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William Kitt has lived in a studio apartment in New York owned by the nonprofit Broadway Housing Communities for 13 years, after decades of living on the streets.Bryan Thomas for NPR
Editors' note: It's Invisibilia bonus time! Sometimes we've got more wonderful stories than we can fit into the Invisibilia show and podcast. But we can't let them go. This story is being heard exclusively on NPR's Morning Edition.
These days you can find William Kitt in a small, bright solarium on the corner of 150th Street and Edgecombe Avenue in Manhattan, where he lives. Most hours on any day he sits here, sketching over a desk cluttered with colored pencils and pastels. What you could not know from looking at Kitt, a slender, laughing man who wears a beret and surrounds himself with drawings, is that he spent decades living on the streets.
Broadway Housing Communities building on Edgecombe Avenue in Manhattan provides housing for 21 formerly homeless adults.Bryan Thomas for NPR
Kitt says he spent 34 years of his life being homeless and maddened by drug-induced hallucinations. Now he lives in an apartment owned by a housing nonprofit called Broadway Housing Communities, which was founded in 1983 and owns seven buildings housing over 600 tenants.
Like most supportive housing projects, Broadway Housing Communities provides apartments and medical, psychiatric or other services to people who, like William Kitt, have physical or mental health problems or are low income. Kitt, now 65, has leased a room from this Broadway Housing property on Edgecombe Avenue for the past 13 years.
He's alive today in part because of this Harlem building. "He was so not well when he first arrived that had he not been in Broadway Housing, he would not have had long to live," says Russell Baptist, a social work manager who has worked with Kitt. "Maybe just of his own neglect."
Kitt says he became homeless right after he turned 18. He was living in New York City with his mother. "Yeah, I came home one day and the house was dark and everything was gone. The rent was paid for the end of that month. I didn't know how to pay no bills or nothing like that," he says. His mother had just left without a word. "She ain't sit down and talk to me. She didn't want to give me the option of saying, hey I'll go with y'all."
Kitt, 65, spends mornings and afternoons drawing.Bryan Thomas for NPR
He moved into a New York City homeless shelter and made money from scheming. He stole cans out of recycling bins and forged identities to make cash. He says he made a lot of money this way. "But I was a drug addict. Heroin. Cocaine. Crack," he says. "All the money went into the habit."
That's when Kitt says he started having strange thoughts, sometimes even hallucinations. "You could walk by the park and spirits would come out and the devils start playing with your mind," he says.Additional Information: Solutions
Americans love solutions — to political conflicts, social ills, clogged drains. But are there ever problems we shouldn't try to solve? Explore this question in the latest episode of the NPR podcast and show Invisibilia.
It was like this until he was in his 50s, when he met a social worker who told him that she could help him find a place to live. She told him it would be subsidized and permanent, so he agreed to work with her. From others, he had heard that the city was giving preference to people with a mental illness. So he says he decided to do what had kept him alive for the last three decades — come up with a scheme that would ensure a place in one of the city's new supportive housing projects. "I had to act crazy," he says.
An unnecessary move, according to Ellen Baxter, the executive director and founder of Broadway Housing Communities. She says people don't have to have a mental disorder to live in the units, and many of the tenants have no mental health diagnoses.
Baptist says that Kitt really was very mentally unstable at the time, and Kitt himself admits that he wasn't the same person he is today. "Coming in off the street for 34 years, you a wild — a wild dude, you know what I mean? It took me about five years before I started letting [other people] in," he says.
Kitt uses pastels and pencils to draw vibrant renderings of life in New York.Bryan Thomas for NPR
- Hide caption William Kitt's portraits are based on his observations of the vibrant street life of Manhattan. Previous Next Artwork by William Kitt/Bryan Thomas for NPR
- Hide caption He often walks to Times Square and asks people to strike quick poses while he photographs them. Previous Next Artwork by William Kitt/Bryan Thomas for NPR
- Hide caption Working from the photographs, Kitt uses pastels to create each portrait. Previous Next Artwork by William Kitt/Bryan Thomas for NPR
- Hide caption Kitt lived on the streets for decades; now they're a source of creative inspiration. Previous Next Artwork by William Kitt/Bryan Thomas for NPR
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After three decades of homelessness, Kitt was extremely socially withdrawn. "He would just stay in his apartment and not come out," Baptist says. "He was just so disorganized. That's how I'll put it. He was so disorganized he couldn't come upstairs to the social services. He needed a worker to take him, to transport him everywhere."
But Baptist says that after five years of effort by him and other social workers, Kitt started to change. "Just little by little, he started coming out," Baptist says. "And then he asked for paper. He said I want to draw. And we brought him some papers and charcoal and pencils, and he threw himself into that artwork. He became alive. He began to talk, to trust. It was amazing."
