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First Edition: February 26, 2020

As The Coronavirus Spreads, Americans Lose Ground Against Other Health Threats

For much of the 20th century, medical progress seemed limitless.

Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.

Yet today, some of the greatest success stories in public health are unraveling.

Even as the world struggles to control a mysterious new virus known as COVID-19, U.S. health officials are refighting battles they thought they had won, such as halting measles outbreaks, reducing deaths from heart disease and protecting young people from tobacco. These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.

Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years — the longest sustained drop since the Spanish flu of 1918, which killed about 675,000 Americans and 50 million people worldwide, said Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.

Although life expectancy inched up slightly in 2018, it hasn’t yet regained the lost ground, according to the Centers for Disease Control and Prevention.

“These trends show we’re going backwards,” said Dr. Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.

While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.

“We’ve had an overwhelming investment in doctors and medicine,” said Dr. Sandro Galea, dean of the Boston University School of Public Health. “We need to invest in prevention — safe housing, good schools, living wages, clean air and water.”

The country has split into two states of health, often living side by side, but with vastly different life expectancies. Americans in the fittest neighborhoods are living longer and better — hoping to live to 100 and beyond — while residents of the sickest communities are dying from preventable causes decades earlier, which pulls down life expectancy overall.

Superbugs — resistant to even the strongest antibiotics — threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, in spite of treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the U.S.

With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, said the world has entered a “post-antibiotic era.” Half of all new gonorrhea infections, for example, are resistant to at least one type of antibiotic, and the CDC warns that “little now stands between us and untreatable gonorrhea.”

That news comes as the CDC also reports a record number of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.

The United States has seen a resurgence of congenital syphilis, a scourge of the 19th century, which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.

Those numbers illustrate the “failure of American public health,” said Dr. Cornelius “Neil” Clancy, a spokesperson for the Infectious Diseases Society of America. “It should be a global embarrassment.”

The proliferation of resistant microbes has been fueled by overuse, by doctors who write unnecessary prescriptions as well as farmers who give the drugs to livestock, said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

Although new medications are urgently needed, drug companies are reluctant to develop antibiotics because of the financial risk, said Clancy, noting that two developers of antibiotics recently went out of business. The federal government needs to do more to make sure patients have access to effective treatments, he said. “The antibiotic market is on life support,” Clancy said. “That shows the real perversion in how the health care system is set up.”

A Slow Decline

A closer look at the data shows that American health was beginning to suffer 30 years ago. Increases in life expectancy slowed as manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.

By the 1990s, life expectancy in the United States was falling behind that of other developed countries.

The obesity epidemic, which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, “the gains we’re making at the tail end of life cannot make up for what’s happening in midlife.”

Progress against overall heart disease has stalled since 2010. Deaths from heart failure — which can be caused by high blood pressure and blocked arteries around the heart — are rising among middle-aged people. Deaths from high blood pressure, which can lead to kidney failure, also have increased since 1999.

“It’s not that we don’t have good blood pressure drugs,” Khan said. “But those drugs don’t do any good if people don’t have access to them.”

Addicting A New Generation

While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking activists were optimistic enough to talk about the “tobacco endgame.”

Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students fell from 36% in 1997 to 5.8% today, studies show 31% of seniors used electronic cigarettes in the previous month.

FDA officials say they’ve taken “vigorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren’t being marketed or sold to kids.” But Myers said FDA officials were slow to recognize the threat to children.

With more than 5 million teens using e-cigarettes, Myers said, “more kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn’t reversed rapidly and dynamically, it threatens to undermine 40 years of progress.”

Ignoring Science

Where children live has long determined their risk of infectious disease. Around the world, children in the poorest countries often lack access to lifesaving vaccines.

Yet in the United States — where a federal program provides free vaccines — some of the lowest vaccination rates are in affluent communities, where some parents disregard the medical evidence that vaccinating kids is safe.

Studies show that vaccination rates are drastically lower in some private schools and “holistic kindergartens” than in public schools.

It could be argued that vaccines have been a victim of their own success.

Before the development of a vaccine in the 1960s, measles infected an estimated 4 million Americans a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.

By 2000, measles cases had fallen to 86, and the United States declared that year that it had eliminated the routine spread of measles.

“Now, mothers say, ‘I don’t see any measles. Why do we have to keep vaccinating?’” Schaffner said. “When you don’t fear the disease, it becomes very hard to value the vaccine.”

Last year, a measles outbreak in New York communities with low vaccination rates spread to almost 1,300 people — the most in 25 years — and nearly cost the country its measles elimination status. “Measles is still out there,” Schaffner said. “It is our obligation to understand how fragile our victory is.”

Health-Wealth Disparities

To be sure, some aspects of American health are getting better.

Cancer death rates have fallen 27% in the past 25 years, according to the American Cancer Society. The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the Department of Health and Human Services. And HIV, which was once a death sentence, can now be controlled with a single daily pill. With treatment, people with HIV can live into old age.

“It’s important to highlight the enormous successes,” Redfield said. “We’re on the verge of ending the HIV epidemic in the U.S. in the next 10 years.”

Yet the health gap has grown wider in recent years. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a 2016 study in JAMA.

The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the JAMA study.

“We’re not going to erase that difference by telling people to eat right and exercise,” said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. “Personal choices are part of it. But the choices people make depend on the choices they’re given. For far too many people, their choices are extremely limited.”

The infant mortality rate of black babies is twice as high as that of white newborns, according to the Department of Health and Human Services. Babies born to well-educated, middle-class black mothers are more likely to die before their 1st birthday than babies born to poor white mothers with less than a high school education, according to a report from the Brookings Institution.

In trying to improve American health, policymakers in recent years have focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the poverty that erodes mental and physical health.

“So many of the changes in life expectancy are related to changes in opportunity,” Besser said. “Economic opportunity and health go hand in hand.”

Several policies have been shown to improve health.

Children who receive early childhood education, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.

And earned income tax credits — which provide refunds to lower-income people — have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.

Improving a person’s environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America’s Health.

“If we think we can treat our way out of this, we will never solve the problem,” Auerbach said. “We need to look upstream at the underlying causes of poor health.”

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Pharmaceuticals Public Health

Are Foods Labeled ‘Low Sugar’ Misleading Consumers?

The label on Honest Tea’s organic peach-flavored iced tea has a reassuring message for people who want a beverage that is not too sugary: “Just a Tad Sweet,” the label states.

But a single serving of the beverage, the amount in one 16.9 ounce bottle, has 25 grams of added sugar, equivalent to six teaspoons of table sugar. That is half the daily limit for added sugar intake recommended by the federal government.

Critics say that Honest Tea, which is owned by Coca-Cola, is one of many food companies that mislead consumers about the amount of sugar that is added to their products. Health authorities in recent years have linked consumption of added sugars to heart disease, Type 2 diabetes and obesity and warned Americans to cut their intake. Yet according to some experts, companies routinely market beverages, breakfast cereals, snack bars and other foods as lightly sweetened, heart healthy or nutritious despite containing significant amounts of sugar.

