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Around The World, When It Comes To Health Advice Mom Knows Best

Sun, 06/19/2016 - 7:00am
Rose Jaffe for NPR

We had kids later in life, knowing little about children and with no parents to guide us. I depended upon Sofiya, our stern Russian day care provider, for child-rearing advice. She reminded me of my Lithuanian grandmother who took care of me as a child.

When the children caught colds, my husband took their temperature and carefully measured out a draught of flavored Tylenol. Then the children would demand Sofiya's special treatment — Vicks VapoRub on the soles of their feet.

Additional Information: The New Norm

Social norms determine much of our behavior — how we dress, talk, eat and even what we feel. Alix Spiegel and new co-host Hanna Rosin examine experiments that attempt to shift these norms in the first episode of the NPR podcast Invisibilia.

My mother had smeared Vicks VapoRub on our chests. Mentholating tiny feet when the cold was affecting very different body parts seemed bizarre, but we were cowed by Sofiya and followed her diktats. And whatever her methods, our kids thrived under her care. (They also behaved impeccably at her house, unlike at home.)

Having someone you trust to ask about health is pretty important. When people have serious health issues, 70 percent of U.S. adults got information or care from a doctor or other health care professional, according to a recent Pew Research Center survey. But 60 percent said they got information or support from friends and family.

Health and culture are deeply intertwined, and the accepted norms for managing sickness and health vary widely among cultures, even in this globalized era.

Curious if others have had their Vicks VapoRub moments, I polled friends in foreign lands as well as moms from other countries at my kids' Southern California elementary school. They all use Western allopathic medicine, but often combine this with the health mores of their culture of origin.

Rose Jaffe for NPR

Claire, mother of one of my daughter's friends, said that back in France, people live a more relaxed coexistence with germs than the American scorched-earth policy. "Wash your hands before you do anything, but wipes are not used." Claire said. And French moms appreciate the occasional indulgence; "A glass of champagne during pregnancy is fine now and then."

When you eat your dinner matters in Greece. "If you eat a heavy meal late at night, you are likely to have a nightmare," said Artemis, reporting from Athens. "Despite warnings, Greeks do eat full meals late, but the old wisdom is that the heaviest meal should be at lunch, unless you go out to dinner. The idea being you eat a yogurt and fruit for dinner. Everyone knows this, but few keep it."

Rose Jaffe for NPR

And in Southern India, your whole family may set the clock for your wedding night. According to Rekha, another third-grade mom, elders traditionally determine the most auspicious time for consummation after consulting with the family priest. This "first night" unites the newly wedded couple in a sacred act of procreation. In the old days, Rehka says, a fire sacrifice was performed followed by chanted mantras, increasing the odds of creating a righteous child with high intellect.

And when it comes to caring for children, many mothers said they rely on traditional methods. For example, the idea managing heat or cold runs across cultures.

When children have fever, Iranian moms wash their feet with lukewarm water, said Emites, who I met at the party for the afterschool Farsi class. "That's what my great-grandparents used to do, and it passed to us generation by generation." she said.

My Chinese correspondents choose between Chinese herbal or Western medicine. Claudia said if a child has fever, the adults have the child drink warm water and wear some thick clothes, with the goal of making the child sweat to release the heat in the body. For a cough, minty oil is applied to the chest to relieve congestion. Applying pressure to specific points on the body can stop the nausea of motion sickness. Another Chinese friend, Samantha, said that when her mom put sugar water on her daughter's bee stings, she stopped complaining almost immediately.

Rose Jaffe for NPR

For perspective I turned to Leila Monaghan, an anthropologist at Southern Illinois University and Northern Arizona University. "When you are looking at particular beliefs, they are small parts of a larger picture." Monaghan said. " You can't take them separately. Medicine is always part of a larger belief system, so the French glass of champagne is part of the cultural belief that eating and drinking is part of a healthy lifestyle."

Advice from generations of mothers taking care of children is tested by time, Monaghan said. Vicks VapoRub is like peppermint oil, helping feverish little bodies feel cooler. If you can't go to the doctor, you use what you have.

"You turn to these words of women you know and trust in these matters." Monaghan said. "In some ways it goes back to the whole human need for ritual."

Will our kids smear Vicks VapoRub on their children's feet when they grow up, just because we were intimidated by their day care provider?

I wish for a long life, just to find out.

Wendy Wolfson is a science writer in Orange County, Calif.

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

Vermont Insurers Must Now Cover Vasectomies

Sat, 06/18/2016 - 8:19am
Vermont Insurers Must Now Cover Vasectomies Listen· 3:57 3:57
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Though the federal Affordable Care Act requires health insurers to cover many types of contraception, a vasectomy is not one of them.

Charles Thatcher/Getty Images

Vermont has become one of several states working to make sure vasectomies are among the birth control options couples can afford.

Gov. Peter Shumlin last month signed into law a bill that adds vasectomies to the list of procedures that most health insurance coverage in Vermont must pay for.

At the Gifford Medical Center in Randolph, Vt., nurse Ann Bridges recently pulled together "post-operation goody bags" for what the clinic calls "Vasectomy Friday" — the most popular day of the week to get the permanent birth control operation.

"Instructions, ice pack, condoms, Bacitracin, sample cups," she said, listing items headed to each bag. "One for each vasectomy."

Sterilization is the most common form of birth control relied on by women of reproductive age in the U.S., according to statistics gathered by the Centers for Disease Control and Prevention. Roughly 25 percent choose female sterilization, and roughly 5 percent rely on a male partner's vasectomy.

"For women to be sterilized — it's quite the procedure," Bridges says. "It's in-patient. You're in the O.R., you have anesthesia onboard, you're six weeks [recovering] — it's actually a big deal."

In contrast, she says, men who get a vasectomy "walk in and walk out. It's easier." Gifford Medical Center charges around $1,400 for the procedure, which is performed in what looks more like a gynecologist's office than an operating theater.

The federal Affordable Care Act only addresses issues of health insurance and birth control as they relate to women.

Rep. Christopher Pearson, of Montpelier, who helped oversee the passage of the Vermont legislation, says he's proud to broaden that discussion to include men.

The Vermont legislation was personal for Pearson. His decision to get a vasectomy was a choice he and his wife made together, he says — "in many cases, families make this decision together, and that's appropriate."

Including the procedure in health care coverage seems obvious to him.

"It was just sort of a no-brainer," he says, "that when we're talking about different birth control options, we ought to include vasectomies."

He says federal legislation has addressed the need to cover birth control - for women.

"And what we're saying here in Vermont, and I'm proud of this, is saying, 'No, this is a family decision in many, many cases and we should not pretend that this burden only fall to women at all.' "

Pearson thinks people living in Vermont, a generally liberal state, often forget that access to birth control is limited in many places.

"But we are also part of a national dialogue," he says, "and it's important for us to push in the right direction while we watch so many states try to undo these basic rights."

Still, where there is birth control, there is controversy. In Vermont's legislative debate, the Roman Catholic Diocese of Burlington argued before the House Health Care Committee for a religious exemption from having to include birth control coverage for its employees.

"How can you compel a religious organization to do something which it views as cooperation with evil?" asks Pete Gummere, a deacon with the diocese, who has long studied the intersection of morality and modern medicine.

The diocese will likely not be alone in objecting to the law, Gummere says, adding that many locally owned businesses in Vermont are run by families who have religious objections to providing birth control.

On the federal level, Gummere is right; the U.S. Supreme Court has ruled that certain rights of corporations with religious affiliations do trump federal mandates about contraceptives. But what has not been decided yet is how that will play out for states.

Vermont joins Maryland in adding some birth control benefits for women and men to health coverage. Similiar bills are under consideration in Alaska, Minnesota and a handful of other states.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News.

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

Is It OK For Boys To Cry?

Sat, 06/18/2016 - 7:00am
Keith Negley for NPR

A few weeks ago at a soccer game I was coaching, my team got trounced. They are 7 and they are not used to losing. As soon as I called the game and they realized what had just happened, two of the boys burst out crying.

The first one cried loudly, and desperately. He was upset because he hadn't run hard enough or passed enough or scored enough goals. It was the cry of a battle commander who had let his troops down, and his father hugged him proudly. The second boy cried because of a minor injury and a general sense of exhaustion. His mom gave him a stern face and whisked him away to the car.

Do we care if our sons cry? When I asked that question on Twitter, a handful of moms immediately wrote me back to say: Of course! I want my son to cry! But I suspect that only applies to the kind of parents who follow me on Twitter, and even less so for the dads. The most fulsome and possibly honest answer I received (from a dad) was: "I don't mind at all when my 11-year-old cries when he is overcome with emotion. I do mind when he cries over small injuries."

My conclusion: I think we care a lot less about boys crying than we used to, but more than we will admit. Or to put it another way: boys can cry, if they do it in just the right way.

The academic research about boys and crying – or more accurately, vulnerability – shows that society is right now in a precarious place. One body of research shows that boys will fall further behind in school and in an increasingly complex society if we do not teach them how to be emotionally open and honest, able to recognize and navigate their feelings rather than stuffing them down. But another body of research shows that teaching boys to accept their own vulnerability is harder than we think. Despite our best intentions, our progressive instincts, and an increasingly gender-fluid society — the mama's boy stigma dies hard.

Additional Information: The New Norm

Social norms determine much of your behavior - how we dress, talk, eat and even what we feel. Alix Spiegel and new co-host Hanna Rosin examine experiments that attempt to shift these norms in the first episode of the NPR podcast Invisibilia.

In fact, we have been stuck in this spot for a while. Nearly 20 years ago The Atlantic ran a cover story about the boy crisis in schools. Boys were falling behind in math and reading scores, in high school and college graduation rates. For working-class men this translated into a very slim chance of an easy middle-class life, as I wrote about in my 2012 book The End of Men. Initially researchers thought that what boys needed was more ... boyishness, more rough and tumble play, more adventure stories!

But now it looks like they might need the opposite. In a 2013 report, sociologists Thomas Di Prete and Claudia Buchmann wrote that "boys' underperformance in school has more to do with society's norms about masculinity than with anatomy, hormones or brain structure." Boys who do extracurriculars like music, art and drama tend to get higher grades, they found, but those things are often denigrated as "un-masculine," they write. And they found many examples of boys who strive for good grades being called "pussies" or "fags" by their peers.

Why at a time when acceptable behavior for women has expanded, do men remain stuck? After all, studies of infants and young children show that babies and very young boys are just as emotive as little girls. So why do we socialize it out of them? Sociologist Stephanie Coontz calls this the age of the masculine mystique. In the 50s and early 60s it was women who were stuck in a box. But now it's men who are trapped in a narrow gender stereotype that "prevents them from exploring the full range of their individual capabilities," she writes.

I own a 1958 book called The Decline of the American Male. It shows a picture of a wickedly indifferent goddess woman pulling the puppet strings of a boy. Chapter One is called "Why Do Women Dominate Him?" The fear of female domination runs deep. You can see it in Gamergate, in Donald Trump, in bro culture on campus. In fact, it's a strain of misogyny that runs alongside gender equality. Ask the question: "Can Boys Cry?" and you are only likely to inflame it, confirm the fear that boys are being forced to conform to a girls' world.

My guess is that there has always been an acceptable category of male vulnerability and that it always looked different from the female kind. You can see it in boys' eternal attraction to superheroes, who are simultaneously invincible and tender. You can see it in boy-men's undying love for Bruce Springsteen. Boys seem magnetized to men who express the full range of emotions. But we have lost that along the way, or at least it's gotten perverted. In her 1999 book Stiffed: The Betrayal of the American Man, Susan Faludi says that these days boys are modeling themselves on what she calls "ornamental masculinity" – the flattened, crude version of macho that dominates TV and music and porn.