Services for most residents at Broadway Housing are paid for by the state and city of New York and private foundations. Housing is subsidized from the same sources, and many residents, like Kitt, pay their rent from some combination of welfare, Social Security or work income.
Supportive housing projects like Broadway that provide permanent housing and social support to people who were homeless, many of whom have neglected physical or mental health needs, are often more cost-effective than emergency shelter or medical services. Broadway Housing officials say that supportive housing for one person costs taxpayers $12,500 a year, compared with $25,000 for an emergency shelter cot; $60,000 for a prison cell; or $125,000 for a psychiatric hospital bed.
Kitt says the social services were incidental to his transformation. He says he had decided to extradite himself from his own wildness and "domesticate" himself, as he puts it. Now he says he's found his calling in art. He's working on creating four collections of street portraits. And Baptist says Kitt is an ambassador for the building, a model tenant.
Baptist says in a way it's true that Kitt pulled himself up by his own bootstraps. "He didn't have to comply. Nobody can tell you to stop using drugs. He did do it on his own." But there's another part of it. "Being stable at Broadway Housing and knowing he had a place to live," he says, "helped him become the man you see today."
Invisibilia co-host Lulu Miller contributed to this report.Copyright 2016 NPR. To see more, visit NPR.
Luc Ennekans, 51, is deeply attached to his host, Toni Smit. That's caused some friction in Smit's marriage.Meghan Eckman for NPR
At the center of Geel, a charming Belgian town less than an hour's drive from of Antwerp, is a church dedicated to Dymphna, a saint believed to have the power to cure mental disorders. It's a medieval church with stone arches, spires and a half-built bell tower, and it has inspired an unusual centuries-old practice: For over 700 years, residents of Geel have been accepting people with mental disorders, often very severe mental disorders, into their homes and caring for them.
It isn't meant to be a treatment or therapy. The people are not called patients, but guests or boarders. They go to Geel and join households to share a life with people who can watch over them. Today, there are about 250 boarders in Geel. One of them is a Flemish man named Luc Ennekans. He's slim and has green eyes, and he's 51 years old. NPR's Lulu Miller went to Geel and met him and his host family there and reported this story for Invisibilia.
Like all of the guests in the town today, Ennekans first went to a public psychiatric hospital in Geel that manages the boarder program. Ennekans saw medical professionals and received treatment and an evaluation. Then he was paired with a household. His hosts, Toni Smit and Arthur Shouten, say that living with Ennekans was rough at the start.
Ennekans became deeply attached to Smit. "If it were up to Luc, he would be hugging and kissing me all day," Smit says. He showered her with such affection, bringing her flowers, little kisses, linking arms with her on walks, that it began to interfere with Smit and Shouten's marriage. "You couldn't even give each other a hug or Luc is standing behind us," Shouten says. Wrinkles like this are common, according to the couple. They've had six boarders over the years, each with a unique set of challenges.
One boarder used to lock Smit and Shouten out of the bathroom to furiously wash his hands, and another used to struggle to sleep because he saw lions coming out of the walls. "He was really dementing," Smit says. But that doesn't affect the way they see their boarders. Like many hosts in Geel, they accept that this is simply who their boarders are. It's not abnormal or something they need to change. "It's just normal life," Shouten says.
That acceptance of mental differences has become something of a tradition in Geel. It's at the heart of the boarder program, and some observers think it's also responsible for the system's success. Around the world, many different experiments have been attempted over the centuries to provide humane care for people with mental illness and mental disabilities. Geel is one that has endured.
Residents of Geel have not only accepted the eccentric or disruptive behaviors of the boarders but have come up with creative ways to help boarders and residents manage them, says Ellen Baxter, the founder of Broadway Housing Communities, a nonprofit in New York City. It is partially inspired by Geel, which Baxter visited as a young woman.
For example, when Ennekans became too jealous or attached to Smit, Shouten and Smit encouraged him to find a girlfriend or other companionship. When their former boarder hallucinated lions coming through the walls, Smit would pretend to chase the lions away. "And that would work every time," Smit says.
Shouten and Smit receive a stipend from the Belgian government for taking care of Ennekans, as well as training and support from psychiatric professionals. Hospitalization is available if needed. Several studies have found that the incidence of violence by boarders is low; people who have previously exhibited violent behavior are usually not admitted to the program.
The integration of people with mental disorders into Geel society has fascinated scholars for centuries. In 1862, Dr. Louiseau, a visiting French doctor, described it as "the extraordinary phenomenon presented at Geel of 400 insane persons moving freely about in the midst of a population which tolerates them without fear and without emotion." Nearly 100 years after that, an American psychiatrist named Charles D. Aring wrote in the journal JAMA, "The remarkable aspect of the Gheel experience, for the uninitiated[,] is the attitude of the citizenry."