A recent study that examined millions of grocery store purchases in the United States found that dubious claims about sugar, salt and fat were common. Many fruit juices that claimed to be low in sugar, for example, tended to have added sugars and more sugar than comparable juices with no claims on them. Some breakfast cereals labeled low in calories had more calories than the cereals that did not make calorie claims. And sports, energy, tea and coffee drinks with low-sodium claims had almost 17 percent more sodium than similar products with no sodium claims on them.

With sugar increasingly in the public health spotlight, some consumer advocates have urged the Food and Drug Administration to ramp up its enforcement of labeling restrictions on sugary products. They say that the agency needs to define what it means for a product to be low in added sugar — or “healthy” for that matter — to prevent companies from deceiving consumers into buying foods that are higher in sugar than they anticipate.

Clashes over what these terms mean on food labels and whether companies are trying to mislead consumers have led to a flurry of lawsuits.

In October, Kellogg agreed to pay $20 million to settle a class-action lawsuit that accused the company of falsely advertising some of its most popular breakfast cereals as heart healthy and lightly sweetened, such as Raisin Bran and Smart Start. A number of other companies, including Clif Bar, Mondelez, General Mills, Whole Foods, Jamba Juice and Post Foods, have faced similar lawsuits over the level of sugar in their products.

Critics have decried the lawsuits as frivolous. The U.S. Chamber Institute for Legal Reform, a group that represents businesses, described the increase in sugar litigation in a recent report as “a broad attack on products with added sugar” and called the cases against Kellogg and other companies “absurd.”

In January, the Center for Science in the Public Interest, a consumer advocacy group in Washington, sent a letter to the F.D.A. identifying marketing claims on 19 widely sold sugary beverages from five brands that it said were misleading. The group highlighted several flavors of Honest iced tea, which carry the “just a tad sweet” claim, as well as brands like Steaz, which markets several flavors of organic iced tea as “lightly sweetened” despite containing 20 grams of sugar per serving, or roughly five teaspoons.

“If you look at the amounts of sugar in these things that say they are lightly sweetened — I mean, really?” said Marsha Cohen, a law professor and expert on food law at the University of California, Hastings College of the Law. “What’s heavily sweetened to them? It’s a little crazy.”

Sarah Sorscher, the deputy director of regulatory affairs at C.S.P.I., said that such claims give consumers the wrong impression about what it means to have a healthy level of sweetness in their beverages.

“People are drinking these thinking they’re less sweet options,” she said. “But they’re still enormously high in added sugars, and so they’re miseducating consumers about what it means to have a healthy diet.”

At the core of the issue are so-called nutrient content claims. In the early 1990s, the F.D.A. ruled that companies could advertise their products as low in fat, cholesterol, calories and sodium if the amount of those nutrients in their products met certain thresholds. But at the time, health authorities were less concerned about sugar, and the F.D.A. chose not to set a threshold for low-sugar claims because there was no scientific consensus on a healthy level of daily sugar intake. The agency states in its food-labeling guide for industry that the low-sugar claim has not been defined and “may not be used” in marketing.

C.S.P.I. argues that companies flout the rule by using synonyms for low sugar that are known under F.D.A. regulations as “implied” nutrient content claims, such as slightly sweet and lightly sweetened. It said that the agency should take “immediate enforcement action” against companies and define a low-sugar product as one that contains less than three grams of added sugar per serving. That is similar to requirements for other low-nutrient claims, and it is equivalent to roughly 5 percent of the F.D.A’.s daily value, or recommended limit, for added sugar intake.

In a statement, the F.D.A. said that it was reviewing the letter from C.S.P.I. and planned to respond. Steaz did not respond to a request for comment. Honest Tea said that part of the company’s founding mission was to meet consumer demands for beverages that tasted “less sweet than others in the market.”

“We continue to innovate to expand our portfolio to meet our fans’ growing desire for even more unsweetened and less-sweet options,” the company said.

In recent years, health experts have also urged the F.D.A. to update its definition of the term “healthy,” which it last defined in 1993. They say the agency relies on an outdated meaning that lets companies slap “healthy” claims on foods that are low in total fat, cholesterol and sodium but high in sugar. The agency has said it is working on updating its definition to address the fact that public health recommendations on fat, sugar and other nutrients “have evolved” since the early 1990s.

Lawyers, in the meantime, continue to argue that companies are violating state laws against false advertising with false health claims. A recent lawsuit against Honest Tea accused the company of deceptively marketing its beverages as low in sugar. Two lawsuits have accused Whole Foods and Trader Joe’s of disguising added sugar in their instant oatmeal by calling it “organic dehydrated cane juice solids” on their labels. A lawsuit against Jamba Juice alleges that the company portrays its smoothies as containing whole fruits and vegetables while frequently adding sugar, fruit juice concentrates, corn syrup and other additives.

A lawyer in California, Jack Fitzgerald, led a series of lawsuits against General Mills, Kellogg and Post, which together account for 80 percent of cereal sales in America, that accuse the companies of falsely advertising their sugary snacks and cereals as healthy.

The cases have had mixed results. Kellogg has denied any wrongdoing. But as part of its $20 million settlement in October, the company said it would limit or remove “heart health” claims from Raisin Bran and Smart Start cereals and restrict its use of claims like lightly sweetened, wholesome and nutritious on a variety of products. Reached for comment, Kellogg said it did not have anything to add.

In July, a federal judge dismissed Mr. Fitzgerald’s case against General Mills, saying the company properly discloses the amount of sugar in its products and that it is up to consumers to decide whether or not they are healthy. Lawyers for Post meanwhile have asked a judge to dismiss the case against it, saying the company has a First Amendment right to promote the health benefits of its products.

Ms. Sorscher at C.S.P.I. said that by creating new definitions of “healthy” and “low-sugar,” the F.D.A. would make it harder for companies to make claims that confuse consumers. “As long as the F.D.A. is dragging its feet,” she said, “these misleading claims will continue.”

How Exercise Might Affect Our Food Choices, and Our Weight

Taking up exercise could alter our feelings about food in surprising and beneficial ways, according to a compelling new study of exercise and eating. The study finds that novice exercisers start to experience less desire for fattening foods, a change that could have long-term implications for weight control.

The study also shows, though, that different people respond quite differently to the same exercise routine and the same foods, underscoring the complexities of the relationship between exercise, eating and fat loss.

I frequently write about exercise and weight, in part because weight control is a pressing motivation for so many of us to work out, myself included. But the effects of physical activity on waistlines are not straightforward and coherent. They are, in fact, distressingly messy.

Both personal experience and extensive scientific studies tell us that a few people will lose considerable body fat when they start exercising; others will gain; and most will drop a few pounds, though much less than would be expected given how many calories they are burning during their workouts.

At the same time, physical activity seems to be essential for minimizing weight gain as we age and maintaining weight loss if we do manage to shed pounds.

Precisely how exercise influences weight in this topsy-turvy fashion is uncertain. On the one hand, most types of exercise increase appetite in most people, studies show, tempting us to replace calories, blunting any potential fat loss and even initiating weight creep.