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To me the most promising efforts are the ones that address male vulnerability on its own terms, or at least in gender-neutral terms. As it happens, some of the most exciting trends in education right now are ones boys can get behind. New research on motivation encourages kids to fail. The newly trendy concept of grit implies a life of endless obstacle courses and toughness, something boys can also own. And my favorite, psychiatrist Jonathan Shay's program to ease combat trauma with Greek classics. Shay sees that the classics understood something we have forgotten — that men who are coming back from war, or who have just lost a soccer game, or who are just plain tired, would naturally want to cry. But he also sees that the message is easier to take coming from a Greek hero.

Hanna Rosin is a co-host of the NPR podcast Invisibilia. She's written for The Atlantic and Slate, and is the author of The End of Men.

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

Tourette's Tics Are A Challenge, But Misunderstanding Of Tics Can Be Worse

Fri, 06/17/2016 - 10:44am

Jess Thom (left) and Jess Mabel Jones from Thom's show, Backstage in Biscuit Land. Thom's website says she's "changing the world, one tic at a time."

James Lyndsay/Courtesy of Supporting Wall

Jess Thom says the word "biscuit" about 16,000 times every day. Her brother-in-law counted once.

That's just one of the tics that Thom, a London-based performance artist, has to manage as part of her life with Tourette's syndrome, a neurological disorder characterized by involuntary vocal or motor tics. Specialists say the condition affects as many as 300,000 children in the United States, though many are undiagnosed.

Thom has had tics since childhood, but she wasn't diagnosed until her 20s.

"What disables me ... is other people's misunderstanding," she says. "What's exciting is that it's something we all have power to change."

The condition is far more common than many people realize, and many misperceptions about it still exist, says Kevin McNaught, executive vice president of the advocacy group Tourette Association of America.

"It's not a rare disorder," McNaught says, citing an estimated 1 in 100 school-age children with the condition, including many who aren't diagnosed until adulthood, if at all.

Michael Chichioco, a California high school senior who has Tourette's syndrome, says he used to be bullied at school, with kids trying to trigger him to have outbursts. His tics come out more prominently when he is nervous or excited.

"People got a kick out of trying to get me to say the bad words," said Chichioco, now a youth ambassador for the national association. "They would try to get me to say them in bad situations. The big challenge is to remember they don't quite understand the syndrome."

Chichioco says self-assurance has been one of his best coping skills.

"It's easy to get down when people don't seem to understand it," he says. Part of his work as youth ambassador is spreading awareness of the condition and countering the many misunderstandings.

For example, though Chichioco has a vocal tic that leads to involuntary outbursts of curse words, that particular manifestation of Tourette's syndrome — coprolalia — is rare. Only about 10 to 15 percent of people with the syndrome have it, says McNaught.

A neurological disorder, not psychiatric

The symptoms of Tourette's appear in early childhood but can be transient and reappear later in life, McNaught says. Because symptoms come and go and vary in severity, they often lead to a delayed or incorrect diagnosis until the children are much older.

Tourette's syndrome is often misunderstood to be a psychiatric disorder, because it can have some behavioral features and symptoms that worsen at times of stress or anxiety.

Chichioco says he first had tics — "a throat-clearing sound" — at around age 6, but his family and doctors discounted that as perhaps linked to allergies. He wasn't diagnosed with Tourette's until age 13, after he'd developed more elaborate motor tics that involved his face, head and neck.

Chris Mason, author of the e-books "What Makes Me Tic: Living with Tourette Syndrome" and "Touretties," says he wasn't diagnosed until age 20, after his mother became ill. The stress of facing her health issues brought out his tics more prominently, Mason says. His first tics, also motor tics, involved blinking his eyes really fast and tightly.

In his childhood, before his diagnosis, Mason's parents used to refer to his tics as his "bad habits."

"A lot of parents have never heard of the word Tourette's," Mason says, "even though there's a hereditary component."

Though some features of the syndrome seem to cluster in families, the pattern of inheritance isn't yet clear. "A variety of genetic and environmental factors likely play a role in causing Tourette syndrome," explains the National Institutes of Health website, with most of these factors still unknown.

Treatment options

The condition is treated with a combination of medication and behavioral therapy. But the medications can carry serious side effects like cognitive dulling or extreme fatigue, so people with Tourette's often come up with other techniques of coping, as well.

Mason says his medications make him extremely drowsy; he could sleep 18 hours a day if given the chance.

"Anytime I sit down or lay down, I go to sleep," he says. "Being an author, it's taken away my creativity. It's hard to write."

Thom says she couldn't tolerate those side effects of medication so developed some other techniques for dealing with her tics. She helps spread the word about her condition — and her coping strategies — on a website called Tourette's Hero. She wears padded gloves because she punches her chest hundreds of times a day. And she's begun using a wheelchair because her walking is "chaotic."

When she started using the wheelchair, Thom says, she noticed a difference in how people treated her: "People are less frightened of me now."

Thom doesn't know why the word "biscuit" has such a prominent role in her life. She doesn't think about biscuits nearly as much as it seems, she says, and laughs. Her experiences inspired the title of a live show based on her experiences — Backstage in Biscuit Land.

She says she decided to perform onstage in a theatrical production because it was the only seat in the theater from which she couldn't be asked to leave. Having motor and verbal tics makes it highly challenging for someone to attend theater, a space in which people are expected to sit still and quietly, Thom says.

Being in a romantic relationship is another challenge for some people with Tourette's.

Mason compares the situation to disclosing sensitive information in a job interview. "You have to decide if you are going tell someone before you get the job, or right when you get in the relationship," he says. "When I put it out there, it ends shortly after."

Chichioco said he hasn't yet been in a romantic relationship.

"The fear of finding someone you really like, and having them say, 'You have Tourette's, I can't handle it' — it's hard to show vulnerability in that context," Chichioco says. "It's eventually something I'll have to face."

Dating someone else with Tourette's syndrome would bring its own challenges, he says.

"When I'm with other people with Tourette, we mirror our tics," Chichioco says. "That could be a hindrance. At the same time, it would be great to have two people that understand each other."

Seeing the "flip side" of his challenges — the benefits of having his condition — and talking about those, has been the best medicine for him, Chichioco says. He gave a TEDx youth talk last year about "finding the flip side."

"I found throughout high school, I was uptight about it," he says, of Tourette's syndrome, but that changed when he started speaking openly about his experience to friends.

"I felt empowered by the backing of people," the teen says. "The best treatment is being honest and speaking about it."

Michael Chichioco, Jess Thom and others with Tourette's syndrome recently discussed what it's like living with the condition on KQED's Forum program. This post, produced by KQED's State of Health blog, is based on that discussion.

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

Federal Program That Helps Patients Navigate Medicare May Be Cut

Fri, 06/17/2016 - 9:32am

A program that has helped seniors understand the many intricacies of Medicare, as well as save them millions of dollars, would be eliminated by a budget bill overwhelmingly approved last week by the powerful Senate Appropriations Committee.

The State Health Insurance Assistance Program, or SHIP, is among more than a dozen programs left out of the bill by the committee. Cutting these "unnecessary federal programs" helped provide needed funding for other efforts, Sen. Roy Blunt, a Republican from Missouri, said in a statement issued last week. Blunt is chairman of the Appropriations Committee's health and labor subcommittee.

Ending SHIP saves $52 million — which will help pay for a $2 billion increase for the National Institutes of Health, restore year-round Pell Grants for college students, and increase resources to prevent and treat opioid abuse, among other things.

"Seniors should absolutely have access to high-quality, personal customer service as they seek Medicare benefits," said an aide to Sen. Patty Murray of Washington, who is the senior Democrat on the labor and health subcommittee. "Sen. Murray is disappointed that within the tight budget constraints, we were unable to do more to ensure that is the case." The aide said Murray is hopeful she can restore funding.

SHIP counselors are in every state, the District of Columbia and the U.S. territories. These counselors offer Medicare beneficiaries free advice on how to choose from an array of drug and health insurance plans and how to challenge coverage denials. They advise Medicare patients how to get financial subsidies for premiums, co-payments and deductibles. They provide one-on-one counseling, as well as host enrollment clinics, informational meetings, special "Welcome to Medicare" events for new beneficiaries, and answer questions over toll-free telephone help lines.

"Medicare is very complicated," said Howard Bedlin, vice president for public policy and advocacy at the National Council on Aging, a nonprofit service organization. "Last year SHIPs helped 7 million people navigate this program and without those services, people will not be able to make well-informed choices. That's going to cost them money."

On Thursday, the council, along with the Center for Medicare Advocacy, Medicare Rights Center and National Committee to Preserve Social Security and Medicare, called on Senate leaders to restore SHIP.

The full Senate is expected to vote on the budget bill in the fall, and then it would have to be reconciled with a version from the House, which has not yet drafted its bill.

In April, more than 43 groups urged congressional leaders to increase SHIP funding to keep pace with inflation and the growing Medicare population, which adds 10,000 baby boomers each day.

Ohio's SHIP program saved seniors $20.8 million in 2015 and was ranked first in the nation by the Department of Health and Human Services, according to the state's lieutenant governor. It received $1.84 million in federal funding for the 12-month period ending March 31.

California's SHIP program, known as the Health Insurance Counseling and Advocacy Program (HICAP), has also helped beneficiaries save money. In Orange County alone, 1,247 beneficiaries saved an estimated $1.17 million last year when SHIP counselors showed them, among other things, how to switch to drug plans that covered their medications, said Linda Walton, the county's HICAP program manager.

"We have this huge influx of people turning 65 and they are cutting the program that helps this population find benefits they need?" said Bonnie Burns, a training and policy specialist who trains HICAP counselors. "That makes absolutely no sense."

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.
Categories: NPR Blogs

Listen to the episode

Fri, 06/17/2016 - 3:53am
Listen to the episode 1:01:39
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You probably don't even notice them, but social norms determine so much of your behavior - how you dress, talk, eat and even what you allow yourself to feel. These norms are so entrenched we never imagine they can shift. But Alix Spiegel and new co-host, Hanna Rosin, examine two grand social experiments that attempt to do just that: teach McDonald's employees in Russia to smile, and workers on an oil rig how to cry.

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

Invisibilia: How Learning To Be Vulnerable Can Make Life Safer

Fri, 06/17/2016 - 3:00am

Tommy Chreene with his horse, Lady, at home in Meaux, La. Chreene spent 26 years working on offshore oil rigs in the Gulf of Mexico. While working on the Ursa project, he was part of a program designed to get the workers to open up emotionally with one another.

Edmund D. Fountain for NPR

Editors' note: Invisibilia's back! Each Friday for the next seven weeks, we'll feature an excerpt from the latest episode of the NPR podcast and program broadcast on participating public radio stations. We're also creating original features for Shots that explore the Invisibilia theme of the week. This Saturday, Hanna Rosin asks whether social norms have changed enough so that boys are no longer afraid to cry. On Sunday, we explore how the norms for sickness and health vary around the world. Do you put VapoRub on the soles of your children's feet when they have a cold?

Men who worked on oil rigs lived by certain rules. They were tough. They worked under any conditions. They didn't ask questions. It was this way as far back as Tommy Chreene, 60, who started working on rigs in the Gulf of Mexico back when he was 15, can remember.

Back then, it wasn't unusual to see someone die on an oil rig. Chreene remembers the death of one man who had just finished a shift. He was standing before an enormous pipe that the workers twisted into the ground and held in place with a handle. The man kicked the handle, and the tension on the pipe released. It caught the man's ankle as it whipped around.

"In about three seconds, it spun him around about 80 times," Chreene says. A few feet from the man was a post, and "his head was hitting that post like a rotten tomato."

They got 15 minutes to mourn after watching their friend and colleague die, but that was it. "I mean, that hole cost a lot of money," he says. "We got to go to work."

Even though the men faced the risk of death every day, Chreene says they never showed any vulnerability. This made the work even more perilous, because the men didn't ask for help, didn't admit if they weren't up to a certain job.