Early psychiatrists who observed Geel noticed that the treatment prescribed for mental patients was, in fact, no treatment at all. "To them, treating the insane, meant to simply live with them, share their work, their distractions," Jacques-Joseph Moreau wrote in 1845. He and others advocated for that communion. "In a colony, like in Geel, the crazy people ... have not completely lost their dignity as reasonable human beings." In the next half-century, many would uphold Geel's model as the best standard of practice for mental disorders.
How Geel came to be this way begins with the town's devotion to St. Dymphna, whose church stands in the center of town. According to legend, Dymphna was a 7th-century Irish princess who fled to Geel from a maddened father and devoted her life to serving the mentally disabled. But she became a martyr when her father discovered her location and traveled to Geel to behead her.
The town built St. Dymphna's church in the 14th century to honor the saint and enshrine her supposed remains. It became a popular pilgrimage site for people across Europe, who would bring loved ones to the shrine in the hopes of finding relief from their mental distress.
St. Dymphna is said to have fled to Geel from Ireland, where she helped care for people with mental illness.Courtesy of Eric de Smet
By 1480, the town had built a small hospice on the side of the church to accommodate pilgrims, but the shrine became so popular that the pilgrims overwhelmed the annex's capacity. "Sometimes the families would return home and leave their uncured relatives in the hospice," says Mike Jay, a historian of psychiatry and curator for the Wellcome Collection in London, who has studied Geel. "So local people began taking them in as guests or boarders, as they call them."
The early practice was often mutually beneficial for both the hosts and the boarders, Jay says. Many Geel residents were farmers, and boarders offered a source of labor. In exchange, the boarders got stable housing and a family life. But the integration was not always a happy one. There are stories of abuse, Jay says. "One of the laws was that if a boarder committed a crime, it was the fault of the family. If you had a boarder who was difficult, then some of the families would resort to keeping them chained or restrained."
As medical treatment for the mentally ill evolved, so did Geel. In the 19th century, a central medical establishment was set up that provided standard medical and psychiatric care to boarders and other residents. But this was at the same time that large insane asylums were considered the most advanced, scientific form of care. Geel became the source of a great debate in psychiatry. "It was a polarizing example," Jay says. "Some people regarded Geel as a sad remnant of old medieval culture where people were left to toil in the field and never given therapy and no chance of recovery."
Other early observers noted the same things that Baxter and other more recent visitors have: By and large, people in Geel were happy. "One of the agreeable features is the general contentment manifested by the insane," wrote John Sibbald, a Scottish psychiatrist, in 1861.
By the turn of the 20th century, the International Congress of Psychiatry had declared Geel an example of best practice to be copied elsewhere. The program continued to be a source of local pride, and it grew. At the program's peak in 1930, about 4,000 boarders resided in Geel — a quarter of the town's population.
Over time, Jay says, boarders had become such a part of life and society that distinctions between them and nonboarders blurred. And with that, "a lot of the problems we associate [with mental illness] kind of fade away," Jay says. "Like trying to navigate a world full of kind of normal people who don't understand what's going on and aren't tolerant towards it."
There are a few important criteria for acceptance into the Geel program. The program typically selects patients with severe mental illness or cognitive disabilities who have difficulty living independently. In 2003, almost half of the town's 516 boarders had a cognitive disability, and over 20 percent carry a diagnosis of schizophrenia or other psychotic disorder, according to research by Jackie Goldstein, a professor emeritus of psychology at Samford University. Some boarders have traditionally had other conditions such as learning disabilities or autism.Subscribe to Invisibilia
While scholarship of Geel is rich with observation, there remain few long-term, empirical studies on how these patients do in the system. "The successes and shortcomings of Geel's system of foster family care had never been thoroughly or systematically examined," Goldstein noted in a speech presented at the American Psychological Association Annual Convention in 1998. In the 1960s, researchers embarked on a 10-year project studying Geel that Goldstein took part in, but it never reached completion.
Goldstein continued studying Geel throughout her life, and some of her work shows that boarder life is stable. Boarders tend to stay in family care for years. In some cases, when boarders' caretakers grow too old or die, they continue to live with their caretakers' children. In 2005, nearly a third of boarders lived in a foster home for more than 50 years.
But the centuries-old custom has been shrinking. The number of boarders has fallen to roughly 250 today, less than 7 percent of its prewar peak. Eugeen Roosens, a Belgian psychiatrist, and Lieve Van De Walle, a former director for rehabilitation in Geel, write, "the time of extended farmer families, who could do with a helping hand, is gone," in their book, Geel Revisited: After Centuries of Mental Rehabilitation.
There are possible reasons for the program's decline besides the time and professional pressures of modern life. There may be fewer patients who need supported living thanks to improved psychiatric medication, which might contribute to fewer referrals to the program. Roosens and Van De Walle also note the program lacks enough funding to cover the cost of a boarder. The Belgian government pays 40 euros (less than $45) per boarder per day to support the practice, less than half of which goes to the foster family to cover living expenses.