But other evidence suggests that physical fitness may affect people’s everyday responses to food, which could play a role in weight maintenance. In some past studies, active people of normal weight displayed less interest in high-fat, calorie-dense foods than inactive people who were obese.

Most of those studies examined the preferences of men and women who already were or were not fit, however. They did not look at whether altering people’s exercise habits might also transform their feelings about food.

So, for the new study, which was published in November in Medicine & Science in Sports & Exercise, researchers at the University of Leeds in England and other institutions decided to ask a group of sedentary men and women about how they felt about food and to begin working out.

The researchers wound up recruiting 61 volunteers, most of them middle-aged and inactive; all were overweight or obese. The study participants completed detailed questionnaires and online tests of their food preferences and behaviors, picking, for instance, between rapid-fire, on-screen pictures of different foods and also answering questions about bingeing on food and whether they found it hard to not overeat.

Fifteen of the volunteers then were asked to continue with their normal lives as a control group, while the other 46 began exercising, working out on exercise machines at a university facility five times a week for about 45 to 60 minutes or until they had burned about 500 calories per session. They continued this training for 12 weeks, eating as they liked at home.

Then everyone returned to the lab for weigh-ins and to repeat the original tests. Most, but not all, of the exercisers had shed a few pounds, while some of those in the control group had gained weight.

The men and women in the control group also showed little alteration in their feelings about food. But the exercisers’ reactions to pictures of and questions about high-calorie, fatty foods were new. They no longer found them quite so irresistible. In psychological terms, they showed less “wanting” for the most fattening foods.

Interestingly, their scores on measures of “liking,” or how much they expected to enjoy those same foods, remained unchanged and strong. They still felt that they would enjoy a cookie but did not feel quite the same drive to seek one out. They also reported fewer instances of recent binge eating.

Taken as a whole, these results suggest that, in addition to making us healthier, “exercise might improve food reward and eating behavior traits linked to the susceptibility to overconsume,” says Kristine Beaulieu, a research fellow and dietitian at the University of Leeds, who led the new study.

In other words, working out for a period of time could nudge us to rethink the kinds of foods we want to eat.

But the researchers did not monitor what their volunteers actually opted to eat at home, so they do not know if their eating habits shifted in real life. They also do not know if results would be different if people tried other types or amounts of exercise or how the exercise in this experiment affected food preferences, although they suspect it changed the workings of certain parts of the brain that regulate eating behavior.

Perhaps most frustrating, they cannot explain why the final outcomes varied so much from one exerciser to another, with some developing far more disinterest in fatty foods than others. Genetics might be involved, or personality, lifestyle, body composition or other factors. The researchers hope to explore some of those issues in future studies.

But for now, the study reinforces the idea that exercise should be part of our efforts to manage our weight.

“People still liked high-fat foods to the same extent,” after four months of training, Dr. Beaulieu points out, “but they wanted to eat them less, which we view as a favorable outcome.”

Trusting Injection Drug Users With IV Antibiotics At Home: It Can Work

Two mornings a week, Arthur Jackson clears space on half of his cream-colored sofa. He sets out a few rolls of tape and some gauze, then waits for a knock on his front door.

“This is Brenda’s desk,” Jackson said with a chuckle.

Brenda Mastricola is his visiting nurse. After she arrives at Jackson’s home in Boston, she joins him on the couch and starts by taking his blood pressure. Then she changes the bandages on Jackson’s right foot. His big toe was amputated at Brigham and Women’s Hospital in November. A bacterial infection, osteomyelitis, had destroyed the bone.

Jackson is still taking intravenous penicillin to stop the infection. He came home from the hospital wearing a small medication pump that delivers a steady dose of penicillin via a PICC line. PICC stands for a “peripherally inserted” or “percutaneous indwelling” central catheter, and it resembles a flexible IV tube, inserted into Jackson’s chest.

“This all looks good,” Mastricola said, after making sure the line was clean and in place. “You don’t need me.”

When patients need weeks or months of IV antibiotic treatment but otherwise don’t need to be hospitalized, the standard protocol is to discharge them with a PICC line and allow them to finish the medication at home. It saves money and is much more convenient for patients.

But this arrangement is almost never offered to patients with a history of addiction. The fear is that such patients might be tempted to use the PICC line as a fast and easy way to inject drugs like heroin, cocaine or methamphetamine.

Jackson, 69, was addicted to heroin for 40 years. Although he’s been sober for years, most U.S. hospitals would force patients like Jackson to stay in the hospital, sometimes for eight weeks or more. But Brigham and Women’s in Boston, along with a few others in the U.S., is challenging that protocol, allowing some patients with a history of addiction to go home.

Supporters of the change argue that doing so boosts the chances these patients will stay on their antibiotics and beat the infection.

A Path To Safe At-Home Treatment

A small team of Brigham doctors and nurses started planning this unusual option shortly after opening the Bridge Clinic, a walk-in health center in Boston for patients seeking treatment for a substance use disorder. Dr. Christin Price, one of the clinic’s directors, said virtually every patient who injects drugs develops some kind of infection. It’s difficult to avoid injecting bacteria into the bloodstream when using drugs in an alley or a public bathroom. The national opioid epidemic has led, in many cases, to a parallel increase in diseases related to injection drug use, such as HIV, hepatitis C and bacterial infections of the heart and bones. A study of North Carolina hospitals found a twelvefold increase in cases of bacterial endocarditis, a heart infection, from 2010 to 2015.

“Every time someone uses injection drugs, they’re putting themselves at risk for a very complicated infection,” Price said.

Treatment options for endocarditis patients with a history of drug use are limited. Some skilled nursing facilities, home care agencies and antibiotic infusion companies decline to work with these patients once they’re released from a hospital. And, Price said, some of her patients aren’t willing to remain in a hospital for weeks on end just to finish a round of IV antibiotics.

“They kind of get stir crazy,” she said. “You can imagine it’s almost like being held captive for six weeks, especially when you’re feeling fine now because the infection is clearing. A huge problem is that some of them can’t last — and so they leave before the six weeks are over.”

Patients who don’t complete their course of antibiotics can end up with a recurring infection and a repeat trip to the hospital.

Doctors and nurses affiliated with the Bridge Clinic wondered if there was a way to send patients with a history of drug use home — safely. They mapped out three requirements: First, patients would have to be taking an addiction treatment medication such as buprenorphine, or be willing to start one. Second, patients would have to check in weekly at the Bridge Clinic. Third, patients would need to have stable housing, and live with a sober friend or loved one. Price and colleagues began months of discussions with specialists in heart, bone and joint conditions, seeking buy-in from surgeons and nurses, so their patients could participate.

“A lot of people did sort of look aghast,” Price said. “It was just their policy that people with a history of injection drug use would not go home.”

When Dr. Daniel Solomon, who is also with Brigham and Women’s, encountered those looks, he said, he’d remind colleagues that “the alternatives aren’t that good either.”

Holding patients for weeks in a hospital room is hard on both the patients and medical providers, he said. And if patients want to use drugs, they’ll find a way to do it, even in a hospital bed.

In spring 2018, Price, Solomon and others enrolled a few of the first qualified patients, then a few more — intentionally cherry-picking those who wanted to be in treatment and had a sober, stable home.

