE. Hinde and her colleagues say this could be a factor in the large number of women who enter scientific fields but don't continue.

The Two-Way Campus Sexual Assaults Are Targeted In New White House Report

A total of 666 scientists, primarily in the fields of anthropology and archaeology, completed the voluntary Internet survey. And while the results do not reflect the true prevalence of sexual abuse in field research — this type of survey is not designed to measure that — the numbers are still alarming.

While sexual violence can occur in all workplaces — roughly 50 percent of women report experiencing sexual harassment at some point in their careers — Hinde says the particular nature of field sites, where researchers are far from home, and the lines between work life and personal life are blurred, may make them more prone to this type of wrongdoing.

But in the survey, fewer than half of respondents recalled ever having encountered a code of conduct or sexual harassment policy at their field sites.

"People are being told 'what happens in the field stays in the field,' " says biological anthropologist Kathryn Clancy, who led the survey team.

NPR News Investigations Campus Rape Reports Are Up, And Assaults Aren't The Only Reason

Many academic sciences have a problem retaining women. Though they enter the disciplines in high numbers, many leave before they reach the postdoctorate or professor level. The lack of role models and mentors and professional demands that leave little time for family life have been cited as reasons.

"One of the things that is not discussed out loud very much is how sexual harassment and sexual assault play into this problem," says Hinde.

Psychologist Rebecca Campbell, who studies the effect of sexual harassment on communities, says that while all workplace harassment is harmful, it can be particularly damaging when coming from a superior.

Gender Imbalance in Academic Science

She also says these findings should be incorporated into the broader discussion about campus sexual harassment and violence.

"The cultural narrative is that this is two drunk college kids in a dorm room, and we are seeing now that sexual assault is occurring as part of the core curriculum," says Campbell.

While both Hinde and Clancy say that it was difficult to parse so many stories of wrongdoing perpetrated by and against their colleagues, they hope the results spur scientific communities to come together in search of a solution.

"As horrifying as this data is, I'm really excited to have it out there," says Clancy. "Every person who has had this experience will be validated and know there are others out there who have their back. If this keeps just one more woman in science, it is absolutely worth it."

Editor's note:

July 21, 2014 A previous version of this story was illustrated with a file picture of an archaeological site in the United Kingdom. NPR did not intend to suggest that there are links between the content of this story and this archaeological site or the institution that organizes it.

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Skimping On Sleep Can Stress Body And Brain

NPR Health Blog - Thu, 07/17/2014 - 3:31am
Skimping On Sleep Can Stress Body And Brain July 17, 2014 3:31 AM ET Listen to the Story 4 min 48 sec   Maria Fabrizio for NPR

"The lion and calf shall lie down together," Woody Allen once wrote, "but the calf won't get much sleep."

That's pretty much the connection between stress and sleep, researchers say, and NPR's own numbers suggest the same thing. In our recent poll on stress in America, conducted in conjunction with the Robert Wood Johnson Foundation and the Harvard School of Public Health, about 70 percent of those who reported experiencing a great deal of stress in the previous month also said they had trouble sleeping.

"Under stressful circumstances, and when people are haunted by life, they cannot sleep very well," says the University of Pittsburgh's Martica Hall.

“ Sleep isn't a timeout. Everything — all the sadness, all the fears, all the angst that you have — follows you into sleep.

And no wonder. When you're feeling stressed, Hall says, your body marshals its famous fight-or-flight response. Stress hormones, such as cortisol and adrenalin, are pumped out, your heart rate goes up, sugar is released into the blood, and more blood is sent to your brain and muscles. Hall says it's really hard to stay asleep through all that biological activity. She has found, for example, that cortisol — which surges to deal with that deadline or cope with that car payment — stays elevated throughout the night. So, even if you're sound asleep, cortisol is constantly nudging your brain to wake up, deal with danger — real or perceived.

"Daytime stress follows you into the night," Hall says.

Mareba Mack, a 42-year-old Air Force veteran who is now an education specialist with the Department of the Navy, says she typically wakes up four to six times a night. She'll fall asleep quickly and soundly, but be wide awake and worried a couple of hours later.

"I'm typically consumed with a thought or an idea of what I need to do," she says. "They can be work-related, or personal or just a litany of things."

Often it's a litany of stressful events. Mack recently moved from her home in Florida up to Washington, D.C. She's also a single mother of a 7-year-old with cerebral palsy. Mack feels up-rooted, anxious about her daughter, worried about work.

Shots - Health News This Is Your Stressed-Out Brain On Scarcity

"I'll sleep for a couple of hours, and then I'll wake," she says, "then sleep a couple of hours, and then I wake."

Throughout the night. Night after night.

This kind of interrupted sleep prevents a stressed person from ever feeling well-rested.

"It's not like sleep is a timeout," Hall says. "It isn't a timeout. Everything — all the sadness, all the fears, all the angst that you have — follows you into sleep."

All adults, whether stressed or not stressed, typically wake up multiple times in a night, each time very briefly. Scientists call these moments "mini-arousals." Unstressed people go right back into deep sleep in a matter of two or three seconds. But people who report feeling lots of stress have mini-awakenings that last much longer, Hall has discovered — sometimes many minutes longer.

Most adults need between seven and eight hours of sleep every night, says Harvard Medical School's Charles Czeisler, who is chairman of the board of the National Sleep Foundation. Any less than that (if it happens regularly) is a "sleep deficiency," Czeisler says. And when we're not sleeping well, that deficiency follows us right into the next day, making it hard to handle the slings and arrows that come our way.

"The exhaustion associated with that places a physiologic burden on us," Czeisler says, "and we actually are much less resilient."

A woman I met named Amanda (she doesn't want us to use her last name because she's worried about her job) feels that burden every day. She's 34, the mother of a toddler and an infant, and gets up at 5 a.m. each day for a long commute to a full-time job as a social worker helping vets find housing in San Francisco.

"It's very rough," she says. "I've missed a lot of work because of lack of sleep." You can hear the distress in her voice. The lack of sleep, she says, makes her not only exhausted but forgetful, moody, overwhelmed.

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Some mornings, she says, after only two or three hours of sleep, "I'd wake up and my hands are shaking — and I know I can't do it."

Researchers do have some practical suggestions to help: Go to bed and get up at the same time every night, even on weekends. This will train your brain's biological clock to release the sleep hormone, melatonin — key to us getting that seven or eight hours we need.

And get all the gadgets — cellphones, computers, TV — out of the bedroom. The short-wave light that these screens emit suppresses melatonin.

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Patients With Low-Cost Insurance Struggle To Find Specialists

NPR Health Blog - Wed, 07/16/2014 - 4:11pm
Patients With Low-Cost Insurance Struggle To Find Specialists July 16, 2014 4:11 PM ET


Listen to the Story 4 min 53 sec   i i

Dr. Charu Sawhney examines patient Mang Caan. Sawhney supports the Affordable Care Act, but has been frustrated by how difficult it is to find specialists who accept some of the plans her patients bought.

