Tagged California

Your School Assignment For The Day: Spelling And Specs

DELANO, Calif. — Daisy Leon struggles to sit still and read the letters on the eye chart. Her responses tumble out in a quiet, confused garble.

“You know your letters?” asks optometrist Jolly Mamauag-Camat. “Umm, ya,” says Daisy, almost inaudibly.

The 6-year-old kindergartner had her eyes examined for the first time on a recent Thursday morning. Although she hadn’t complained about headaches or blurry vision, her grandmother noticed she’d been inching closer to watch television.

After Daisy’s failed attempts at reading the eye chart, Mamauag-Camat inspects the little girl’s eyes through a phoropter and writes her a prescription for glasses.

At least 20% of school-age children in the U.S. have vision problems. But according to the Centers for Disease Control and Prevention, fewer than 15% of children get an eye exam before entering kindergarten. Because vision problems tend to worsen the longer they go undetected, many children suffer even though there are often simple, relatively inexpensive solutions such as prescription glasses.

Half of the states plus the District of Columbia require screenings or exams for preschoolers, according to the National Center for Children’s Vision & Eye Health. But California has no such requirement, said Xuejuan Jiang, an assistant professor of research ophthalmology at Keck School of Medicine of USC. California does require them for older children.

“The system in California is not as good as it can be,” Jiang said.

In much of California’s Central Valley, where roughly 1 in 5 people live in poverty, two school districts are working with two nonprofits, the Advanced Center for Eyecare and OneSight, to provide vision care to Kern County’s underserved and uninsured children.

Many of the neediest are the children of farmworkers.

“We are an agriculture-based community,” said Linda Hinojosa, coordinator of health services for the Delano Union School District. “Most of our families harvest table grapes 12 hours a day, with very limited time to take their children in for an eye exam.”

The program, funded by the nonprofits and the school districts, operates five school-based clinics in Bakersfield and Delano. Students receive comprehensive eye exams and glasses, along with free transportation. And breakfast.

Most of the children who visit the clinics have coverage through Medi-Cal, California’s Medicaid program for low-income people. There is no out-of-pocket cost for the eye exams and glasses for them, or for children who are uninsured, said Alexander Zahn, chief business development officer for the Advanced Center for Eyecare.

Almost half of the students examined need glasses.

“The need was very apparent” in the Central Valley, Zahn said. “Sixty dollars for an eye exam and $80 for glasses might be the difference between eating dinner a couple days a week.”

Daisy was among 12 students who were bused to the Delano Union School District Vision Center, adjacent to Pioneer School, an elementary school with about 1,000 students. Almost all the students at Pioneer are Hispanic and about three-quarters qualify for free lunches.

Students from throughout the Delano Union Elementary School District visit the clinic. Since it opened in 2018, the clinic has performed 961 eye exams and prescribed 517 pairs of glasses.

For Daisy, whose parents are farmworkers, the clinic has been a tremendous help.

“They prune out in the fields,” said Guadalupe Leon, Daisy’s grandmother. “They can’t afford to take days off.”

The Delano Union School District Vision Center is funded by multiple sources: OneSight, a nonprofit organization dedicated to increasing access to vision care in underserved communities around the world, donated the ophthalmic equipment and provided grant funding for the first year of operation. The Advanced Center for Eyecare provides staff and supplies. And the school district provides the facility, furnishings and transportation. (Heidi de Marco/KHN)

Twelve students from Nueva Vista Language Academy and Fremont Elementary School arrive by bus for their eye exams and follow-ups. Linda Hinojosa, a registered nurse for 20 years, says lack of transportation is a major barrier to vision care. “Parents a lot of times don’t have a car, or it can be a one-vehicle family,” she says. (Heidi de Marco/KHN)

Students are offered breakfast before their appointments with optometrist Jolly Mamauag-Camat. About three-quarters of students in the district are eligible for free/reduced-price meals. (Heidi de Marco/KHN)

Daisy Leon, a kindergartner at Nueva Vista Language Academy, takes a test to check for color blindness. Before beginning, the optical technician asks Daisy if she understands English. Because of the region’s large Spanish-speaking population, clinic staff members often act as interpreters. (Heidi de Marco/KHN)

Daisy looks into an auto refractor as part of her eye exam. (Heidi de Marco/KHN)

Daisy and Jonathon Castro watch a movie as they wait for their eyes to dilate. This is the first eye exam for both of them. (Heidi de Marco/KHN)

Daisy sits on her knees to see through a phoropter, a device to help determine eyeglass prescriptions. Mamauag-Camat says children often can’t tell if they have vision problems because they don’t know any differently. “They can fall through the cracks,” she says. “They don’t know the difference between what’s clear and not clear.” (Heidi de Marco/KHN)

About 45% of Kern County’s population is on Medi-Cal. Medi-Cal covers vision care, including an eye exam and glasses every two years, but in communities like Delano, access is a problem. “We live in an area with a big shortage of providers, particularly specialty care providers like optometrists and ophthalmologists,” says Alexander Zahn, of the Advanced Center for Eyecare. (Heidi de Marco/KHN)

Daisy picks out glasses right after her exam, a pink pair that she had been admiring all morning. “We need to go where students are,” says Hinojosa. “Vision is absolutely vital.” (Heidi de Marco/KHN)

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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The Golden State’s Mixed Record On Lung Cancer

It was a bewildering moment for Zach Jump, the American Lung Association’s national director of epidemiology and statistics. The numbers leaped off the computer screen and prompted an immediate question:

How could California, a leader in reducing lung cancer cases, fall so short on early diagnosis and treatment of the disease?

“It’s like you’d found the needle in the haystack of results,” said Jump. “I don’t know if anyone knew this was going to show up.”

It was right there in the association’s annual “State of Lung Cancer” report, published in November: California had the third-lowest rate of new lung cancer cases in the country, a laudable achievement. But among state residents diagnosed with the disease, nearly a quarter received no treatment — a dismal showing that landed California near the bottom of the heap. Worse, California screened high-risk patients at a lower rate than every state but Nevada.

Nationally, the report showed a dramatic increase in the five-year survival rate of people diagnosed with the disease. That finding was reinforced by an American Cancer Society report released last month showing that from 2016 to 2017, the U.S. experienced the largest single-year drop in cancer mortality ever reported — driven by a decline in deaths from lung cancer.