Brenda Mastricola checks on the PICC line through which Arthur Jackson, a former drug user, is receiving penicillin to treat a bone infection.(Jesse Costa/WBUR)

‘I’m Not Going Back’

Arthur Jackson met the requirement that at-home PICC line candidates take addiction treatment medication. He had been on methadone for 10 years, used heroin again, then switched to Suboxone, a combination medication containing buprenorphine and naloxone, which he has been taking for two years. And, in fact, Jackson said he was insulted when one of the doctors presented the home treatment option to him but said she was worried the PICC line might entice him to inject heroin.

“Stop right there,” Jackson recalled telling the nurse. “When it comes to my recovery, I’m serious because I’ve done so much to lick this — this thing.”

Although the possibility did cross Jackson’s mind.

“First thing I thought was, ‘Oh, I could inject heroin in here easily,’” Jackson said. “But I dismissed that thought because I’m not going back” — back to winters on the streets and living from one heroin fix to the next.

Other Bridge patients scoff at the concerns about PICC lines.

“Everyone makes such a big deal about this PICC line,” said Stephen Connolly, 36, who went home with the open port last year, while being treated for endocarditis. “If I want to get high, I know how to do it. I’m not going to mess around with a PICC.”

Connolly said that when he first came to Brigham and Women’s Hospital he was focused on his heart, ignoring his other disease: addiction. He said he was surprised when every doctor he saw, even his cardiologist, wanted to talk about addiction.

“I’m like, ‘Listen, dude. My heart’s falling apart here, so let’s hold up with the drug talk,’” Connolly recalled. He assured the cardiologist he had his addiction under control, even though he wasn’t so sure. “Obviously, I didn’t, but my mind tells me that. It’s just crazy.”

Connolly said he realizes now that the conversation around drug use was relevant and related to his heart infection.

Connolly finished his antibiotic treatment while staying with family members in Abington, Massachusetts. Brigham doctors say the housing requirement excludes otherwise eligible patients. Recent research shows homeless patients who have HIV or hep C do take their antiviral medicines; there are no equivalent robust studies on treating homeless patients who have bacterial infections.

Nevertheless, a few other hospitals are testing ways to continue outpatient treatment for patients who don’t have a stable home. In Portland, Oregon, a medical center tried providing IV antibiotics inside addiction treatment programs. A hospital in Kentucky combines addiction treatment, counseling and outpatient IV antibiotics. In Vancouver, British Columbia, the Canadian national health program pays for small apartments, staffed with a nurse 24 hours a day, where patients can stay while they complete antibiotic treatment.

“People who use drugs deserve the same standard of care,” said Dr. Christy Sutherland, medical director at the Portland Hotel Society in Vancouver. “We can’t change what we offer as clinicians — to give people subpar treatment with the excuse that they are IV drug users.”

Promising Early Signs

Arthur Jackson lives alone in his studio apartment (he does not live with a sober friend or loved one), but he convinced doctors he’d be better off there than in the hospital, so he could visit his 93-year-old mother daily, feed his tankful of tropical fish and his cat, and attend regular Narcotics Anonymous meetings.

“I guess the best way to put it is, I have a life and I need to get back to it,” he said.

Jackson is one of 40 patients with a history of drug use the Brigham team has discharged from the hospital to complete IV antibiotic treatment at home. The team is paying particular attention to 21 patients within that group who, unlike Jackson, are active drug users. So far, these men and women have finished their antibiotic treatment via a PICC line with no complications. One had to be readmitted because he had trouble administering the antibiotics. Price said three patients relapsed into drug use, but no one used the PICC line to inject illegal drugs.

“I think we’ve shown, through this pilot, that it is safe and feasible for certain patients,” Price said.

Brigham doctors have not yet published these initial results in a medical journal, though they plan to. But already, Price said, the pilot program is helping to cut health care costs.

Taken as a group, the 21 high-risk patients who needed IV antibiotics spent 571 days at home rather than in a hospital or rehab facility. Not including the cost of home care visits by a home nurse, the savings tally more than $850,000, based on estimates of $1,500 per hospital day.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

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Democrats Sharpen Health Care Attacks As Primaries Heat Up

The ideal began to get real on Tuesday, as seven of the top contenders for the Democratic presidential nomination sparred over the price tag on health care reform and even revealed similarities on issues like marijuana legalization.

With Democrats in 15 states and American Samoa set to cast their primary votes in the next week, the candidates eagerly seized their chances on the debate stage in Charleston, S.C., to jab Sen. Bernie Sanders of Vermont, the current frontrunner, during the party’s tenth debate.

For all of their interruptions and talking over each other, though, the candidates offered a few thoughtful answers and, seemingly in spite of themselves, agreed on at least decriminalizing marijuana and expunging past, small-scale marijuana possession charges from Americans’ criminal records.

Sanders said he would remove marijuana from the list of controlled substances on the first day of his presidency and added that he would empower black, Latino, and Native American communities to start businesses selling the drug legally, rather than leave corporations to fill what is already a lucrative market.

Mike Bloomberg, the former mayor of New York City, expressed the most skepticism of full legalization because of his concerns about the drug’s effect on the brains of young people. Until we know the science, it’s just nonsensical to push ahead,” he said.

Rural health was also a topic, giving Sen. Amy Klobuchar of Minnesota the opportunity to tout her leadership on bipartisan legislation that would help rural hospitals as well as an immigration bill that would encourage foreign-born doctors trained in the United States to practice in rural areas.

And though the candidates were not asked about abortion rights, the subject came up, briefly and jarringly. Describing how she lost her job as a young teacher when she became pregnant and had no union or legal support to fight back, Sen. Elizabeth Warren of Massachusetts abruptly turned to the allegations of sexual harassment against Bloomberg.

“At least I didn’t have a boss who said to me, ‘Kill it,’ the way that Mayor Bloomberg is alleged to have said to one of his pregnant employees,” Warren said, eliciting gasps.

“I never said that,” Bloomberg said.

Let’s look at what else the candidates claimed.

‘The Incredible Shrinking Price Tag’

Pete Buttigieg, the former mayor of South Bend, Ind., took issue with Sanders’ changing cost estimates for his “Medicare for All” plan.

“Senator Sanders at one point said it was going to be $40 trillion, then 30, then 17. It’s an incredible shrinking price tag,” Buttigieg said. “At some point he said it is unknowable to see what the price tag will be.”

Sanders has indeed cited differing estimates of what Medicare for All would cost.

The $30 to $40 trillion figure alludes to work done by the Urban Institute, a Washington think-tank. It is the only analysis to factor in the price of long-term care — one of the most expensive components of Medicare for All — and finds the program would cost $34 trillion in new federal spending over 10 years. (In terms of national health spending — both public and private dollars, that is — it would result in an increase of just $7 trillion over a decade.) The research makes assumptions that Sanders’ bill leaves open-ended, for instance, estimating what Medicare for All would ultimately pay hospitals and health professionals. Experts note that this is a major hole in Sanders’ plan.