Carrie Feibel for NPR Shots - Health News So You Found An Exchange Plan. But Can You Find A Provider?

The Hope Clinic in southwest Houston is in the very heart of Asia Town, a part of the city where bland strip malls hide culinary treasures — Vietnamese pho, Malaysian noodles, Sichuan rabbit and bubble tea.

Inside the clinic, internist Charu Sawhney sees patients from many countries and circumstances. She's a big believer in the Affordable Care Act since most of her patients have been uninsured. She actively pushed many of them to sign up for the new plans.

But now she's seeing something she didn't expect. When patients need treatment unavailable at the clinic, it's been hard to find specialists and hospitals that accept the insurance.

"I was so consumed with just getting people to sign up," she says, "I didn't take the next step to say 'Oh, by the way, when you sign up, make sure you sign up for the right plan.' "

Understandably, a lot of her patients picked lower-cost plans, she says, "and we're running into problems with coverage in the same way we were when they were uninsured."

One of her patients is a Chinese immigrant to Houston who purchased a Blue Cross Blue Shield HMO silver plan. Soon after, he was diagnosed with stomach cancer. Sawhney found an oncologist to coordinate his treatment, but she and the oncologist ran into trouble trying to schedule chemotherapy and radiation. "The process just isn't as easy as we thought it would be," she says.

That's because the two largest hospital chains in Houston, Houston Methodist and Memorial Hermann, are not in that plan's network. Neither is Houston's premier cancer hospital, MD Anderson Cancer Center.

Those are the hospitals that the patient's oncologist, Paul Zhang, calls on the most. He says coordinating surgery or radiation usually isn't a problem, because most of his patients have insurance plans with wide networks.

"I could not find a surgeon," says Zhang. Eventually Zhang found one who took the insurance, though they'd never worked together. After the surgery, Zhang tried to set up the patient's chemotherapy and radiation at Houston Methodist. But that hospital wasn't taking the plan.

Zhang says he cannot refer patients with these narrow plans to the specialists he thinks are best, and that's a problem if the cancer is particularly complicated.

"You have limited options. So you're like a second-class citizen, you know. That's my feeling, you have this insurance and you cannot see certain doctors," he says.

Sawhney was less surprised by the barriers. Medicaid patients have similar problems finding doctors, and her uninsured patients have always struggled to find care. But she thought the Affordable Care Act would be an improvement.

Her patient with stomach cancer thought so too. He asked not to be identified because he has not shared his diagnosis with close family members.

"The (insurance) agent said that a lot of doctors will accept that insurance but when I got sick I found out nobody wants that kind of insurance."

The biggest irony, she added, is that even Harris Health, the county-wide public hospital system in Houston, doesn't take all the new marketplace plans. Yet Sawhney can still send uninsured patients there for cancer treatment. As people learn that some doors are closed, she worries people will decide insurance isn't worth the money.

"I don't want patients to get discouraged," she says. "I don't want patients when they have a choice again to say, 'You know what? I'm just not going to sign up because it doesn't matter if I have insurance or I don't have insurance, I still have problems getting health care.' "

Narrow networks of doctors and hospitals aren't new, but they've attracted attention with the rollout of the Affordable Care Act. Analysts point out that narrow networks are a powerful tool for insurance companies seeking to control costs – especially since they can no longer control costs by excluding sick people or adjusting premiums by gender or age.

By restricting the choices in a plan, the insurer can promise more customers for the doctors and hospitals that are included. In exchange, the insurers can get a break on what they pay those doctors and hospitals.

The industry's position is that patients have choices. Plans with access to more hospitals and specialists are available, but usually at a higher price.

Louis Adams is a spokesperson for Blue Cross Blue Shield of Texas. "Our goal was to offer an array of plan choices," he says. "We created more focused networks as a way to offer a broad range of plans with lower premium prices."

Sawhney and Zhang eventually found a place for the patient to get chemotherapy and radiation.

Despite the delays and difficulties, Sawhney still believes it's better to have insurance, and she still believes in the law. But, she says, from now on she'll tell her patients to shop more carefully, taking into account price and whether they have a chronic illness. It won't be about the cheapest plan anymore, but rather the plan that best meets their medical needs.

This story is part of a reporting partnership between NPR, Houston Public Media and Kaiser Health News.

Copyright 2014 KUHF-FM. To see more, visit
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Dialing Back Stress With A Bubble Bath, Beach Trip And Bees

NPR Health Blog - Wed, 07/16/2014 - 10:57am
Dialing Back Stress With A Bubble Bath, Beach Trip And Bees July 16, 201410:57 AM ET NPR/YouTube

Standing in the middle of a swarm of bees might not be your idea of stress relief, but it works for Ray Von Culin. He's a beekeeper in Washington, D.C., and he says caring for bees is one of the most relaxing things in his life.

We ran into Von Culin as we were canvassing the National Mall, microphones in hand, asking people how they deal with stress. The responses ran the gamut: from bubble baths to recreational drug use, from "staring at candles" to "hiking the entire Appalachian Trail."

Everyone had some sort of answer for us. Everyone — regardless of age or origin — had a strategy for getting rid of stress.

Of course, scientists are quick to point out that banishing stress entirely would be a big problem. "Our bodies respond to stress in order to literally keep us alive," says Bruce McEwen, head of the neuroendocrinology laboratory at Rockefeller University.

Stress raises our heart rate and ramps our immune systems to prepare for injury and danger. "The problem is if we don't turn those responses off efficiently when the danger is over ... they can cause damage," McEwen says.

So how do people turn off their stress response? We heard from a few people out on the National Mall, but we also took a more rigorous scientific approach. NPR teamed up with the Robert Wood Johnson Foundation and the Harvard School of Public Health to ask more than 2,500 Americans about the ways they relieve stress.

Socializing topped the list of stress reducers for those dealing with a great deal of stress, with about 7 in 10 respondents saying they spend time with family and friends to deal with stress. Just under 6 in 10 said they regularly prayed or meditated. And about half of respondents also tried exercising, eating healthful food and playing with pets.

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According to the poll, spending time outdoors wasn't the most popular chill pill, but it was the most powerful for those with a high level of stress. Ninety-four percent of those who spent time outdoors said it was an effective way to reduce stress. That rang true for the people we met on the National Mall. They mentioned trips to the ocean, naps by a lake and watching the leaves change color in the fall.

Only 46 percent of those surveyed said they pursued a hobby to try to relieve stress, but 93 percent of those who did said it was effective. Many on the Mall endorsed the calming power of hobbies including beekeeper Von Culin.