Still, the tradition persists, in large part because Geelians are proud of it. In a 1962 survey of Geel foster families, American psychiatrist Matthew Dumont found that their main reason for accepting boarders was custom. Roosens and Van De Walle describe the program as part of Geel's heritage. It's part of the town's identity. But, they write, that may not be enough to sustain the program.
With reporting by Lulu Miller.Copyright 2016 NPR. To see more, visit NPR.
When mental health professionals don't take insurance, only the wealthy can afford their help.Joe Houghton/Getty Images
There's something that really bothers Stanford psychiatry professor Keith Humphreys. When he thinks of all the years he has spent training the next generation of psychiatrists, the enormous investment in medical school and residency, he wants those doctors to devote that education to taking care of people with serious mental illness.
But, he says, many of them instead set up a private practice, where they can charge $400 an hour in cash to help people who Humphreys calls "the worried well" –- people who enjoy the self-exploration of therapy but don't necessarily have a mental health problem.
"A minute I spend training that person is a minute of my life wasted," Humphreys says. "That very well-trained person should be taking care of very, very troubled people. When they don't, everyone who needs that care loses out."
Humphreys says this trend of mental health clinicians shunning the health insurance industry and decamping to the cash market dates back 70 years, to the end of World War II.
In 1946, the majority of veterans cared for by what was then called the Veterans Administration were mental health patients, Humphreys says. But there weren't enough psychologists and psychiatrists to take care of them. So the VA partnered with several universities, including Stanford, to train mental health professionals.
The VA became the largest employer of psychologists, and those schools started turning out hundreds and hundreds of psychologists a year. The expansion dovetailed with soaring American affluence — and soaring American interest in self-exploration.
Having a psychoanalyst became "a sort of status symbol," Humphreys says.
A lot of psychologists who were trained to work in the public sector saw a better financial opportunity and jumped ship. They hung shingles and started their own private practices where they could charge wealthy people much higher rates.
"When you put in a free market in a society where people were very interested in self-exploration, a lot of them went out and did their own thing," Humphreys says.
The reason this was possible is because of how the overall U.S. health care system was established, Humphreys says. Most people got their health insurance through work. Employers competed with each other for the best employees by offering better benefits.
"When you put in a free market in a society where people were very interested in self-exploration, a lot of them went out and did their own thing," says Stanford psychiatry professor Keith Humphreys.Courtesy of Keith Humphreys
So the standards for coverage developed over time in a piecemeal, haphazard way.
As health policy evolved, mental health benefits continuously lagged, Humphreys says. Coverage for mental health treatments or hospitalizations was meager or nonexistent.
"We don't seem to have this problem with cardiology or oncology," Humphreys says. "You don't see people lining up to pay cash for those services because the benefits are so low."
This wouldn't happen in places that have single-payer health systems, like Canada, Humphreys says, because all the health care payments are controlled by the government. Mental health care was baked into that system earlier on. But in the U.S., he says, "If it's a market where you pretty much have to pay for yourself, the rich are always going to win."
The growing workforce of psychiatrists, psychologists, marriage and family therapists, and licensed social workers has responded to that market demand.
And not just because it's better money. Treating high-functioning professionals in a private office is a lot less stressful than doing rounds on a psychiatric ward in a public hospital.
Especially in affluent places like the San Francisco Bay Area, this creates a divide, a culture of mental health haves and have-nots. Mental health clinicians don't need to participate in the health care system or take insurance to keep their schedules full — making it harder and harder for people of lower income to find a therapist.
"That's why you can have a lot of mental health professionals in an area, but still have a shortage of care for people in need," Humphreys adds. "The person who's hurt is the person who's suicidal, maybe they're horribly addicted to OxyContin or their child is showing signs of bipolar disorder, and they can't find somebody to take their insurance. It's unjust."
Mental health advocates have worked to shift this balance, passing the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act in 2010. Together, those laws require health plans to offer mental health coverage on par with other medical coverage.
But so far, it hasn't put a dent in the cash market for mental health. Humphreys says given the nature of mental health care and the American obsession with self-improvement, the cash market will be here to stay.
"Accessing mental health care is often pleasurable and enjoyable, and accessing a lot of other health care isn't," Humphreys says. "I mean, who goes to the dentist for fun?" As grateful as we are for dentists — nobody.
This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
Why do people act the way they do? Many of us intuitively gravitate toward explaining human behavior in terms of personality traits: characteristic patterns of thinking, feeling and behaving that tend to be stable over time and consistent across situations.
This intuition has been a topic of fierce scientific debate since the 1960s, with some psychologists arguing that situations — not traits — are the most important causes of behavior. Some have even argued that personality traits are figments of our imagination that don't exist at all.
But in the past two decades, a large and still-growing body of research has established that personality traits are very much real, and that how people describe someone's personality accurately predicts that person's actual behavior.
