History > 2015 > USA > Health (I)

U.S. Still in Danger

of Losing War on AIDS,

C.D.C. Director Says

 

DEC. 1, 2015

The New York Times

By DONALD G. McNEIL Jr.

Despite major medical advances and more than 30 years of effort, the United States is still in danger of losing the war on AIDS, according to the country’s top disease-control official.

In an essay in The New England Journal of Medicine published on Tuesday, World AIDS Day, Dr. Thomas R. Frieden, the director of the Centers for Disease Control and Prevention, and Dr. Jonathan Mermin, the agency’s chief of AIDS prevention, paint a bleak picture of the fight.

“Hundreds of thousands of people with diagnosed H.I.V. infection are not receiving care or antiretroviral treatment,” they wrote. “These people account for most new H.I.V. transmission.”

There are 45,000 new H.I.V. infections each year, the article noted.

In an interview, Dr. Frieden said he “still views the glass as half full.” While medicines are improving, legal barriers have been lifted and Americans are getting tested, more people with H.I.V. need to be put on treatment and kept on it.

While the article’s language was dry and academic, some AIDS experts said it amounted to a call for radical changes in how the disease is fought. But those changes can be made only by state and local health departments, over which the C.D.C. has little control.

“Tom is giving the view from 30,000 feet,” said Dr. William Schaffner, the chairman of preventive medicine at Vanderbilt University. “He’s trying to be the conductor of a disparate orchestra in which the drums and trombones have different bosses and are paid by different people.”

Other experts complained that Dr. Frieden should have gone further, calling for much more funding, a heavier reliance on preventive drugs and the decriminalization of H.I.V. transmission. “It’s a pretty weak piece,” said Mark Harrington, the executive director of the Treatment Action Group, an AIDS activist organization.

Dr. Frieden was effectively calling for H.I.V. to be fought the same way that syphilis and gonorrhea are, “and we’re doing terribly on those,” Mr. Harrington said.

He and other advocates urged wider adoption of a multipronged approach to treatment and prevention like that used in San Francisco, which offers services to the most difficult patients, including addiction and mental health treatment, help with housing and even escorts to the hospital.

Among the most notable failures cited by Dr. Frieden and Dr. Mermin:

Nearly 65 percent of the estimated 1.2 million Americans with H.I.V. are not on treatment; many disappear right after being tested. Those patients, whose H.I.V. is undiagnosed or newly diagnosed but who are untreated, account for 90 percent of all new infections.

Infected people are rarely asked to name their sexual partners so that health providers can reach out to them. When health providers do have names, little is done with the information.

Risky behaviors — including unprotected anal sex and needle-sharing — appear to be increasing.

Infection rates are rising among young gay men, especially blacks and Hispanics.

The essay is a follow-up to one Dr. Frieden wrote for the journal for World AIDS Day 10 years ago, when he was New York City’s health commissioner.

That one was equally pessimistic and dryly radical. In it, Dr. Frieden expressed frustration with “AIDS exceptionalism” — laws that made it difficult for public health authorities to treat AIDS as they might tuberculosis, syphilis or meningitis.

A decade ago, it was almost impossible to even test for H.I.V. because intensive counseling was often required first, which took time and money and scared people off. Lab results were reported to health officials with no names attached, leaving them unable to find infected people or to tell if treatment was working.

Dr. Frieden argued then for a public health approach to outweigh a strictly medical one. The difference is that a medical doctor’s first duty is to the patient, while health officials like him are charged with protecting the population at large.

The two come into conflict, for example, when an infectious patient willfully refuses treatment and keeps passing on a disease. In the 1990s, during an outbreak of drug-resistant tuberculosis in New York City, Dr. Frieden famously detained patients who refused to take their pills, locking them in hospitals for months until they were cured.

In 2005, he advocated H.I.V.-control measures that he said would “offend both sides of the political establishment.” Condoms and clean syringes were needed even if conservatives disliked them, he said, and the tracing of sexual partners needed to be done even if H.I.V. activists opposed it.

Some of those goals have become law.

Although H.I.V. testing is not mandatory except in the military and under a few other circumstances, the counseling requirement has been dropped. Many hospitals test all patients unless they specifically refuse, and some cities even pay people applying for driver’s licenses to take H.I.V. tests.

Lab results are now reported by name almost everywhere. That makes it possible for local health workers to contact patients to make sure they receive help and to ask for the names of their sex partners so they, too, can be treated.

But that is failing, Dr. Frieden said in the interview. Only about half of those testing positive for H.I.V. are ever asked for names, and those who choose to answer “named relatively few.”

Local health departments lack the staff to trace contacts. “To be fair, it’s legitimately hard,” Dr. Frieden added. Some people find sex partners through apps like Grindr without ever learning their names.

New tests can detect the virus within 10 days of infection, but they are not being used enough, he said. An estimated 155,000 Americans with H.I.V. do not know it. And of those who are tested, 20 percent already have AIDS or are close to it — meaning they may have been spreading the virus for years.

The C.D.C. recommends that sexually active gay men be tested four times a year, but that rarely happens.

Treatment is also inadequate. Multiple studies have shown that patients who are immediately put on drugs remain healthy longer and stop infecting others. Yet only about 36 percent of those infected have prescriptions, Dr. Frieden said. (Others have put the figure higher. In San Francisco, 82 percent of H.I.V. patients get prescriptions.)

The national averages are dragged down by states, mostly in the South, that have high H.I.V. rates but rejected the Affordable Care Act’s expansion of Medicaid, which would have covered testing and treatment.

There have been important scientific advances, like new milder drugs and the rollout of Truvada, a pill that prevents infections.

But “the fact that the dial hasn’t moved on 45,000 new infections a year is a tragedy,” said Mitchell J. Warren, the executive director of AVAC, an organization lobbying for AIDS prevention.

A version of this article appears in print on December 2, 2015, on page A15 of the New York edition with the headline: U.S. Remains in Danger of Losing the War on AIDS, C.D.C. Director Says.

U.S. Still in Danger of Losing War on AIDS, C.D.C. Director Says,
NYT,
DEC. 1, 2015,
http://www.nytimes.com/2015/12/02/
health/us-still-in-danger-of-losing-war-on-aids-cdc-director-says.html

The Toll of Violent Anti-Abortion Speech

DEC. 1, 2015

The New York Times

The Opinion Pages | Op-Ed Contributor

By KATHA POLLITT

HERE are some things abortion opponents have said about Robert L. Dear Jr., the shooter accused of killing three and wounding nine at the Planned Parenthood clinic in Colorado Springs last Friday. He was just a lunatic. He wasn’t attacking Planned Parenthood, he ran in there after trying to rob a bank. My personal favorite, from the Republican presidential candidate Sen. Ted Cruz: He is reported to be a “transgendered leftist activist.”

Given that Mr. Dear is said to have told the police “no more baby parts,” could the attack be related to the deceptively edited incendiary videos from the anti-abortion group Center for Medical Progress, which purport to show that Planned Parenthood sells fetal tissue for profit? Another Republican presidential contender, Carly Fiorina, called it “typical left-wing tactics” to connect them.

Who is she kidding? Since the videos appeared over the summer, there have been four arsons at or near Planned Parenthood clinics. Abortion providers say threats and harassment have increased as well. But then, disclaiming any connection with violence has a long history in the anti-abortion movement. Black Lives Matter activists are accused by some of promoting the murder of police officers, and every Muslim on earth is seemingly expected to condemn jihadi terrorism on practically a daily basis. Meanwhile, I’m not aware of any prominent abortion opponents who have publicly accepted responsibility for fomenting violence by using language that equates abortion with the Holocaust or murder on an industrial scale — atrocities that would seem to call for resistance by any means necessary.

In fact, even when deploring violence, opponents equate it with the practice of abortion. As Mike Huckabee, who is also seeking the Republican presidential nomination, said in the wake of the Colorado Springs shooting, “There’s no excuse for killing other people, whether it’s happening inside the Planned Parenthood headquarters, inside their clinics where many millions of babies die, or whether it’s people attacking Planned Parenthood.” Millions of dead babies versus “people attacking” a clinic? Which sounds like the greater evil to you?

Violence against abortion clinics and providers has been part of the so-called pro-life movement virtually since 1973, when the Supreme Court ruled in Roe v. Wade that abortion is a constitutionally protected right. The National Abortion Federation, the professional association of abortion providers, has recorded a staggering 6,948 acts of violence against clinics and providers between 1977 and 2014, including eight murders, 17 attempted murders, 42 bombings and 182 arsons.

Anti-abortion leaders portray violence as the doings of madmen, and probably some of the perpetrators are indeed unstable. But when prominent voices in the anti-abortion movement compare clinics to Auschwitz, when they equate embryos with slaves, when Bill O’Reilly says that people feel fetal tissue donation is “Nazi stuff” and Rush Limbaugh suggests the way to stop abortion is to “require that each one occur with a gun,” it is not surprising that susceptible people will act on what they hear as a call for violence.