We handed his answer (and a few of our other favorites) over to animator Avi Ofer. He brought their anecdotes to life in the video at the top of this page.

We hope it inspires you to find new ways to beat the stress in your life. And don't worry. Not all of the stress-relief strategies in the video involve stinging insects.

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Coping With A Co-Worker's Body Odor Takes Tact

NPR Health Blog - Wed, 07/16/2014 - 3:27am
Coping With A Co-Worker's Body Odor Takes Tact July 16, 2014 3:27 AM ET Listen to the Story 3 min 52 sec   i i

We can all work up a stinky sweat — welders, ballerinas and number-crunchers alike. Would you want to know?


It's summer. It's sweaty. And sometimes that means people are trailing some pungent body odors that their colleagues can't help but smell. But how do you tactfully inform co-workers that they stink and need to address it? As Cath Ludeman-Hall will tell you, it isn't easy.

She was just out of college and a newbie at a staffing firm when she was asked to gently talk to an older worker in a retail warehouse after his colleagues complained that he stank.

“ As a man, his virility, his masculinity was associated with his smell. Are you asking him to redefine who he is to fit into an office environment where he's making $4.50 an hour?

"The company loved him and wanted to hire him permanently," she remembers. "However, he did have a pretty strong body odor issue."

The man was a recent immigrant, Ludeman-Hall remembers — hard-working and earnest. Twenty years later, she still remembers the details. She brought a kit of deodorant and soap to offer him. In addition to overcoming her own mortification, she says, she also had to bridge a difference in how his culture regarded sweat.

"As a man, his virility, his masculinity was associated with his smell," she says. "Are you asking him to redefine who he is to fit into an office environment where he's making $4.50 an hour?"

She figured out an acceptable way to frame the issue; the man apologized, complied and was eventually hired.

A global workforce just complicates matters, says Steve Fitzgerald, vice president of human resources for Avaya, a telecom software firm with offices worldwide.

"There are personal hygiene standards in all societies," Fitzgerald says, "and there are times when people deviate from those standards. And when those deviations occur, then I think you enter into that moment where, as an H.R. professional, you groan, and you go, 'Oh, God, I've to go have that conversation.' "

Be Direct, Compassionate And Discreet

That conversation can be triggered in any number of ways. Some people develop odors from eating spicy foods; some don't wash their hair often. "We have a lot of older workers in the workforce nowadays, and sometimes incontinence can be an issue," he says. "Bad breath."

Margaret Fiester, a director of the Knowledge Center at the Society for Human Resource Management, says her group fields a couple of calls every week from human resources professionals asking how to broach the body odor issue. She advises discussing it in private, being direct and showing compassion for the offender.

But really, Fiester says, the people calling in often need their own moral support. For them, she says, "This is sort of like a rite of passage, almost."

I asked her where this topic ranks in the pantheon of embarrassing talks, and she says she ranks it "probably No. 1 or No. 2."

Fiester speaks from experience. Years ago, she had the talk with a welder working in a hot manufacturing plant in Alabama, who was really embarrassed. "I thought he was going to cry," she says. "I think I was going to cry."

Several Showers A Day Couldn't Eliminate The Odor

But imagine what it's like to be on the receiving end of such a talk. Jennifer LaChance struggled with severe body odor brought on by anxiety since her teen years.

"I could take several showers a day and still have some degree of odor," she remembers.

Deodorants, soaps and medication didn't solve it. LaChance says she abandoned dreams of becoming a teacher, because she couldn't bear the thought of sidling up to parents at teacher conferences. Instead, she went to work at an insurance firm. She says she tried being open with co-workers and supervisors about her medical issue. Still, emails from HR started to circulate in the office, imploring colleagues to address their body odor.

"After that email circulates," LaChance says, "you've got a hundred eyeballs zeroed in on you. There's nothing that feels more hostile or more devastating than that."

LaChance felt deeply embarrassed, immediately left work and resigned days later.

"I just felt like, wow, there's no place for me," she says. "I never want to walk into an office again. I don't want to be an offensive person to anybody."

Now, she says, she's back in school studying medical data management — a job she says she can do largely from home, and avoid having body odor be an issue for her at work.

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Want More Stress In Your Life? Try Parenting A Teenager

NPR Health Blog - Wed, 07/16/2014 - 3:27am
Want More Stress In Your Life? Try Parenting A Teenager July 16, 2014 3:27 AM ET Listen to the Story 5 min 18 sec   i i

Amy Myers talks with her son Kamron, 18, in the backyard of their home in Boise, Idaho. She has found raising a teenager to be extremely stressful.

Kyle Green for NPR

If anyone can handle the stress of parenting in the teen years, you'd think it would be a high school teacher.

That's how Amy Myers felt. She teaches high school English in a suburb of Boise, Idaho, where she says she has "pseudo parented" about 3,000 teenagers "who I have talked to, given advice to, guided, directed, even lectured about teenage issues," she says.

So Myers, 41, felt pretty prepared for her own children's teenage years. That is until her oldest son, Kamron, turned 15. Suddenly, their close relationship turned sour. "Everything I demanded, he fought back. Advice? He didn't need it. Conversation? He didn't want it. It was hands down the toughest journey of my life so far, and that is coming from someone who has raised two children alone from day one and has worked for and earned two degrees," she says.

Shots - Health News Stressed Out: Americans Tell Us About Stress In Their Lives

NPR recently conducted a poll with our partners at the Robert Wood Johnson Foundation and the Harvard School of Public Health looking at the extent of stress in America.

We found that about one-third (34 percent) of those who live with one or more teenagers said they'd had a great deal of stress in the past month. Once we saw these results, we wanted to know more about the stories behind these numbers. So we put out a call on NPR's Facebook page. Hundreds of parents wrote to us.

From Marion, Iowa, Ann Brendes, 48, who has two sons, 15 and 17, and a daughter, 11, writes that it's "mind-blowing how stressful having teenagers is."

JoAnn Zeise, who's raising a 14-year-old son and a 12-year-old daughter, says the stress she feels now is a lot different than what she felt when the kids were young. "Once, I controlled the big decisions in their life," says Zeise, 39, who lives in Columbia, S.C. "Now they make decisions that can have drastic consequences. I feel like I am running out of time to teach them the important lessons they need," she writes.

i i

Amy Myers and Kamron, then age 3, in Pocatello, Idaho.

Courtesy of the Myers family

And numerous parents wrote to us about the difficulties of teenage defiance.

When it comes to stress, parenting a teen is "inherently stressful even in the best scenarios," according to David Palmiter, a clinical psychologist, professor at Marywood University in Scranton, Pa., and creator of the blog Hectic

He says it essentially boils down to a teenager's quest for independence. And that is understandably stressful for parents who used to be "driving the bus," he says. Now, he says, there's someone in the back seat saying (or yelling) "No, don't put the blinker on here, take that exit, what are you thinking?"