California’s low rate of new lung cancer cases makes sense given its aggressive anti-tobacco laws and high taxes on tobacco products. Between 85% and 90% of people who die of lung cancer in the U.S. were smokers, and “California is the poster child for tobacco control,” said Jump.

But what explains the state’s dramatically weaker performance on early diagnosis and treatment?

The answer is complicated in a state as large as California, but lung cancer experts agree on the influence of several factors: the state’s large income inequality, broad cultural and linguistic diversity, inconsistency of health care access by region — and neighborhood — and a financial reluctance by many medical professionals to treat poor people, who smoke at higher rates than those of the general population.

“People aren’t getting screened in the places where the incidence of smoking is the highest,” said Dr. Jorge Nieva, an oncologist with Keck Medicine of the University of Southern California.

A low-dose CT scan, the only recommended screening exam for lung cancer, is highly effective, research shows. In one large clinical trial, it reduced lung cancer deaths by 20% among people at high risk, who were defined as those between ages 55 and 80 with a history of heavy smoking, even if they had quit within the previous 15 years.

The lung association study shows that just 4.2% of patients in the United States who are at high risk for lung cancer get screened for it — seen as an alarmingly low figure by those who work in the area of prevention. But compared with that low national figure, California’s screening rate is woefully inadequate: just 0.9%.

Performing the exam is profitable — but only if insurance payments are high enough. Medi-Cal, the government-funded insurance program for low-income people that covers about a third of all Californians, has long paid rates far below the national average.

Not surprisingly, scans are performed much more commonly in areas where people are likely to have good private insurance. “Unfortunately, it’s the population that doesn’t have great insurance that needs the screening the most,” said Nieva.

Medical experts say the state’s low screening numbers help explain why 24% of California’s diagnosed lung cancer patients receive no treatment at all, well above the national average of around 15%. Without adequate screening, lung cancer generally is discovered at later stages, when treatment is far less effective and many clinical trials aren’t offered.

Other factors weigh heavily on California’s ability to boost screening and treatment, according to people with deep experience in the field. Among them:

Cultural barriers. Especially among immigrant groups, “we need culturally sensitive approaches that include materials, educational tools, awareness campaigns and doctors who can speak to people in their native languages,” said Laurie Fenton Ambrose, president and CEO of the GO2 Foundation for Lung Cancer, a patient advocacy group.

Homelessness. As California’s unhoused population has swelled to over 150,000, health care providers have more difficulty reaching those in need of services. “Many of the 60,000 homeless in L.A. County would very likely be considered at risk for lung cancer, and they are not being screened,” said Dr. Steven Dubinett, a pulmonologist at UCLA.

Access to primary care. “California has some uniqueness in how hard it is to see a doctor in lots of parts of the state,” Nieva said. “That’s incredibly important when it comes to getting things early on, like that persistent cough you’ve had for a few months.”

Lack of statewide coordination. The state’s Comprehensive Cancer Control Plan hasn’t been updated in almost a decade. “It is inefficient and slow to improve. You don’t even have a plan that lays out its goals for fighting lung cancer,” Fenton Ambrose said.

Numerous personal factors can also influence whether patients get screening and treatment, experts say. Some people may be reluctant to be tested for fear of learning they have a terrible disease — including medical problems unrelated to lung cancer that the exam might uncover.

Nieva and Fenton Ambrose said the stigma attached to lung cancer — the notion that patients caused it themselves by smoking — can contribute to a sense of fatalism in both patients and their doctors.

Dubinett favors rolling out screening programs throughout the state, especially in areas where access to health care is spotty. Given the effectiveness of the exams and follow-up treatment if lung cancer is detected early, the state might well improve upon its five-year survival rate for lung cancer patients, which stands at 21.5% — roughly matching the national average of 21.7%, according to the lung association.

Such an initiative may fall to the state, with help from academic medical systems including USC and UCLA.

Nieva noted that USC has begun an outreach program in South Los Angeles offering high-risk patients free rides to Keck Hospital for screening.

“This should be getting done everywhere, and at a 100% rate,” Nieva said. The fact that it’s not is “a real indictment of our health care system.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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California Defends Authority To Require Insurers To Cover Abortion As Protecting Women’s Rights

Congressional Candidates Go Head-To-Head On Health Care — Again

The California Democrats who fought to flip Republican congressional seats in 2018 used health care as their crowbar. The Republicans had just voted to repeal the Affordable Care Act in the U.S. House — and Democrats didn’t let voters forget it.

Two years later, Democrats are defending the seven seats they flipped from red to blue in California. And once again, they plan to go after their Republican opponents on health care in this year’s elections.

But this time around, it’s not just about the Affordable Care Act, whose fate now rests with the federal courts. Democrats are highlighting the high costs of prescription drugs, surprise medical bills and cuts to safety-net programs.

Health care “remains the single-biggest priority for most voters in 2020,” said U.S. Rep. Josh Harder, a Democrat who represents California’s 10th congressional district, in the northern San Joaquin Valley, which includes the cities of Modesto, Turlock, Tracy and Manteca.

Harder, who defeated Republican Jeff Denham in 2018, made the case then that eliminating the federal health law and its protections for people with preexisting conditions would harm thousands of people in his district, including his younger brother, whose premature birth yielded $2 million in hospital bills.

Health care affordability — from drug costs to premiums — is still the No. 1 issue his constituents raise in conversations with him, he said.

“The problems haven’t been solved,” said Harder, who blamed the Republican-controlled U.S. Senate for stalling on health care legislation addressing prescription and other health care costs. “A lot of folks out here feel like there’s still an unbelievably long period before they can see a doctor, and they think that the costs are way too high.”

Multiple calls and emails to Republican congressional candidates and the California Republican Party requesting comment were not returned. California voters will select their party’s congressional candidates in the Super Tuesday primary March 3.

Health care is indeed a top issue for voters, confirmed Mollyann Brodie, executive director of public opinion and survey research for the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“What concerns people the most is health care costs and their own affordability of health care,” Brodie said. “And when we asked people what they thought Congress should be working on, prescription drug costs came right on top.”

A national Kaiser Family Foundation tracking poll from September 2019 found that 81% of Democrats and 62% of Republicans surveyed said lowering prescription drug costs should be a top priority for Congress. Voters in both parties also want Congress to maintain protections for people with preexisting conditions and limit surprise medical bills.