The $17 trillion comes from a paper released this month in the medical journal, The Lancet. The researchers say Medicare for All would save $450 billion annually. That would drop the cost significantly, to just about $17 trillion over 10 years.

This figure is what Sanders relies on in calculating his own plan to finance the single-payer plan. His proposed set of revenues would raise about $17.14 trillion in a decade. (For more information on the Lancet study — whose methodology prompted skepticism from many policy analysts — see our full fact-check.)

Sanders has also said in at least one interview that the price of Medicare for All is “impossible to predict.” This is perhaps the most correct. As analysts repeatedly have told us, the switch to single-payer would represent a shift of unprecedented magnitude in American history. And before you can predict what it would cost, you need to decide what you would pay hospitals and doctors.

Pandemic Specialists: Where Are You Now’?

When the debate turned to the global threat of the new coronavirus, COVID-19, Bloomberg, Klobuchar, and former Vice President Joe Biden used similar talking points: that President Donald Trump cut global health experts from his national security team, leaving the U.S. unprepared to face the virus outbreak either globally or domestically.

“The president fired the pandemic specialists in this country two years ago,” Bloomberg said.

It’s true that, in May 2018, the top White House official who was in charge of the U.S. response to pandemics left the administration. Rear Admiral Timothy Ziemer was the senior director of global health and biodefense on the National Security Council and oversaw global health security issues. That global health team was disbanded after Ziemer’s departure and reorganized as part of a streamlining effort headed by then-National Security Adviser John Bolton.

Ziemer’s position on the NSC has not been filled in the last two years. Tom Bossert, a homeland security adviser who recommended strong defenses against disease and biological warfare, also departed in 2018.  

Last month, Trump announced that Health and Human Services Secretary Alex Azar would be the chair of the coronavirus task force that’s in charge of the U.S. response to the disease. But many are still urging that this position be filled to coordinate the federal response. 

Last week a group of 27 senators sent a letter to current National Security Adviser Robert O’Brien to ask him to appoint a new global health security expert to the NSC.

Preparedness Funding For Global Infections 

Former Vice President Joe Biden said President Donald Trump “cut the funding for CDC.”

Trump has consistently proposed funding cuts to the Centers for Disease Control and Prevention. But Congress has consistently overruled him. 

Because the comment came during a discussion of the United States’ preparedness for emerging global infections like the coronavirus, we looked at the budgets for emerging and zoonotic infectious diseases at CDC, rather than for the CDC as a whole.

The Trump administration’s initial budget proposal has consistently been lower than what was spent the previous year. The administration proposed $61.7 million less in 2018 than 2017; $96.4 million less in 2019 than in 2018; $114.4 million less in 2020 than in 2019; and $85.3 million less in 2021 than 2020.

However, Congress usually treats any president’s budget proposal as an opening volley, with lawmakers reshaping the federal budget as they see fit when they craft final spending bills.

Every year since Trump has been president, lawmakers have passed bills — bills that were eventually signed by the president — that not only exceeded what Trump had asked for on emerging infections but also exceeded what had been spent the previous year.

The next debate, the eleventh of what the Democratic National Committee has said will be 12 presidential primary debates, is scheduled for Sunday, March 15.

PolitiFact’s Louis Jacobson contributed to this story.`

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Bernie Sanders Embraces A New Study That Lowers ‘Medicare For All’s’ Price Tag, But Skepticism Abounds

Defending his signature health plan — a single-payer system known “Medicare for All” that would move all Americans to government-funded coverage  — Vermont Sen. Bernie Sanders argued that the massive health care expansion would actually save the system hundreds of billions of dollars.

Sanders’ figures come from a study published Feb. 15 in The Lancet, a British medical journal.

“It said ‘Medicare for All’ will lower health care costs in this country by $450 billion a year and save the lives of 68,000 people who would otherwise have died,” Sanders said at the Feb. 25 Democratic presidential debate.

The price tag of Medicare for All has been fiercely debated, and some previous analyses have suggested that the proposal would increase health spending, not decrease it. But Sanders is relying on the Lancet paper — which has a cost estimate that is the lowest, in the neighborhood of $17 trillion over 10 years — to argue that the suite of financing mechanisms he has proposed would more than cover the cost of his health bill. (Funding would include taxes on high earners, a new payroll tax, and 4% income premiums for the majority of families.) Most other estimates place the cost between $30 trillion and $40 trillion over a decade, which would make paying for it far more difficult.  So we decided to take a closer look.

We reached out to one of the study’s authors, but never heard back. 

A spokesperson for the Sanders campaign said the paper is “similar to 22 other recent studies that have also shown that moving to a single-payer healthcare system will cost less than our current dysfunctional healthcare system.” (We asked for those 22 other studies but, as of publication, hadn’t received them.)

But independent experts were skeptical of the study’s estimate — arguing it exaggerates potential savings, cherry-picks evidence and downplays some of the potential tradeoffs.

“I don’t think this study, albeit in a prestigious, peer-reviewed journal, should be given any deference in the Medicare for All debate,” said Robert Berenson, a fellow at the Urban Institute who studies hospital pricing.

So, Savings?

Largely, the Lancet paper is more generous in its assumptions than other Medicare for All analysis, noted Jodi Liu, an economist at the RAND Corp., who studies single-payer plans. To the researchers’ credit, she said, they acknowledge that their findings are based on uncertain assumptions.

For instance, the researchers calculate $78.2 billion in savings from providing primary care to uninsured people — $70.4 billion from avoided hospitalizations and $7.8 from avoided emergency room visits. But previous evidence suggests that logic is suspect at best. 

When states expanded Medicaid under the Affordable Care Act, providing new insurance to people who had previously lacked coverage, avoidable hospitalizations and emergency room visits didn’t disappear because people could suddenly use preventive care, noted Ellen Meara, a professor at the Harvard T.H. Chan School of Public Health. That evidence doesn’t appear anywhere in the Lancet paper.

“The notion that we’re going to get rid of all these avoidable visits — that’s not been borne out,” she said. 

The researchers also assume that a Medicare for All system would pay hospitals at a maximum of Medicare rates.

That’s tricky. In 2017, the nonpartisan Medicare Payment Advisory Commission estimated that, on average, a hospital has a -9.9% margin on a patient who is insured through Medicare. (Private pay helps make up that difference.) Some hospitals certainly would be able to swallow this cost. But others would struggle to stay afloat, said Adrianna McIntyre, a health policy researcher at Harvard University 

Given the political influence hospitals in particular carry in Congress — where most members are sensitive to their concerns — passing a plan offering such a low payment rate would be politically challenging.

Sanders’ bill doesn’t actually  specify the rates at which hospitals would be paid.

Beyond the lower payments, the researchers also suggest hospitals would spend less money on overhead, only having to navigate a single insurance plan. That change accounts for $219 billion in their estimated savings.

But again, that ignores some of the reality of how hospitals work. While a single-payer system would undoubtedly cost less to administer — requiring a smaller back-end staff, for instance — it would not eliminate the need for expensive items like electronic health records, which coordinate care between hospitals.