This constant questioning and challenging can be stressful for parents, of course, but Palmiter says it's actually a healthy part of growing up, and it often means parents are doing everything right.

Amy Myers' son Kamron is 18 now, and headed off to college. But the past three years, she says, have been extremely stressful for a number of reasons. She worried about his driving, about parties, about alcohol and drugs. And there were many late nights for Myers because, like many parents, she just couldn't fall asleep until she knew Kamron was safely home.

And like JoAnn Zeise, her biggest worries even now continue to be about her child's future. She's scared that Kamron might make a mistake that just can't be repaired.

Shots - Health News This Is Your Stressed-Out Brain On Scarcity

"I love this child more than I love myself, and I know what's around the corner and I'm trying to tell him and he's just ignoring me, and I really can't say or do anything about it. I just have to let him experience it and hope and pray that it's not a life-changing mistake," Myers says. Many psychologists say the best parents can do is making sure they have instilled positive values in their children and then just hope for the best.

As for dealing with their own stress, Palmiter suggests parents seek support from other parents, not just about their concerns but also about decisions. He also promotes special "one on one" time with your teenager. This means "being there" completely, cellphone unplugged, talking with your teen or observing them do an activity they enjoy like drawing, shooting basketball or playing an instrument. Just one hour a week of this special time can repair major differences, Palmiter says, and bring much-needed calm to households with teens.

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Stroke Rate May Be Declining In Older Adults

NPR Health Blog - Tue, 07/15/2014 - 6:24pm
Stroke Rate May Be Declining In Older Adults July 15, 2014 6:24 PM ET i i

Film CT scans show these people have suffered strokes.


Stroke is the fourth highest cause of death among adults in the U.S. But among people older than 65, stroke rates may be going down, a study published Tuesday suggests. And compared with 10 or 20 years ago, more of those hit with a stroke are surviving.

In 1987, researchers from several universities recruited a group of 14,300 healthy adults who were above the age of 45, then kept track of their medical progress for 24 years. To see whether stroke rates were increasing or decreasing, the scientists compared people within the same age groups. For example, they compared adults who were between the ages of 65 and 69 in 1993 to men and women in that age range in 2003.

By 2011, the incidence of stroke among people over 65 had decreased by about 50 percent. In younger age groups, that rate stayed stable — but stroke-related deaths in this group went down. "The decreases varied across age groups," the scientists report, "but were similar across sex and race."

The results were published Tuesday in the Journal of the American Medical Association.

So should we be celebrating?

Not quite yet, says Dr. Joe Coresh, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, and one of the authors of the study. "We should feel good that we're making progress," he tells Shots. "But we shouldn't be completely reassured."

Shots - Health News Even A Small Change In Habits Helps Fend Off Stroke

These events, which have come to be called "brain attacks," happen when a blood vessel feeding the brain bursts or is blocked. And a number of factors — including smoking, obesity, high blood pressure and high cholesterol — can increase the risk.

Strokes have likely declined because we're getting better at addressing these risk factors, Coresh says. More people these days take medications for high cholesterol and hypertension. And more people are making the decision to quit smoking — or never start.

Shots - Health News Hospitals Can Speed Stroke Treatment, But It's Not Easy

The scientists can't say for sure why more people are surviving a stroke, Coresh says. But it may be because doctors have gotten better at quickly getting them effective treatment.

Still, doctors and policymakers can and should be doing more to address this public health issue, Coresh says. Diabetes — another big risk factor for stroke — is on the rise, he notes. And questions still remain as to why stroke rates went down among those over 65, but not among younger adults.

"We know a lot about how to prevent stroke," he says. "And we should continue to be diligent about prevention."

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What's Going On In There? How Babies' Brains Practice Speech

NPR Health Blog - Tue, 07/15/2014 - 5:08pm
What's Going On In There? How Babies' Brains Practice Speech July 15, 2014 5:08 PM ET

The magnetoencephalograph can record electrical signals from a baby's brain without requiring the child to be perfectly still.

University of Washington

A baby's first words may seem spur of the moment, but really, the little ones have practiced their "Mamas" and "Dadas" for months in their minds.

Using what looks like a hair dryer from Mars, researchers from the University of Washington have taken the most precise peeks yet into the fireworks display of neural activity that occurs when infants listen to people speak.

They found that the motor area of the brain, which we use to produce speech, is very active in babies 7 to 12 months old when they listen to speech components.

"What we're seeing is that the babies are practicing because they want to talk back," says Patricia Kuhl, a speech psychologist at the University of Washington and the lead author on the paper, published Monday in the Proceedings of the National Academies of Sciences.

Kuhl used a machine called a magnetoencephalograph, or MEG, that measures the brain's magnetic field from outside the head. Unlike MRIs or CTs, which require that patients be completely still, the MEG can scan images in moving patients, which works out perfectly for fidgety babies.

University of Washington/YouTube

The scanner lets scientists glimpse at what's going on in that little head.

Babies undergo a huge transition from 7 months to 12 months that is very important for language acquisition, Kuhl says. At the age of 7 months, a baby can distinguish sounds from different languages, such as English or Spanish. But by 12 months the baby focuses in on her or his native language and begins to tune out foreign speech.

Kuhl placed 57 babies aged either 7 months or 12 months under the machine and played repeated human sounds for them. The speakers played repeated "da" and "ta" syllables in English and then "da" in Spanish.

They found that the motor part of the brain lit up when the baby listened to the sounds, indicating that they were trying to mimic or respond to the speech. By 12 months, the babies, who had English-speaking parents, had a harder time responding to the Spanish-language sounds.

Susan Goldin-Meadow, a developmental psychologist from the University of Chicago who was not involved in the study, says it furthers understanding of how babies process language. "We've had the behavioral data for a while," she says. "But this provides evidence on the neural level."

Kuhl says that her research supports parent's use of "parentese," or baby speak, a form of talking to babies with a higher pitch, slower pace and exaggerated facial expressions. "This is a good way to promote their itty-bitty social skills to develop," she says.

Not everyone sees this as an endorsement of parentese, though. Barbara Lust, a cognitive scientist from Cornell University who was not involved in the study, says the results "show more generally how important surrounding your child with language is, but it doesn't make a strong enough argument for needing to talk to a baby in a motherese way."

Kuhl says her next steps are to have researchers speak to the baby using parentese and analyze the baby's reactions, to see if the children respond more strongly to it.

The take-home message for new moms and dads, she says: "Talk to your baby; you're prompting it to act on the world."

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Most Employers See A Benefit In Covering Contraceptives

NPR Health Blog - Tue, 07/15/2014 - 10:32am
Most Employers See A Benefit In Covering Contraceptives July 15, 201410:32 AM ET

Partner content from

Despite questions raised by the Supreme Court decision in the Hobby Lobby case, women in most health plans will still be able to get their birth control covered with no out-of-pocket expenses.