Both Democratic and Republican candidates are taking note and are likely to feature health care prominently in their campaigns, but their messages will be different, said Nathan Gonzales, editor and publisher of Inside Elections, a campaign analysis site.

For example, progressive Democrats often advocate for “Medicare for All,” a national health care program that would cover everyone in the U.S.

Republicans oppose this idea fervently.

“Republicans will talk about a government takeover of health care, socialism, Democratic efforts to get rid of private health insurance and the cost of Democratic plans,” Gonzales said.

Ted Howze, one of three Republicans gunning in the primary to replace Harder, fits this description. He is running for Congress after “personally struggling with the failure of the health care system,” he said during a January debate in Modesto. His first wife died in 2013 from an undiagnosed heart condition “that could have been treated,” according to his campaign website.

Among his top three priorities, he said, is making quality health care affordable for all Americans. But he proposes to do so through the private market, not more government-run programs.

“I will support any plan that covers preexisting conditions and that increases transparency and competition to drive costs down,” he said during the debate.

In at least one California district, health care has popped up in campaign advertising.

Twelve candidates are vying for the 25th Congressional District seat, which includes portions of Los Angeles and Ventura counties. The seat was vacated by former U.S. Rep. Katie Hill, a Democrat who resigned in October.

Voters in that district will face a double election on March 3: The first is a special election for the remainder of Hill’s term, which runs through the end of this year. The second is the primary for the full 2021-23 congressional term.

Among the candidates is former U.S. Rep. Steve Knight, the Republican who lost his seat to Hill in 2018. After voting to repeal Obamacare in Congress, he introduced a bill that he argued would have protected people with preexisting conditions. His campaign did not return multiple calls and emails for comment.

State Assembly member Christy Smith, a Democrat who is running for the seat, shared a personal story about prescription drug costs in her first television ad.

Smith’s mom, a nurse, “died too young because she couldn’t afford the insulin to treat her diabetes and heart disease,” Smith says in the ad.

“My mom couldn’t afford the medicine and care she needed. I’m running for Congress to make sure you can.”

Another Democratic candidate, Cenk Uygur, co-founder of “The Young Turks,” a progressive YouTube news show, also made health care the topic of his first TV ad. Tens of thousands of people die every year because they don’t have health insurance, he says in the ad. “What if your own child was one of them?”

Democrats may find more health care fodder for their campaigns as the year progresses, said Ivy Cargile, an assistant professor of political science at California State University-Bakersfield.

For instance, she said, on Feb. 10 the Trump administration released its $4.8 trillion 2020 federal budget proposal, which includes deep cuts to Medicaid, the public health insurance program for low-income people.

Medi-Cal, California’s Medicaid program, has about 13 million enrollees. “Let’s assume this goes through,” she said. “That’s going to be fresh in the mind of voters going into the general election.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Newsom: To Fix Homelessness, California Must Fix Mental Health

SACRAMENTO, Calif. — Gov. Gavin Newsom made a bold move Wednesday. In his second State of the State address, an annual speech that usually focuses on political wins or the state’s booming economy, Newsom dedicated 35 of 42 minutes to the urgent but unsexy issue of homelessness.

By proclaiming homelessness the most “pernicious crisis in our midst,” the first-term Democratic governor staked his political reputation on his ability to solve it.

That means his reputation also rides on his ability to fix mental health care in California.

“Health care and housing can no longer be divorced,” Newsom declared in the ornate, mint-chip-ice-cream-hued state Assembly chambers. In attendance were the state’s other executive officers, legislators from both houses, and their families and guests.

During the speech, Newsom outlined several mental health proposals he plans to push this year.

He touted his ambitious “once-in-a-generation reform” plan for Medi-Cal, California’s public insurance program for low-income people. Newsom wants to invest $695 million to help the state’s most vulnerable residents, including homeless people and those with mental health problems, in unconventional ways, such as housing aid.

He also raised the controversial issue of involuntary treatment for people with behavioral health problems.

While he criticized the historic practice of confining patients with mental illness to asylums, he said the state needs to make it easier for law enforcement, health care providers and families to get people into treatment. ”All within the bounds of deep respect for civil liberties and personal freedoms,” he added.

One of the impassioned parts of Newsom’s speech was his call to reform the Mental Health Services Act, or Proposition 63. Adopted by voters in 2004, the law imposes a 1% tax on personal income over $1 million to help counties expand mental health care.

Newsom said the problem is that counties aren’t held accountable for how the money is spent.

“The money is used in 58 counties in 58 different ways,” said Tom Insel, chair of the board of the Steinberg Institute, a nonprofit that focuses on mental health and homelessness, whom Newsom calls his “mental health czar.”

That’s not going to work for Newsom, who said in his speech that he wants the money to be spent primarily on three populations: children, homeless people and formerly incarcerated people.

And, he demanded, the money has to be spent.

Newsom said counties are hoarding $160 million in funding that could be used to get people off the streets and into treatment.

“My message is this: Spend your mental health dollars by June 30th, or we’ll make sure they get spent for you,” Newsom said.

State Sen. Scott Wiener, a Democrat from San Francisco, has made mental health and housing reform signature issues. He said Newsom’s speech has created “political space” to accomplish some controversial housing reform that has stalled in the legislature.

“Impactful housing bills are controversial, impactful homelessness bills are controversial, and impactful mental health and addiction bills are controversial,” Wiener said.

It’s not the first time Newsom has taken responsibility for an intractable issue. A month before the State of the State address, he promised $105 million in new spending to fix the wildfire crisis, saying he would dedicate “emphasis, energy and sense of urgency” to the issue.

Now, he’ll also be judged on how he tackles homelessness, a problem that worries 85% of Californians.

“The governor has a very full plate,” said Mike Gatto, a former Democratic state Assembly member from Los Angeles who is trying to put a November ballot measure before voters that would increase involuntary treatment.

“We saw him take ownership of the wildfire issue and now he has boldly taken ownership of this issue, too. The state has to be ready to help him with these tremendous endeavors.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Distritos escolares lidian con cuarentenas, mascarillas y miedo

En un distrito escolar, las familias están sacando a sus hijos de la escuela. En otros, los estudiantes aparecen con mascarillas.