The effects of personality traits on behavior are easiest to see when people are observed repeatedly across a variety of situations. On any one occasion, a person's behavior is influenced by both their personality and the situation, as well as other factors such as their current thoughts, feelings and goals. But when someone is observed in many different situations, the influence of personality on behavior is hard to miss. For example, you probably know some people who consistently (but not always) show up on time, and others who consistently run late.
We've also gained a clear sense of which personality traits are most generally useful for understanding behavior. The world's languages include many thousands of words for describing personality, but most of these can be organized in terms of the "Big Five" trait dimensions: extraversion (characterized by adjectives like outgoing, assertive and energetic vs. quiet and reserved); agreeableness (compassionate, respectful and trusting vs. uncaring and argumentative); conscientiousness (orderly, hard-working and responsible vs. disorganized and distractible); negative emotionality (prone to worry, sadness and mood swings vs. calm and emotionally resilient); and open-mindedness (intellectually curious, artistic and imaginative vs. disinterested in art, beauty and abstract ideas).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? Explore that question in the latest episode of the NPR podcast and show Invisibilia.
And while personality traits are relatively stable over time, they can and often do gradually change across the life span. What's more, those changes are usually for the better. Many studies, including some of my own, show that most adults become more agreeable, conscientious and emotionally resilient as they age. But these changes tend to unfold across years or decades, rather than days or weeks. Sudden, dramatic changes in personality are rare.
Due to their effects on behavior and continuity over time, personality traits help shape the course of people's lives. When measured using scientifically constructed and validated personality tests, like one that Oliver John and I recently developed, the Big Five traits predict a long list of consequential life outcomes: performance in school and at work, relationships with family, friends, and romantic partners, life satisfaction and emotional well-being, physical health and longevity, and many more. Of course, none of these outcomes are entirely determined by personality; all of them are also influenced by people's life circumstances. But personality traits clearly influence people's lives in important ways and help explain why two people in similar circumstances often end up with different outcomes.
Consider one of life's most important and potentially difficult decisions: who (if anyone!) to choose as your mate. The research evidence indicates that personality should play a role in this decision. Studies following couples over time have consistently found that choosing a spouse who is kind, responsible and emotionally resilient will substantially improve your chances of maintaining a stable and satisfying marriage. In fact, personality traits are some of the most powerful predictors of long-term relationship quality.
This is not to say that we've already figured out everything there is to know about personality traits.Shots - Health News Invisibilia: Is Your Personality Fixed, Or Can You Change Who You Are?
For example, we know that personality change can happen, that it usually happens gradually, and that it's usually for the better. But we don't fully understand the causes of personality change just yet.
Research by Brent Roberts, Joshua Jackson, Wiebke Bleidorn and others highlights the importance of social roles. When we invest in a role that calls for particular kinds of behavior, such as a job that calls for being hard-working and responsible, then over time those behaviors tend to become integrated into our personality.
A 2015 study by Nathan Hudson and Chris Fraley indicates that some people may even be able to intentionally change their own personality through sustained personal effort and careful goal-setting. A study of mine published last year, and another by Jule Specht, suggest that positive personality changes accelerate when people are leading meaningful and satisfying lives.
So although we now know a lot more about personality than we did even a few years ago, we certainly don't know everything. The nature, development and consequences of personality traits remain hot topics of research, and we're learning new things all the time. Stay tuned.NPR.
HeLa cells, commonly used in research, were derived from cervical cancer cells taken in 1951 from Henrietta Lacks without her permission.Science Source
An influential federal panel has taken the unusual step of telling the Obama administration to withdraw a controversial proposal to revise regulations that protect people who volunteer for medical research.
The proposal is "marred by omissions, the absence of essential elements, and a lack of clarity," according to the National Academies of Sciences, Engineering and Medicine. The conclusions are part of a 283-page report released Wednesday.
The regulations are known collectively as the Common Rule. They were put in place decades ago to make sure medical experiments are conducted ethically.
But the rules haven't been updated in nearly a quarter century. So last year the Department of Health and Human Services proposed a major revision.
But the proposal prompted a wide range of criticism. Some argued the revisions were too vague, complex and confusing. Others attacked specific changes.Shots - Health News A Controversial Rewrite For Rules To Protect Humans In Experiments
One especially contentious requirement would oblige scientists to obtain explicit consent from patients before using their blood or tissue for research.
The requirement aims to prevent a repeat of what happened to Henrietta Lacks. She was an African-American woman who died of cervical cancer in 1951. Tumor cells taken from her were used without her consent to produce a research cell line that has been kept alive in labs around the world ever since.
But many researchers feared the new requirement would create unnecessary red tape and significantly hinder important research.
The academies report appears to agree. It concludes that "much of this research does not involve physical risk to participants; rather, risks are limited to the more remote possibility of informational harm resulting from the inadvertent release of confidential information."