Indeed, sometimes the call is explicit. The president of the anti-abortion group Operation Rescue, Troy Newman, who serves on the board of the Center for Medical Progress, views abortion as a capital crime and has called for the execution of abortion providers. His second in command, Cheryl Sullenger, was convicted of attempting to bomb a clinic. Has Mr. Newman been ostracized by mainstream abortion opponents? Not really. Mr. Cruz, on his website, declares himself “grateful” for Mr. Newman’s endorsement.

Law enforcement and the news media have been reluctant to call this continuing violence by its rightful name: terrorism. Is it because the perpetrators are generally white and Christian? Unless there’s a death, each incident gets little attention. It’s as if we take abusive anti-abortion tactics for granted. Most Americans probably have no idea how hostile anti-abortion “sidewalk counseling” outside clinics can be. There’s a reason pro-choicers volunteer to escort patients as they make their way past angry crowds to the clinic door.

Here is the dirty little secret about anti-abortion violence: It works. After Dr. George Tiller was assassinated in 2009, his clinic, in Wichita, Kan., closed. (A new clinic opened in the same location in 2013, though it offers a narrower range of services.) In Kalispell, Mont., the son of a prominent local abortion opponent destroyed All Families Healthcare, the only abortion provider in the area. It’s gone, too.

Most targeted clinics stay open, but there’s a toll. When I asked abortion providers how the threat of violence had affected the way they provided care, people listed everything from armed security guards and metal detectors to safe rooms and regular emergency drills. Technicians have to decide whether a patient’s elevated blood pressure is caused by a medical condition or from the anxiety of wading through a crowd of protesters shouting, “The doctors aren’t licensed!” and “You’ll die in there!” It can be hard to hire and keep staff when the job description includes feeling threatened every day. As one provider summed it up, “10 to 15 percent of our resources of time, talent and treasure are devoted to compensating for harassment and threats.”

To abortion opponents that’s all good news. But what about the rest of us? A majority of Americans, according to recent Pew data, believe abortion should be legal in all or most cases. Do we want to live in a country where extremists use violence to deny women legal health care, and people whose words may well spur them to action insist they have nothing to do with it?

Katha Pollitt is a columnist at The Nation and the author, most recently, of “Pro: Reclaiming Abortion Rights.”

A version of this op-ed appears in print on December 2, 2015, on page A31 of the New York edition with the headline: The Roots of Anti-Abortion Violence.

The Toll of Violent Anti-Abortion Speech,
NYT, DEC 1., 2015,
http://www.nytimes.com/2015/12/02/
opinion/the-toll-of-violent-anti-abortion-speech.html

Death Rates,

Declining for Decades,

Have Flattened, Study Finds

 

OCT. 27, 2015

The New York Times

By SABRINA TAVERNISE

WASHINGTON — Gains in the American life span have slowed in recent years, according to a new report, with death rates flattening for the first time since researchers started measuring them in the late 1960s.

Researchers from the American Cancer Society used federal mortality data to analyze trends in longevity from 1969 to 2013. Death rates in the United States have been declining for decades, an effect of improvements in health care, disease management and medical technology — and the researchers had expected to find more of the same.

Instead, they stumbled upon a disturbing shift. The declines in death rates flattened in the most recent period, from 2010 to 2013, dropping by an average of just 0.4 percent annually, a rate so slight that it was not statistically significant. The rate had slowed in previous periods but never this substantially, researchers said.

Researchers did not attempt to find the reason for the slowdown, saying their analysis — which was published in JAMA on Tuesday and was the first of its kind using the federal data — was limited to identifying the broader trends, not explaining them. But researchers who did not participate in the study said the obesity epidemic, which has plagued Americans of all ages since the 1980s, was probably a factor.

Dr. Ahmedin Jemal, head of surveillance and health services research at the American Cancer Society and one of the report’s authors, cautioned that the slowdown had taken place over just four years, a very short period for the purposes of long-term mortality trends. He said that it was too early to tell whether the finding marked the start of a trend. Even so, it was the first departure from years of declines, and it caught researchers off guard.

“I was surprised,” Dr. Jemal said. “We were expecting to see more declines.”

S. Jay Olshansky, a public health professor at the University of Illinois at Chicago, said the study was the first indication of what could be the early stages of obesity’s toll on American life spans. It took decades for smoking to appear in death rates, in the form of lung cancer and other ailments, and obesity is expected to have a similarly delayed effect.

“The medical community seems to be under a fog that we can constantly and forever reduce death rates, and that’s simply not true,” said Professor Olshansky, who published a study in 2012 showing that life spans for white women without a high school degree had declined, a rare event in developed countries.

“You need to look at the health status of the living, not the mortality dynamics of the deceased,” he said. “The younger cohorts moving through the age structure are not doing so well.”

The theory seemed to be supported by another finding in the study: The rate of decline in death rates had slowed for heart disease, stroke and diabetes, all ailments associated with obesity.

Still, the past few years could not erase gains since the study began in 1969. Death rates over all dropped by about 43 percent, and mortality rates for various ailments also fell, by 77 percent for stroke, by 68 percent for heart disease, by 18 percent for cancer, and by 17 percent for diabetes. But not for everything: The death rate for chronic obstructive pulmonary disease, a lung ailment often associated with smoking, doubled during the period.

Death Rates, Declining for Decades, Have Flattened, Study Finds,
NYT, OCT. 27, 2015,
http://www.nytimes.com/2015/10/28/
health/death-rates-declining-for-decades-have-flattened-study-finds.html

Valeant’s Drug Price Strategy Enriches It,

but Infuriates Patients and Lawmakers

OCT. 4, 2015

The New York Times

By ANDREW POLLACK

and SABRINA TAVERNISE

J. Michael Pearson has become a billionaire from his tough tactics as the head of the fast-growing Valeant Pharmaceuticals International.

And consumers like Bruce Mannes, a 68-year-old retired carpenter from Grandville, Mich., are facing the consequences.

Mr. Mannes has been taking the same drug, Cuprimine, for 55 years to treat Wilson disease, an inherited disorder that can cause severe liver and nerve damage. This summer, Valeant more than quadrupled its price overnight.

Medicare will now have to cover about $35,000 for the 120 capsules he takes each month, and Mr. Mannes will have to pay about $1,800 a month out of pocket, compared with about $366 he paid in May.

“My husband will die without the medicine,” said his wife, Susan, who is now working a second part-time job to help pay for health care. “We just can’t manage another two, three thousand dollars a month for pills.”

Cuprimine is just one of many Valeant drugs whose prices have spiked as part of the company’s concerted strategy, which has richly rewarded its investors and made it one of Wall Street’s most popular health stocks.

But Valeant’s habit of buying up existing drugs and raising prices aggressively, rather than trying to develop new drugs, has also drawn the ire of lawmakers and helped stoke public outrage against the growing trend of higher and higher drug prices imposed by big drug companies. This year alone, Valeant raised prices on its brand-name drugs an average of 66 percent, according to a Deutsche Bank analysis, about five times as much as its closest industry peers.

Some presidential candidates have also seized on the issue. Hillary Rodham Clinton, who is seeking the Democratic nomination, called for efforts to control “price gouging” after a public outcry over the actions of Turing Pharmaceuticals, which abruptly increased the price on a drug to $750 a tablet from $13.50.

And last week, Democrats on the House Committee on Oversight and Government Reform demanded that Valeant be subpoenaed for information about big price increases on two old heart drugs that the company acquired in February.

The threat of government action is making the pharmaceutical industry nervous. A big sell-off in biotechnology stocks over the last two weeks helped wipe out the sector’s gains for the entire year. Valeant’s stock has been among the hardest hit, losing about a quarter of its value since Sept. 18. Still, the stock is trading for about six times as much as it was five years ago, a meteoric rise that far outpaced most drug companies.

Valeant defended itself, saying in a statement that it “prices its treatments based on a range of factors, including clinical benefits and the value they bring to patients, physicians, payers and society.” It says patients are largely shielded from price increases by insurance and financial assistance programs the company offers, so that virtually no one is denied a drug they need.

But Mr. Pearson, a former McKinsey & Company consultant, has been blunt about saying he has a duty to shareholders to wring the maximum profit out of each drug. And in some cases old neglected drugs sell for far less than newer drugs for the same diseases.

If “products are sort of mispriced and there’s an opportunity, we will act appropriately in terms of doing what I assume our shareholders would like us to do,” he told analysts in a conference call in April.

Valeant is an extreme example of practices that have been around in the pharmaceutical industry for years. The United States, unlike most countries, does not control drug prices, and pharmaceutical manufacturers have relied heavily on steady and sometimes outsize price increases in this country to bolster their revenue and profits.

Valeant is known for buying one company after another, and laying off their employees to achieve savings, while accumulating a debt of about $30 billion. It spends an amount equivalent to only 3 percent of its sales on research and development, which it views as risky and inefficient compared to buying existing drugs. Traditional big drug companies spend 15 to 20 percent of sales on research and development. Valeant also pays extremely low taxes because it is officially based in Canada, although Mr. Pearson operates from New Jersey.

Price increases provide an extra boost to the company’s sales and profits.