Los distritos escolares a lo largo del país, y en particular aquellos con grandes poblaciones asiático-americanas, se han apresurado a responder al brote del nuevo coronavirus, que ha matado a más de 2,000 personas (al 19 de febrero) y ha enfermado a decenas de miles más, casi todas en China.

Hasta el momento, se han confirmado 15 casos en los Estados Unidos (además de los 14 pasajeros del crucero Diamond Princess que arribaron enfermos), principalmente en California, hogar de aproximadamente un tercio de los inmigrantes chinos de la nación.

Los distritos pisan territorio desconocido cuando aplican reglas federales a sus cuerpos estudiantiles. Y, en algunos casos, están tomando decisiones para abordar los temores de los padres, no la enfermedad real, sin orientación oficial. Están sopesando si permitir que los estudiantes trabajen desde casa, incluso si no han viajado al extranjero recientemente, o si les permiten usar mascarillas en clase.

“Estamos haciendo todo lo posible para cumplir” a medida que evolucionan las reglas y el brote, dijo Jenny Owen, vocera del Distrito Escolar Unificado de Duarte, unas 20 millas al noreste del centro de Los Ángeles y donde aproximadamente el 6% de los estudiantes se identifican como asiáticos.

Los síntomas de la enfermedad por coronavirus, denominado COVID-19, varían desde tos leve o secreción nasal hasta neumonía grave y dificultad para respirar. Los científicos estiman que el período de incubación abarca hasta 14 días y aún están investigando si puede propagarse cuando las personas no tienen síntomas visibles.

Para evitar la diseminación del virus en los Estados Unidos, el gobierno federal ha emitido reglas para los viajeros que regresan: los ciudadanos estadounidenses y los residentes permanentes que estuvieron en el epicentro del brote en la provincia de Hubei, en China, en los 14 días anteriores deben someterse a una cuarentena obligatoria de dos semanas en una instalación administrada por el gobierno. Aquellos que visitaron otras partes de China deben quedarse en casa, en “auto-cuarentena” durante dos semanas.

Estas normas entraron en vigencia el 2 de febrero y, como resultado, un programa de intercambio que traía a niños de China a las escuelas de Duarte se canceló temporalmente para evitar que los estudiantes fueran puestos en cuarentena, dijo Owen.

Las nuevas normas ayudaron a aclarar la confusión, especialmente para las familias que habían viajado recientemente desde China y se preguntaban si debían o no enviar a sus hijos a la escuela, dijo Don Austin, superintendente del Distrito Escolar Unificado de Palo Alto en el Area de la Bahía, de casi 12,000 estudiantes y en el que aproximadamente el 36% de los estudiantes se identifican como asiáticos.

“Cuando escuché por primera vez sobre el concepto de auto-cuarentena, mi primer instinto fue que esto podría ser problemático si estamos solos, tratando de crear algunas de estas políticas y prácticas sobre la marcha”, agregó.

Pero los distritos escolares y los departamentos de salud locales aún tienen que tomar decisiones rápidas en casos que caen fuera de las pautas federales.

Los funcionarios de salud del condado de Ohio, en West Virginia, pidieron a una familia que retirara a un niño de la escuela el 3 de febrero para someterse a una cuarentena de 14 días, a pesar que las pautas federales no se aplicaban al historial de viajes del estudiante, dijo Howard Gamble, vocero del Departamento de Salud del condado de Wheeling-Ohio. El niño acababa de regresar de Hong Kong, que no es parte de China continental. Pero un miembro de la familia que había viajado informó síntomas similares a los de la gripe al regresar.

Los Centros para el Control y Prevención de Enfermedades (CDC) respaldaron la decisión del distrito, dijo Gamble. Los CDC no respondieron a una solicitud de comentarios.

Falta orientación federal sobre otras preguntas que los distritos escolares están considerando.

En el Distrito Escolar Unificado de San Ramón Valley, en el Área de la Bahía, casi el 40% de los 32,000 estudiantes se identifican como asiáticos. Algunas familias sacaron a sus hijos de la escuela y pidieron al distrito que disculpe sus ausencias mientras completan el trabajo escolar desde casa, a pesar que no han viajado recientemente a China o no han estado en contacto cercano con viajeros de China, dijo Christopher George, vocero del distrito.

El distrito dijo que sí.

“Queremos que nuestras familias tengan la opción, incluso para las que tienen miedo de enviar a sus hijos a la escuela”, dijo.

El Distrito Escolar Unificado de Palo Alto ha recibido solicitudes similares, y el superintendente Austin dijo que está permitiendo que, por ahora, las escuelas decidan.

A diferencia de las cuarentenas que terminan después de 14 días, quedarse en casa para evitar la exposición al coronavirus no tiene fecha de finalización, dijo.

“Si este virus continúa propagándose por todo el mundo durante X cantidad de meses, ¿en qué momento diríamos que tienes que volver a la escuela?”, se preguntó George. “La intención no es que todos los estudiantes que no están expuestos se queden en casa como medida de precaución”.

Otra área gris para los distritos escolares es el uso de mascarillas.

Los CDC no recomiendan el uso de máscaras para el público en general porque no son una forma efectiva de prevenir infecciones. Pero en algunos países asiáticos, usar una máscara facial para protegerse contra la contaminación del aire o los gérmenes se considera normal.

Algunos distritos escolares, incluido el Distrito Escolar Unificado de Arcadia, en el condado de Los Ángeles, permiten que los estudiantes y miembros del personal vayan a la escuela con mascarillas si lo desean, siempre que las usen por razones preventivas y no porque estén enfermos.

“Fue una decisión bastante fácil para nosotros”, dijo Ryan Foran, portavoz del distrito, donde cerca del 66% de los 9.400 estudiantes se identifican como asiáticos. “Usar máscaras no es nada nuevo en nuestra comunidad”.

En el cercano Distrito Escolar de Garvey, los maestros y el personal les preguntan a los estudiantes con mascarillas si se sienten bien, pero no los excluyen de las actividades escolares, dijo Anita Chu, superintendente del distrito, donde cerca del 60% de los estudiantes son de ascendencia asiática.

En el Distrito Escolar Unificado de Alhambra, donde aproximadamente la mitad de los estudiantes se definen como asiáticos, los administradores desalientan el uso de máscaras y tratan de explicar a las familias que no protegen contra la enfermedad, dijo Toby Gilbert, vocero del distrito.