The court ruling did not change the health law's requirement that preventive care services, including all Food and Drug Administration-approved forms of contraception for women, be provided by most health plans to customers without cost. The 5-4 decision said that only certain "closely held" firms that assert a religious objection to the birth control mandate can't be required to provide contraceptive coverage if they offer insurance to their workers.

Moreover, many firms see a benefit in providing coverage for contraceptives, says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a research and policy organization that focuses on reproductive health.

Shots - Health News Hobby Lobby Ruling Cuts Into Contraceptive Mandate

"There are so many incentives for companies to cover contraception," says Sonfield, including cost savings to insurers and self-funded employer plans because birth control is cheaper to cover than maternity and delivery.

Most companies provided contraceptive coverage even before the Affordable Care Act passed: 85 percent of companies with more than 200 workers and 63 percent of companies did overall, according to the Kaiser Family Foundation's 2010 annual employer health benefits survey.

For A Business Built 'On Bended Knee,' Hobby Lobby Ruling Is A Boon

Before the contraceptive mandate took effect, companies offering plans could generally choose which contraceptive methods they would cover. In the Supreme Court case, for example, the Hobby Lobby craft store chain offered workers birth control coverage but objected to two IUDs and emergency methods such as Plan B and Ella that can prevent pregnancy if taken shortly after unprotected sex. The chain's owners argued that those methods induce abortions, an argument that many scientists dispute.

The health law does allow some exemptions to the mandate. Those are for plans that were in place when the law took effect and have not changed substantially, and plans covering religious employers such as churches.

In addition, nonprofit religious organizations that object to covering birth control, such as some Catholic charities or universities, can elect instead to have their insurer or third-party administrator pay for the workers' contraceptive coverage. However, that accommodation is being litigated, and the outcome for female employees of those sorts of organizations is not clear.

Copyright 2014 Kaiser Health News. To see more, visit
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When Work Becomes A Haven From Stress At Home

NPR Health Blog - Tue, 07/15/2014 - 3:30am
When Work Becomes A Haven From Stress At Home July 15, 2014 3:30 AM ET Listen to the Story 3 min 43 sec   i i Lucinda Schreiber for NPR

In the land that came up with the phrase "Thank God it's Friday," and a restaurant chain to capitalize on the sense of relief many feel as the work week ends, researchers made an unusual finding in 2012.

Moms who worked full time reported significantly better physical and mental health than moms who worked part time, research involving more than 2,500 mothers found. And mothers who worked part time reported better health than moms who didn't work at all.

Working and juggling family responsibilities can be stressful. But can work, despite its demands, be less stressful than the alternative?

Mothers who worked longer hours had more juggling to do. They had more demands on their time and more stress. How could they possibly be in better physical and mental health?

One answer, of course, is self-selection. Mothers who were in better health to begin with may have chosen to work regularly. Researchers Adrianne Frech and Sarah Damaske, who conducted the 2012 study, also found that moms who worked steadily had other advantages. They were more likely to have grown up with two married parents, more likely to have completed high school and more likely to be in a stable relationship before the birth of their first child.

But in new research, Damaske argues that another factor might have been at play. It's a factor that sociologists such as Arlie Hochschild and psychiatrists such as Sigmund Freud have examined in the past. Hochschild, for one, found that many people find work to be less stressful than their home lives. Work was, in fact, a haven. Freud once said work and love were two wellsprings of emotional satisfaction in life.

In a study of 122 working men and women, Damaske had volunteers collect samples of saliva throughout the day. The samples were later tested to measure the levels of cortisol, a stress hormone.

Cortisol levels didn't spike when the volunteers were at work. They soared when the volunteers were home.

"When we looked at the difference between home and work in terms of their cortisol levels — that biological marker of stress — we found that people's cortisol levels were significantly lower at work than they were at home," Damaske said. The results "suggested to us that people — at least biologically speaking — had lower levels of stress ... at work," she said.

Low-income people and those without children were especially likely to report lower levels of the stress hormone when they were at work.

The idea that work might be less stressful than home life for many people is mirrored in a nationwide poll conducted by NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health: Health problems, the death of loved ones and juggling busy family schedules often scored among the top sources of stress in people's lives.

Damaske said there was an important difference between the kind of stress people experience at home and the kind of stress they experience in the workplace.

"No matter how urgent something is at work, you are not as attached to that urgency as you would be to, say, a health scare or the death of a loved one, because we are emotionally entangled at home in a way that we aren't at work," she said in an interview.

Besides, she added, most workers have a trump card to play at work, which they may not feel they have in their personal lives.

"You still know that you can quit, you can look for something else, that you can leave — leave your boss and your bad day behind," Damaske said. "Those aren't exactly strategies that you have for home, right? Most of us aren't going to up and leave our families because they're stressful, although most people's families are stressful from time to time."

Damaske said the study offered a different window into why women who work steady jobs might experience better physical and mental health than those who work part time, or not at all. It is still possible that women who are healthier to begin with are more likely to hold steady jobs, but Damaske said it might also be the case that work had positive effects on women's health.

So why do we hear so much about stressful jobs, bad bosses and difficult demands at work?

One reason could be that people might find it easier to talk about problems at work than to talk about problems and challenges in their personal lives. Social norms, Damaske said, make it acceptable to complain in public about our work lives, but make it difficult to talk publicly about health problems and other stressors in our personal lives.

All this points to one thing. There is pent-up demand in the United States for a new restaurant named "TGIM" — Thank God it's Monday!

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This Is Your Stressed-Out Brain On Scarcity

NPR Health Blog - Mon, 07/14/2014 - 4:06pm
This Is Your Stressed-Out Brain On Scarcity July 14, 2014 4:06 PM ET Listen to the Story 12 min 49 sec   i i Josh Neufeld for NPR

Being poor is stressful. That's no big surprise.

In a poll by NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health, 1 in 3 people making less than $20,000 a year said they'd experienced "a great deal of stress" in the previous month. And of those very stressed-out people, 70 percent said that money problems were to blame.

Shots - Health News For Many Americans, Stress Takes A Toll On Health And Family

Scientists have long recognized that poverty can aggravate health problems. Now they're also beginning to understand that the stress of too little income actually changes the way people think.

Take Lauren Boria, a single mom from the Bronx in her early 30s. Boria's an upbeat redhead supporting herself and her 4-year-old daughter, Fallon. They're barely scraping by on the paychecks from Boria's waitressing job. So Boria finds herself constantly doing a mental tally.

“ When so many moments of the day require your full attention, there's very little of it left to worry about things that are not right in front of your eyes ... and then you start doing things you wish you hadn't done.