For example, after Valeant acquired Salix Pharmaceuticals this year, it raised the price of one Salix drug, the diabetes pill Glumetza, about 800 percent, in two steps.

“How can they just do this?” said Gail Mayer, a retired computer systems analyst on Long Island, who said her monthly supply of Glumetza went from $519.92 in May to $4,643 in August. For now, her insurance is covering most of that increase, but she is worried that it will stop covering the drug altogether, as others have.

“I’m sure it didn’t cost them $4,000 more to make,” Ms. Mayer said. “You don’t just go buy a bottle of milk and suddenly the supermarket charges you $100.”

Mr. Pearson has told analysts that it is standard industry practice to raise the price of a drug shortly before it faces generic competition, which Glumetza might face in February.

The drug industry argues that list prices are typically not what health plans pay after discounts and rebates are negotiated, and there is evidence that these discounts are increasing.

But even if patients are often shielded, the costs are paid by insurers, hospitals and taxpayers and lead to higher premiums and co-payments for everyone, critics say.

Jeffrey M. Rosner, the senior director for pharmacy sourcing and purchasing at the Cleveland Clinic, said that nine drugs with particularly egregious price increases had cost the hospital an additional $11.2 million annually, an increase of about 10 percent in drug costs for hospitalized patients. And Valeant’s products represented 80 percent of that additional cost, he said.

The price of one Valeant drug, Mephyton, which helps blood clot better, has been increased eight times since July 2014, he said, and now costs about $58.76 a tablet, up from $9.37. The price of another, Edecrin, a diuretic, has gone up nine times since May 2014 and is now at $4,600 a vial, up from about $470. When his staff called to inquire, Valeant refused to discuss pricing over the phone, Mr. Rosner said.

Many of the drugs undergoing gigantic price increases are old and no longer have patent protection, raising the question of why generic alternatives do not pop up.

The generic equivalent of Cuprimine, the drug taken by Mr. Mannes, is being sold by some foreign pharmacies for $1 a tablet, in contrast to the $260 Valeant is now charging.

For some Valeant drugs there are generic alternatives. For others, the sales have been too small to interest a generic company. That could change now that the prices are higher, but it would probably take several years for a generic-drug maker to win approval from the Food and Drug Administration to start selling such a product.

More conventional pharmaceutical and biotechnology companies, which conduct their own research and development, have rushed to distance themselves from companies like Turing and Valeant. The Biotechnology Industry Organization, a trade group, expelled Turing, saying it did not reflect the organization’s values. Martin Shkreli, the former hedge fund manager who runs Turing, is also facing a federal criminal inquiry into his activities at a previous company, Retrophin, according to Retrophin regulatory filings.

But while more conventional companies do not typically triple or quadruple prices overnight, they do often raise them year after year at a rate far faster than inflation. Big pharmaceutical companies like Pfizer and Merck raised list prices an average of 13 percent in 2014 and 8 percent so far this year, according to Deutsche Bank.

Ronny Gal, a pharmaceutical analyst at Sanford C. Bernstein & Company, said smaller price increases on widely used drugs had a much bigger effect on health care spending than the larger increases by Valeant on drugs with small sales.

Dr. Irl B. Hirsch, a diabetes specialist at the University of Washington School of Medicine in Seattle, said insulin prices had risen so much in recent years that some patients were scrimping on groceries to pay for it. The price of a package of five Lantus injectable pens from Sanofi has gone from about $179 in 2010 to $372 last year, he said, and insurance will often cover only one package at a time.

“All of this stuff that makes life so inconvenient, this would have been unheard of five or 10 years ago,” he said.

The more conventional companies and their backers argue that research and development has a high risk of failure, so they deserve premium prices when a drug succeeds. They now are concerned that innovation will be undermined by a reaction to price increases imposed by companies like Turing and Valeant.

Jacking up prices of old drugs, “with no R&D risk-taking, is just not right,” Bruce Booth, a prominent life sciences venture capitalist, tweeted on Tuesday, adding that the practice “hurts the industry & innovators.”

With Valeant’s stock price falling, Mr. Pearson sent a letter to employees Monday, arguing that increased prices accounted for only a small and declining part of the company’s business. “Valeant is well positioned for strong organic growth, even assuming little to no price increases,” he wrote.

But in the company’s regulatory filing for the second quarter, Valeant said that its growth in the United States and other developed markets “was driven primarily by price,” not by increased volume. Analysts at Morgan Stanley estimated that “outsized” price increases on eight drugs accounted for about 7 percent of Valeant’s revenue and 13 percent of its earnings before taxes and interest in the second quarter.

For now, with Congress in the hands of Republicans and election season in full swing, quick government action on drug prices is considered unlikely.

The Manneses are applying for financial assistance from a foundation recommended by Valeant to help pay for Cuprimine. But Ms. Mannes was upset enough to write to elected officials and call local television stations.

“This madness has to stop,” she said.

Valeant’s Drug Price Strategy Enriches It,
but Infuriates Patients and Lawmakers,
NYT, OCT. 4, 2015,
http://www.nytimes.com/2015/10/05/business/
valeants-drug-price-strategy-enriches-it-but-infuriates-patients-and-lawmakers.html

Missing the Warnings

on Legionnaires’ Disease

AUG. 7, 2015

The New York Times

The Opinion Pages | Editorial

By THE EDITORIAL BOARD

The recent outbreak of Legionnaires’ disease in the Bronx, the largest in New York City’s history, shows how little is known about the cooling towers for air-conditioning systems that are the main incubators of the disease-causing bacteria. Even more dismaying has been the city’s sluggishness in responding to early-warning signs of a potential health problem.

The disease, a form of pneumonia that can be treated with antibiotics, has infected at least 100 people in four Bronx neighborhoods. Ten of them died, all of whom were especially susceptible because of old age and pre-existing health conditions. Some 200 to 300 cases are reported annually in the city, and this year’s toll has already reached 260, with five more months to go.

The cases in the Bronx were traced to one or more of five cooling towers that were found to have legionella bacteria. The cooling towers that provide water for air-conditioning systems are typically located on rooftops and emit a mist, which can contain bacteria. If inhaled, legionella causes symptoms that include high fever, muscle aches, coughing, shortness of breath and headaches.

Nobody knows how many such towers there are in the city or how many have not been well maintained. The number of towers could be in the tens of thousands. Other plumbing systems favorable to legionella include whirlpool spas, hot tubs, humidifiers, hot water tanks and evaporative condensers of large air-conditioning systems.

The city’s Health Department was slow off the mark this time. And it had advance warning. Last January, eight cases were reported at Co-op City, a housing complex in the Bronx, and traced to a cooling tower. In May, nine cases in Flushing, Queens, were tied to a cooling tower and a water system in a senior citizens’ center. Although the equipment involved in these small clusters was quickly disinfected, no concerted effort was made by the city to inspect or monitor cooling towers more broadly.

The Bronx cases have finally stirred the city to action. Mayor Bill de Blasio and members of the City Council plan to introduce legislation next week to require registration of all buildings with cooling towers, as well as testing and inspections to detect contamination, remediation after positive tests and penalties for failure to comply.

The health commissioner issued an order on Thursday requiring owners or managers of buildings with cooling towers to hire environmental consultants and disinfect their systems within two weeks if they haven’t been in the last 30 days. And Gov. Andrew Cuomo announced that the state, which has been doing all the tests for the city during the outbreak, will now offer free testing to all private building owners across the state with cooling towers or evaporative condensers that can be sources of the bacteria.

Between 8,000 and 18,000 people are hospitalized with Legionnaires’ disease in the United States every year, according to the Centers for Disease Control and Prevention, and many more cases may go unreported when the symptoms are subtle. Every state should consider actions like those proposed by New York.
 

A version of this editorial appears in print on August 7, 2015, on page A26 of the New York edition with the headline: Missing the Warnings on Legionnaires’ Disease.

Missing the Warnings on Legionnaires’ Disease,
NYT, AUGUST 7, 2015,
http://www.nytimes.com/2015/08/07/opinion/
missing-the-warnings-on-legionnaires-disease.html

Medicare and Medicaid at 50

JULY 3, 2015

The New York Times

The Opinion Pages | Editorial

THE EDITORIAL BOARD

Medicare and Medicaid, the two mainstays of government health insurance, turn 50 this month, having made it possible for most Americans in poverty and old age to get medical care. While the Affordable Care Act fills the gap for people who don’t qualify for help from those two programs, there are important improvements still needed in both Medicare and Medicaid.

At the time the two programs were enacted in July 1965, advocates of Medicare, which today covers 46 million Americans over the age of 65 and nine million younger disabled people, expected that it would expand to cover virtually all Americans. Although polls between 1999 and 2009 showed consistent majorities in favor of expanding Medicare to people between the ages of 55 and 64 to cover more of the uninsured, it never happened.

Still, its achievement in improving life expectancy and reducing poverty among the elderly has been enormous. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number is 2 percent. Analysts say that between 1970 and 2010, Medicare contributed to a five-year increase in life expectancy at age 65, by providing early access to needed medical care. Even compared with people under age 65 who have insurance, those on Medicare are less likely to miss needed care or have unmanageable medical bills.