Eso es un buen consejo científico. Sin embargo, los esfuerzos del distrito se han encontrado con una petición en línea de change.org pidiendo a los administradores que permitan a los estudiantes usar mascarillas y que cancelen las clases por temor al virus. La petición tiene más de 14,000 firmas electrónicas, pero no está claro cuántas son del distrito.

Funcionarios de salud pública del condado de Los Ángeles “nos dijeron que las máscaras dan una falsa sensación de protección y se suman a un clima de alarma sin ayudar”, dijo Gilbert. “Siempre hemos permitido las máscaras, pero queríamos que los padres supieran que no estaban protegiendo”.

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School Districts Grapple With Quarantines, Face Masks And Fear

In one school district, families are pulling their kids out of school. In others, students show up in face masks.

Educators in one Southern California community agreed to suspend an exchange program to keep visiting Chinese students out of quarantine.

School districts across the U.S., particularly those with large Asian American populations, have scrambled to respond to the outbreak of the novel coronavirus, which has killed more than 2,000 people and sickened tens of thousands more, almost all in China.

So far, 15 cases have been confirmed in the U.S., mostly in California, home to about one-third of the nation’s Chinese immigrants.

The districts find themselves in uncharted territory as they apply new federal travel rules to their student bodies. And, in some cases, administrators are making decisions to address parental fears — not actual disease — with no official guidance. They’re weighing whether to allow students to work from home, even if they haven’t traveled abroad recently, or let them wear face masks in class.

Balancing these requests against broader public health needs often leads to different conclusions.

“We’re just doing our best to comply” as the rules and outbreak evolve, said Jenny Owen, spokesperson for the Duarte Unified School District, about 20 miles northeast of downtown Los Angeles and where about 6% of students identify as Asian.

Symptoms of the coronavirus disease, dubbed COVID-19, range from a mild cough or a runny nose to severe pneumonia and difficulty breathing. Scientists estimate the incubation period spans up to 14 days and are still investigating whether the illness can spread when people have no obvious symptoms.

To prevent the virus’s spread in the U.S., the federal government has issued rules for returning travelers: U.S. citizens and legal permanent residents who visited the epicenter of the outbreak in China, Hubei province, in the previous 14 days must undergo a mandatory two-week quarantine at a government-run facility. Those who visited other parts of China must stay home and “self-quarantine” for two weeks.

The policies began Feb. 2, and as a result, an exchange program that brought children from China to Duarte schools has been temporarily halted to prevent the students from being quarantined, Owen said.

State public health departments are using the federal rules to draft guidelines for school districts.

The policies made a “night and day” difference in clearing up confusion, especially for families who had recently traveled from China and were wondering whether or not to send their kids to school, said Don Austin, superintendent of the nearly 12,000-student Palo Alto Unified School District in the Bay Area, where about 36% of students identify as Asian.

“When I first heard of the concept of self-quarantine, my first instinct was, this could be problematic if we’re alone on that and trying to create some of these policies and practices on the fly,” he said.

But school districts and local health departments still have to make quick decisions in cases that fall outside federal guidelines.

Health officials in Ohio County, West Virginia, asked a family to retrieve a child from school on Feb. 3 to undergo a 14-day self-quarantine, even though federal guidelines did not apply to the student’s travel history, said Howard Gamble, a spokesperson for the Wheeling-Ohio County Health Department. The child had just returned from Hong Kong, which is not part of mainland China. But a family member who made the trip reported flu-like symptoms upon return.

The Centers for Disease Control and Prevention supported the district’s decision, Gamble said. The CDC did not respond to a request for comment.

Federal guidance is lacking on other questions school districts are weighing.

At the San Ramon Valley Unified School District in the Bay Area, nearly 40% of 32,000 students identify as Asian. A few families have pulled their kids out of school and asked the district to excuse their absences while they complete schoolwork from home, even though they have not traveled to China recently or come in close contact with travelers from China, said Christopher George, spokesperson for the district.

The district said yes.

“We want our families to have the option, even for the families who are afraid to send their kid to school,” he said.

Palo Alto Unified School District has received similar requests, and superintendent Austin said he’s allowing individual schools to decide — for now.

Unlike the quarantines that end after 14 days, staying home from school to avoid coronavirus exposure has no end date, he said.

“If this virus continues to spread around the world for X number of months, at what point would we say that you have to come back to school?” he said. “The intent is not for every student who has no exposure to stay home as a precaution.”

Another gray area for school districts is the use of face masks.

The CDC doesn’t recommend the use of masks for the general public because they aren’t an effective way to prevent infections. But in some Asian countries, wearing a face mask to protect against air pollution or germs is considered normal.

Some school districts, including the Arcadia Unified School District in Los Angeles County, allow students and staff members to come to school with face masks if they wish — provided they’re wearing them for preventive reasons and aren’t sick.

“It was a pretty easy decision for us,” said Ryan Foran, spokesperson for the district, where about 66% of the 9,400 students identify as Asian. “Wearing masks is nothing new in our community.”

At nearby Garvey School District, teachers and staff “respectfully and gently” ask masked students if they are feeling well but don’t exclude them from school activities, said Anita Chu, superintendent of the district, where about 60% of students are of Asian descent.

In the Alhambra Unified School District, where about half of the students identify as Asian, administrators discourage the use of face masks and try to explain to families that they don’t protect from disease, said Toby Gilbert, a spokesperson for the district.

That is sound scientific advice. Yet the district’s efforts have been met with an online change.org petition asking administrators to allow students to wear face masks and cancel classes over fears of the virus. The petition has more than 14,000 electronic signatures, but it’s not clear how many of those are from within the district.

Los Angeles County public health officials “advised us that masks give a false sense of protection and add to a climate of alarm without being of help,” Gilbert said. “We have always allowed masks but wanted parents to know they weren’t providing protection.”

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California Public Health

Abortion-Rights Supporters Fear Loss Of Access If Adventist Saves Hospital

For more than two years, physician assistant Dawn Hofberg fought to bring access to abortions back to California’s Mendocino Coast, a picturesque stretch of shoreline about three hours north of San Francisco and 90 minutes from the nearest facility offering abortions.