But in the 1990s, the oil companies started exploring in much deeper water — more than 3,000 feet below the surface of the Gulf. That meant whole new challenges, logistically and technologically.

In 1997, Shell began building a deepwater platform, Ursa — a $1.45 billion behemoth that would stand 48 stories tall and, when completed, would become the world's deepest offshore well. Rick Fox, the asset leader for Ursa, says executing something this vast was a struggle, beyond the scale of anything they'd ever attempted. Something needed to change, he says, if Ursa was going to be built and operated safely.

"We had to look at the organization and see if we could do something better," Fox says. "And who knew what that was going to open?"

Then Fox got a call from a woman named Claire Nuer. She was a leadership consultant, a Holocaust survivor and a devotee of California New Age circles. She had heard about the seemingly insurmountable project, and she said she could help. When Fox started talking about technical problems like drilling schedules, she stopped him. She said he wasn't dealing with his real problem: his fear. The change Fox needed, she said, to make Ursa work, was in how the men dealt with their feelings.

That wasn't going to be easy. These men had been raised on the rig code, at work and at home. Fox was raising his son, Roger, with it, although it was getting in the way of their relationship. Roger remembers the first time he heard the term "Phillips head screwdriver," when his dad had asked him to get one.

"I didn't think to say, 'Hey, Dad ... I don't know what you're talking about,' " Roger Fox says. "So I went to the shop to look for something, I had no idea what it was, and felt stuck 'cause — I didn't want to be vulnerable."

Shell's Ursa platform, 130 miles southeast of New Orleans, was the largest in the world when it was finished in 1999.

Phil Carter/Courtesy of Shell

"We're guarded. We're fearful. We're so angry at each other because we don't see each other, really," Fox's son, Roger, says now.

Nuer felt that management problems had a lot more to do with interior struggles than with the kinds of things typically taught in business school. Creating environments where people supported each other, she thought, would free them to make great contributions. For people to make those kinds of fundamental changes, it helped to have the involvement of not just their co-workers but their family members, too.

Fox was moved by Nuer, and convinced his son Roger to attend one of her seminars with him in California. There's a recording from back then where Roger tells his father that he's intolerant of weakness. "Yeah, that would be me," Fox replies. "Roger, you know, I take this really seriously. It's ruined a lot of our good times together."

Fox says the session worked. It transformed his relationship with his son. He thought that if Nuer could cut through 18 years of family tension, then she just might be what he needed for the Ursa project.

Over the next year and a half, while Ursa was under construction, Fox had more than a hundred oil rig workers come to Shell's headquarters in New Orleans. Nuer's company and other groups came and put the men through a series of exercises designed to open them up.

George Horn was one of those men. He was not receptive to sharing. "This has nothing to do with an oil field. What is this for?" he says. A lot of the men felt the same way. One exercise asked them to draw their families and personal timelines and stand before the group and talk about it.

"They began to tell the story of their lives, and some of them are not real happy," Horn says.

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The men told stories of failed relationships and alcoholic parents. They talked about how they were hungry as children. "It felt vulnerable. You put your personal life out there for everybody to hear and everybody to see," Horn says.

Once one man did it, others followed suit. They drilled deeper and deeper. Tommy Chreene, who had a tough reputation, broke down and wept before the group as he talked about his son's terminal illness. "I was weeping like a baby," he says. "And nobody ever come to me and said, 'Aw, you big crybaby.' "

The sessions were long and intense. The men went through the exercises from 6 in the morning to 11 at night. Mark Gatlin, one of the workers, says one of the Ursa managers completely dissociated during a session.

Chreene, now retired, walks on his cattle farm in Meaux.

Edmund D. Fountain for NPR

"I guess through the exhaustion or the constant, you know, diving into emotion kind of thing. He absolutely forgot — he just kinda woke up and said, 'Where am I?' " Gatlin says. The man forgot his own name, who he was — everything. They sent him to a doctor, and he recovered.

Some of the men had to stand face to face and ask questions like, "If there was one thing you could change about me, what would it be?" Gatlin says he heard some pretty rough responses: "I had people tell me I don't listen. I had some people tell me, 'You talk too much.' I'd say, 'Tell me more.' "

Gatlin says he started realizing things about himself he had never noticed before. The men were learning about each other and about themselves. Later, they learned about running an oil platform safely. Robin Ely, a Harvard business school professor, and Debra Meyerson, a professor at Stanford, began studying Fox and Nuer's experiment.

In an article in the Harvard Business Review, Ely and Meyerson write that the men had changed. By allowing themselves to become vulnerable to one another, they had altered "their sense of who they were and could be as men."

Ely says that as the men became more open with their feelings, other communication was starting to flow more freely. "Part of safety in an environment like that is being able to admit mistakes and being open to learning — to say, 'I need help, I can't lift this thing by myself, I'm not sure how to read this meter,' " she says. "That alone is about being vulnerable."

That helped contribute to an 84 percent decline in Shell's accident rate companywide, Ely says. "In that same period, the company's level of productivity in terms of numbers of barrels and efficiency and reliability exceeded the industry's previous benchmark."

The old way of being an oil rig worker — the the stoniness, the complete self-reliance — Ely thinks it was endangering the workers and holding back efficiency.

And the men themselves changed. "They're opening up and becoming more themselves," says Art Kleiner, an author who has studied corporate cultures for decades. He says the men let go of the self-image of a steely rig hand and embraced a different version of themselves.

"[Fox] did it," says Floyd Guidry, one of the Ursa workers. "Built a new kind of person. Maybe not a new physical man, but a new mental man."

The men are glad for the change.

"I'm so grateful my son did not have to wait till he was 40-something years old to have the experience of being able to question his own habits and his own way of thinking about things," Fox says. "My son is a beautiful human being, and I cannot get enough of being around him."

Horn feels the same way: "I'm glad the old way's gone. It was no fun whatsoever."

Horn says that after his stepmother's funeral, his son told him, " 'It could be a total stranger. I'd still cry for them. I have empathy for those I don't even know.' So where did he learn that? You know, instead of all this tough-guy stuff that you're raised with in the South. Did he learn that from me? I don't know."

This story is based on reporting by Invisibilia co-host Hanna Rosin.

Copyright 2016 NPR. To see more, visit NPR.
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Will Genetic Advances Make Sex Obsolete?

Thu, 06/16/2016 - 1:47pm

The creation of eggs from skin cells and genetic screening of embryos could transform in vitro fertilization for the masses.

Ted Horowitz/Getty Images

Stanford law professor and bioethicist Hank Greely predicts that in the future most people in developed countries won't have sex to make babies. Instead they'll choose to control their child's genetics by making embryos in a lab.

Additional Information: The End of Sex and the Future of Human Reproduction

by Henry T. Greely

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On KQED's Forum program, Michael Krasny spoke with Greely about his new book, The End of Sex and the Future of Human Reproduction. Greely highlights the ethical and legal questions that might arise in the future's reproductive paradigm.

This conversation has been edited for length and clarity.

Krasny: There are a lot of new advances, technology and so forth. We reached the point where you get some sperm donor and a little piece of skin and you're in business because of stem cells.

Greely: My book argues that two different biomedical innovations coming from different directions and not really propelled by reproduction are going to combine here. One is whole-genome sequencing, and the other is what I call easy PGD, preimplantation genetic diagnosis, [that] is, getting rid of egg harvest ... which is unpleasant, dangerous and really expensive.

This ties in with in vitro fertilization also being not as onerous as it has been in the past.

What I think is going to happen, we'll be able to take some skin cells from anyone and turn them into any cell type. Make these into eggs or sperm and that is going to make IVF much easier, cheaper and less dangerous.

You [can] decide, "Well, I want these traits," and it becomes a selective process.

Yes, I think we will see an increased and broad use of embryo selection. I would be careful to set the time frame at 20-40 years. I think we'll actually see a world where most babies born to people with good health coverage will be conceived in the lab. People will make about a hundred embryos, each will have its whole genome tested, and the parents will be [asked ... "Tell] us what you want to know and then tell us what embryo you want."

This could bring down health care costs, and it is also good for same-sex couples, isn't it?

Well, yes and maybe. I think it should bring down health care costs, and, in fact, one of the advantages to it is that it would be so beneficial for public health care costs that I think it would be provided for free. If it costs say, $10,000 to start a baby this way, 100 babies is a million dollars. If you avoid the birth of one baby with a serious genetic disease, you've saved $3 [million to] $5 million. The same-sex issue, I think that's going to work, but that's another jump. That would be taking a skin cell ... from a woman and turning it into a sperm. I think [it's] probable, but that hasn't been done yet.

This is not the end of sex — because recreational sex will always be with us — it's the end of sex as a way of procreating.

I think it will not be the complete end. I think people will still get pregnant the old-fashioned way, right, sometimes for religious reasons, sometimes for philosophical reasons, sometimes for romantic reasons, sometimes because they are teenagers and the back seat of the car is there.

A lot of people talk about playing God, but before we get into that, there's the rubric of consumer eugenics. And there is a eugenics fear when we start talking about selection.

There certainly is. Eugenics is a slippery word; it means many things to different people. To some, it's state-enforced reproductive control. To some ... what we had was state-enforced sterilization. To some, it's any kind of reproductive choices, but those are different things. For me, I think the coercion is much more important than the issues of selection. The concern about the state or the insurance company or someone else, forcing you to pick particular babies, worries me a lot more than having parents make choices, though that raises its own set of questions.

What do you see as the biggest question here?

I worry about the dilemma of Republican legislators in very conservative states. They want to spend as little money as possible on Medicaid. I could imagine a state saying, "We're not going to pay for this via Medicaid," which would mean that the roughly 40-50 percent of babies born in that state who are paid for by Medicaid wouldn't get to go through this, and although they are not "superbabies," adding another 10-20 percent health advantage to the babies of the rich over the babies of the poor is a bad thing.

Listen to the full interview here. Greely shares his thoughts on cost, socioeconomics, gene editing and the ethics of designer babies.

This story was produced by KQED's daily health and technology blog, Future of You. The blog's host and editor is Jon Brooks.

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
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More Generics And Negotiating Leverage Could Slow Medicare Drug Spending

Thu, 06/16/2016 - 11:39am

An independent commission recommended changes to Medicare Part D, including reducing or waiving copayments for generic drugs for low-income enrollees.

Shana Novak/Getty Images

Congress should move to slow spending in Medicare's drug benefit by adopting a package of changes that could save billions of dollars, but that would also add costs for insurers and have mixed effects on enrollees, an independent advisory commission said Wednesday.

The Medicare Payment Advisory Commission warned in its June report to Congress that rising drug costs and other factors helped drive Medicare Part D spending up nearly 60 percent between 2007 and 2014.

MedPAC recommendations are considered influential, but don't expect Congress to pursue those changes during an election year.

Still, the commission makes proposals it estimates could save at least $10 billion over five years, partly by encouraging more use of generic drugs and also by creating incentives for insurers to negotiate better prices from drugmakers.

The proposals would:

  • Sharply reduce or even eliminate the copayments that about 12 million low-income Medicare enrollees pay for generic drugs — to encourage the use of the lower-cost medications.
  • Create an annual out-of-pocket spending cap for higher-income enrollees that is similar to one already in place for low-income beneficiaries. After enrollees hit the cap, Medicare would cover 100 percent of the cost of their medications.
  • Make it harder to reach that annual cap by not allowing a drug discount given by manufacturers to count toward the enrollees' out-of-pocket maximum.
  • Require insurers to pay 80 percent of drug costs, up from the current 15 percent, after patients hit the out-of-pocket maximum.

Patient groups like the idea of reducing generic copayments for low-income enrollees and setting an annual cap, yet they fear that the proposal would mean patients would remain in the coverage gap known as the "doughnut hole" for longer periods.