While Medicare, which covers hospital care, doctors’ services and prescription drugs, is comprehensive, many people are still left struggling to pay premiums, cost-sharing for various services and the full cost of items not covered by Medicare, like dental care and extended stays in nursing homes. Roughly half of all Medicare recipients live on incomes of less than $24,000 per person, and while the poorest of them get additional help from Medicaid, many do not. Medicare still lacks a cap on the amount a beneficiary has to pay out of pocket, the most basic function of insurance. By contrast, the Affordable Care Act puts limits on beneficiary spending per year and over a lifetime.

The Affordable Care Act has helped Medicare beneficiaries by eliminating co-payments and deductibles for preventive care like mammograms and colonoscopies, and by providing discounts for very heavy users of prescription drugs. It will strengthen Medicare as a system through demonstration projects to find new ways to deliver care that will improve its quality and lower its cost. The challenge will be to identify and spread the most promising innovations so that they benefit not just Medicare, but the entire health care system.

Medicaid, the other part of the medical safety net, is a joint state-federal program for the poor. For the past five decades, it has been critical in reducing childhood deaths and infant mortality. It has saved the lives of patients with chronic conditions like heart disease, diabetes and asthma. Last year it covered some 64 million people in a typical month and 80 million people at some point during the year. If Medicaid did not exist, life expectancy in America would be much lower.

The problem with Medicaid is that federal rules give states great leeway in deciding whom the program helps. Many states are so cheap that only extremely poor parents qualify for Medicaid coverage and childless adults are excluded entirely. Texas, for example, only covers parents who earn up to 15 percent of the federal poverty level, or less than $4,000 a year for a family of four, and does not cover other non-disabled adults at all, while other states, including New York and California, offer far better coverage. The result is huge differences across the country for assistance to poor, sick people.

The Affordable Care Act was intended to reduce this disparity by offering additional federal funding for states to expand their Medicaid programs to cover all adults up to 138 percent of the federal poverty level, or $32,913 for a family of four. Yet 21 states, the vast majority run by Republican governors, have chosen not to expand.

Medicaid could be improved by raising its payments to doctors, who often refuse to take Medicaid patients because the rates are so low compared to private insurance and Medicare. Medicaid should also cover legal immigrants, who currently have to wait five years to be eligible, and illegal immigrants, who are currently denied coverage entirely.

Despite the perennial fear that the costs of these two programs will grow uncontrolled, spending in both has been growing at a relatively modest rate in recent years. Medicare and Medicaid have changed and grown over the decades, through Republican and Democratic administrations, to meet new challenges. Their performance and popular support has allowed them to withstand ideologically-driven attacks on their continuance as government entitlements. These programs succeed, in fact, because they entitle all eligible Americans to receive the health care they need.

A version of this editorial appears in print on July 3, 2015, on page A20 of the New York edition with the headline: Medicare and Medicaid at 50.

Medicare and Medicaid at 50,
NYT, JULY 3, 2015,
http://www.nytimes.com/2015/07/03/opinion/medicare-and-medicaid-at-50.html

Health Problems Take Root

in a West Baltimore Neighborhood

That Is Sick of Neglect

 

APRIL 29, 2015

The New York Times

By SABRINA TAVERNISE

BALTIMORE — At 49, Annette Booth already feels old.

She is obese and has trouble walking a block, never mind playing with her grandchildren. She has had two knee replacements. She rattles when she breathes because of asthma, and takes about nine pills a day, including medications for anxiety and high blood pressure.

“I can’t walk too far,” she said. “If I do, I can’t breathe.”

In Upton-Druid Heights in West Baltimore — one of the city’s poorest neighborhoods and, in recent days, the scene of some of its most vocal protests — the cost of long-term poverty is counted in lives. Its residents die from nearly every major disease at substantially higher rates than the city as a whole — nearly double the rate from heart disease, more than double the rate from prostate cancer, and triple the rate from AIDS. Life expectancy here is just 68 years, one notch above Pakistan.

The fact that 94 percent of its population is black is lost on no one. “If the statistics that are present in these communities were present in any white community in Baltimore, it would be declared a state of emergency,” said Bishop Douglas Miles, the pastor at Koinonia Baptist Church in Northeast Baltimore. “Health disparities loom as a giant lurking in the shadows. They never get talked about.”

Protests that have rolled across the country since the killing of Michael Brown in Ferguson, Mo., last year may be largely about policing, but the anger and frustration that power them have come from a deeper, less visible set of issues that burden poor black Americans.

Poor health is a physical manifestation of systemic disadvantage. Years of industrial decline have left swaths of this city jobless. Half the people in Upton-Druid Heights live in poverty, slightly more than in 1970, and 64 percent of working-age black men are not employed, according to Marc V. Levine, a professor of history and economic development at the University of Wisconsin-Milwaukee, who has studied black employment in Baltimore.

Manufacturing jobs in the city have declined by 90 percent since the late 1960s, and much of what replaced them was too far away or required too many skills for the local work force. In 2010, the typical household in Upton-Druid Heights had an income of about $15,700.

“There are factors that build up and something makes it pop,” said Ralph Moore, 62, who grew up a few streets over in Sandtown-Winchester, where Freddie Gray, the man whose death sparked Monday’s riots, was chased by police officers. “Freddie Gray’s death made it pop. This isn’t just happening as a consequence of his death; it was always around.”

The legacy is a grim landscape with far more vacant buildings and liquor stores than in the rest of the city.

Mr. Moore, a program manager at Restoration Gardens, a shelter for homeless young people, recalls having to look hard for an abandoned building in Baltimore for a high school yearbook photograph he and his friends wanted to take in 1969. Now they are everywhere.

“People are angry,” he said. “They don’t feel a connection with any positive Baltimore existence. They feel like they are being ignored.”

Dynece Maberry, 54, who lives a few blocks from the CVS drugstore that was burned and looted on Monday night, agreed. “Freddie Gray was one thing, but what all triggered it off was years of frustration,” said Ms. Maberry, who joined the protests. “We were marching for a rec center, we were marching for schools. We were marching for jobs.”

At Total Health Care, a tidy brick community health center in Upton-Druid Heights where Ms. Booth had come Wednesday morning to figure out how to renew her prescriptions — she had been using CVS — clinicians see the problems up close.

Janice Stevenson, clinical director for the mental health program at Total Health Care, described a patient whose daughter, 18, was killed and thrown in a Dumpster. The patient’s grandson died in a drive-by shooting. In all, perhaps 10 people in the patient’s immediate family had died from disease or violence by the time she joined the program.

“It’s a lot like being in a war,” said Ms. Stevenson, who drew an analogy to the vacant houses that dot Baltimore’s streets like broken teeth. “There’s an emptiness inside of them that’s like the houses.”

She said children in the area had high rates of exposures to lead paint, which can cause mental and physical impairments. City data appeared to back that up: Upton-Druid Heights has twice the rate of lead paint violations compared with the rest of the city.

Marcia A. Cort, the chief medical officer for the clinic, used to work in the emergency room where patients from this neighborhood commonly went. She said rates of intubation for asthma there were two to three times those of a hospital just a mile and a half away downtown whose patients were less impoverished.

“Look at the life expectancy — you are old at 49,” said Faye Royale-Larkins, the chief executive of the clinic. But she said health disparities were not part of the anger of recent days. “You would be angry if something was taken away from you. But if you never had it,” she added, “it doesn’t make you angry.”

Ms. Booth, who grew up in Upton-Druid Heights and now lives farther south, lived in some of those abandoned buildings in her 20s. She was addicted to drugs and spending all her money getting high. She says those years permanently damaged her health. But she has something unusual: a partner, who stayed with her throughout. They got clean together.

She said she was not surprised by the low life expectancy in the neighborhood. Recovering drug addicts are not given too many years to live, she said. But she has signed up for nutrition classes at the Total Health clinic and aims to lose 100 pounds.

“I don’t like broccoli, but I’m going to eat it,” she said. “I want to live long enough to see my grandkids get married. I really want to be here for that.”

A version of this article appears in print on April 30, 2015, on page A19 of the New York edition with the headline: Health Problems Take Root in a Neighborhood That Is Sick of Neglect.

Health Problems Take Root in a West Baltimore Neighborhood That Is Sick of Neglect,
NYT, APRIL 29, 2015,
http://www.nytimes.com/2015/04/30/us/
health-problems-take-root-in-a-west-baltimore-neighborhood-that-is-sick-of-neglect.html

Best, Brightest — and Saddest?

APRIL 11, 2015

The New York Times

SundayReview | Op-Ed Columnist

PALO ALTO, Calif. — I HAD heard about all of the dying, about all of the grief, and still I didn’t immediately understand what I was seeing when, at a railroad crossing here, I spotted a man in a blaring orange vest, the kind that road crews and public-safety workers wear. He wasn’t carrying any equipment. He wasn’t engaged in any obvious activity. He shuffled his feet, staring into the distance.