The assumptions are unrealistic,” said Gerard Anderson, a health economist at Johns Hopkins University in Baltimore. “You are never going to save that much money from the various providers.” 

The Cost-Sharing Question

Medicare for All would enroll all Americans in coverage far more generous than what most experience now — eliminating virtually all cost-sharing associated with using health care. 

That’s a major change, researchers told us. Previous evidence suggests that such a shift would encourage consumers to use health care more than they currently do. 

The Lancet paper acknowledges that — but only partially. It allows that people who are uninsured or “underinsured” — that is, who have particularly high levels of cost-sharing now — would use more medical care under Sanders’ system than they currently do. It factors that into the price tag. 

But its estimate does not account for people who already have decent or adequate insurance and who would still be moving to a richer benefit, and therefore more likely to use their insurance. 

“It drastically underestimates the utilization increases we would expect to see under Medicare for All,” McIntyre said. “People have different views on whether the increased utilization is good or bad,” she added — it makes the program more expensive, but also means more people are getting treatment.

Other Estimates?

Context is helpful, too. Other estimates — namely, a projection by the Urban Institute — of Medicare for All have suggested it would increase federal health spending by about $34 trillion over 10 years. But elimination of other health spending would make the overall change smaller. 

To implement the Sanders proposal, national health spending — public and private dollars, both — would increase by $7 trillion over a decade, Urban said. And Medicare for All would be bringing new services: more insurance for more people, and more generous coverage for those already covered.

Urban’s estimate of $7 trillion more in spending over 10 years is far removed from the study’s estimate of $450 billion less annually. And, experts said, relying on the latter figure isn’t a good idea.

“I think they need more work to prove” the savings, Meara said. “They’re not being complete, and by not being complete, they’re not being honest.”

It’s also worth noting that the study’s lead author was also an informal unpaid adviser to the Sanders staff in drafting its 2019 version of the Medicare for All bill, according to the paper’s disclosures section.

The “Lives Saved”

Experts agree that expanding access to health insurance would probably reduce early mortality. But the 68,000 figure is another example of cherry-picking, Meara said.

The figure is based on a 2009 paper. It doesn’t acknowledge a body of research that came after, including multiple studies that examined how expanding Medicaid  affected mortality — and maybe offered less dramatic numbers.

“When they so clearly are cherry-picking, when they clearly have all the  information on studies in front of them, it’s concerning,” Meara said. “It’s a situation where you’re going to overpromise and underdeliver.”

Our Ruling

Sanders said a recent study suggested Medicare for All would save $450 billion annually and saves 68,000 lives.

That study does exist. And it cites some evidence. But many of its assumptions are flawed, and experts uniformly told us it overestimates the potential savings. It cherry-picks data in calculating mortality effects.

This statement has some truth, but ignores context that would create a dramatically different impression. We rate it Mostly False.

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Tiny Love Stories: ‘The Twin Bed We Were Forced to Share’

A Safe Haven in Bed

I left Pittsburgh and Michael left Brooklyn for the dreamy, woodsy school we had only heard good things about. We did not realize that those things would be permitted only to me, with my white skin. For Michael, school was a constant terror. A few nights after we met, Michael abandoned his room for mine to escape his school-assigned roommate, who encouraged other students to shout racial slurs and pound on his dormitory door. That first night, we held each other tight, fearful of falling out of the twin bed we were forced to share. We haven’t slept apart since. — Eimile McKinnon


Most of Our Years Were Good Ones

Stuck in a box in a closet, the hat my ex-husband gave me was now just an extravagant thing owned by a non-extravagant woman. I asked furriers for help, but they said the hat could only be what it was. Not a headband. Not a collar. “Most women would kill for this,” said one. “Put it on and strut,” said another. But I didn’t want a trophy hat. I just wanted a small memento in the cold, reminding me that most of our years had been good ones, a time when he had warmed my winters and I had warmed his. — Marsha Jacobson


‘Mommy, I Am You’

On a lazy Sunday, Olivia disappears from the living room, later returning “dressed as Mommy.” She wears my red dress, green flats and crossbody bag. I don’t need to go upstairs to know what my bedroom looks like. I suppress a smile and get ready to tell her off. But then she gives me that look — that unmatched, adoring look — and says matter-of-factly, “Mommy, I am you.” I look at this loving little girl, who sees the version of me I can never be. Soon enough she will be grown up. Until then, let us enjoy this moment. — Sophia Nikoleishvili


Please Wear That Dress

Both young poets, we met on the set of “The United States of Poetry,” a documentary Bob Holman produced and I participated in. I recited my poems in a striped, blue-and-white dress. Twenty-five years later, Bob is widowed and I’m divorced. He contacts me online, asking me to meet and, please, to wear the dress. That dress is long-gone, but when we reunite I am reminded of the stripes in Bob’s blue eyes. We kiss in a taxi and I feel love. When we pull back, I see him seeing me in that dress of my youth. — Thylias Moss

See more Tiny Love Stories at nytimes.com/modernlove. Submit yours at nytimes.com/tinylovestories.

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Watch the trailer for the Modern Love TV show, coming to Amazon Prime Video on Oct. 18; listen to the Modern Love Podcast on iTunes or Google Play Music; check out the updated anthology “Modern Love: True Stories of Love, Loss, and Redemption;” follow Modern Love on Facebook.

Past As Prologue: Questioning Buttigieg’s Claim About Keeping Your Health Care

As the Democratic presidential campaign moves to the battleground of South Carolina this weekend, candidate Pete Buttigieg, the former mayor of South Bend, Indiana, is highlighting his health plan as he seeks to slow the momentum of the front-runner, Vermont Sen. Bernie Sanders.

In a video ad airing across the state, Buttigieg argues that his health plan — called “Medicare for All Who Want It” — offers Americans their choice of insurance plans, in a way he says Sanders’ more sweeping “Medicare for All” plan does not.

The Sanders plan would eliminate private insurance and move everyone into a government-run program.

Under Buttigieg’s proposal, the ad says, “Everyone gets access to Medicare, if they choose.” Specifically, according to campaign documents, people or employers could buy into a government-provided health plan, which the campaign says would provide an “affordable, comprehensive alternative” to what is sold on the private market.

But, the voiceover adds, “if you like your private plan, you can keep it.”

This isn’t the first time a politician has made such a promise. Arguing in favor of the Affordable Care Act, then-President Barack Obama repeatedly said the health law would let people keep their private health plans, if they liked them.

That didn’t pan out: Millions of Americans’ plans were canceled, spawning months of controversy. In 2013, PolitiFact rated Obama’s statement the “Lie of the Year.”

With that context, we decided to look deeper at Buttigieg’s remark. We reached out to his campaign but never heard back.

An Uncertain Market

Experts we talked to said the former mayor’s remark is remarkably similar to Obama’s ― right down to the pitfalls it encounters.

Those policy analysts said Buttigieg is trying to differentiate his plan from Sanders’ sweeping proposal, arguing his offering is more moderate than Sanders’ and preserves choice. He suggests many Americans would be able to pick between buying private insurance or opting into the government plan.

But does that mean that if you like your plan, you can keep it? As the Obama White House learned, not necessarily.