While in the doughnut hole, enrollees pay a higher percentage of drug costs. MedPAC estimates that its proposal would mean about half of beneficiaries whose drug spending is high enough to hit this gap would remain in it longer, paying about $1,000 more each as a result.

"We're pleased that some of the recommendations would protect beneficiaries from the rising cost of medications ... but we have concerns that fewer beneficiaries would benefit from the out-of-pocket maximum," said Stacy Sanders, federal policy director for the Medicare Rights Center.

Some proposals have been rejected before, but the report could spark discussion under a new administration and Congress in 2017.

"Once MedPAC makes a recommendation, it gives it legitimacy," Sanders said. "In future years, we could see the proposals as a starting point for some legislation."

This year, the doughnut hole occurs after patients and their insurers combined have spent $3,310 on covered drugs. In the coverage gap, enrollees must pay a larger share of the cost of their drugs until catastrophic coverage kicks in. That happens when spending hits $4,850 and enrollees then pay 5 percent of the cost of their drugs.

While 5 percent isn't much when a low-cost generic is taken, it can be substantial for expensive drugs, such as many used to treat hepatitis, cancer, multiple sclerosis and some forms of arthritis.

The Affordable Care Act gradually phases out the coverage gap by requiring drugmakers to give enrollees discounts. This year, the discount is 50 percent of the cost of the drug. Even though enrollees are not paying that discounted amount out of their own pockets, the ACA allowed the dollar value to count toward the $4,850 threshold for catastrophic coverage to begin. Since the ACA took effect, the number of Medicare Part D enrollees who reach the catastrophic coverage level has grown from 400,000 in 2010 to 700,000 by 2013, according to MedPAC. That shift costs Medicare and taxpayers more because the program pays 80 percent of the costs for drugs after enrollees go through the coverage gap.

Under the commission's proposal, enrollees would no longer be allowed to count those drugmaker discounts toward the total, meaning it would take longer to hit the out-of-pocket cap. Indeed, about half of enrollees might not reach the threshold in a given year and not benefit from the 100 percent coverage, the report notes.

"For many people, this will actually increase spending," said Caroline Pearson of consulting firm Avalere in Washington, D.C., which is in the process of analyzing the financial impacts of the MedPAC proposals. "While our results aren't finalized yet, our generalized finding is that a small number of beneficiaries would save a lot of money ... but a lot would spend more."

Other elements of the proposal would affect insurers. MedPAC recommends insurers shoulder more of the cost of prescriptions after enrollees exit the doughnut hole. That would encourage insurers to try to keep enrollees from hitting the coverage gap's upper limit by getting them to choose lower-cost drugs or by driving harder bargains with drugmakers, said Mark Miller, executive director of the commission.

"A good portion of that payment is because beneficiaries are either using more expensive drugs or the prices of their drugs are going up relatively aggressively," said Miller. "We're trying to say ... you're going to want to negotiate as tough prices as you can."

MedPAC says the proposals are needed because rising drug prices and other factors helped drive spending in the program to $73 billion in 2014, and more high-cost drugs will hit the market soon. Without action, the rising costs could drive up program costs and probably premiums for enrollees, MedPAC said.

When MedPAC adopted its recommendations unanimously this spring, they drew mixed reviews and many comments from the drug industry, consumer groups and insurers. All the groups found elements they liked in the plans and parts they opposed.

Little change was seen in the final version released to Congress.

"PhRMA remains concerned about the sweeping recommendations MedPAC approved in April and opposes changes to Medicare Part D that taken together could harm beneficiaries by eroding coverage and protections for many of the most vulnerable enrollees in the program," said Allyson Funk, spokeswoman for the drug industry's trade group PhRMA.

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Summer Camps Say They're Not Sweating Over Zika Risk

Thu, 06/16/2016 - 5:00am

Canoes, water, mosquitoes — what would summer camp be without them? This year, bug spray will also be in the mix.

Mike Powell/Getty Images

Summer camp and mosquitoes go together like chicken and waffles, particularly in the South. But Zika virus may raise the stakes in the age-old struggle of campers versus pests. The mosquito species capable of carrying Zika can be found in much of the Southern United States.

Anxious parents need not panic; no Zika-infected mosquitoes have been identified in the country. Nonetheless, Tisha Bolger, board president of the American Camp Association, says camp administrators are particularly interested in what they can do to prevent mosquito bites this summer.

The Centers for Disease Control and Prevention hasn't released guidelines specific to summer camps for Zika prevention, but camp managers should follow general prevention guidelines, CDC spokesman Benjamin Haynes tells Shots. Many of those suggestions, such as wearing long-sleeved shirts and long pants and staying inside air-conditioned buildings with windows, seem a tad unrealistic for kids having fun outdoors.

"If you've got a kid in summer camp," says mosquito biologist Todd Livdahl of Clark University, "they're wearing shorts or they're wearing swimsuits when they're outside." And unless you're sending your child to summer camp at the Four Seasons, air-conditioned cabins may also be in short supply.

Another tip in the CDC guidelines suggests treating clothing and gear with permethrin, a chemical that kills insects and can cause skin rashes in humans. "I don't see most parents deciding that's an OK thing to do," says Livdahl of coating clothes with the chemical. "Most people have never heard of this approach."

Don't lock your children indoors for a summer of video games just yet. First, some perspective.

There's still no evidence that Aedes aegypti mosquitoes carrying Zika have reached the U.S.

As of June 8, all 691 recorded cases in the country have been linked to international travel or sexual transmission. What's more, the most serious of Zika's known side effects — abnormally small heads, or microcephaly, in infants — only appears to affect babies whose mothers became infected while pregnant.

That said, campers aren't totally out of the woods.

If the culprit mosquitoes do spread to the Southern U.S., as CDC scientists have suggested they might, some campers infected with Zika could suffer fever, joint pain, and in rare cases get sick enough to require hospitalization. In a much smaller set of cases, Zika may be linked to a neurological disorder called Guillain-Barré syndrome, which can cause muscle weakness and paralysis. (The CDC is investigating the connection between Zika and this syndrome.)

Finally, because scientists still don't know how long Zika can stay in someone's system, it's possible that summer mosquito bites could someday cause the virus to be spread later by sexually active teens.

"I guess we're just stressing applying bug repellent more," says camp director Alyson Gondek of Camp Woodmont in Cloudland, Ga. She says the camp has not invested in mosquito netting for each of the camp's beds, another recommendation from the CDC. And she's not planning to net larger areas either.

"It would be nice to have a huge dome over our property," Gondek says, but "we'd have to net an entire 170 acres."

Managers from other Southeastern camps reported a similar approach, namely, business as usual, with extra bug spray. And several said that they hoped a drier spring would cut back on insects.

"I'm out a lot, and they all love to eat on me," says Mark Magee, executive director of Twin Lakes camp in Florence, Miss. "And I haven't been chosen this summer to be eaten yet."

Summer camps have few weapons in their arsenals to combat a potential mosquito invasion, but they may be spared in the battle with Zika, at least this season. That means administrators can focus on other staples of the camp experience: sports, s'mores and sunburn.

Copyright 2016 NPR. To see more, visit NPR.
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Dying In A Hospital Means More Procedures, Tests And Costs

Wed, 06/15/2016 - 11:50am

When it comes to the end of life, hospital stays are more intensive and more expensive than alternatives.

Medicimage/Science Source

People who die in the hospital undergo more intense tests and procedures than those who die anywhere else.

An analysis by Arcadia Healthcare Solutions also shows that spending on people who die in a hospital is about seven times that on people who die at home.

The work confirms with hard data what most doctors and policymakers already know: Hospital deaths are more expensive and intrusive than deaths at home, in hospice care, or even in nursing homes.

"This intensity of services in the hospital shows a lot of suffering that is not probably in the end going to offer people more quality of life and may not offer them more quantity of life either," says Dr. Richard Parker, chief medical officer at Arcadia.

Where people died and how much the final month of care cost:

  • 42% of patients died at home: $4,760
  • 40% of patients died in the hospital: $32,379
  • 7% of patients died in hospice: $17,845
  • 7% of patients died in a nursing facility: $21,221
  • 5% of patients died in the ER: $7,969

Source: Arcadia Healthcare Solutions

Arcadia analyzed all the Medicaid claims data for a private Medicaid insurance company in one Western state and detailed how many billable medical procedures each patient received and where. Patients in hospitals were billed for far more medical interventions in the last days of their lives than people who died in other settings. The company declined to name the state or company.

The study showed that 42 percent of patients died at home at a cost of about $4,760 for their last month of life, while 40 percent died in a hospital at a cost of $32,379. Dying in a nursing home was the second most expensive locale, inpatient hospice was third and an emergency room was fourth.

"In the end, everyone died. They all died," Parker tells Shots. "If we look at this retroactively, retrospectively — and we could go back and ask people — I bet most of them would say I'd rather be home with my family."

Parker says the cost of hospital deaths paid for by Medicare or private insurance are likely even higher because they pay doctors and hospitals more for their services.

Many studies have shown that people, when asked, say they'd prefer to die at home rather than in a hospital. However, those wishes aren't always realized if a person hasn't given clear instructions to a doctor or family member.

Parker says hospitals are designed to cure people who are ill rather than to allow people to die peacefully.

"The culture of American medicine today and for the last several decades is to keep treating patients regardless of the quality of life," he says. "A lot of physicians have been reluctant to admit that the patient's life is coming to an end."

The picture is more complicated than the data show, says Dr. Lachlan Forrow, a professor of medicine and medical ethics at Harvard University.

Many patients move from home to hospice to hospitals and back during the last 30 days of life. And some may end up in the hospital because their pain or symptoms weren't adequately controlled at home.

Still, he says, hospitals are just not good at caring for dying people.

"We do lots of very expensive things in hospitals to people in the last part of life who would rather be home, and we do those in part because in the hospital they get paid for," he says.

It's the only way to justify keeping in a hospital the people who need around the clock nursing care but can't get it at home.

"If we really tried to make sure people at home could have what they needed at home, we could take better care of them, with less medical system-caused suffering, at lower cost, sometimes much lower cost," he says.

Copyright 2016 NPR. To see more, visit NPR.
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Despite Overdose Epidemic, Georgia Caps The Number Of Opioid Treatment Clinics

Wed, 06/15/2016 - 4:33am
Despite Overdose Epidemic, Georgia Caps The Number Of Opioid Treatment Clinics Listen· 4:25 4:25
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June 15, 20164:33 AM ET Heard on Morning Edition

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Methadone and similar drugs are legal synthetic opioids that are used to help block the cravings and withdrawal symptoms of people trying to wean themselves off prescription painkillers or heroin.

Michell Eloy/WABE

Zac Talbott sees the irony of running an opioid treatment program from a former doctor's office.

"The funny thing is, a lot of patients are like, 'This is where I first started getting prescribed pain pills,' " Talbott says.

Now, the Tennessee native says those same patients are coming to his clinic in Chatsworth, Ga., a small city about a half-hour south of the Tennessee border, to fight their addiction to those very pills.

Outpatient clinics like the one Talbott co-owns dispense drugs like methadone and buprenorphine, which are legal synthetic opioids that block cravings and withdrawal symptoms. Federal health officials say this medication-assisted treatment, coupled with counseling, is the best way to treat an addiction to prescription painkillers or heroin. Patients are required to show up a set number of times a week — the number of visits determined by how long they've been receiving treatment — to take their medicine in front of a nurse.

Talbott's clinic, Counseling Solutions, started treating patients in February, but he says it is already treating 150 people in a space that's fit for about 200. There's such a need in this part of the state, Talbott says, he is already making expansion plans.

More than 1,200 people died of an overdose in Georgia in 2014, according to the Centers for Disease Control and Prevention, with opioid drugs frequently implicated in those deaths. That's a 10 percent increase over the previous year. So Talbott is outraged that Georgia has put a one-year moratorium on issuing licenses to clinics that use medicine to treat people addicted to heroin or painkillers.