Hours later, at the same crossing: an orange-vested woman. Like the man, she just stood there, without evident purpose.

“They’re on the lookout,” a friend of mine who lives here explained.

“For what?” I asked.

“Suicides,” my friend said.

Between May 2009 and January 2010, five Palo Alto teenagers ended their lives by stepping in front of trains. And since October of last year, another three Palo Alto teenagers have killed themselves that way, prompting longer hours by more sentries along the tracks. The Palo Alto Weekly refers to the deaths as a “suicide contagion.”

And while mental health professionals are rightly careful not to oversimplify or trivialize the psychic distress behind them by focusing on any one possible factor, the contagion has prompted an emotional debate about the kinds of pressures felt by high school students in epicenters of overachievement.

This is one such place. Children here grow up in the shadow of Stanford University, which established a new precedent for exclusivity during the recent admissions season, accepting just 5 percent of its applicants.

They grow up with parents who have scaled the pinnacles of their professions or are determined to have their offspring do precisely that. They grow up with advanced-placement classes galore, convinced that their futures hinge on perfect SAT scores and preternatural grade-point averages. Experts on sleep are in keen demand. The kids here don’t get enough of it.

But the situation isn’t so different in the Virginia suburbs of Washington, D.C., where a separate cluster of teen suicides in recent years forced educators and parents to re-examine the messages they give teenagers, intentionally and unintentionally, about what’s expected of them and what’s needed to get ahead in this world.

It’s not so different in Chicago’s western suburbs, where a high school teacher recently pulled me aside and, in a pained whisper, insisted that the number of advanced-placement classes that local students feel compelled to take and the number of hospitalizations for depression rise in tandem.

These are to some extent problems of affluence and privilege. But they have relevance beyond any one subset of our country’s populace. They reflect a status consciousness that bedevils Americans at all income levels, and they underscore an economic trepidation that is sadly widespread and is seemingly intensified by the gaping divide between the haves and have-nots.

The suicide rate among all teenagers has seemingly risen a bit over the last decade. According to the Centers for Disease Control and Prevention, it was 8.15 per every 100,000 Americans between the ages of 10 and 24 in 2013, the last year for which complete data is available; the rate was 6.74 in 2003.

Many more children think about taking their own lives. According to a 2013 survey by the C.D.C., 17 percent of American high school students had considered suicide in the previous year. Eight percent said they’d attempted it.

And suicide clusters have at least as much to do with imitation as with environment, each instance of self-annihilation planting an idea and heightening the possibility of the next.

There’s no direct line connecting the pressures of Palo Alto and the deaths. But the community’s soul searching goes beyond those tragedies, to matters plenty important in and of themselves. Are kids here getting to be kids? Does a brand of hovering, exactingly prescriptive parenting put them in unforgiving boxes and prevent them from finding their true selves and true grit?

“There’s something about childhood itself in Palo Alto and in communities like Palo Alto that undermines the mental health and wellness of our children,” Julie Lythcott-Haims told me.

Lythcott-Haims was a dean at Stanford from 2002 to 2012. She lives in Palo Alto. Her two children, ages 13 and 15, go to school here. And she’s the author of a new book, to be published in June, called “How to Raise an Adult.”

It reflects on the shortfalls of some modern parenting, which, in her view, can be not only overprotective but overbearing, micromanaging the lives of children, pointing them toward specific mile markers of achievement and denying them any time to flail or room to fail. They wind up simultaneously frazzled and fragile.

“The suicides are tragic, but they are at the pointy head of the pyramid, the tippy top,” she said. “Beneath them is a larger number of kids who are really struggling and beneath them is an even larger number of kids who feel an amount of stress and pressure that they shouldn’t be made to and that’s untenable.”

THE local media has been rife with commentary, from many perspectives, about the mental health of Palo Alto teenagers.

Here is what Carolyn Walworth, a junior at Palo Alto High School, recently wrote: “As I sit in my room staring at the list of colleges I’ve resolved to try to get into, trying to determine my odds of getting into each, I can’t help but feel desolate.”

She confessed to panic attacks in class, to menstrual periods missed as a result of exhaustion. “We are not teenagers,” she added. “We are lifeless bodies in a system that breeds competition, hatred, and discourages teamwork and genuine learning.”

Adam Strassberg, a psychiatrist and the father of two Palo Alto teenagers, wrote that while many Palo Alto parents are “wealthy and secure beyond imagining,” they’re consumed by fear of losing that perch or failing to bequeath it to their kids. “Maintaining and advancing insidiously high educational standards in our children is a way to soothe this anxiety,” he said.

He made these observations apart from the suicides, for which, he emphasized, “There is no single cause.” He recommended lightening children’s schedules, limiting the number of times that they take the SAT, lessening the message that it’s Stanford or bust.

“I will never be neutral on this issue,” he wrote. “The ‘Koala Dad’ is the far better parent than the ‘Tiger Mom.’ ”

What he was saying — and what’s obvious, but warrants repeating — is that ushering children toward a bright future means getting them there in one piece.

There’s a fresh awareness of that here, and perhaps a new receptiveness to some words of his that should echo far beyond Palo Alto: “Want the best for your child, not for your child to be the best.”
 

I invite you to visit my blog, follow me on Twitter at twitter.com/frankbruni and join me on Facebook.

A version of this op-ed appears in print on April 12, 2015, on page SR3 of the New York edition with the headline: Best, Brightest — and Saddest?.

Best, Brightest — and Saddest?, NYT,
APRIL 11, 2015,
http://www.nytimes.com/2015/04/12/opinion/sunday/
frank-bruni-best-brightest-and-saddest.html

Kansas Tries to Stamp Out Abortion

APRIL 9, 2015

The New York Times

The Opinion Pages | Editorial

By THE EDITORIAL BOARD

During the past four years, the state of Kansas has become ground zero in the war to criminalize all abortions, and in the process to remove a woman’s ability to control what happens in her own body.

Under Gov. Sam Brownback, a staunch foe of a woman’s right to choose, Kansas’ increasingly hard-line conservative lawmakers have enacted more than two dozen restrictions curtailing women’s reproductive freedom. These include, among many others, banning all abortions after 20 weeks, restricting health insurance plans from covering the procedure, defining life as beginning at fertilization, and forcing women to undergo ultrasounds, as well as to sit through medically inaccurate lectures, before ending a pregnancy.

On Tuesday the state went still further, becoming the first to ban the safest and by far the most common method of ending a second-trimester pregnancy, dilation and evacuation, which involves dilating the cervix and removing the fetus, often in parts. (On Wednesday, a similar bill passed the Oklahoma Legislature, and awaits the governor’s signature. Bills are also pending in Missouri and South Carolina.)

The anti-abortion activists in Kansas avoided actual medical terminology in drafting Senate Bill 95, which refers to the banned procedure as a “dismemberment abortion.” The law’s language aims for maximum shock value, describing “clamps, grasping forceps, tongs, scissors” or other instruments that “slice, crush or grasp a portion of the unborn child’s body in order to cut or rip it off.”

The law makes no exceptions in cases of rape or incest, but only to save the life of the mother or to protect her from irreversible bodily harm.

Of course, the Supreme Court has repeatedly upheld the right of a woman to terminate her pregnancy before the fetus is viable outside the womb, or at about 24 weeks. Different abortion procedures are appropriate at different points in a pregnancy, and that judgment must be left to doctors, not lawmakers.

But the anti-abortion armies forge tirelessly ahead, helping to enact hundreds of duplicitous restrictions on abortion in recent years. Already in 2015, legislators in various states have introduced more than 300 such provisions. Some require doctors to provide women with misleading or unverified information, like ones passed recently in Arizona and Arkansas that claim certain drug-induced abortions can be “reversed.” Others aim to shut down stand-alone clinics under the guise of protecting women’s health. And then there are those, like Kansas’ new law, that try to capitalize on public squeamishness about safe and well-established medical procedures.

This same strategy drove earlier bans on “partial-birth” abortions (what doctors call intact dilation and extraction), the federal version of which the Supreme Court upheld, by a 5-to-4 vote, in 2007. The court allowed that law to stand because women could still rely on other safe abortion methods like dilation and evacuation, which is used in less than 10 percent of abortions. Now this method is under legislative assault, too, even though there is no dispute among doctors as to its safety or reliability.

Here, as with other recent legislation limiting doctors’ ability to prescribe abortion-inducing medications in the first trimester, lawmakers have imposed their own moral judgments and restricted or criminalized decisions doctors make in caring for their patients.

The overall effect, as intended, has been to make an abortion harder to get than at any time since before the 1973 Supreme Court ruling in Roe v. Wade. This is true especially for lower-income and other vulnerable women, who are often the first to be denied the choice they have under the Constitution.

A version of this editorial appears in print on April 10, 2015, on page A26 of the New York edition with the headline: Kansas Tries to Stamp Out Abortion.

Kansas Tries to Stamp Out Abortion, NYT,
APRIL 9, 2015,
http://www.nytimes.com/2015/04/10/opinion/kansas-tries-to-stamp-out-abortion.html

How to Fight the Next Epidemic

Bill Gates: The Ebola Crisis Was Terrible.