Hofberg enlisted help from local health care providers and the American Civil Liberties Union, which sent letters to the Mendocino Coast Health Care District that operates the hospital in Fort Bragg and other medical services. The letters noted that the state constitution requires public hospitals to offer abortions if they offer other pregnancy-related care.

Late last year, district CEO Wayne Allen granted a doctor at its North Coast Family Health Center permission to start providing medication abortions, which involve two drugs that can end a pregnancy.

But Hofberg and others worry that the community’s newly won abortion access could be in peril. With a net loss of $1.2 million in the 2018 fiscal year alone, the district says its only shot at survival is to lease its operations to Adventist Health, a Roseville, California-based system affiliated with the Seventh-day Adventist Church, which opposes most abortions.

Dawn Hofberg, a physician assistant in Fort Bragg, California, turned to other local health care providers and the American Civil Liberties Union to help persuade the local hospital to make abortions available to some patients in her community. (Courtesy of Dawn Hofberg)

Voters will decide whether to approve the 30-year lease agreement on March 3.

Adventist officials said that despite their religious teachings that abortions should be limited to cases of life- or health-threatening pregnancies, rape, incest or severe fetal anomalies, they will not restrict the use of medication abortions at the clinic.

“We don’t control our physician practices in the way some others do and we don’t put constraints around what they can and can’t prescribe,” said Bob Beehler, an Adventist Health mergers and acquisitions executive.

Beehler said the introduction of abortion-inducing pills had changed the system’s approach to abortions. “Our historical position has been based on the way they used to be done, in a hospital.”

But abortion-rights supporters still fear what could be coming.

“Obviously, we do have a lot of concerns about Adventist’s position with respect to restricting abortion access in its facilities, and so we’re going to keep a close eye on the situation,” said Phyllida Burlingame, director of reproductive justice and gender equity for the ACLU of Northern California.

Burlingame said the deal also raises broader concerns about the spread of religious health systems that restrict care. “Not only are they taking over the private marketplace, but now they’re even spreading into these public spheres,” Burlingame said.

Similar objections from the ACLU and staff at the University of California-San Francisco last year scuttled a proposed affiliation between UCSF Medical Center and Dignity Health, a Catholic-affiliated system that restricts reproductive and transition-related care for transgender patients.

The expansion of religious systems can leave leaders of struggling hospitals with few choices when they seek to affiliate. Of the five systems to which the Mendocino hospital district issued its request for proposals last year, three were faith-based. Two responded, and Adventist was the only one that met the community’s needs, according to the district board’s treasurer, John Redding.

Nationwide, four of the largest 10 health systems and 1 in 6 acute care hospital beds are Catholic-owned or -affiliated. Seventh-day Adventists are Protestant Christian, and Adventist-affiliated systems run 87 hospitals and more than 300 other facilities in the United States, according to the Adventist Health Policy Association.

As these systems have grown, rural health care districts across California are struggling with waning patient volume and a lack of leverage to negotiate with insurers, said Sherreta Lane, senior vice president of finance policy at the District Hospital Leadership Forum, a trade association that represents all the state’s district and municipal hospitals. Many of these hospitals have closed or affiliated with private systems.

When the forum launched a decade ago, 45 districts or municipalities ran hospitals; now 35 do, Lane said.

While Catholic-affiliated systems like Dignity have received greater scrutiny for policies that restrict access to abortion, contraception, sterilization and end-of-life care, the impact of Adventist teachings on church-affiliated health systems is less known. In October, the Seventh-day Adventist Church raised concerns among reproductive health care advocates when it approved a statement saying it “considers abortion out of harmony with God’s plan for human life.”

Officials said at the time that they would develop updated protocols for church-affiliated health care institutions, where, they emphasized, few abortions are performed.

Adventist Health spokesperson Jill Kinney said in an emailed statement that the hospital system’s usual practice “is not to provide elective abortions, but we respect that patients may wish to have them.” If that’s the case, she added, “clinicians help coordinate referral and transfer to capable facilities without prejudice.”

In a response to detailed questions from California Attorney General Xavier Becerra before his office approved the system’s takeover of Delano Regional Medical Center in November, Adventist Health said it bans “elective abortions” but allows the procedure “for fetal distress and other medical reasons.” It added: “Medical abortions are performed in Adventist Health facilities,” without providing details.

In 2014, Adventist Health purchased a clinic in Fort Bragg where Dr. Eric Gutnick and his colleagues had provided reproductive health services since the 1970s. Under a contract with Adventist, Gutnick continued to see abortion patients for preoperative care in the clinic and performed surgical abortions at the Mendocino Coast District Hospital, until he retired later that year.

The Seventh-day Adventist Church’s teachings can influence other issues, too. It has opposed what it calls “transgenderism,” stating that gender identity “is determined by our biological sex at birth,” and has called homosexuality “a manifestation of the disturbance and brokenness in human inclinations and relations caused by the entrance of sin into the world.”

Arneta Rogers, an attorney for the ACLU of Northern California, voiced concern about these beliefs. “It’s not about shutting down religious entities; we just don’t want people to be discriminated against,” Rogers said in an interview.

Jason Wells, president of the Adventist Health hospitals in Ukiah and Willits, said the system cherishes diversity and its LGBTQ employees. In its statement to the attorney general, Adventist said some of its physicians provide hormones for transgender patients but none of its facilities offer “gender reconstruction surgery.”

In a statement provided by Kinney, Adventist Health said that it “strives to be free from biases related to gender identity” but that its hospitals “are not currently equipped to offer the complex, comprehensive programmatic approach necessary to provide gender reassignment treatments and surgeries.”

For many in the Mendocino community, uncertainty over the hospital’s finances has overshadowed concerns about Adventist Health’s religious affiliation as residents prepare for the vote next month. “If the affiliation doesn’t go through, I don’t know how we’ll stay in business,” said Karen Arnold, secretary of the district board.

Redding said lease payments from Adventist would allow the district to afford the estimated $24 million needed to finance upgrades required by the state to protect against catastrophic earthquake damage to its facilities.

“I wasn’t sure how we were going to do this, and now I feel that we’ve secured the future of a hospital here on the coast,” Redding said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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California Health Industry

Changing Clocks Is Bad For Your Health, But Which Time To Choose?