"We're in the middle of an opioid addiction and overdose epidemic," Talbott says. "You just think about that for a minute."

Too Many Clinics?

The reason for the moratorium, according to state Sen. Jeff Mullis, a Republican, is the state needs to figure out why so many opioid treatment programs have opened in Georgia. Mullis sponsored the legislation — which has since been signed into law — that created the freeze on new clinics. The law also required that a committee be established to look into Mullis' question.

"If you go to the parking lot of any of these clinics in northwest Georgia," Mullis says, "you'll see as many Tennessee, Alabama, North Carolina, Kentucky tags as you do Georgia tags." People are driving in from all over the South, he says, to get treatment there.

Georgia has 67 opioid treatment programs, more than any other Southeastern state. Tennessee has only 12, in contrast; Alabama has 24, and Mississippi has one. Only Florida comes close numbers-wise, with 65 clinics. But its population is nearly double that of Georgia's.

While individuals who want to open a clinic in Georgia still have to fulfill multiple licensing requirements and approvals from both the state and federal governments, Mullis says it's too easy; unlike other surrounding states, Georgia doesn't have a certificate of need program for narcotic treatment centers. Those programs limit entry or expansion of some health care facilities by requiring operators to show there's a need for it. For opioid treatment programs in Georgia, open competition has been the only real constraint on the number of clinics.

"I don't want to take these facilities away from people who need it, but we need to manage, and govern, and regulate the ones that are here, and the ones that are coming here," Mullis says.

More Enforcement

There's also stigma around the addiction drugs used at opioid treatment centers because the drugs dispensed are opioids themselves. Critics say drugs like methadone are replacing one addiction with another.

Tapering off these treatment drugs is optional, and some patients can stay on them all their lives.

Jonathan Connell, who heads the Opioid Treatment Providers of Georgia, an advocacy group for state providers, says pushing people off medication-assisted treatment shouldn't be the focus of lawmakers' efforts.

"If someone stays on a medication, that's not really the issue," he says. "People can still be dependent on something, but not live an active addiction."

Connell, who operates three opioid treatment programs in southwest Georgia, rejects Mullis' claim that Georgia clinics lack regulations. However, he does support the moratorium.

He says the problem is that regulations are not enforced properly by the Georgia Department of Community Health, which oversees the clinics.

"We have had some clinics open up — some people with limited knowledge of the field," Connell says. "They have not received surveys. How do we know they're functioning correctly?"

The Department of Community Health has only a small staff to keep track of the 67 clinics — three workers, with another person now in training. An agency spokesman says its rules and regulations also do not specify how frequently treatment centers should be inspected but that re-licensure surveys are conducted every two years.

A Treatment Shortage

A shortage of clinics in other states means Georgia's are filling a need other Southern states aren't meeting, Talbott argues.

He has some personal experience to bring to bear on this issue — he is in long-term recovery for an opiate addiction.

Zac Talbott, who runs an opioid treatment program in Chatsworth, Ga., says drugs like methadone and buprenorphine can help people kick addictions to prescription painkillers and heroin.

Michell Eloy/WABE

While getting his master's degree in social work eight years ago, Talbott was prescribed painkillers for some lower back pain. He says things spiraled from there.

"I still recall to this day, learning how to help people with behavioral conditions in class, and then going to the bathroom to shoot pills and/or heroin," Talbott says.

He says there were long wait lists at the three Tennessee clinics closest to him that were authorized to treat his opioid dependency. Rather than wait, he drove four hours back and forth between Knoxville and a clinic in Rossville, Ga., nearly every day for six months to get treatment.

He says he's grateful for that Georgia clinic.

"The old Zac — that Zac that was in that graduate program for clinical social work — quickly came back," he says, once he was able to stop the opioid use.

Georgia's moratorium went into effect June 1. It will last a year, to give the state Legislature time to look at new ways to regulate the clinics.

This story is part of NPR's reporting partnership with WABE and Kaiser Health News.

Copyright 2016 WABE-FM. To see more, visit WABE-FM.
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What Does It Take To Get A Drug Banned For Enhancing Athletes' Performance?

Tue, 06/14/2016 - 1:38pm

Russia's Maria Sharapova appealed a two-year suspension for taking the banned drug meldonium.

William West/AFP/Getty Images

Tennis champion Maria Sharapova wasn't breaking any rules when she took her first dose of meldonium a decade ago.

But her continued use of the heart medication after the World Anti-Doping Agency banned it on Jan. 1 prompted the International Tennis Federation to announce last Wednesday that Sharapova would be suspended for two years. She appealed the suspension Tuesday, and a decision is expected by July 18.

Until banned, meldonium was just one of over a dozen drugs in WADA's monitoring program, a sort of watch list for substances the agency may ban in the future. The list is public and currently includes drugs ranging from antidepressant bupropion to telmisartan, a blood pressure medication.

WADA doesn't release estimates of the numbers of athletes currently taking drugs on its monitoring program list. For meldonium, the number was likely high. A study published in the British Journal of Sports Medicine reported that 66 of the 762 urine samples from athletes at the 2015 European Games tested positive for meldonium.

Whether athletes use drugs on the current watch list to treat legitimate medical conditions or gain an unfair edge on the competition isn't clear. An international team of scientists that make up WADA's Prohibited List Expert Group ultimately makes that distinction. (Athletes who have a legitimate medical need for a banned substance can apply for a therapeutic use exemption.)

What gets a drug banned? We asked toxicologist Olivier Rabin, WADA's science director since 2002, about the science behind the blackball.

The interview has been edited for length and clarity.

What criteria do your scientists use when deciding whether to ban a drug?

Our decision to ban a drug is about more than just performance enhancement. That is one consideration, yes. But we also consider whether the drug could harm the health of the athlete and whether taking the drug goes against the spirit of sport. Two of these three criteria must be satisfied for a drug to make it onto the prohibited list. There are some substances where all three criteria are fulfilled. The hormone EPO, for example, is clearly performance enhancing. [It boosts production of red blood cells.] EPO clearly has a risk for health. And, of course, some athletes take it to get an edge.

"We've seen some illegal drugs that went directly from a test tube to humans without any safety tests, so we don't have the slightest knowledge of the drugs' toxicity," says Olivier Rabin, science director for the World Anti-Doping Agency.

Jacqueline La Cruz/Courtesy of World Anti-Doping Agency

Meldonium was on the monitoring program list for one year. How did your scientists determine so quickly that it should be banned?

There are 34 WADA-accredited anti-doping laboratories around the world that can help inform us when drugs on our monitoring program list are used by athletes. For meldonium, it quickly came to our attention that there were clear patterns of use by entire teams, which usually suggests a drug isn't being taken for medical purposes. How could every member of a team need the same medical treatment? A few studies in the scientific literature also showed that meldonium had a potential performance-enhancing benefit. These elements left our experts with little doubt that the drug should be banned. In terms of being a health risk to the athletes, meldonium is probably not a very toxic substance, although there have been a couple of papers recently questioning its safety.

Does WADA ever run its own scientific tests to determine whether drugs enhance performance?

Yes, we work with sport labs around the world to conduct studies with athletes who aren't currently competing. For example, Don McKenzie's exercise physiology laboratory at the University of British Columbia did some studies for us looking at the asthma medication salbutamol, also known as albuterol.

We were able to define a threshold that would allow people to take the drug if they have a clear need to treat asthma.

If a drug is legal up to a certain dosage, how can you ensure that athletes using the drug properly don't test positive?

We have to consider a lot of confounding factors when we design detection tests for these drugs. For example, the drug pseudoephedrine is a cold medication that we've banned at high doses. Acidic beverages can increase the rate that pseudoephedrine passes through the body. So you could have an athlete who tests positive and says it was because he drank a lot of orange juice before a match. We funded extremely well-controlled studies that define how different variables like dosage, physical activity, beverage intake and timing of testing affect the levels of pseudoephedrine that we find in urine. We want to make sure the science we put in place is solid because we do not want to sanction a clean athlete.

How can you conduct studies to test whether a drug enhances performance if you're concerned it could harm athletes?

For some drugs, we cannot run studies. It would be unethical. We've seen some illegal drugs that went directly from a test tube to humans without any safety tests, so we don't have the slightest knowledge of the drugs' toxicity. Also, in the United States, for example, in order to administer a drug to humans, you have to have approval from the Food and Drug Administration, which these drugs do not have. But in the end, why would an athlete take an illegal drug other than for performance enhancement? The performance-enhancing effect may be big or small. We don't know. But we have to act to protect the health of the athletes, which falls under our second criterion for banning a drug.

How long are drugs typically on the monitored list before you make a decision?

It really depends on the patterns of use we see and the kind of information we need to collect. Caffeine has been on the list for close to 13 years. Meldonium was on the list for only one. Sometimes we monitor a drug for two or three years and then realize there is no pattern of abuse and we remove it. The minute we have enough information, we make a decision.

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If Zika May Derail A Trip, Look At 'Cancel-For-Any-Reason' Travel Insurance

Tue, 06/14/2016 - 10:53am

Would the threat of Zika lead you to rethink a scheduled trip to Ipanema beach or the Summer Olympics in Rio de Janeiro, Brazil? You'd need the right kind of travel insurance to cover the cost of a canceled trip.

Mario Tama/Getty Images

As the summer unfolds, people are understandably interested in whether travel insurance will cover them if they cancel a trip because of concerns about the Zika virus. Other readers asked whether student health plans are a better option than the coverage from a health law marketplace and how an employer can't offer mental health coverage. Here are the answers.

My wife and I have a trip planned to South America, but we're increasingly worried about the Zika virus. We bought travel insurance when we booked the trip. If we cancel, will we be able to get our money back?

A typical travel insurance policy won't reimburse you for trip expenses if you cancel because you're afraid of traveling to a country where there have been reports of an outbreak of a disease such as the Zika virus.

But if you purchased a "cancel-for-any-reason" policy, your claim is more likely to be approved, said Megan Freedman, executive director of the U.S. Travel Insurance Association, a trade group. Like standard trip cancellation policies, these policies provide financial protection for unreimbursed expenses if you have to cancel your trip before it starts or interrupt it once you're there. These policies also allow you to cancel for any reason, including pregnancy, a particular concern with the Zika virus. They typically cost a bit more than a standard policy. If you cancel, you'll generally be reimbursed for about 75 percent of your prepaid expenses.

The Zika virus causes only mild flu-like symptoms in most people, but if women contract it during pregnancy, it can cause a devastating birth defect called microcephaly in their baby. Researchers estimate that babies born to between 1 and 13 percent of pregnant women who are infected during their first trimester will have that problem.

The virus is generally passed along through the bite of an infected mosquito.

Even if your travel insurance policy won't approve your claim, it's worth contacting your airline or hotel to ask about refunds, Freedman said.

"Ask what if any concessions your hotel or airline is extending," she said.

I'm leaving my job to go to graduate school this summer. The college offers a student health plan, but would I be better off buying an individual plan on the marketplace? Since I worked half of the year, I suspect I won't get much in subsidies.

The best choice for you will depend on a couple of factors, including how good the student plan is at your school and your coverage priorities: Do you want a plan with generous coverage or would you prefer something that may have a higher deductible, for example, but probably has a lower price tag?

Student health plans vary widely from school to school, said Stephen Beckley, a higher education health care consultant in Fort Collins, Colo. At many schools, coverage is equivalent to a platinum level plan on the state marketplace, meaning it pays 90 percent of the cost of medical services. A survey of student health plans at 38 public and private schools conducted by Hodgkins Beckley Consulting found average premiums were $184 at public universities and $217 at private colleges.