The report recommends that the proposal be withdrawn. Instead, it says the president should appoint an independent national commission modeled on the President's Commission for the Study of Ethical Problems in Medicine and Biomedical And Behavioral Research to essentially start from scratch in revising the regulations.
HHS says it is reviewing the report, along with more than 2,100 public comments on the proposed revision.Copyright 2016 NPR. To see more, visit NPR.
Glenn Baker, 44, stands in his South Side apartment that is paid for by a program of the University of Illinois Hospital in Chicago.Miles Bryan/WBEZ
For a lot of us, the hospital's emergency room is a stressful place.
Not so for Glenn Baker.
When Baker, 44, steps into the emergency room at the University of Illinois Hospital in Chicago, he's completely comfortable.
He has a favorite double-wide chair in the corner, knows where to find the Cheetos in the vending machine, and the staff is like family.
Patty Zion, a nurse at the hospital on the West Side, says she knows Baker well: "He's one of our very famous patients who comes around and sees us quite often when he's not feeling well."
Baker has severe asthma and other chronic medical issues. But he's quick to admit he often ends up in this hospital not because he was sick, but because he was homeless.
"I would just try and fake an illness or something so that the hospital would admit me," Baker says, "so I wouldn't have to be on the streets when it was cold."
Baker says that last winter he spent about 20 nights every month checked into different Chicago hospitals.
In the medical world, patients like Baker are often called "superutilizers" or "frequent fliers" — people with a mix of chronic medical problems, mental health issues and homelessness that drive them to visit the hospital far more than the average patient.
There are thousands of these patients across the country. More than 55 million people are on Medicaid in the U.S. But according to a recent government report, about half of the program's annual resources go to just 5 percent of its beneficiaries.
This year the University of Illinois Hospital is trying something different to care for Glenn Baker and its other "superutilizers."
The hospital is paying to get them out of the emergency room and into housing.
"I think this is a program that is a win, win, win for everybody involved," says hospital CEO Avijit Ghosh. "Glenn wins, other patients who are in that same situation win, the hospital wins ... and I think society and the state win by the cost savings."
The hospital's pilot project is using $250,000 of its own money to get 25 patients like Baker into "housing first" style housing.
Along with an apartment, patients get a case manager who helps them do things like schedule doctor's appointments instead of going to the ER. The program is run in partnership with Chicago's Center for Housing and Health.
Ghosh is quick to note the program is focused on getting patients healthy — it's not simply a financial calculus. But he does point out that hospital care costs about $3,000 per day.
By contrast, the hospital pays about $1,000 a month for the patients' apartments.
"So you can see the difference between $3,000 a day, and $1,000 a month," Ghosh says.
And the program is already showing results: Currently, the health care costs of the 15 people the hospital has helped house so far, including Baker, are down 75 percent.
That's good for them, Ghosh says, and good for the hospital's other patients as well. "Quite often we are at capacity. So if we are using a bed for somebody who really doesn't need to be there, somebody else is forgoing the care."
Treating housing as part of a patient's health is an idea that has caught on in recent years, says Dr. Kelly Doran. She's an assistant professor of emergency medicine at the New York University School of Medicine who studies how homeless people use emergency services.Shots - Health News How Oregon Is Getting 'Frequent Fliers' Out Of The ER
"The new thing here, really, is that the hospital is putting forth money for this effort," Doran says.
But for a program like this to work, there needs to be a long-term investment, Doran says. The Chicago hospital's pilot project is set to run out of funding by next summer.
"Housing is an intervention that goes on for many years," Doran says. "So, for how many years will they be paying for the housing? And after they stop paying, who's going to pay for the housing?"
Hospital officials say they are looking into ways to continue the project, but they pledge that nobody who has been housed already will lose housing if that does not happen.
The hospital's investment so far has got Glenn Baker into a light, airy one-bedroom apartment with a living room and kitchen.
He says he is thrilled to have a home of his own. Even if there are some things he misses about the hospital.
"This bed here is like, it's kind of firm," he says, laughing. "So, I mean, I would take a soft, comfortable hospital bed any day."Copyright 2016 Chicago Public Radio. To see more, visit Chicago Public Radio.
The backlog of appeals of denied Medicare claims will take years to clear up even after changes proposed by the Department of Health and Human Services.Alex Brandon/AP
The Department of Health and Human Services Tuesday proposed key changes in the Medicare appeals process to help reduce the backlog of more than 700,000 cases involving denied claims.
The measures "will help us get a leg up on this problem," said Nancy Griswold, chief law judge of the Office of Medicare Hearing and Appeals.
If there weren't a single additional appeal filed and no changes in the system, it would take 11 years to eliminate the backlog, Griswold said in an interview.
Her office has faced increased criticism from health care providers and beneficiary advocates lately for its inability to speed up appeals and reduce the backlog. The latest critique came earlier in June in an investigation from the Government Accountability Office.