Changing over to daylight saving time — a major annoyance for many people — may be on its way out as lawmakers cite public health as a prime reason to ditch the twice-yearly clock-resetting ritual.

The time change, especially in the spring, has been blamed for increases in heart attacks and traffic accidents as people adjust to a temporary sleep deficit. But as legislatures across the country consider bills to end the clock shift, a big question looms ahead of this year’s March 8 change: Which is better, summer hours or standard time?

There are some strong opinions, it turns out. And they are split, with scientists and politicians at odds.

Retailers, chambers of commerce and recreational industries have historically wanted the sunny evenings that allow more time to shop and play.

Researchers on human biological rhythms come down squarely on the side of the standard, wintertime hours referred to as “God’s time” by angry farmers who objected to daylight saving time when it was first widely adopted during World War I.

What’s not in question is that the clock switching is unpopular. Some 71% of people want to stop springing forward and falling back, according to a 2019 Associated Press-NORC Center for Public Affairs Research poll.

Politicians have reacted accordingly. More than 200 state bills have been filed since 2015 to either keep summer hours or go to permanent standard time, according to the National Conference of State Legislatures.

The measures getting the most traction right now are for permanent daylight saving time, which makes more sun available for after-work activities. In 2018, Florida passed a bill and California voters backed a ballot measure to do so. Maine, Delaware, Tennessee, Oregon and Washington joined in 2019, passing permanent daylight saving bills. President Donald Trump even joined the conversation last March, tweeting: “Making Daylight Saving Time permanent is O.K. with me!”

But none of those efforts can become reality without the blessing of Congress. States have always been able to opt out of summer hours and adopt standard time permanently, as Arizona and Hawaii have done. But making daylight saving time year-round is another story.

Still, Scott Yates, whose #Lock the Clock website has become a resource for lawmakers pushing for change, believes this year will be another big year. Yates is particularly encouraged by the attitude he saw from state legislators in August when he presented on the issue at the legislators’ annual national summit in Nashville, Tennessee.

“I wasn’t the court jester and it wasn’t entertainment,” he said. “It was like, ‘What are the practical ways we can get this thing passed?’”

Seeking To End ‘Spring Ahead, Fall Back’ Cycle

Yates, 54, a tech startup CEO based in Denver, has been promoting an end to clock switching for six years. He doesn’t pick a side. It’s the switching itself that he wants to end. At first, it was just about the grogginess and annoyance of being off schedule, he said. But then he began to see scientific studies that showed the changes were doing actual harm.

A German study of autopsies from 2006 to 2015, for instance, showed a significant uptick just after the spring switch in deaths caused by cardiac disease, traffic accidents and suicides. Researchers have also noted a significant increased risk for heart attacks and strokes.

Three measures pending in Congress would allow states to make daylight saving time permanent. But, in the meantime, state lawmakers who want the extra evening sunlight are preparing resolutions and bills, some of which would be triggered by congressional approval and the adoption of daylight time in surrounding states.

The Illinois Senate passed such a bill, and Kansas is considering one after a bill to end daylight saving time died there last year. Utah passed a resolution in support of the congressional bill last year, and state Rep. Ray Ward, a Republican family physician from Bountiful, is steering a recently passed state Senate permanent daylight bill through the House.

“The human clock was not built to jump back and forth. That’s why we get jet lag,” said Ward, who was a co-presenter with Yates at the NCSL summit. “It is very easy to show that if you knock people off an hour of sleep there’s a bump temporarily in bad things that will happen.”

Efforts have been particularly strong in California, where 60% of voters passed a ballot issue for permanent daylight time in 2018. A bill is pending in the state Assembly.

Science Backs Sticking With Standard Time

All of this alarms scientists who study human biological rhythms.

Researchers in the U.S. and the European Union have taken strong positions about permanent summer hours. The Society for Research on Biological Rhythms posts its opposition prominently at the top of its website.

Messing with the body’s relationship to the sun can negatively affect not only sleep but also cardiac function, weight and cancer risk, the society’s members wrote. According to one often-quoted study on different health outcomes within the same time zones, each 20 minutes of later sunrise corresponded to an increase in certain cancers by 4% to 12%.

“Believe it or not, having light in the morning actually not only makes you feel more alert but helps you go to bed at the right time at night,” said Dr. Beth Malow, director of the sleep division of Vanderbilt University School of Medicine. Malow has seen a lot of anecdotal evidence to back that up at the sleep clinic. Parents report their children with autism have a particularly hard time adjusting to the time change, she said.

Jay Pea, a freelance software engineer in San Francisco, was unhappy enough about California’s proposed permanent daylight time that he started the Save Standard Time website to promote the health arguments for keeping it permanent. He said he doesn’t think the scientific community is being heard.

“Essentially it’s like science denial,” he said. “It’s bizarre to me that politicians are not hearing the experts on this.”

Pea, 41 and an amateur astronomer, understands the human need to have the sun directly overhead at noon. “It’s a wonderful connection to natural reality that unfortunately is lost on many people,” he said. Daylight saving time “distances us from the natural world.”

At the very least, lawmakers ought to consider history, he said. Daylight saving time was originally a plan to save energy during the two world wars but wasn’t popular enough to be uniformly embraced after the conflicts were over. In 1974, the federal government decided to make it temporarily year-round as a way to deal with the energy crisis (although energy savings were later found to be underwhelming).

Its popularity fell off a cliff after the first winter, when people discovered the sun didn’t rise until 8 a.m. or later and parents worried for the safety of kids waiting in the dark for school buses.

Pea finds it frustrating that the momentum now is for permanent summer hours — a fact he attributes to the emotional attachment with summer. “It’s a shame that every generation we have to revisit this issue,” he said.

The AP-NORC poll found 40% of its respondents support permanent standard time, with 31% opting for permanent daylight saving time.

Ward said people have gotten comfortable with daylight saving time since its duration has been lengthened to eight months by extensions in 1986 and 2007. (Before 1986, daylight saving time lasted six months.)

“So now really most of the year we are on the summer schedule, and people are used to that and they like it,” he said. “That makes them more aggrieved when we change back to the winter schedule.”

In any case, changing the clocks is a rare issue in that it isn’t partisan, Ward said. “If the government can’t respond to people when they want something and it’s not even a partisan issue, that’s just a sad commentary,” he said. “Can’t we please fix something that doesn’t make sense anymore?”