But Next Time Could Be Much Worse.

 

MARCH 18, 2015

The New York Times

The Opinion Pages | Op-Ed Contributor

By BILL GATES

SEATTLE — The Ebola epidemic in West Africa has killed more than 10,000 people. If anything good can come from this continuing tragedy, it is that Ebola can awaken the world to a sobering fact: We are simply not prepared to deal with a global epidemic.

Of all the things that could kill more than 10 million people around the world in the coming years, by far the most likely is an epidemic. But it almost certainly won’t be Ebola. As awful as it is, Ebola spreads only through physical contact, and by the time patients can infect other people, they are already showing symptoms of the disease, which makes them relatively easy to identify.

Other diseases — flu, for example — spread through the air, and people can be infectious before they feel sick, which means that one person can infect many strangers just by going to a public place. We’ve seen it happen before, with horrific results: In 1918, the Spanish flu killed more than 30 million people. Imagine what it could do in today’s highly mobile world.

Much of the public discussion about the world’s response to Ebola has focused on whether the World Health Organization, the Centers for Disease Control and Prevention and other groups could have responded more effectively. These are worthwhile questions, but they miss the larger point. The problem isn’t so much that the system didn’t work well enough. The problem is that we hardly have a system at all.

To begin with, most poor countries, where a natural epidemic is most likely to start, have no systematic disease surveillance in place. Even once the Ebola crisis was recognized last year, there were no resources to effectively map where cases occurred, or to use people’s travel patterns to predict where the disease might go next.

Then, once it became clear that a serious emergency was underway, trained personnel should have flooded the affected countries within days. Instead it took months. Doctors Without Borders deserves a lot of credit for mobilizing volunteers faster than any government did. But we should not count on nonprofit groups to mount a global response.

Even if we signed up lots of experts and volunteers right away, it’s not clear how we would deploy them quickly into the affected area, or how we would transport patients. Few organizations are capable of moving thousands of people, some of them infected, to different locations on the globe with a week’s notice.

The Ebola epidemic might have been a lot worse if the United States, Britain and other governments had not used military resources to fly people and equipment into and out of affected areas. But we should not assume that the next epidemic will limit itself to countries that welcome Western troops.

Data is another crucial problem. During the Ebola epidemic, the database that tracks cases has not always been accurate. This is partly because the situation is so chaotic, but also because much of the case reporting has been done on paper and then sent to a central location for data entry.

Then there’s our failure to invest in effective medical tools like diagnostic tests, drugs and vaccines. On average it has taken an estimated one to three days for Ebola test results to come back — an eternity when you need to quarantine people until you know whether they’re infected. Drugs that might help stop Ebola were not tested in patients until after the epidemic had peaked, partly because the world has no clear process for expediting drug approvals.

Compare all this to the preparation that nations put into defense. Armies have systems for recruiting, training and equipping soldiers. NATO has a mobile unit that is ready to deploy quickly. Although the system isn’t perfect, NATO members do joint exercises where they work out logistics like how troops will get food and what language they will use to communicate.

Few if any of these approaches exist for an epidemic response. The world does not fund any organization (not even the W.H.O.) to coordinate all the activities needed to stop an epidemic. In short, in a battle against a severe epidemic, we would be taking a knife to a bazooka fight.

I believe that we can solve this problem, just as we’ve solved many others — with ingenuity and innovation.

We need a global warning and response system for outbreaks. It would start with strengthening poor countries’ health systems. For example, when you build a clinic to deliver primary health care, you’re also creating part of the infrastructure for fighting epidemics. Trained health care workers not only deliver vaccines; they can also monitor disease patterns, serving as part of the early warning systems that will alert the world to potential outbreaks. Some of the personnel who were in Nigeria to fight polio were redeployed to work on Ebola — and that country was able to contain the disease very quickly.

We also need to invest in disease surveillance. We need a case database that is instantly accessible to the relevant organizations, with rules requiring countries to share their information. We need lists of trained personnel, from local leaders to global experts, prepared to deal with an epidemic immediately. We need trained military resources ready to respond, and a list of supplies to be stockpiled or commandeered in an emergency.

Finally, we need to invest far more in research on drugs, vaccines and diagnostic tests, and make it possible to accelerate the approval of new approaches in times of crisis.

The United Nations should empower and fund a global institution to coordinate these efforts. The United Nations and the W.H.O. are studying the lessons of this epidemic; their evaluations would be a good starting point for a conversation about how to strengthen the W.H.O. and what pieces of the system it should lead.

I have not seen a rigorous projection for what a system like this would cost. But we know the cost of failing to act. According to the World Bank, a worldwide flu epidemic would reduce global wealth by $3 trillion, not to mention the immeasurable misery caused by millions of deaths. Preventing such a catastrophe is well worth the world’s time and attention.
 

Bill Gates is co-chairman of the Bill & Melinda Gates Foundation.

A version of this op-ed appears in print on March 18, 2015,
in The International New York Times.

How to Fight the Next Epidemic, NYT,
MARCH 18, 2015,
http://www.nytimes.com/2015/03/18/opinion/bill-gates-the-ebola-crisis-was-terrible-but-next-time-could-be-much-worse.html

Blocking the Paths to Suicide

MARCH 9, 2015

The New York Times

By CELIA WATSON SEUPEL

Every year, nearly 40,000 Americans kill themselves. The majority are men, and most of them use guns. In fact, more than half of all gun deaths in the United States are suicides.

Experts and laymen have long assumed that people who died by suicide will ultimately do it even if temporarily deterred. “People think if you’re really intent on dying, you’ll find a way,” said Cathy Barber, the director of the Means Matters campaign at Harvard Injury Control Research Center.

Prevention, it follows, depends largely on identifying those likely to harm themselves and getting them into treatment. But a growing body of evidence challenges this view.

Suicide can be a very impulsive act, especially among the young, and therefore difficult to predict. Its deadliness depends more upon the means than the determination of the suicide victim.

Now many experts are calling for a reconsideration of suicide-prevention strategies. While mental health and substance abuse treatment must always be important components in treating suicidality, researchers like Ms. Barber are stressing another avenue: “means restriction.”

Instead of treating individual risk, means restriction entails modifying the environment by removing the means by which people usually die by suicide. The world cannot be made suicide-proof, of course. But, these researchers argue, if the walkway over a bridge is fenced off, a struggling college freshman cannot throw herself over the side. If parents leave guns in a locked safe, a teenage son cannot shoot himself if he suddenly decides life is hopeless.

With the focus on who dies by suicide, these experts say, not enough attention has been paid to restricting the means to do it — particularly access to guns.

“You can reduce the rate of suicide in the United States substantially, without attending to underlying mental health problems, if fewer people had guns in their homes and fewer people who are at risk for suicide had access to guns in their home,” said Dr. Matthew Miller, a director of Harvard Injury Control Research Center.

About 90 percent of the people who try suicide and live ultimately never die by suicide. If the people who died had not had easy access to lethal means, researchers like Dr. Miller reason, most would still be alive.

The public has long held the opposite perception. In 2006, researchers at the Harvard center published an opinion survey about people who jump from the Golden Gate Bridge. Seventy-four percent of respondents believed that most or all jumpers would have completed suicide some other way if they had been deterred.

“People think of suicide in this linear way, as if you get more and more depressed and go on to create a more specific plan,” Ms. Barber said.

In fact, suicide is often a convergence of factors leading to a sudden, tragic event. In one study of people who survived a suicide attempt, almost half reported that the whole process, from the first suicidal thought to the final act, took 10 minutes or less.

Among those who thought about it a little longer (say, for about an hour), more than three-quarters acted within 10 minutes once the decision was made.

“We’re very bad at predicting who from a group of at-risk people will go on to complete suicide,” Dr Miller said. “We can say it will be about 10 out of the 100 who are at risk. But which 10, we don’t know.”

Dr. Igor Galynker, the director of biological psychiatry at Mount Sinai Beth Israel, noted that in one study, 60 percent of patients who were judged to be at low risk died of suicide after their discharge from an acute care psychiatric unit.

“The assessments are not good,” he said. So Dr. Galynker and his colleagues are developing a novel suicide assessment to predict imminent risk, based upon new findings about the acute suicidal state.

“What people experience before attempting suicide is a combination of panic, agitation and franticness,” he said. “A desire to escape from unbearable pain and feeling trapped.”

Sometimes, depression isn’t even in the picture. In one study, 60 percent of college students who said they were thinking about ways to kill themselves tested negative for depression.

“There are kids for whom it’s very difficult to predict suicide — there doesn’t seem to be that much that is wrong with them,” said Dr. David Brent, an adolescent psychiatrist who studies suicide at the University of Pittsburgh.

Dr. Brent’s research showed that 40 percent of children younger than 16 who died by suicide did not have a clearly definable psychiatric disorder.

What they did have was a loaded gun in the home.