"I have, like, I think $320 in my checking account right now," she says. "And I have a $300 check that I'm going to deposit. Then I have to write a $600 money order. So, what's that leave me with? I think twenty bucks."

Money seems to rule Boria's brain. Princeton psychologist Eldar Shafir says that's normal for someone who's not making ends meet. Shafir studies the brain on scarcity. He told me that it doesn't matter what kind of scarcity you're dealing with. When humans don't have enough of something, that fact dominates our consciousness.

"When you're very lonely, or when you're hungry, or when you're poor, a large portion of the day is spent entertaining thoughts related to the source of your scarcity. If you're lonely, you spend a big part of the day worrying about how to make social connections, which is actually distracting you from other things." And if you're poor, you worry about money. Constantly.

Putting this constant mental attention on money can be a good thing — in part.

In making day-to-day financial decisions, Shafir says, "the poor are just better than the rich. They use their dollar better than the rich. They're more efficient. They're more effective. They pay greater attention. So when [Boria] pays attention to these issues, she can do extremely well."

But the same attention that helps Boria survive day-to-day hurts her in the long run.

Shafir says that's because constantly solving money problems takes up a huge amount of Boria's cognitive capacity — a limited resource. "When so many moments of the day require your full attention, there's very little of it left to worry about things that are not right in front of your eyes ... and then you start doing things you wish you hadn't done. You don't quite remember to do things in time. You don't anticipate things that are going to happen tomorrow."

Shots - Health News How Money Worries Can Scramble Your Thinking

Shafir calls this problem bandwidth poverty. When you're bandwidth poor, you're thinking about how to pay for food and make rent today — and it's almost impossible to think about the future.

War On Poverty, 50 Years Later In Confronting Poverty, 'Harvest Of Shame' Reaped Praise And Criticism

Shafir says that the poor are often judged for being myopic — for not saving money for the future, or not making better decisions. But what looks like short-sightedness from the outside is actually bandwidth poverty, trapping people like Boria in the moment to such a degree that they literally can't think about the future.

Boria struggles with bandwidth poverty in lots of small ways, every day. But there's one big decision that haunts her: going on welfare after she lost her job about a year ago. Made in the throes of bandwidth poverty, she now calls that "the worst decision of her life."

Once Boria enrolled, she started getting a check for $145 twice a month. But what she didn't anticipate was that those checks would come with a whole new list of responsibilities.

The big requirement was that Boria had to show up for what's called a work preparedness program, Monday through Friday, from 9 a.m. to 5 p.m. for three months. "It's like a job, but you get no money for it," she told me. "You have to go there ready for an interview, every day."

But Boria says there never were any actual job interviews. In fact, Dr. Shafir told me that programs like work preparedness are intentionally complicated and demanding, to make sure that only the most driven and needy people will jump through the hoops to keep their benefits. The idea behind that is that people who just want an easy check get weeded out.

The actual effect on people like Boria is what Shafir calls a "cognitive tax" — taxing their limited bandwidth, and adding even more stress.

"The minute they make you show up every day at the right hour, dressed well, with a form," Shafir says, "[they're] just imposing more cognitive tax on you and increasing the chance that you won't succeed."

The expense of commuting to the program, and the time it took up, eventually took its toll on Boria, and she dropped out. But her time on cash assistance left a big footprint in her life. Just a few months ago, she learned she'd been accused of concealing funds — a crime she could do jail time for. The charge is that Boria hadn't reported some unemployment benefits she'd gotten while she was on cash assistance. The funds in question are a little over $1,000.

Thinking back on it now, Boria feels like if she'd just had the mental space and time to research all the options and what they'd lead to, she would never have signed up for welfare in the first place.

So what can the millions of people like Boria do to alleviate bandwidth poverty?

Shots - Health News Despite Health Law, Many People May Be Left Underinsured

Shafir says that, for a start, policy-makers can ease the cognitive burden of people who are financially strapped by simplifying the complicated forms and extensive bureaucratic requirements that make it hard to access public assistance. This is the opposite of a "cognitive tax" — what Shafir calls a "cognitive gift."

And Boria has gotten pretty good at giving herself cognitive gifts — a few moments of quiet out on the dock at her job, waitressing at a private yacht club in the Bronx, or a cheeseburger and a milkshake when she's feeling extra stressed.

Dr. Shafir says these kinds of mental breaks are more important than they might seem. "When you're struggling, poor ... a lot of the day is not so much fun. And people fail to appreciate the fact that when I buy myself a big ice cream, or a small gift" — something he says many people criticize the poor for doing — "I'm giving myself a nice minute after a complicated week, which is a good thing to do."

For Boria, the ultimate cognitive gift is a day away from appointments and obligations, playing at the beach with her daughter Fallon.

"Having children is the ultimate collection of wonderful, satisfying minutes and warmth and love in your life," Shafir says. "So that can be an enormous boost. It doesn't make her juggling easier. In fact there's every reason to believe her juggling has gotten much more complicated. But it does give you some meaning, which is what we're all here for, in some sense."

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Do We Choose Our Friends Because They Share Our Genes?

NPR Health Blog - Mon, 07/14/2014 - 3:08pm
Do We Choose Our Friends Because They Share Our Genes? July 14, 2014 3:08 PM ET Listen to the Story 3 min 40 sec  

People often talk about how their friends feel like family. Well, there's some new research out that suggests there's more to that than just a feeling. People appear to be more like their friends genetically than they are to strangers, the research found.

"The striking thing here is that friends are actually significantly more similar to one another than we were expecting," says James Fowler, a professor of political science and medical genetics at the University of California, San Diego, who conducted the study with Dr. Nicholas Christakis, a social scientist at Yale University.

In fact, the study in Monday's issue of the Proceedings of the National Academy of Sciences found that friends are as genetically similar as fourth cousins.

"It's as if they shared a great- great- great-grandparent in common," Fowler told Shots.

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Some of the genes that friends were most likely to have in common involve smell. "We tend to smell things the same way that our friends do," Fowler says. The study involved nearly 2,000 adults.

This suggests that as humans evolved, the ability to tolerate and be drawn to certain smells may have influenced where people hung out. Today we might call this the Starbucks effect.

"You may really love the smell of coffee. And you're drawn to a place where other people have been drawn to who also love the smell of coffee," Fowler says. "And so that might be the opportunity space for you to make friends. You're all there together because you love coffee and you make friends because you all love coffee."

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They also found some interesting differences among friends: They tend to have very different genes for their immune systems. Other researchers have reported similar findings among spouses.

"One of the reasons why we think this is true is because it gives us extra protection. If our spouses have an immune system that fights off a disease that we're susceptible to, they'll never get it, and then we'll never get it," Fowler says. "And so it gives us an extra layer of protection."