A platinum-level plan on the health law marketplaces would likely run more than that, especially if you don't qualify for a federal tax credit to help pay the premium. On the state marketplaces, more than three-quarters of people who buy plans get premium tax credits, which are available to people with annual incomes up to 400 percent of the federal poverty level (about $47,000 for an individual). This year, after factoring in an average premium tax credit of $290, consumers paid on average $106 per month for coverage in the 38 states where the federal government operates the marketplace. Most people buy silver plans on the state exchanges, which pay for 70 percent of medical services, leaving them to pick up more of the cost of care than a platinum plan does.

My employer does not offer mental health benefits. What can I do?

You're in a tough spot. The federal mental health parity law doesn't require companies to offer mental health benefits. Rather, it says that if they do, the benefits have to be at least as generous as their medical/surgical benefits.

You have several options, but none of them is a slam dunk. Some therapists charge on a sliding scale for a small proportion of their caseload, said Lynn Bufka, a psychologist who is the associate executive director for practice research and policy at the American Psychological Association.

Depending on where you live, you may be able to find a local mental health clinic or federally qualified health center that offers mental health services for less than you'd pay a private therapist, Bufka said. You could also check out universities near you that have training programs for mental health professionals. You might be able to work with a student who's under close supervision by a trained professional.

Once you find someone, ask if there are things you can do to help accelerate the work using self-help books or guided exercises between sessions.

"It's important for people to understand that psychotherapy does not need to be a forever thing," Bufka said. "It could be a 10 to 12 week intervention."

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Email questions for future columns: KHNHelp@KFF.org. Michelle Andrews is on Twitter: @mandrews110.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Here's Really Where Zika Mosquitoes Are Likely In The U.S.

Mon, 06/13/2016 - 4:14pm

A few months ago, the Centers for Disease Control and Prevention published a startling map that showed the parts of the U.S. that could harbor mosquitoes capable of carrying Zika.

Many readers, including myself, thought, "Zika could come to my town! It could come to Connecticut! To Ohio and Indiana! Or to Northern California! Oh goodness!"

The map made it look like a vast swath of the country was at risk for Zika, including New England and the Upper Midwest.

Well, not quite.

On Thursday, CDC scientists published another mosquito map for the U.S. And it paints a very different picture.

The new map shows counties in which scientists, over the past two decades, have collected Aedes aegypti mosquitoes — the type of insect thought to be spreading Zika in Latin American and the Caribbean.

"The new map is more accurate than the initial one," says Thomas Scott, an entomologist at the University of California, Davis. "The distribution of the A. aegypti mosquito is much more restricted than the initial map showed."

In the map, counties colored yellow reported A. aegypti mosquitoes during one year between 1995 and 2016. Orange counties had the mosquitoes in two years. And red counties are the hot spots: Scientists there found A. aegypti mosquitoes during three or more years in the past two decades.

This map represents "the best knowledge of the current distribution of this mosquito based on collection records," entomologist John-Paul Mutebi and his colleagues at the CDC wrote in the Journal of Medical Entomology.

Many of the hot spots for this mosquito aren't surprising. They're places that we already knew are vulnerable to Zika, including counties in southern Florida, along the Gulf Coast and southern Texas. These places have had problems with a virus closely related to Zika, called dengue. They're already on high alert for Zika.

But several hot spots are bit more unexpected — and concerning. "Perhaps the most concerning development for A. aegypti is its establishment in the Southwest, most recently in California in 2013," Mutebi and his co-authors write.

Other surprises include parts of the Bay Area, greater Washington, D.C., and the Dallas-Fort Worth region, which all have established populations of A. aegypti, the map shows.

"The country is really a patchwork," Scott says. "When you drill down into one particular state, you find that the mosquito isn't found across the whole state. And when you drill down into a county, you find the same thing. The mosquito is found in just a small part."

So why did the first map from the CDC make it look like such an extensive part of the country was at risk for Zika?

"The two maps show different things," Mutebi tells Shots. "The first map showed where the climate is able to sustain populations of A. aegypti. This new map shows reports from counties where these mosquitoes were found in the last 20 years."

And the new map, Mutebi says, is not complete. "Not all counties have mosquito surveillance programs looking for mosquitoes," he says. In places that do, they are often targeting the mosquito that causes West Nile virus, not A. aegypti.

"So just because a county hasn't reported having any A. aegypti mosquitoes doesn't mean they're not there," Mutebi says.

A. aegypti mosquitoes are nasty critters. They chase down people so they can feed on their blood, says virologist Scott Weaver at the University of Texas Medical Branch in Galveston.

"A. aegypti lives in close association with people, feeds almost exclusively on people — not animals — and even comes into people's home," he says. "Its behavior and its ecology are almost ideal for a mosquito to transmit a human virus."

Copyright 2016 NPR. To see more, visit NPR.
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Millennials May Be Losing Their Grip

Mon, 06/13/2016 - 1:07pm

Tough thumbs but weak hands? Millennials use technology in their workplaces more than their counterparts in 1985.

Joy Sharon Yi/NPR

Millennials, the thoroughbreds of texting, may lag behind previous generations when it comes to old-fashioned hand strength.

In a study of Americans ages 20-34, occupational therapists found that men younger than 30 have significantly weaker hand grips than their counterparts in 1985 did. The same was true of women ages 20-24, according to the study published online by the Journal of Hand Therapy a few months back.

The findings suggest that it's time to update what constitutes normal hand strength. The norms are used to assess the severity of injuries and how well people are recovering.

"Work patterns have changed dramatically since 1985, when the first norms were established," says Elizabeth Fain of Winston-Salem State University, who led the study with Cara Weatherford. "As a society, we're no longer agricultural or manufacturing ... What we're doing more now is technology-related, especially for millennials."

To find out if millennials are more flimsy-fingered than older Americans, Fain and Weatherford collected data from 237 volunteers. After conducting a test to exclude anyone with preexisting thumb injuries, the researchers had millennials squeeze a hand dynamometer — a joystick-like device with a dial to measure the strength of a grip in pounds.

A hearty hold indicates not only sturdy hand muscles, but also strong wrists and arms.

In 1985, men ages 20-24 had an average right-handed grip of 121 pounds and left-handed grip of 105 pounds. Today, men that age had grips of only 101 and 99 pounds, the study found. Men 25-29 posted losses of 26 and 19 pounds.

Women ages 20-24 showed smaller, but significant losses in their right hand grip. With right-handed grips today of 60 pounds, they've lost roughly 10 pounds of force. (The researchers found strength diminished in men 30-34 as well, but there were only four participants in this age group.)

Physicians and occupational therapists commonly use grip strength norms to assess injury, recovery and workers' compensation. Plastic surgeon Dr. Scott Hansen, of University of California, San Francisco tells Shots the findings are important, though he would like to see a follow-up study with more participants.

"If we have a patient who had a work-related injury and we want to document how they're recovering, we always compare how they're recovering to the norms," says Hansen. "The perfect comparison would be to their own hand, but we don't have pre-injury data."

"I buy their argument," says University of Delaware physical therapist Lynn Snyder-Mackler of the authors' call to change grip norms. That said, Snyder-Mackler says the study would need to be expanded before pronouncing millennials wimps. Still, she found the case for a reboot strong: "It's kind of silly to be using something from 30 years ago."

Like fashion trends, co-author Fain says healthcare norms should be updated roughly every 10 years. That makes handgrip measurement well overdue for reassessment.

In other words, the 1985 norms may belong in a drawer—replaced but not forgotten—along with leg warmers, Swatches and scrunchies.

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How YouTube Videos Help People Cope With Mental Illness

Mon, 06/13/2016 - 4:42am
How YouTube Videos Help People Cope With Mental Illness Listen· 6:33 6:33
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June 13, 20164:42 AM ET Heard on Morning Edition

Rachel Star Withers says that talking about her schizophrenia on YouTube has helped her. Some people who see the videos say the videos help them, too.

Nii Ofoli Yartey/Courtesy of Rachel Star Withers

Rachel Star Withers runs a YouTube channel where she performs goofy stunts on camera and talks about her schizophrenia.

Since 2008, when the then 22-year-old revealed her diagnosis online, tens of thousands of people have seen her videos. Some of them have a psychotic disorder or mood disorders themselves, or know people who do.

They say her explanation about what a symptom like hallucinations feels like can be really helpful. So can Rachel's advice on ways to cope with them, like getting a dog or a cat. If the animal doesn't react to the hallucination, then it's probably not real, she says.

We talked with people about how Withers' videos have helped them understand these diseases. What follows is a Q&A with two of these people. The interviews have been edited for length and clarity.

Julia Billingsley is 22 years old and from Peoria, Ill. She learned she has schizophrenia last year, but she says her earliest encounter with the disease was back when she was very young. Her mother has schizophrenia, too, Billingsley says, and often had a delusion that their home was bugged.

Julia, you started developing symptoms last year. Do you remember the first thing that happened to you?

I'd just started dating my current boyfriend. And I'd be over at his house and I'd go to the bathroom. And this thought, this intrusive thought that wasn't my own at all would pop into my head like with force. And it would be like, hey. This room is bugged. And I was like, what? It made me stop. I stopped what I was doing and I didn't understand why my brain was thinking that.

Then it clicked. This might be a symptom.

That's actually how I found Rachel's videos. I knew what was happening to me, and I got obsessed. I had to know everything about it. And I came across her videos. It really put a name and a face to everything I was going through. It showed me I wasn't alone.

Sometimes I would just click through all of her videos and I would find a video on something I had no idea about. Like depersonalization [feeling disconnected from yourself]. And it prepared me in a way. So when it did happen to me, I was like this is just depersonalization. I just have to ride it out, and I'll be fine.

Seeing the videos and knowing that Rachel had made it through that too, did it make you feel safer?

No, not safer. Just stronger. Schizophrenia is so smart in a way. I had a delusion where I thought my boyfriend wasn't my boyfriend. I thought he was a doppelganger or something. I started rationalizing like, this is just a schizophrenic thought. And it turned around and was like, that's just what he wants you to think. And just seeing all of Rachel's videos and hearing her coping mechanisms really made me stronger.

You say you actually had to hide your disorder from your family. Did the videos sort of stand in as a support system in a way?

Yeah. Growing up, [schizophrenia] was the root of all evil in my family. And my boyfriend, bless his heart, he is amazing. But he has no idea. He can try, but he can't even comprehend what it's like. So when you come across someone who goes through the same exact thing as you — it's — you don't even have to explain it. It's like one word, and they're like, oh yeah. Me, too. Definitely seeing other YouTubers, especially Rachel, it's definitely a support system.

Rachel Star YouTube

Don Moore is 64 years old and from Portland, Ore. His daughter has schizophrenia and was diagnosed in 2003. A few years later, a friend of his saw Rachel's first video, Normal: Living with Schizophrenia, and sent it to him. "I saw that and I said, wow. That's so much like my family and my daughter and our experience," he says.

Don, what did it feel like when you first saw the videos?

Oh, I was in tears. Mostly I watched it myself. I watched it multiple times. It kind of changes you. You always hear the story that you're not alone. Well, in this case, truly, truly I was not the only one.

That [first video] was fascinating, when I saw her with her parents and talking about some of the difficulties. The parents would say wow, she'd be great and really wonderful and turn around and it would be like, whoa, who is this? I could relate to that. It's very hard to find someone who has a commonality of experience. And Rachel's' videos at first were like, wow. OK. Now I have something to see and something to compare with.

When you watch Rachel's videos, does it help you recognize when your daughter started getting symptoms?

We noticed something wrong from birth. Whenever she would wake up, she would scream at the top of her lungs. One night this happened, my wife's sister was staying with us and she came over. My wife was rocking Tracy to sleep, and her sister said, what are you doing to that kid? It sounds awful. And Pamela said, I'm trying to comfort her.

And when I listen to Rachel describe her childhood, visualizing monsters and being disturbed or bothered by certain kinds of things, I could relate to that. That helped me understand some of the things I saw when I was with my daughter and I couldn't put my finger on exactly what they were.