“If the kids are under 16, the availability of a gun is more important than psychiatric disorder,” Dr. Brent said. “They’re not suicidal one minute, then they are. Or they’re mad and they have a gun available.”

Availability is a consistent factor in how most people choose to attempt suicide, said Ms. Barber, regardless of age. People trying to die by suicide tend to choose not the most effective method, but the one most at hand.

“Some methods have a case fatality rate as low as 1 or 2 percent,” she said. “With a gun, it’s closer to 85 or 90 percent. So it makes a difference what you’re reaching for in these low-planned or unplanned suicide attempts.”

Statistically, having a gun in the home increases the probability of suicide for all age groups. If the gun is unloaded and locked away, the risk is reduced. If there is no gun in the house at all, the suicide risk goes down even further.

Findings like these are far from popular. Taxpayers resist spending public money on infrastructure that they believe will not prevent people determined to die by suicide, and the political tide has turned against gun control. But growing evidence of suicide’s unpredictability, coupled with studies showing that means restriction can work, may leave public health officials little choice if they wish to reduce suicide rates.

Ken Baldwin, who jumped from the Golden Gate Bridge and lived, told reporters that he knew as soon as he had jumped that he had made a terrible mistake. He wanted to live. Mr. Baldwin was lucky.

Ms. Barber tells another story: On a friend’s very first day as an emergency room physician, a patient was wheeled in, a young man who had shot himself in a suicide attempt. “He was begging the doctors to save him,” she said. But they could not.
 

A version of this article appears in print on March 10, 2015, on page D2 of the New York edition with the headline: Blocking the Paths to Suicide.

Blocking the Paths to Suicide, NYT,
MARCH 9, 2015,
http://www.nytimes.com/2015/03/10/health/blocking-the-paths-to-suicide.html

A Disease Doctors Refuse to See

Chronic Fatigue Syndrome Needs Effective Treatments

FEB. 25, 2015

By JULIE REHMEYER

The Opinion Pages | Op-Ed Contributor

SANTA FE, N.M. — TOO often, doctors don’t understand chronic fatigue syndrome. They don’t know how to diagnose it, and they frequently even believe that patients with the disease are just whining or suffering from psychological problems. This needs to change.

That was the message from the Institute of Medicine’s recent report on the illness, which proposed new criteria to diagnose it and recommended ditching the syndrome’s confusing and demeaning name. The proposed alternative: systemic exertion intolerance disease, or S.E.I.D.

As a patient for 16 years, I’ve dealt with plenty of doctors who were ignorant about the disease. So my questions were: Will this work? Is a report from one of the most prestigious bodies in American medicine, an arm of the National Academy of Sciences, enough to make doctors take the disease seriously? Will patients get diagnoses faster and be treated more effectively?

Early indications are discouraging. An article about the report on Medscape, a website for doctors, received 273 comments as of Tuesday, and most were dismissive. Here are a few examples:

■ “Absent hard biological evidence, Chronic Fatigue Syndrome might” count “lots of people as ‘Sick’ who are in monotonous jobs, bad marriages, or plain bored with life.”

■ “great, disability here I come! glad I got that plan a long time ago.”

■ “Chronic fatigue and fibromyalgia — two wastebasket diagnoses in search of pathology.”

The nearly 300-page report explicitly argued against these sentiments with a thorough review of the scientific literature. It pointed out that chronic fatigue (the condition of being tired all the time) and chronic fatigue syndrome (an illness in which exhaustion is just one of many debilitating symptoms) are very different.

The hallmark symptom of chronic fatigue syndrome isn’t fatigue at all: It’s a dramatic worsening of symptoms after exertion (which for some patients can be as little as lifting a toothbrush). On top of that, patients have cognitive problems, sometimes so extreme they can’t talk or read; within half an hour of standing, their blood pressure drops or their heart rate soars; and sleep makes them feel no better. Most have additional symptoms, too, including pain and neurological and immune problems.

But many doctors, it seems, aren’t persuaded by this scientific evidence.

So what would persuade them? Doctors may be a scientifically minded lot, but they are also slow to change and are focused on their daily work. “Real” for a doctor often translates to “indicated by some objective test.”

Unfortunately, no one test can reliably distinguish patients who have chronic fatigue syndrome from those who don’t. The closest thing to a reliable, objective test is a two-day exercise-to-exhaustion challenge on a stationary bike. Sick patients of all varieties may poop out quickly on Day 1 but whatever they do, they can generally repeat it the next day. Not C.F.S. patients; their performance tanks. Physiological measures ensure that the results can’t be faked, and so far, researchers haven’t seen similar results in any other illness. But large studies haven’t been done. The test also has a big problem. It can leave patients much sicker for months.

A more practical test for exertion intolerance may come from examining the gene expression in the spinal fluid of C.F.S. patients after moderate exercise, which has been shown to be distinctively abnormal in small samples. But much more research will be required before doctors are able to order a test for it.

The other thing that would change doctors’ attitudes is effective treatment, which is also what patients desperately need. The problem is, very few treatments have proved effective.

That may be about to change. Rituximab, a lymphoma drug, has produced remarkable remissions in C.F.S. patients in a small study and is now undergoing a large trial. In my case, I have improved almost unbelievably by taking extreme steps to avoid mold, an approach that has become an underground movement among patients but that has received very little study.

Developing tests and treatments isn’t cheap. Every disease community argues that it needs more money, but the situation with C.F.S. is extreme: The National Institutes of Health spends a mere $5 million a year on C.F.S. research, when an estimated one million Americans are affected, with many disabled and some so ill they languish for years in darkened rooms, unable to move or speak. By comparison, the N.I.H. spends $3 billion on H.I.V./AIDS a year. Ellen Wright Clayton, the chairwoman of the committee that produced the report, is encouraging patients to advocate as AIDS activists once did and demand more research funding — a tall order for patients who are often housebound.

I hope, and believe, that this report will help some patients get diagnoses more quickly and accurately. But to get anywhere close to the care that patients so desperately need, no report is enough. It will require objective tests and effective treatments. For that, federal agencies will have to start making an investment in this disease that’s proportional to the devastation it causes.
 

Julie Rehmeyer is a science writer and contributing editor at Discover Magazine.

A version of this op-ed appears in print on February 25, 2015, on page A23 of the New York edition with the headline: A Disease Doctors Refuse to See.

A Disease Doctors Refuse to See, NYT,
FEB. 25, 2015,
http://www.nytimes.com/2015/02/25/opinion/understanding-chronic-fatigue.html

Save the Children’s Insurance

Hillary Clinton and Bill Frist

on Health Care for America’s Kids

 

FEB. 12, 2015

Thre New York Times

The Opinion Pages | Op-Ed Contributors

By HILLARY RODHAM CLINTON

and BILL FRIST

NO child in America should be denied the chance to see a doctor when he or she needs one — but if Congress doesn’t act soon, that’s exactly what might happen.

For the past 18 years, the Children’s Health Insurance Program has provided much-needed coverage to millions of American children. And yet, despite strong bipartisan support, we are concerned that gridlock in Washington and unrelated disputes over the Affordable Care Act could prevent an extension of the program. As parents, grandparents and former legislators, we believe that partisan politics should never stand between our kids and quality health care.

We may be from different political parties, but both of us have dedicated our careers to supporting the health of children and their families. This shared commitment inspired us to work together in the late 1990s to help create CHIP to address the needs of the two million children whose families make too much money to be covered by Medicaid, but cannot afford private insurance.

The resulting program, a compromise between Republicans and Democrats, disburses money to the states but gives them flexibility to tailor how they provide coverage to meet the needs of their own children and families. Some expanded Medicaid; others created separate programs. As a result, the number of uninsured children in America has dropped by half. Children miss less school because of illness or injury, and we’ve seen a significant decline in childhood mortality.

Today, state governments continue to rely on the program to meet crucial health and budget priorities. It’s not surprising that every single governor who responded to a 2014 survey — 39 in all — supported saving CHIP.

Of course, the American health care landscape has changed significantly since CHIP started. Under the Affordable Care Act, many families with children are now receiving financial help to enroll in private health coverage through the new health insurance marketplace. But while it is possible that private, family-wide policies offered by employers and marketplaces may one day render CHIP unnecessary, for now substantial gaps still exist — and too many children can still fall through them.

One specific provision of the Affordable Care Act, often called the “family glitch,” has been interpreted to prevent many families from receiving subsidized health coverage in the new marketplace if one parent is offered “affordable coverage” through his or her job. In this case, “affordable” is defined as less than roughly 9.5 percent of household income for that parent to sign up alone — even though the actual cost of available family coverage is far higher. For families affected by this glitch, CHIP may be the only affordable option for making sure their children are covered.

We already know what happens when CHIP is no longer an option for families. According to a recent report from the Georgetown University Health Policy Institute, as many as 14,000 children in Arizona lost their health insurance after 2010, when it became the only state to drop CHIP.

We don’t want to see the same thing happen across the country. If CHIP is not reauthorized, more families will be hit with higher costs. As many as two million children could lose coverage altogether. Millions more will have fewer health care benefits and much higher out-of-pocket costs, threatening access to needed health services. And because families without adequate insurance often miss out on preventive care and instead receive more expensive treatment in hospital emergency rooms, all of us will be likely to end up paying part of the bill.