"It's obvious that humans tend to associate with other people who are very similar to themselves," says Matthew Jackson, a professor of economics at Stanford University who studies social networks. "This gives us evidence that it's operating not just at a level of very obvious characteristics but also ones that might be more subtle — things that that we hadn't really anticipated."

Taken together, Fowler says the findings could help explain all sorts of things, including how relationships are driven by genetics and how that, in turn, may be influencing human evolution.

"I think the biggest implication is that evolution can't be studied as a Robinson Crusoe phenomenon. We didn't evolve isolated — separate from others. We evolved in communities. We evolved with our friends."

On a more personal level, it could help explain that cozy feeling we get with our friends.

"It's as if we were surrounding ourselves with a new family," Fowler says. "It's the family we chose, rather than the family we're born with."

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Why A Spoonful Of Medicine Can Be A Big Safety Risk For Kids

NPR Health Blog - Mon, 07/14/2014 - 2:11pm
Why A Spoonful Of Medicine Can Be A Big Safety Risk For Kids July 14, 2014 2:11 PM ET i i

Ordinary spoons vary widely in size and shape. Confusing regular spoons for accurate measurements of teaspoons and tablespoons can lead to accidental overdoses.

Meredith Rizzo/NPR

We've all done it. The bottle of Pepto-Bismol says to take two tablespoons, so you grab the nearest spoon from the silverware drawer and drink down two of those. It's probably pretty close, right?

Maybe not. With all the different sizes and shapes of spoons out there — soup spoons, dessert spoons, grapefruit spoons and coffee spoons, to name just a few — who knows if the spoon you chose is actually close to a tablespoon.

And when it comes to children, that lack of precision can be dangerous.

Forty percent of parents make significant errors in measuring medication for their children, according to a study published Monday in the journal Pediatrics. And they were twice as likely to make an error when doses were listed in teaspoons or tablespoons rather than milliliters, in part because they measured out the medication using an ordinary spoon.

"Terms like 'teaspoon' and 'tablespoon' inadvertently endorse the use of kitchen spoons, which can vary in size and shape," says Dr. H. Shonna Yin, a pediatrician at the New York University School of Medicine and lead author on the study.

In the study, 30 percent of parents who thought of the medication dose in terms of teaspoons or tablespoons ended up using a kitchen spoon rather than a measuring device provided with the medication, compared with only 1 percent who thought of the medication dose in terms of milliliters. The use of kitchen spoons led to a greater frequency of dosing errors, which were defined as measured doses that were 20 percent higher or lower than the prescribed amount.

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"We recommend that parents always use standard dosing tools like syringes and droppers," says Yin.

Confusion over liquid medication doses for children is a huge safety issue, contributing to upward of 10,000 calls to national poison control centers annually. The problem stems in part from the lack of a standard measurement unit on liquid medications. Parents may face instructions with dosing units ranging from the familiar — teaspoons and tablespoons — to the seemingly archaic — drams and dropperfuls.

Organizations including the Centers for Disease Control and Prevention, the Food and Drug Administration and the American Academy of Pediatrics have called for doctors, pharmacists and drug manufacturers to adopt a standard unit of measure for liquid medications, with the milliliter being the top pick.

Many drug companies have already moved to using more standardized labeling that combines milliliters and teaspoons, according to Barbara Kochanowski of the Consumer Healthcare Products Association, a trade group for manufacturers of over-the-counter medications.

But some health literacy advocates are still hesitant to get rid of the traditional teaspoon and tablespoon measures altogether, Kochanowski says, out of fear that the less familiar milliliter might cause more confusion.

"We're not a metric country," Kochanowski says. "So people weren't willing to take the leap to get rid of spoons." This study shows that people can understand metric measurements, she adds, with real safety benefits for children.

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Why Are Obstetricians Top Billers For Group Therapy In Illinois?

NPR Health Blog - Mon, 07/14/2014 - 12:03pm
Why Are Obstetricians Top Billers For Group Therapy In Illinois? July 14, 201412:03 PM ET

Partner content from

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Unusual billing for group therapy led to a crackdown on Medicaid payments in Illinois.


A few years ago, Illinois' Medicaid program for the poor noticed some odd trends in its billings for group psychotherapy sessions.

Nursing home residents were being taken several times a week to off-site locations, and Medicaid was picking up the tab for both the services and the transportation.

And then there was this: The sessions were often being performed by obstetrician-gynecologists, oncologists and urologists — "people who didn't have any training really in psychiatry," Illinois Medicaid director Theresa Eagleson recalled.

So Medicaid began cracking down, and spending plummeted after new rules were implemented. In July 2012, the program stopped paying for group psychotherapy altogether for residents of nursing homes.

Yet Illinois doctors are still billing the federal Medicare program for large numbers of the same services, a ProPublica analysis of federal data shows.

Medicare paid Illinois providers for more than 290,000 group psychotherapy sessions in 2012 — more than twice as many sessions as were reimbursed to providers in New York, the state with the second-highest total.

Among the highest billers for group psychotherapy in Illinois were three OB-GYNs and a thoracic surgeon. The four combined for 37,864 sessions that year, more than the total for all providers in the state of California. They were reimbursed more than $730,000 by Medicare in 2012 just for psychotherapy sessions, according to an analysis of a separate Medicare data set released in April.

"That's not good," Eagleson said when told of the Medicare numbers.

Medicare's recent data release has led to a string of analyses showing how waste and fraud is inflating the nation's bill for health care. This work has echoed the findings of ProPublica's investigation last year into Medicare's prescription drug program known as Part D, which had fewer barriers to waste and fraud than other government health care programs – and was making less effective use of its own data.

Of the Illinois OB-GYNs billing for group psychotherapy, Dr. Josephine Kamper had the highest number of sessions. She was paid for 10,400 sessions in 2012, at a cost to Medicare of $207,980.

In 2011, the state Department of Financial and Professional Regulation placed Kamper on two years' probation for failing to evaluate a patient undergoing an abortion prior to anesthesia and failing to collaborate with a certified registered nurse anesthetist. The terms of her probation didn't prohibit providing psychotherapy.

Efforts to reach Kamper for comment were unsuccessful.

A OB-GYN named Lofton Kennedy Jr. billed for 9,154 group psychotherapy services. He declined to comment.

The third-highest-billing OB-GYN, Philip Okwuje, charged Medicare for 8,584 group therapy sessions. In a brief interview, he said he doesn't do them anymore. Okwuje was barred from Medicare and Medicaid from 2002 to 2005, records show, though the reason wasn't immediately available.

Thoracic surgeon Mark Lubienski said he began working with a company that offered group psychotherapy because he had to go on disability and could no longer perform surgeries. He had been experiencing episodes in which he temporarily lost consciousness.

Medicare paid $194,540 for more than 9,700 of his sessions in 2012, though Lubienski shared a tax form showing he received only about $52,000 from the company, Unified Therapeutics.