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California Public Health States

Sweetgreen Makes Healthful Fast Food — But Can You Afford It?

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Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.

Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.Credit Jason Henry for The New York Times

Healthful, fast and affordable food is the holy grail of the public health and nutrition community. A popular restaurant chain shows just how much of a challenge that is.

It began when three Georgetown University students were frustrated that they could not find a healthy fast-food restaurant near their campus. With money raised from family and friends, they started their own, renting a small storefront on M Street in Georgetown. The result was Sweetgreen, a restaurant that offered organic salads, wraps and frozen yogurt. Pretty soon, the daily line of lunchtime customers stretched out the door and around the corner.

Ten years later, the line is still there, but Sweetgreen has grown into a nationwide salad chain, with more than 40 locations. Sweetgreen is part of a small but growing breed of farm-to-table fast-food chains – like Chopt Creative Salad Company on the East Coast and Tender Greens in California – that are giving fast-food restaurants a plant-based makeover. Their mission: to fix fast food, which has long been fattening and heavily processed.

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At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.

At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.Credit Jason Henry for The New York Times

Sweetgreen’s owners say their goal is to offer customers foods made with nutritious, sustainable and locally grown ingredients. The company has decentralized its food sourcing and production. Fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site. They don’t sell soda or use refined sugar.
Sweetgreen expects to open another 20 stores in major cities around the country this year, and eventually to expand to places where experts say healthy, delicious fast food is needed most — low-income neighborhoods.

But while the chain has proven there is a big appetite for more healthful fast food, the goal of taking this concept to poor areas may be a distant reality. The company and other chains like it operate almost exclusively in affluent communities, far from the low-income food deserts where obesity is rampant and farmers’ markets and healthy food stores are scarce. And with salads that typically cost between $9 and $14, some question whether a healthful fast-food chain like Sweetgreen can ever be affordable for average Americans.

Maegan George, a Columbia University student who lives near a Sweetgreen, calculated that for the price of one Sweetgreen salad, she could buy the same ingredients in bulk at a local market and make several similar salads at home.

“I’m a first-generation student and I’m on full financial aid,” she said. “Sweetgreen is delicious and I enjoy it. But there’s no way I could afford to eat there on a regular basis.”

Jackie Hajdenberg, another Columbia student, wrote about the restaurant for the campus newspaper, The Spectator, earlier this year, lamenting that on a per calorie basis, a salad at Sweetgreen was three times the price of a Big Mac at McDonald’s.

“Sweetgreen has not only made it easier for people to make healthy decisions – it has also illustrated the unequal socioeconomic landscape of the world in which we live,” she wrote.

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Salad options at Sweetgreen change often, depending on what is available at local farms.

Salad options at Sweetgreen change often, depending on what is available at local farms.Credit Jason Henry for The New York Times

Sweetgreen says it prices its food so that it can compensate its suppliers and employees fairly, and that it expects nutritious fast food to become more affordable as the healthy food movement grows. Nicolas Jammet, a co-founder of Sweetgreen, said the company wants to serve lower-income customers, and has long-term plans to expand to low-income communities.

To get there, he said, the company will have to overcome hurdles involving its supply chain, the minimum wage and greater nutrition awareness and education among the public. For the past six years the company has been running a nutrition education program in schools that teaches children about healthier eating and locally grown food.

“It’s a long-term goal for us to be part of this larger systematic change that needs to happen,” he said. “But there are so many parts of this problem that need to be addressed.”

Mr. Jammet notes that the company was among the first to show that fast-food chains don’t need profits from soda and sugary drinks to succeed. He believes chains like Sweetgreen have caused a ripple effect throughout the fast-food industry.

In January, for example, Chick-fil-A unveiled a new kale, broccolini and nut “superfood” salad, responding to customer demands for “new tastes and healthier ways to eat in our restaurants.” McDonald’s is experimenting with kale salads, and Wendy’s is testing a spinach, chicken and quinoa salad.

“Companies like McDonald’s have more power to change the way that people eat than we do,” Mr. Jammet said. “We don’t see these companies as the enemy. We just have to force change on them.”

Public health experts say that such changes cannot come soon enough. A University of Toronto study recently showed that people have a higher risk of developing diabetes if they live in “food swamps” – an area with three or more fast-food restaurants and no healthy dining options.

Another study published in JAMA in June found that the percentage of Americans eating an unhealthy diet — high in sugar, refined grains, soft drinks and processed foods and low in fruits and vegetables — was on the decline, but the improvements in diet were much smaller for lower-income Americans.

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Customers wait in line at Sweetgreen in Berkeley, Calif.

Customers wait in line at Sweetgreen in Berkeley, Calif.Credit Jason Henry for The New York Times

Overall about twice as many people from poor households have poor diets compared to those at higher income levels.
Why is traditional fast food so cheap? One reason is the underlying infrastructure of the industry. Many of the ingredients, like the soy that’s turned into oil for deep fryers, or the the corn that’s fed to animals and used to make high-fructose corn syrup, begin with crops that are heavily subsidized by the government. To make their food economical, many traditional fast-food chains mass-produce their food in large factories, often stripping it of fiber and other nutrients that decrease its shelf life, while adding salt, sugar and other flavorings and preservatives.

Then they freeze and ship the processed components, like burger patties, bread, pickles and sauce, to their restaurants. There they are reheated and assembled, often with minimal effort, ensuring that a Big Mac in Seattle looks and tastes the same as a Big Mac in Charlotte, N.C.

By comparison, every Sweetgreen location has a chalkboard that lists the farms where its organic arugula, peaches, yogurt or blueberries are produced. As a result, the menus vary by location and by season. In Boston, Sweetgreen stores use New England Hubbard squash. In Los Angeles, the menu features a different variety of squash grown locally in California.

Those differences mean fresher, more nutritious ingredients, but ultimately costlier food for customers — one of the obstacles that Sweetgreen and other chains like it will have to overcome if they hope to make their food more accessible to all income brackets.
Marion Nestle, a professor of nutrition, food studies and public health at New York University and the author of “Food Politics,’’ says restaurants like Sweetgreen offer an encouraging, but imperfect, model for making fast food more healthful.

“What’s not to like?” she asks. “The cost, maybe, but for people who can afford it the quality is worth it. Next step: Moving the concept into low-income areas.”

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