“It’s like déjà vu all over again,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

The problem is that private insurance availability isn’t up to the government. To be sure, state and federal regulators have the power to dictate, for example, the inclusion of certain benefits and to set basic consumer protections. But the government cannot specifically require insurance companies to offer plans, and any carrier has the option to stop providing coverage.

Already, market forces dictate what health insurance is available from year to year. For example, negotiations between an insurer and physicians could mean that an insurer drops doctors from its network. Changing profit margins could drive a private carrier to exit a certain market. An employer looking to trim expenses might decide to change health insurers, changing coverage offerings for employees.

Buttigieg’s health plan — which would more generously subsidize people buying private insurance than the ACA does and create a public health insurance option that individuals and employers could buy ― wouldn’t change any of those economic scenarios.

“When you have private plans offered and sold by private companies, those private companies are going to make business decisions that might affect your coverage,” Corlette said. “They can opt to get out of the business.”

That’s been especially clear in the ACA individual marketplace. In many counties, only one private insurer sells coverage on the marketplace. It’s impossible to predict, but a competing public option might change the financial incentives for those plans and push some of those carriers to abandon the exchange. If that happened, people using that plan would lose the insurance they have, regardless of how they feel about it.

Put more forcefully, “There’s no way the government can guarantee a private plan will continue, without mandating it will,” said Cynthia Cox, a vice president at the Kaiser Family Foundation.

So, she added, suggesting that people who like their private plans will have the option to keep them under Buttigieg’s proposal is “probably not true.” (KHN is an editorially independent program of the foundation.)

The Employer Question

This is especially the case when it comes to the nearly 160 million people who get their insurance from an employer.

Already, that group experiences volatility when it comes to their health insurance. In 2019, 53% of employers providing coverage considered changing the plan or the carrier they offered, according to a KFF survey. Of that group, almost a fifth — 18% ― ultimately did change insurance carriers.

That flux would likely increase under a plan like Buttigieg’s. Already, many employers (particularly smaller ones) indicate frustration with providing a health benefit that is increasingly complex and expensive. If a public option were cheaper, more might shift employees into that pool, dropping private insurance.

“Even if you don’t want the public option, your employer might decide that they do,” Cox said.

How big the change would be is difficult to gauge. It depends, for instance, on how generous the public option is, how much it costs employers and whether current private insurance trends continue.

Still, “any change you make to the health care environment would cause changes to reverberate throughout the system,” said Sherry Glied, a health economist and dean of New York University’s Wagner School of Public Service. “Any government action will cause change to happen more than they would otherwise.”

It’s worth noting that many people may not be affected. Under the ACA, for instance, 4 million lost their plans, or fewer than 2% of all people who had coverage.

Most people who move from private insurance to the public option would likely have better benefits, said Benjamin Sommers, a health economist at the Harvard T.H. Chan School of Public Health. But, some would be unhappy to lose the existing, private coverage that they know.

“The more accurate soundbite would be most people with private insurance would be able to keep it,” he added. “That would beg the question of who isn’t included there — and the answer is, we don’t know.”

And, in contrast with Sanders’ Medicare for All single-payer proposal, Buttigieg’s plan would preserve much of the current private insurance. But Buttigieg suggests that Medicare for All Who Want It — if administered well — could function as a “glide path” to a Medicare for All world, eventually bringing everyone into the public system.

“There’s good reason to think some of the private insurance competition won’t fare well against ‘Medicare for All Who Want It,’ ” Sommers said. “You might see some of the private plans dropping out. And that may be a sign the policy is working.”

Our Ruling

In a new campaign ad, Buttigieg claims that under his proposal to overhaul the health care system, “if you like your private plan, you can keep it.”

This may be true for some Americans who have private coverage, but it is not true for all. It ignores the inherent instability of the private insurance markets — in which plans are canceled or changed all the time, people often don’t get to pick which private plan is even available to them, and government intervention would likely exacerbate that volatility.

Introducing a public option, as Buttigieg intends to do, could create more incentives for employers to drop private coverage and switch to the public Medicare plan — and, in some cases, for private carriers to exit the individual marketplace. The fact that it would be less disruptive than Medicare for All doesn’t change this.

Buttigieg’s claim has some truth to it, but leaves out key facts and context. We rate it Mostly False.

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Vitamin D During Pregnancy May Benefit Children’s Bones

Most experts recommend that pregnant women take a daily supplement of 400 units of vitamin D. Now a randomized clinical trial suggests that a much larger dose may be beneficial for children’s bone health.

The study, in JAMA Pediatrics, randomized 517 women to take either a 2,400-unit vitamin D supplement or a placebo from 24 weeks of pregnancy until one week after birth.

In addition, all the women were advised to take a 400-unit vitamin D supplement, in line with Danish health recommendations.

The researchers followed the offspring with periodic bone scans through age 6, recording bone density and evidence of fractures. Over all, children whose mothers took 2,800 units had significantly higher bone density at age 6 than children in the placebo group. The effects were particularly robust in women who were initially deficient in vitamin D and in those who gave birth during the winter, when sunlight levels are lower and vitamin D blood levels tend to drop.

About 7 percent of children whose mothers took the high dose suffered bone fractures through age 6, compared with 11 percent in the placebo group. High doses had no effect on birth weight, or on the height or weight of the 6-year-old children.

“There is no concern about safety, and no risk of side effects” at the doses given, said the senior author, Dr. Hans Bisgaard, a professor of pediatrics at the University of Copenhagen. “We have the data suggesting it’s useful, so let’s use it. Health begins early in life. That’s where we can make a difference.”

U.S. Medical Panel Thinks Twice About Pushing Cognitive Screening For Dementia

A leading group of medical experts on Tuesday declined to endorse cognitive screening for older adults, fueling a debate that has simmered for years.

The U.S. Preventive Services Task Force said it could neither recommend nor oppose cognitive screening, citing insufficient scientific evidence of the practice’s benefits and harms and calling for further studies.

The task force’s work informs policies set by Medicare and private insurers. Its recommendations, an accompanying scientific statement and two editorials were published Tuesday in the Journal of the American Medical Association.

The task force’s new position comes as concern mounts over a rising tide of older adults with Alzheimer’s disease and other dementias and treatments remain elusive. Nearly 6 million Americans have Alzheimer’s disease; that population is expected to swell to nearly 14 million by 2050.

Because seniors are at higher risk of cognitive impairment, proponents say screening ― testing people without any symptoms — is an important strategy to identify people with unrecognized difficulties and potentially lead to better care.

“This can start a discussion with your doctor: ‘You know, you’re having problems with your cognition, let’s follow this up,’” said Stephen Rao of Cleveland Clinic’s Lou Ruvo Center for Brain Health.

Opponents say the benefits of screening are unproven and the potential for harm is worrisome. “Getting a positive result can make someone wary about their cognition and memory for the rest of their life,” said Benjamin Bensadon, an associate professor of geriatric medicine at the University of Florida College of Medicine.