This latest effort (summarized here) still falls short of what is needed, said Tom Nickels, executive vice president at the American Hospital Association. "We are deeply disappointed that HHS has not made more progress in addressing the delays despite the more than two years since the delays began," he said.
The new proposals, as well as increased funding requests, are expected to eliminate the backlog by 2021 by streamlining the decision-making process and reducing the number of cases that go to the third level of appeals, where many cases linger waiting for a hearing and then a decision from an administrative law judge. From the day of the hearing, it currently takes an average of slightly more than two years for a decision in appeals from hospitals, nursing homes, medical device suppliers and other health care providers.
Among the proposed changes:
- Designate some decisions from the Medicare Appeals Council, the last of four stages of appeals, as precedents that decision-makers at lower levels would have to follow. That could eliminate redundant appeals and resolve inconsistencies in interpretation of Medicare policies.
- Allow senior attorneys to handle some of the procedural matters that come before the administrative law judges, such as dismissing a request for a hearing after the appellant has withdrawn the request, Griswold said.
- Revise how the minimum amount necessary to lodge an appeal is determined. Under current rules, an appeal must involve payment of at least $150, based on the amount the provider charged. HHS proposes using Medicare's allowed amount instead, which tends to be lower, and that could reduce the number of claims that could be appealed.
- Eliminate some steps in the appeals process to simplify the system.
Although advocates have sought changes to speed up the appeal process, Alice Bers, an attorney at the Center for Medicare Advocacy, was skeptical about some of the proposals. The effort to set up a system of precedents, she said, "could restrict coverage for needed items and benefits for seniors that they are entitled to by law."
And the change in calculating the minimal amounts "could make it harder for beneficiaries to reach that threshold," said Bers. It might not sound like a lot of money, Bers said, "but for an elderly woman living on Social Security that's several meals or copays for medicine."
The proposals do not address what hospital representatives say is a key cause of increasing appeals, independent audit contractors who can reject payments to hospitals. The American Hospital Association contends that those contractors unnecessarily cut off many payments and that hospitals frequently win the appeals.
According to the GAO study, audit-related appeals decided at the administrative law judge stage — the third level of appeals — increased thirty-sevenfold from 2010 through 2014, compared with only 1.5 times for appeals of other kinds of claims.
But Griswold said that currently only about a third of the pending cases at this stage involved recovery audit contractors, after settlements were reached with hospitals that agreed to accept partial payment in return for withdrawing more than 220,000 cases.
Griswold also said Medicare will continue to process beneficiary appeals before those from hospitals, doctors and other health care providers. The practice began in 2014.
The proposed changes will be posted on the Federal Register website and open for comments through Aug. 29.
Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Ten-year-old Matthew Husby gets some low-tech comfort from his father after surgery at Lucile Packard Children's Hospital Stanford in Palo Alto, Calif.Heidi de Marco/Kaiser Health News
Surgery can make anyone anxious, but it is especially hard for young children. Kids going into surgery may be separated from their parents for the first time in a frightening new environment, and they may not understand what's happening.
"For many families and kids, this is one of the most stressful events in their entire lives," says Dr. Samuel Rodriguez, an anesthesiologist at the Lucile Packard Children's Hospital Stanford in Palo Alto, Calif.
Panicking before surgery can cause both physical and emotional problems, research shows. If children are crying, for example, they're sucking air into their stomachs, which increases the risk that they'll aspirate saliva into their lungs. Anxiety before surgery can also cause long-term psychological distress and behavioral issues in kids, and it's been associated with a more painful recovery.
It is dangerous enough that many children are given an anti-anxiety medication before general anesthesia. But medications always carry risks.
"Anytime we can decrease exposure to a medication, especially in a young child who has a developing brain, it's preferential to use some of these nonmedication techniques to get them off to sleep," says Rodriguez. He wanted to come up with a safer, cheaper and more entertaining alternative.
So Rodriguez and his coworker Dr. Thomas Caruso, also an anesthesiologist at Lucile Packard, began tinkering with various pieces of technology that they purchased online.
"My wife gets upset because I'm getting all these packages from camera and tech shops. For a while one of the rooms in our house and whole garage was filled with all these parts," Rodriguez says, laughing.
Eventually, they came up with the final product: an easily disinfected video unit, which they could mount on any hospital bed, that projects an image onto a large screen that hooks onto the bed right in front of the patient's eyes. The screen travels with the patient through pre-op and feels more immersive to the child than a small, distant TV screen.
Kids waiting for surgery at the hospital can choose from a menu of age-appropriate entertainment options that include certain TV shows, movies and music videos. The big, close screen helps make the experience "immersive," the doctors who designed it say.Heidi de Marco/Kaiser Health News
They called it BERT, short for Bedside Entertainment Theater. It looks high-tech, but the whole thing costs about $900 to build. Lucile Packard now has 10 BERT units across the hospital. They're used before surgery, of course, and also to calm kids who are at the hospital to get radiation therapy or MRI.