While reauthorization is not due until the end of September, Congress needs to act now. With more than four-fifths of state legislatures adjourning by the end of June, lack of action and clarity from Washington by then will make budgeting and planning virtually impossible.

Reauthorizing CHIP for the next four years would cost about $10 billion — an investment in our children that will pay off for decades to come. This is an opportunity to send a message that Washington is still capable of making common-sense progress for American families.

As 2015 unfolds, we know Congress will continue to debate the future of health care reform. We most likely won’t see eye to eye about some of the more contentious questions. But one thing everyone should be able to agree on is that our most vulnerable children shouldn’t be caught in the crossfire.

This isn’t about politics. It’s about our kids and our nation’s future. What could be more important than that?
 

Hillary Rodham Clinton, a Democrat, was secretary of state from 2009 to 2013, a senator from New York from 2001 to 2009 and first lady from 1993 to 2001. Bill Frist, a Republican, a surgeon and a businessman, was a senator from Tennessee from 1995 to 2007.

A version of this op-ed appears in print on February 13, 2015, on page A27 of the New York edition with the headline: Save the Children’s Insurance.

Save the Children’s Insurance,, NYT,
FEB 12, 2015,
http://www.nytimes.com/2015/02/13/opinion/hillary-clinton-and-bill-frist-on-health-care-for-americas-kids.html

Will the F.D.A. Kill Off E-Cigs?

JAN. 18, 2015

The New York Times

The Opinion Pages | Op-Ed Contributor

By SALLY SATEL

WASHINGTON — ELECTRONIC cigarettes, battery-powered devices that convert a solution of nicotine and other chemicals into a vapor that can be inhaled, or “vaped,” have the potential to wean a vast number of smokers off cigarettes. No burned tobacco leaves, no cancer-causing tar: a public health revolution in waiting.

The problem is, not enough smokers are switching to e-cigarettes, despite their relative safety — and understandably so. Smokers are barraged with news about inaccurate labeling, shoddy counterfeits and poorly made e-cigarettes that emit toxins and cancer-causing chemicals in vapor. And to the frustration of smokers, public health experts and, yes, manufacturers, the Food and Drug Administration, which has not yet set up sensible regulations, is making the situation worse.

There’s no doubt that the initial public enthusiasm over e-cigarettes is waning: A report last year in the American Journal of Preventive Medicine showed that while nearly 85 percent of smokers believed that e-cigarettes were safer than cigarettes in 2010, that number had dropped to 65 percent in 2013.

Quality concerns are likely to keep rising: This year Chinese manufacturers, the most frequent culprit in safety oversight, are expected to ship more than 300 million e-cigarettes to the United States and Europe. Many of these products will be perfectly safe; the issue is that, so far, we lack an effective regulatory regime to distinguish the good from the bad.

It’s not that the F.D.A. has been idle. Last year it proposed a “deeming rule” — in effect, a blueprint for a regulatory framework for e-cigarettes. But given the avalanche of public comments (more than 135,000) and the importance of getting it right, a regulatory pathway will not be cleared anytime soon.

Consider the complexity. The proposal has some useful provisions, such as a ban on sale to minors and a requirement to disclose ingredients. But the proposal would also push e-cigarettes into the hugely burdensome regulatory framework that Congress set up for any new tobacco product.

That would be a mistake. To appreciate the extent of the unnecessary burden, consider “pre-market review.” Companies would have to demonstrate not only that each specific product was beneficial to intended users (adult smokers), but they would also have to show the consequences to teens and nonsmokers. Gathering these data would be vastly time consuming and expensive: According to the agency’s own estimates, conducting the necessary scientific investigations and preparing a pre-market application would take on average more than 5,000 hours and cost more than $300,000.

Only the large tobacco producers would be able to shoulder these costs, driving many of the 450 or so small e-cigarette makers from the market. This would suppress the innovation that’s crucial to expanding, refining and enhancing the safety and appeal of e-cigarettes.

Pre-market review is commonly used to prove that very risky products, like drugs, medical devices, pesticides and aircraft engines, aren’t harmful. But the point of e-cigarettes is not that they are safe, but that they are significantly safer than cigarettes.

Instead of waiting years to develop burdensome regulations, the F.D.A. should act now by setting interim safety guidelines. These guidelines would not carry the force of law, but they could go far to bolster smokers’ confidence that a safer way to inhale nicotine exists.

The agency should start by focusing on a few basic steps. It should outline basic good-manufacturing practices for the devices and liquids, including limits on the amount of chemicals, like formaldehyde, and metals, like nickel, that can be present in the aerosols. It should disallow outright some contaminants in the nicotine solution and flavorings.

It should require manufacturers to ensure that all batches of chemicals are traceable and that all sources of hardware are known. The guidelines should also require makers to verify that e-cigarette batteries can be charged safely and that they will operate safely in the course of normal use. Interim guidelines should require manufacturers to use childproof packaging that carries a warning: “This product contains nicotine, which is addictive and is intended for adult smokers only.” Also, a mechanism for reporting adverse effects is needed.

Finally, the F.D.A. should allow companies to tell smokers about the benefits of switching to vaping products. Labels could read: “While more research is needed, it is likely that e-cigarettes meeting F.D.A. interim safety guidelines are much safer than smoking.”

Such minimal standards are overdue. The longer it takes the F.D.A. to set them, the longer smokers risk confusion about the virtues of switching — and keep inhaling deadly smoke.

Sally Satel is a resident scholar at the American Enterprise Institute.

Will the F.D.A. Kill Off E-Cigs?,
NYT, JAN 18, 2015,
http://www.nytimes.com/2015/01/19/opinion/will-the-fda-kill-off-e-cigs.html

Financial Distress

Connected to Medical Bills

Shows a Decline,

the First in Years

JAN. 15, 2015

The New York Times

The Upshot

The New Health Care

Margot Sanger-Katz

After rising for a decade, the number of Americans experiencing financial distress from their medical bills has started to decline, a new survey has found.

The result provides new evidence that the Affordable Care Act, by providing uninsured people with health insurance, is also improving their financial security, a major goal of the law.

The large telephone survey, from the New York-based health research group the Commonwealth Fund, has been asking people about their medical bills every few years for a decade. In each survey through 2012, a higher percentage of Americans said they struggled to pay their medical bills, were paying off medical debt or had been contacted by a collection agency. The most recent installment of the survey, the first since the health law’s major provisions kicked in, shows a reversal in that trend.

The survey also found that fewer people were avoiding doctors’ visits because of concerns about cost.

“Health insurance really provides people with a financial means to get care,” said Sara Collins, a vice president at Commonwealth, who worked on the study. “We don’t know yet that the law is improving people’s health, but this is a first indication that people are affording care that they weren’t able to get in the past.”

The cost of medical care remains a financial hardship for many Americans. According to the survey, the percentage of Americans who experienced trouble with a medical bill or medical debt in the last year declined from a high of 41 percent in 2012 to 35 percent in 2014.

But that still means more than a third of all Americans struggle to afford the cost of their medical care. The high rate of problems with medical debt was the subject of a recent study from the federal Consumer Financial Protection Bureau, which estimated that more than a fifth of Americans have medical debt on their credit reports. Medical debt has been found to be a leading cause of personal bankruptcies.

Financial distress was a clear target of the health law, which sought to make health care more accessible and more affordable.

The survey also found that about 43 percent of Americans had avoided some sort of medical care in 2012 because of concerns about the cost. That rate fell in 2014 to 36 percent.

The reductions in problems with medical bills and debt mostly reflect the increases in the number of Americans with insurance, Ms. Collins said. The addition of health insurance means that people who in the past had no help paying medical bills now have new financing for doctors’ visits, prescription drugs and hospital stays. (Paradoxically, people who lack insurance often face the highest prices for such services, meaning they have less financial assistance and pay more than insured customers.)

But Commonwealth also found that, over all, even people who had insurance before 2014 were having fewer problems with medical bills than they were before. That change may reflect rules in the health law that require individual insurance plans to cover a minimum set of benefits for every customer.

There is another trend cutting against those improving financial protections for individuals. Employers are increasingly asking their workers to pay deductibles and other fees when they seek health care, and several recent surveys have shown that the average size of those deductibles and fees is rising. A recent national poll from The New York Times and CBS News found that 33 percent of people said that their out-of-pocket costs had “gone up a lot.”

The Commonwealth survey suggests that, in the last two years, the benefits for some people have outweighed the difficulties for others.
 

The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter. Sign up for our weekly newsletter here.

A version of this article appears in print on January 15, 2015, on page A19 of the New York edition with the headline: Distress Appears to Ease Over Cost of Health Care.

Financial Distress Connected to Medical Bills
Shows a Decline, the First in Years,
NYT, JAN 15, 2015,
http://www.nytimes.com/2015/01/15/upshot/
financial-distress-connected-to-medical-bills-shows-a-decline-the-first-in-years.html