What helped, exactly?

Rachel was good about explaining how she felt, what she was going through. My daughter tended to hide that. But now you could get a window into the mind of a young person who was going through this, and she was very descriptive about what was happening in her. My daughter was not. That helped me understand what I was seeing on the outside of my daughter. It helped me break through. It just helps you understand it. It's tremendous.

Think about this. You're trying to raise this kid and get them through high school. And at graduation, she didn't walk across the stage because she freaked out and did something else. She'd go off on standardized tests and be really brilliant, and then couldn't figure out how to do something really simple. And so you're sitting here, scratching your head, going why is this? It makes no sense.

Because you've been told by mental health professionals, oh, she doesn't have schizophrenia, that's really serious stuff. She's just depressed or whatever. You're sitting here trying to figure it out. When you have Rachel here talking about it, you just go, oh, OK. And it's part of a key that just helps unlock it.

For more on WNYC's Only Human podcast series on mental health, check here. You can stay in touch with @OnlyHuman on Twitter and @Only Human on Facebook.

Additional Information: Sharing Your Story

WNYC and NPR recently asked listeners: Have you ever had a hard time talking openly about your mental health? We'll be posting some of these responses on Facebook throughout the series.

Copyright 2016 NPR. To see more, visit NPR.
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This Doctor Wants To Help California Figure Out Aid-In-Dying

Sat, 06/11/2016 - 8:27am
This Doctor Wants To Help California Figure Out Aid-In-Dying Listen· 4:42 4:42
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June 11, 20168:27 AM ET Heard on Weekend Edition Saturday

From

Lonny Shavelson has studied America's experiments with aid in dying. He's now helping patients and doctors in California come to grips with the state's new law.

Courtesy of PhotoWords.com

Few people have the unusual set of professional experiences that Lonny Shavelson does. He worked as an emergency room physician in Berkeley, Calif., for years, while also working as a journalist. He has written several books and takes hauntingly beautiful photographs.

Now he'll add another specialty.

California's End of Life Option Act, a law legalizing physician aid-in-dying for people who are terminally ill, took effect this week. Shavelson has become a consultant aimed at answering questions from physicians and patients about the practice — and plans to become a physician to terminally ill patients seeking to end their lives.

I first met Shavelson in 1996 as I was covering the reaction to Oregon voters' approval of Measure 16, the state's Death with Dignity Act.

Oregon was the first state to approve the practice, and in 1996 the law was held up in court. I turned to Shavelson as he had published A Chosen Death, a moving book that followed five terminally ill people over two years as they determined whether to amass drugs on their own and end their lives at a time of their choosing. He was present at the death of all of them.

He followed the issue of assisted suicide closely for several years more, but ultimately moved on to other projects, among them a book about addiction and a documentary about people who identify as neither male nor female.

Then last fall came the surprising passage of California's End of Life Option Act, giving terminally ill adults with six months to live the right to request lethal medication to end their lives. The law took effect Thursday.

Copies of the covers of Shavelson's books decorate his office wall.

Lisa Aliferis/KQED

Shavelson decided he has to act, although he feels "quite guilty" about having been away from the issue while others pushed it forward.

"Can I just sit back and watch?" Shavelson told me from his cottage office in his backyard in Berkeley. "This is really an amazing opportunity to be part of establishing policy and initiating something in medicine. This is a major change ... [that] very, very few people know anything about and how to do it."

His website, Bay Area End of Life Options, went up in April, and he outlined the law at grand rounds at several Bay Area hospitals this spring. His practice will be focused on consulting not only with physicians whose patients request aid-in-dying, but also with patients themselves, including offering care to patients who choose him as their "attending End-of-Life physician," as he indicates on his site.

Shavelson is adamant that this is "something that has to be done right." To him, that means starting every patient encounter with a one-word question: "Why?"

"In fact, it's the only initial approach that I think is acceptable. If somebody calls me and says, 'I want to take the medication,' my first question is, 'Why? Let me talk to you about all the various alternatives and all the ways that we can think about this,' " he predicts he will say.

Shavelson worries that patients may seek aid-in-dying because they are in pain. So first, he would like all his patients to be enrolled in hospice care.

"This can only work when you're sure that the patients have been given the best end-of-life care, which to me is most guaranteed by being a part of hospice or at least having a good palliative care physician. Then this is a rational decision. If you're doing it otherwise, it's because of lack of good care."

California is the fifth state to legalize aid-in-dying, joining Oregon, Washington, Vermont and Montana. The option is very rarely used. For example, in 2014 in Oregon, 155 lethal prescriptions were written under the state's law, and 105 people ultimately took the medicine and died, a death rate under this method of less than 0.5 percent.

Under the California law, two doctors must agree that a mentally competent patient has six months or less to live. One of the patient-doctor meetings must be private, between only the patient and the physician, to ensure the patient is acting independently. Patients must be able to swallow the medication themselves and must state in writing, in the 48 hours before taking the medication, that they will do so.

Shavelson says he has been surprised by the lack of understanding he hears from some health care providers about the law. One person insisted the law was not taking effect this year; another asked how the law would benefit his patients with Alzheimer's disease. To be clear, the law took effect June 9, and patients with dementia cannot access the law because they are not mentally competent.

Renee Sahm was one of five terminally ill people whose experiences were chronicled by Shavelson in his 1995 book A Chosen Death.

Courtesy of Lonny Shavelson

The law does not mandate participation by any health care providers. Many physicians are "queasy" with the new law, Shavelson says he's hearing, and are unwilling to prescribe to patients who request the lethal medication — even though they tell him they think the law is the right thing to do.

"My response to that is as health care providers, you might have been uncomfortable the first time you drew blood. You might have been uncomfortable the first time you took out somebody's gall bladder," he says. "If it's a medical procedure you believe in and you believe it's the patient's right, then it's your obligation to learn how to do it — and do it correctly."

Shavelson said he predicts that many physicians who are initially reluctant to provide this option to their patients may become more comfortable after the law goes into effect and they see how it works.

Burt Presberg, an East Bay psychiatrist who works with cancer patients and their families, saysa talk he attended by Shavelson sparked a conversation at his practice. In my own talk with him, he peppered his statements with "on the other hand," as he clearly wrestled with his own comfort level of handling potential patient requests.

Presberg spoke of his concern that patients can suffer from clinical depression at the end of life, sometimes feeling they are a burden to family members who could "really push for the end of life to happen a little sooner than the patient themselves." He spoke from his experience of successfully treating terminally ill patients with clinical depression.

"Depression is something that's really undertreated," Presberg said. "I often talk to people about the difference between [that and] normal sadness and normal grieving at the end of life."

He said he believes Shavelson will be aware of treating depression, "but I do have concerns about other physicians," he said. "On the other hand, I think it's really good that this is an option."

Shavelson says he's already received a handful of calls from patients, but he mostly spent the time before the law took effect talking to other physicians. He needs a consulting physician and a pharmacist who will accept prescriptions for the lethal dose of medicine.

Then he returns to the patient. "It's important ... that we're moving forward," he says. "It's crucial that we do that because this is part of the rights of patient care to have a certain level of autonomy in how they die."

To many of the doctors who feel "queasy" about moving to end a patient's life, this type of care "isn't so tangibly different to me," Shavelson says, than other kinds of questions doctors address.

"I'm just one of those docs who sees dying as a process, and method of death is less important than making sure it's a good death."

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
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How A Team Of Elite Doctors Changed The Military's Stance On Brain Trauma

Fri, 06/10/2016 - 5:21pm
How A Team Of Elite Doctors Changed The Military's Stance On Brain Trauma Listen· 8:16 8:16
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June 10, 20165:21 PM ET Heard on All Things Considered

The Gray Team with Maj. Jennifer Bell (center), who ran a concussion clinic, seen in the Helmand province of Afghanistan in 2010: Col. Michael Jaffee (from left) , Capt. James Hancock, Col. Geoffrey Ling, Lt. Col. Shean Phelps and Col. Robert Saum.

Courtesy of Christian Macedonia

During the wars in Iraq and Afghanistan, the U.S. military did an about-face on detecting and treating brain injuries caused by explosions. After years of routinely sending blast-exposed troops back into combat, the military implemented a system that requires screening and treatment for traumatic brain injury.

The change came about in large part because of a remarkable campaign by an elite team of military officers who were also doctors and scientists. They worked for the highest-ranking officer in the armed forces. And they were known simply as the Gray Team.

The Gray Team began with a contentious job interview between the doctor who would lead the team and the man who would be his boss.

It was 2008 and Army surgeon Christian Macedonia had been told there was a high-level opening for a doctor who wanted to change the military's approach to battlefield brain injuries. When Macedonia arrived for the interview, he found himself face to face with Adm. Michael Mullen, chairman of the Joint Chiefs of Staff.

"And he looks at me and he goes, 'Who are you and what are you doing in my office?' " Macedonia says.

Macedonia explained he was there about the job. Mullen replied that he had decided he didn't need a doctor on his staff. "And I said, 'Sir, I'm going to disagree with you,' " Macedonia recalls.

Macedonia, a lieutenant colonel, told the admiral that if he really wanted to do something about brain injuries, he did need a doctor. What's more, he needed one with combat experience, strong scientific credentials and a high-level security clearance. "I said, 'Sir, you really only have one person and that's me.' "

Mullen smiled. He had been looking for someone he might have to rein in, but would never have to push. "And Macedonia fit that model for me perfectly," he says. "He's very outspoken, very straightforward. We talk about out-of-the-box thinkers; he just lives outside the box."

Assembling The Gray Team

Macedonia's first assignment was to put together a team. He recruited four other military doctors with combat experience and impressive resumes.

They were called the Gray Team, after the brain's gray matter, the gray issues surrounding traumatic brain injuries and the graying team members themselves.

Their mission was to challenge something military doctors had been taught about blast exposure since World War I:

Christian Macedonia led the Gray Teams. Now, he's a maternal and fetal health specialist at Lancaster General Health's Women and Babies Hospital in Lancaster, Pa.

Meredith Rizzo/NPR

"If you don't have blood coming out of your head, if you don't have a penetrating injury, you have not been injured," Macedonia says. "Your job as a doctor at that point is to say, 'You're gonna be fine' and basically minimize any of the symptoms."

Macedonia himself believed that when he was deployed to Iraq in 2004, to serve as chief of a combat support hospital near Fallujah. He was seeing horrendous injuries, so he didn't have much time for people who looked OK, even if they'd been dangerously close to a blast.

Macedonia and other military doctors actually became suspicious of service members who suggested blast exposure was the cause of their headaches, fatigue or sleep problems. "The attitude was that these people were trying to get a Purple Heart or something like that," he says. "In retrospect, it was just awful. It was really a bad thing to do to people."

Macedonia's conversion occurred one day in Iraq, when he got caught in a mortar attack.

"I was out with a young Marine. We were in the middle of the attack. And the mortar was probably about 50 meters away," he says.

The blast wave shook them violently. But they were alive. And they weren't bleeding. So Macedonia went back to the hospital. He did surgery until midnight. Then, he headed for bed.

Shots - Health News An Army Buddy's Call For Help Sends A Scientist On A Brain Injury Quest

"I had a shaving mirror hung up by my cot and I looked in that mirror and I didn't recognize the person looking back at me," he says. Macedonia realized that he couldn't remember anything from the operating room that night.

And he recognized the vacant expression he saw in the mirror: "The same sort of strange look in the eye that I had seen in people who had been in IED blasts up and down the route near our base."

Macedonia was pretty sure he wasn't having a purely psychological reaction to combat. The blast had injured his brain.

The Brain Battle Begins

In early 2009, Mullen's Gray Team headed for Iraq and Afghanistan. By this time, IEDs had become the weapon of choice for insurgents attacking coalition forces. Tens of thousands of soldiers were being exposed to bomb blasts. And many were experiencing memory loss, confusion and sleep problems.