It is not the only technique Lucile Packard and other hospitals use to help kids relax without medicine. Some hospitals give kids iPads loaded with games. And there are low-tech approaches, like telling jokes, letting kids decorate their anesthesia masks with stickers, or playing doctor with their stuffed animals. The doctors and nurses and other specialists at Lucile Packard use all those techniques, depending on what the particular patient seems to like.
Ten-year-old Matthew Husby enjoys trying out a BERT unit. An articulate redhead with a face full of freckles, Matthew has been sick from birth with a rare genetic disorder that affects his mitochondria. As part of his treatment, he's had to go under anesthesia dozens of times — five procedures in the past month alone.
This time, he's having a gastrostomy tube inserted into his stomach, to help relieve the gas in his struggling digestive tract.
Matthew explains his condition: "My colon doesn't work. And it has a lot of gas in there that can't get out, so it starts hurting. The G-tube is to let the gas out."
Matthew Husby points to a gastrostomy tube on his teddy bear that is similar to the one surgeons inserted in his own stomach. Role-playing helps kids relax, doctors say.Heidi de Marco/Kaiser Health News
He is used to the surgical process and says he feels calm and prepared. But even this pro still gets some butterflies right before surgery.
When he was younger, the experience was terrifying. "I think it feels really closed in when you have a mask put on you and there are people all around you," says his mother, Cullen Husby. "And he would shake and cry and scream."
Rodriguez visits Matthew in his pre-op room, wearing a Spider-Man surgical cap, and begins explaining exactly how BERT will work. Matthew is excited to pick his own video out of the many options already programmed into the projector unit, including action, sports, cartoons and music videos.
He picks out an episode of the cartoon show Ninjago. Rodriguez says they had to stop letting kids pick videos off YouTube, because too many choices were questionable.
"Believe it or not, all of the most recent Justin Bieber videos are inappropriate," says Rodriguez.
As soon as the video begins, Matthew is completely immersed as Rodriguez unlocks the bed to take him to the operating room. This is often the worst moment for kids — the moment of separation from their parents — but Matthew hardly seems to notice as his father kisses him goodbye. Rodriguez — also a Ninjago fan — peppers him with questions.
"Matthew, do you have any of the Ninjago characters, toys, anything like that?" he asks, and Matthew answers everything enthusiastically.
In the operating room, Rodriguez and the nurses move Matthew over to the operating bed, quickly moving the projector unit as well. The movie is now projected onto the back of a surgical light above Matthew.
Rodriguez switches the movie from Ninjago over to one he has designed and edited himself. It's a compilation of clips from NASA, Toy Story's Buzz Lightyear and Minions, which together create a full blastoff experience. The idea is for the child to feel like he is taking a trip to the moon instead of going under for surgery.
Dr. Sam Rodriguez administers anesthesia to Matthew Husby at Lucile Packard Children's Hospital in March.Heidi de Marco/Kaiser Health News
"Let's get our space monitors! We've got our space masks right now," says Rodriguez excitedly as he places the anesthesia mask over Matthew's face. "All right, let's get ready for our countdown!"
Rodriguez counts down from 19, along with the NASA clip still playing above. "All right, let's get ready for our blastoff! You're gonna start feeling the rocket begin to move!"
The nurses gather round the bed, shaking it.
"You feel it? Can you smell the rocket fuel? Take a deep breath man." Matthew's eyes begin to flutter as he drifts off to sleep. "Good job, buddy. Matthew are you still with us?"
No answer. Matthew is asleep and ready for surgery.
Afterward, his mother looks relieved.
"I don't think he even saw all the machines and everything around him," she says.Heidi de Marco/Kaiser Health News YouTube
A few hours later, Matthew woke up. He didn't feel great, but he was still in good spirits. He wanted to make clear that he did not actually believe he was going to the moon.
"But it was really fun anyway," he says. And fun isn't a bad way to go into surgery.Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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 prerecorded 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 to 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 use wheelchairs; 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.
FromHannah Birch and David Sleight/Propublica
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 are available. Nationally, the rate was 66 percent. (Look up your hospital using ProPublica's new tool.)Additional Information: What Percentage Of Doctors At Your Hospital Take Drug, Device Payments?
Source: Centers for Medicare and Medicaid Services; ProPublica analysis
Credit: Fan Fei and Sisi Wei / ProPublica
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 Hospital-Bartlett, 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 Hospitals 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.
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."Interview Highlights Additional Information: Zika
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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.
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.
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.Shots - Health News Asking Mom: 'Did You Know I Was Depressed In High School?'
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.
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.
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_applebyCopyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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.
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.
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.
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.Subscribe to Invisibilia
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.
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.Subscribe to Invisibilia!
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.