"I basically supervise social workers who run therapy sessions in intermediate and long-term care facilities for people who have psychiatric diagnoses," Lubienski said. "I'm there, I pitch in, I discuss things with the residents and stuff. We have a calendar of Medicare-approved topics that we go by."

And for residents who can't participate in the group sessions, "we see them individually."

Lubienski also was paid for 96 psychiatric interviews to diagnose mental illness. Lubienski said he doesn't see a problem with doctors who are not psychiatrists performing these services. "In certain states, it's mandated that the facilities have to offer these services yet there's nowhere near enough psychiatrists, psychologists, doctors, social workers to do it," he said.

Unified Therapeutics chief executive Todd Occomy said his company stopped providing the service in 2012 after the Medicaid changes in Illinois and has essentially ceased operations. "We were just getting squeezed," he said. "It got to the point where we could barely pay our physicians."

Aaron Albright, a spokesman for the U.S. Centers for Medicare and Medicaid Services, said in an email that Medicare has no policy regarding which physicians may perform group psychotherapy. During such sessions, "personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction, insight, and support," according to rules set out by one of Medicare's contractors.

Group psychotherapy doesn't cover such activities as socialization, music therapy, art classes, excursions, sensory stimulation or eating together. Typically groups can be no larger than 12 people.

Albright said he couldn't comment on individual providers but added that "deterring improper payments is a top priority for CMS in order to protect beneficiaries and taxpayers."

The billings for group psychotherapy reveal other unusual patterns. A Queens, N.Y., primary care doctor, Mark Burke, was paid for more sessions than anyone else in the country — 20,841. He accounted for nearly 1 in every 6 sessions delivered in the entire state of New York in Medicare, separate data show. He didn't return messages left at his office.

Another large biller was Makeba Gordon, a social worker in Detroit. She was reimbursed for nearly 5,000 group therapy sessions for her 26 Medicare patients, an average of 190 each. She also billed for 2,820 individual psychotherapy visits for the same 26 patients, who allegedly would have received an average of 298 therapy sessions apiece in 2012. Gordon couldn't be reached for comment.

A Chicago internist named Amjad Zureikat, who billed for 6,983 sessions, said he served two nursing homes and used books to help guide his discussions with patients. "We take the subjects from those books and we discuss it," he said.

Zureikat said he no longer practices as an internist but works three or four hours a week providing the therapy sessions and also is president of a local managed care organization.

"It is not that I enjoy it, it is something to do and it is useful to the residents and their families and the nursing home," Zureikat said.

To limit group psychotherapy billings, Illinois Medicaid first implemented rules that limited patients to no more than two sessions in a seven-day period, with a maximum of one a day. It then began requiring that physicians who bill for group psychotherapy complete a psychiatry residency program or be part of one.

The rules brought immediate results. In the year before September 2009, when the first changes were instituted, the program paid $30.4 million for these services, including almost $3.7 million to a single urologist. In the year afterward, the spending dropped by more than two-thirds. Payments for nursing home residents were cut off entirely in 2012.

Asked why Medicare hadn't taken similar steps, Eagleson, the Illinois Medicaid director, said she couldn't explain it. "I'm sure we can always all learn from one another," she said. "Trying to get this more coordinated is certainly one of our goals."

For more, read ProPublica's Examining Medicare series, which looks at providers with unusual billing patterns, and search for your own health provider in Treatment Tracker.

Copyright 2014 ProPublica. To see more, visit
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To Make Children Healthier, A Doctor Prescribes A Trip To The Park

NPR Health Blog - Mon, 07/14/2014 - 4:28am
To Make Children Healthier, A Doctor Prescribes A Trip To The Park July 14, 2014 4:28 AM ET Listen to the Story 4 min 7 sec  

When Dr. Robert Zarr wanted a young patient to get more exercise, he gave her an unusual prescription: Get off the bus to school earlier.

"She has to take a bus to the train, then a train to another bus, then that bus to her school," says Zarr, a pediatrician at Unity Health Care, a clinic that serves low-income and uninsured families in Washington, D.C. So the prescription read: "Walk the remaining four blocks on the second bus on your route to school from home, every day."

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Zarr with Kellsi Aguilar and her father, Felipe, in Zarr's Washington, D.C., office.

Sam Sanders/NPR

Kelssi Aguilar, his 13-year-old patient, wasn't exactly excited about the change at first. "He told me about the four blocks and I told him it was a 40-minute walk and I was too lazy," she said. "I was thinking, am I really doing this? I'm going to be late for school."

Kelssi was actually 10 minutes early the first day she tried the modified route. Kelssi has kept up the walking. And Zarr says she's moved from obese to just overweight — which is very good.

About 40 percent of Zarr's young patients are overweight or obese, which has led the doctor to come up with ways to give them very specific recommendations for physical activity. And that has meant mapping out all of the parks in the District of Columbia — 380 parks so far.

The parks, mapped and rated based on facilities and in a searchable database by zip code, can be linked to patients' electronic medical records. Zarr did it with help from the National Park Service and volunteers from George Washington University's School of Public Health, park rangers and other doctors. Zarr also received some funding for the project from the National Recreation and Park Association, the National Environmental Education Foundation, and the American Academy of Pediatrics.

Zarr writes park prescriptions on a special prescription pad, in English and Spanish, with the words "Rx for Outdoor Activity" on top, and a schedule slot that asks, "When and where will you play outside this week?"

But it's not just about the parks. It's about what the patients want, too.

"I like to listen and find out what it is my patients like to do," Zarr says, "and then gauge the parks based on their interests, based on their schedules, based on the things they're willing to do."

There are other park prescriptions projects getting started across the country, but none have matched the level of detail in Zarr's parks database.

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Many children aren't used to going to parks, notes Dr. Steven Pont, medical director for the Texas Center for the Prevention and Treatment of Childhood Obesity in Austin.

"If you didn't grow up in a family that went camping or experienced outdoors and if you're more from an urban environment, then going out to a park and experiencing nature might seem a little daunting," Pont says.

A program like Zarr's can help reduce that discomfort, Pont says. "The park prescriptions really help kids and families engage and get to those parks and say, 'Hey, I belong here too.' "

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Of course, not every park is safe, especially in the District. The neighborhood next to one of the parks Zarr discussed with Kelssi, Kingman Island, had 30 incidents of violent crime over the past year.

"The more parks are used, the more people are there, the safer and the better they are," Zarr says. "We want people first and foremost to be safe, and be active and be part of the solution to fixing parks that aren't quite what they should be."

Ultimately, Zarr says, he wants his parks database to exist in an app, on your smartphone, where doctors and patients alike can use it. And, one day he'd like to be able to track his patients' activity in parks, to find out exactly how much good a little green space can do.

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