But the military still wasn't taking the problem seriously. "We would tolerate multiple blasts [in] deployment after deployment," Mullen says. "And I was determined to see if I could do something about this."

So he sent the Gray Team to the battlefield to have a close-up look at what was happening to troops exposed to bomb blasts. "Quite simply, the Gray Team was there to establish ground truth with respect to traumatic brain injury," Macedonia says.

And the truth was pretty grim. Often, troops weren't even being checked for TBIs.

The military relies on something called the MACE exam — Military Acute Concussion Evaluation — to assess service members who have sustained a TBI or concussion. And Macedonia had been told the MACE exam was being administered to pretty much every service member near an explosion.

How A Blast Wave Affects The Brain

The integrin protein (red) connects the outermost layers of a cell to the structures inside. The shock wave from a blast can cause the integrin to send unhealthy and sometimes fatal signals to the structures inside cells.

Source: Harvard University

Credit: Katherine Du/NPR

"But then you would go out and you would talk to these young medics and corpsmen — who are great patriots and doing wonderful things — and you would say, 'Hey, son, how often do you administer the MACE exam?' And they would look at you and say, 'Sir, I'm sorry, what's a MACE exam?' "

Because the military wasn't doing much to look for TBIs, it was usually up to individual service members to report their own brain injuries.

"If you were in a blast, you basically had one of two choices," Mullen says. "You either didn't admit you had a problem, or if you admitted a problem we put you on a plane, sent you home."

And Mullen knew from visiting hundreds of wounded troops that they didn't want to get sent home. "The first thing they tell you is they want to get back in the fight," he says. "So nobody would admit they had a problem."

When the Gray Team got back to the U.S., they began suggesting reforms. Their ideas got a hostile reception in the Pentagon.

"I would literally have people behind closed doors say, 'Who gave those people medical degrees?' " Macedonia says. It was a surprising allegation, considering the team members included people like Geoffrey Ling, an M.D.-Ph.D. considered the military's leading expert on traumatic brain injury.

But many senior medical officers just couldn't accept that there were real brain injuries you couldn't see on MRI or CT scans, Macedonia says. "The organized military medical system was still trying to hold back the ocean and say: No big deal, most of these injuries are psychiatric and our job is basically to provide counseling centers and get these people over the shock of being at war."

In the Pentagon, some medical officers feared that TBIs could become the next Gulf War syndrome — a poorly defined problem with no obvious cause and no good treatment.

Others had visions of the military medical system stateside being overwhelmed by newly diagnosed TBI patients. And more than a few just didn't like having someone outside their chain of command telling them what do.

Macedonia says bureaucratic concerns often seemed to trump the growing scientific evidence that blast-induced TBIs were real. "I can't tell you the number of times I walked out of rooms just being sorely disappointed at people who knew what the right thing to do was but chose to look the other way," he says.

But Macedonia was equal parts tenacious and ferocious. "He was a dog on a bone," Mullen says.

"Christian Macedonia doesn't give a f*** what anybody thinks if he believes he's on the right course," says Kit Parker, a Harvard professor and Army lieutenant colonel who served on the Gray Team in 2011.

MRIs On The Battlefield

The conflict between the Gray Team and the military medical establishment reached a peak over the issue of MRI scanners.

Conventional scanners usually couldn't detect the damage from a blast. But the Gray Team now included David Brody, a civilian scientist from Washington University in St. Louis, who was using a new MRI technique to study troops at the U.S. military hospital in Landstuhl, Germany.

"We went out there to Landstuhl, started enrolling patients, and started discovering immediately all sorts of injuries that were completely invisible to the conventional scans," Brody says.

Even though the Department of Defense was paying for Brody's research, the military medical establishment wasn't embracing the results. "There was a strong current in the military at that time that this was a problem that was going to go away if we ignored it," he says.

Macedonia wanted to deploy the new technology to hospitals near the battlefield. So during a Gray Team trip to Iraq, he made a pitch to a group of senior medical staff.

"I said, 'We're very seriously considering putting MRI machines in theater, what say you?' " he recalls. The reaction was as if he had proposed "bringing in a pile of radioactive waste to drop in your hospital."

Macedonia eventually got his MRIs, largely because his boss, Mullen, had clout. As chairman of the Joint Chiefs, Mullen was the highest-ranking officer in the armed forces. "But even the chairman can be ignored," Mullen says.

To make sure that didn't happen, Mullen, Macedonia and the Gray Team had been building a coalition that included Gen. Peter Chiarelli, the Army's vice chief of staff, and Gen. James Amos, assistant commandant of the Marine Corps. The Gray Team's allies simply outranked its opponents.

The team's decisive victory came in 2010, when the Department of Defense issued a memo that transformed the system for managing battlefield brain injury. "I can still remember Macedonia coming into my office saying, 'Chairman, we got it,' " Mullen says.

Geoffrey Ling and Christian Macedonia wore body armor with blast sensors.

Courtesy of Christian Macedonia

The memo requires evaluation and a 24-hour rest period for troops within 50 meters of a blast, and several other measures to ensure that TBIs are detected and treated. It also includes special provisions for service members who sustain multiple TBIs.

And the 2010 mandate was just the beginning. Today, combat troops often wear sensors that indicate when a bomb blast is strong enough to cause a brain injury. Military doctors are taught that blast waves really can cause physical brain injuries. And service members can get treatment for a TBI without being put on a plane and sent home.

The sweeping changes have brought solace to Macedonia, who still regrets that he once doubted blast waves could physically injure the brain.

"Doing the Gray Team's missions was probably the most awesome healing process that could have ever happened for me," says Macedonia, who has retired from the military. "It really was a way for me to make up for the lapses, the lack of understanding about TBI."

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Categories: NPR Blogs

Investors See Big Opportunities In Opioid Addiction Treatment

Fri, 06/10/2016 - 2:59pm
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June 10, 20162:59 PM ET Heard on All Things Considered Jonathan McHugh/Ikon Images/Getty Images

The first time Ray Tamasi got hit up by an investor, it was kind of out of the blue.

"This guy called me up," says Tamasi, president of Gosnold on Cape Cod, an addiction treatment center with seven sites in Massachusetts.

"The guy" represented a group of investors; Tamasi declines to say whom. But they were looking to buy addiction treatment centers like Gosnold.

"He had checked around and learned that we were one of the more reputable programs. We had a good reputations in the community — nice array of services," Tamasi recalls. "He wanted to know if we were interested in becoming part of his company."

Tamasi was intrigued. Gosnold is a not-for-profit system. It makes money on some services, like inpatient rehabilitation, and uses that income to pay for stuff that doesn't make money, like family support groups.

Every crisis presents an opportunity, as the saying goes. And when it comes to opioid addiction, investors and businesses are seeing a big opportunity in addiction treatment.

Places like Gosnold are being gobbled up by private equity companies and publicly-traded chains looking to do what is known in Wall Street jargon as a roll-up play. They take a fragmented industry, buy up the bits and pieces and consolidate them into big, branded companies where they hope to make a profit by streamlining and cutting costs.

One company that advises investors listed 27 transactions in which private equity firms or public companies bought or invested in addiction treatment centers and other so-called behavioral health companies in 2014 and 2015 alone.

Acadia Healthcare is one national chain that has been on a shopping spree. In 2010 it had only six facilities, but today it has 587 across the country and in the United Kingdom.

What's driving the growth?

The opioid addiction crisis is boosting demand for treatment and two relatively recent laws are making it easier to get insurers to pay for it.

The Mental Health Parity Act of 2008 requires insurers to cover mental health care as they would cover physical health care.

"Mental health parity was the beginning. We saw a big benefit. And then the Affordable Care Act was very positive for our industry," says Joey Jacobs, Acadia's CEO. He spoke at an investor conference last month.

Obamacare is driving their growth in part because so many more people have health insurance, and in particular because of a provision in the law that allows people up to age 26 to stay on their parents' insurance policies. That's the age of many opioid and heroin abusers.

Suddenly there's a huge stream of cash for Acadia and other companies to tap into.

Addiction treatment isn't all that Acadia does. It has residential schools for teenagers, inpatient psychiatric facilities, and centers for people eating disorders.

But addiction is certainly a big part of the business. It has more than 100 inpatient detox and rehab centers and runs 110 opioid treatment programs, better known as methadone clinics, which it bought from private equity firm Bain Capital in 2014 for $1.18 billion.

Bain, which was founded by Mitt Romney, had purchased CRC Health, a chain of treatment centers, in 2005 for $720 million. It then bought at least 20 more rehab centers and then added a Massachusetts-based chain of methadone clinics in 2014 for $58 million, just before selling the entire package to Acadia.

In the slide show Jacobs presented at the investor conference, the company referred to the rising use of heroin as a "favorable industry tailwind" and predicted its revenue would continue to grow.

Jacobs says his company is filling a growing demand.

"We do a lot of good right here in this space, a lot of good," he said at the conference. "And we think this market will continue to grow, and the need for our services are definitely out there."

Acadia is not unique. American Addiction Centers is a chain of 11 residential and 19 outpatient treatment centers that went public last year. The company said at the same investor conference in May that it had acquired five treatment centers last year and has two more acquisitions in the works.

And a handful of companies still owned by private equity investors are also growing into regional powers.

Companies like Acadia fill a needed void, says Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, outpatient programs that treat addiction using methadone or other medications.

"There is a need for expanded access to care. Everybody seems to understand that," he says.

But state governments aren't paying to build more methadone clinics and there's little money available in the non-profit sector for them either, Parrino says.

Still, the number of programs has nearly doubled in the last 10 years, largely thanks to private investment, which he says is a positive development.

Not everyone agrees.

Linda Rosenberg, president of the National Council on Behavioral Health, which represents non-profit addiction treatment programs, worries that private investors are too focused on the profitable inpatient beds and will neglect the services that help patients re-enter society.

"After rehab, you come back to your family and your family knows very little," Rosenberg says. "You need a job, you need health insurance, you need medication-assisted treatment for addiction, you need counseling."

She says there's very little private investment in all that.

"I think that's the biggest danger," she says.

And that's exactly what Tamasi found.

When he met with the first group of investors, he learned they only wanted to buy Gosnold's money-making programs — inpatient detox and rehab,

"A detox setting or a rehab program, they have a much wider stream of where revenue can come from," Tamasi tells Shots. "They're covered by insurance, people are willing to pay for it if they have the resources to pay for it."

The investors didn't want the prevention programs, the long-term care or the school-based programs. They didn't want to invest in the recovery managers that help people get back on their feet once they get out of rehab.

But Tamasi thinks those things are important, so he didn't sell.

"They're almost like investments that a community-minded provider would make in order to do the things that they think the community could use," he says

Since that first meeting two years ago, the calls have kept coming. At a conference in May, he was approached three times in a single day by people interested in buying parts of Gosnold.

When a private equity firm invited him to New York to talk about the industry, he says the meeting hosts asked him about occupancy rates, insurance reimbursement and future demand for detox and treatment.

"There weren't a lot of questions about what do you do, what actually happens in these places — a little but not much," he recalls.

But why do so many smaller companies and nonprofits sell?

To Tamasi it was clear that this investor had the money to build new buildings or add treatment beds, something that it would take him years of fund raising to achieve.

That's why he took the first meeting. And that's why he occasionally still does.

But he's not convinced they will offer the breadth and depth of care that Gosnold on Cape Cod does today.

"That's a classic discussion between for-profits and not-for-profits," says Eric Coburn, managing director at Duff and Phelps, which advises private equity firms on how to value and finance acquisitions. Coburn specializes in health care mergers.

"The not-for-profits say the for-profits don't care about care," he added. "The truth is that if you're providing a service that doesn't provide good care in the health care space, that's not a very good long-term strategy."

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Categories: NPR Blogs