The task force’s stance is controversial, given how poorly the health care system serves seniors with memory and thinking problems. Physicians routinely overlook cognitive impairment and dementia in older patients, failing to recognize these conditions at least 50% of the time, according to several studies.

When the Alzheimer’s Association surveyed 1,954 seniors in December 2018, 82% said they thought it was important to have their thinking or memory checked. But only 16% said physicians regularly checked their cognition.

What’s more, Medicare policies appear to affirm the value of screening. Since 2011, Medicare has required that physicians assess a patient’s cognition during an annual wellness visit if the patient asks for a checkup of this kind. But only 19% of seniors took advantage of this benefit in 2016, the most recent year for which data is available.

Dr. Ronald Petersen, co-author of an editorial accompanying the recommendations, cautioned that they shouldn’t discourage physicians from evaluating older patients’ memory and thinking.

“There is increased awareness, both on the part of patients and physicians, of the importance of cognitive impairment,” said Petersen, director of the Mayo Clinic’s Alzheimer’s Disease Research Center. “It would be a mistake if physicians didn’t pay more attention to cognition and consider screening on a case-by-case basis.”

Similarly, seniors shouldn’t avoid addressing worrisome symptoms.

“If someone has concerns or a family member has concerns about their memory or cognitive abilities, they should certainly discuss that with their clinician,” said Dr. Douglas Owens, chair of the task force and a professor at Stanford University School of Medicine.

In more than a dozen interviews, experts teased out complexities surrounding this topic. Here’s what they told me:

Screening basics. Cognitive screening involves administering short tests (usually five minutes or less) to people without any symptoms of cognitive decline. It’s an effort to bring to light problems with thinking and memory that otherwise might escape attention.

Depending on the test, people may be asked to recall words, draw a clock face, name the date, spell a word backward, relate a recent news event or sort items into different categories, among other tasks. Common tests include the Mini-Cog, the Memory Impairment Screen, the General Practitioner Assessment of Cognition and the Mini-Mental Status Examination.

The task force’s evaluation focuses on “universal screening”: whether all adults age 65 and older without symptoms should be given tests to assess their cognition. It found a lack of high-quality scientific evidence that this practice would improve older adults’ quality of life, ensure that they get better care or positively affect other outcomes such as caregivers’ efficacy and well-being.

A disappointing study. High hopes had rested on a study by researchers at Indiana University, published in December. In that trial, 1,723 older adults were screened for cognitive impairment, while 1,693 were not.

A year later, seniors in the screening group were not more depressed or anxious — important evidence of the lack of harm from the assessment. But the study failed to find evidence that people screened had a better health-related quality of life or lower rates of hospitalizations or emergency department visits.

Two-thirds of seniors who tested positive for cognitive impairment in her study declined to undergo further evaluation. That’s consistent with findings from other studies, and it testifies to “how many people are terrified of dementia,” said Dr. Timothy Holden, an assistant professor at Washington University School of Medicine in St. Louis.

“What seems clear is that screening in and of itself doesn’t yield benefits unless it’s accompanied by appropriate diagnostic follow-up and care,” said Nicole Foster, associate director of the Center for Aging Research at Indiana University’s Regenstrief Institute.

Selective screening. “Selective screening” for cognitive impairment is an alternative to universal screening and has gained support.

In a statement published last fall, the American Academy of Neurology recommended that all patients 65 and older seen by neurologists get yearly cognitive health assessments. Also, the American Diabetes Association  recommends that all adults with diabetes age 65 and older be screened for cognitive impairment at an initial visit and annually thereafter “as appropriate.” And the American College of Surgeons now recommends screening older adults for cognitive impairment before surgery.

Why test select groups? Many patients with diabetes or neurological conditions have overlapping cognitive symptoms and “it’s important to know if a patient is having trouble remembering what the doctor said,” said Dr. Norman Foster, chair of the workgroup that developed the neurology statement and a professor of neurology at the University of Utah.

Physicians may need to alter treatment regimens for older adults with cognitive impairment or work more closely with family members. “If someone needs to manage their own care, it’s important to know if they can do that reliably,” Foster said.

With surgery, older patients who have preexisting cognitive impairments are at higher risk of developing delirium, an acute, sudden-onset brain disorder. Identifying these patients can alert medical staff to this risk, which can be prevented or mitigated with appropriate medical attention.

Also, people who learn they have early-stage cognitive impairment can be connected with community resources and take steps to plan for their future, medically and financially. The hope is that, one day, medical treatments will be able to halt or slow the progression of dementia. But treatments currently available don’t fulfill that promise.

Steps after screening. Screening shouldn’t be confused with diagnosis: All these short tests can do is signal potential problems.

If results indicate reason for concern, a physician should ask knowledgeable family members or friends what’s going on with an older patient. “Are they depressed? Having problems taking care of themselves? Asking the same question repeatedly?” said Dr. David Reuben, chief of geriatrics at UCLA’s David Geffen School of Medicine and director of UCLA’s Alzheimer’s and Dementia Care program.

A comprehensive history and physical examination should then be undertaken to rule out potential reversible causes of cognitive difficulties, implicated in about 10% of cases. These include sleep apnea, depression, hearing or vision loss, vitamin B12 or folic acid deficiencies, alcohol abuse and side effects from anticholinergic drugs or other medications, among other conditions.

Once other causes are ruled out, neuropsychological tests can help establish a diagnosis.

“If I detect mild cognitive impairment, the first thing I’ll do is tell a patient I don’t have any drugs for that but I can help you compensate for deficits,” Reuben said. The good news, he said: A substantial number of patients with MCI ― about 50% — don’t develop dementia within five years of being diagnosed.

The bottom line. “If you’re concerned about your memory or thinking, ask your physician for an assessment,” said Dr. David Knopman, a neurologist at the Mayo Clinic. If that test indicates reason for concern, make sure you get appropriate follow-up.

That’s easier said than done if you want to see a dementia specialist, noted Dr. Soo Borson, a professor emerita of psychiatry at the University of Washington. “Everyone I know who’s doing clinical dementia care says they have wait lists of four to six months,” she said.

With shortages of geriatric psychiatrists, geriatricians, neuropsychologists and neurologists, there aren’t enough specialists to handle demands that would arise if universal screening for cognitive impairment were implemented, Borson warned.

If you’re a family member of an older adult who’s resisting getting tested, “reach out privately to your primary care physician and express your concerns,” said Holden of Washington University. “And let your doctor know if the person isn’t seeing these changes or is resistant to talk about it.”

This happens frequently because people with cognitive impairments are often unaware of their problems. “But there are ways that we, as physicians, can work around that,” Holden said. “If a physician handles the situation with sensitivity and takes things one step at a time, you can build trust and that can make things much easier.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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Insurers Steering Patients Toward Clinics They’ve Bought In New Threat To Hospitals, Providers

Lawmakers Want IHS To Be Held Accountable For Its Role In Protecting Pediatrician Convicted Of Sexually Assaulting Boys

Juul To Propose Selling E-Cigarette That Will Only Unlock For Users Who Are At Least 21 Years Old

Immigration Advocates Braced As ‘Public Charge’ Rule Goes Into Effect

First Edition: February 25, 2020