Tagged Public Health

Must-Reads Of The Week From Brianna Labuskes

A turbulent news week is capped off by a bit of hope arising from Alzheimer’s research. Disappointment and dashed hopes are the norm in the field, but there’s been a tiny breakthrough: Scientists uncovered a link between the disease and common viruses that lay dormant in the brain after childhood. There’s lots of cautionary language being bandied about (like, don’t get association and causation confused!), but it does open new possibilities for research that has been at a standstill for decades.

And now for what you might have missed this week.

Dr. Atul Gawande, who has just been named to head the health initiative formed by Amazon, Berkshire Hathaway and JPMorgan Chase, has said the U.S. health system is like a car built with Porsche brakes, a Ferrari engine and a BMW chassis. “You put it all together and what do you get? A very expensive pile of junk that does not go anywhere.” Now that Gawande is in the driver’s seat, will he actually be able to do anything about high costs? Those in the medical field were quick to praise him as a “luminary,” but many had concerns about his lack of experience managing a large organization — and the fact that he seems to have lots of other big jobs from Harvard to The New Yorker already demanding his time.

Bloomberg: Can This Surgeon Help Buffett, Bezos and Dimon Solve America’s Health-Care Crisis?

Bloomberg: Doctor and Journalist Atul Gawande Picked for Dimon-Bezos-Buffett Health Firm

And, pharma might be breathing a small sigh of relief. Gawande insists that, despite all the headlines, drug costs aren’t what’s driving spending. The No. 1 culprit according to him? Surgery.

Reuters: Head of New U.S. Corporate Health Plan Cites Surgery As Biggest Cost

President Donald Trump ended his policy to separate migrant children from their parents this week, but chaos at the border continues. Mental health experts and physicians are focusing on the lasting psychological and physical toll on the kids — many who remain in detention centers. Other questions are percolating as well, like: Who benefits from the business of separation? Providing care for those who have been detained is expensive and private contractors are lining up for the work.

Modern Healthcare: Immigrant Detention Crisis Could Yield Profit for Some Providers and Payers

Los Angeles Times: ‘Children Must Not Be Abused for Political Purposes’: What Health Groups Say About Family Separation

Back before the health law, “unauthorized or bogus” insurance schemes were thick on the ground. Now that Trump has released his rule on association health plans (which give small businesses access to insurance options like those available to large companies and let them skirt some of the health law’s requirements), fraud experts are worried the era is going to make a return.

Modern Healthcare: Fraud Fears Rise As Feds Expand Access to Association Health Plans

And if you thought repeal-and-replace was a thing of the past, a group of conservatives helmed in part by the Heritage Foundation have released a new “repeal” plan. While it is extremely unlikely any Republicans in Congress will touch it with a 10-foot pole this close to midterms, the blueprint does show that there’s still an appetite to completely upend the health law.

The Hill: Conservative Groups Outline New ObamaCare Repeal Plan

What’s in a name? Well, critics of the administration’s plans to rename HHS — replated as the Department of Health and Public Welfare — says it means quite a lot. As part of a larger shake-up of agencies, Trump wants to tuck all public assistance programs (like SNAP) into HHS and change its name. But while officials say that adding “welfare” to the department’s title would make it clear what services it provides, others say the word brings with it a negative connotation that would make the programs vulnerable to budget cuts. (Spoiler alert: These moves require congressional approval and would strip some lawmakers of authority, so they’re unlikely to actually come to pass.)

Modern Healthcare: White House Proposes HHS Restructuring and Renaming to Consolidate Welfare Programs

The Wall Street Journal: Trump Proposes Combining Workforce Training, Welfare Programs in Agency Revamp

In the miscellaneous file this week: Some disabled veterans are being told they owe the government thousands of dollars because of an insurance program they didn’t even know existed; it’s not often you can all but feel the giddiness radiating off of articles, but these jaw-dropping results from a new therapy for Duchenne muscular dystrophy is getting everyone emotional; a drugmaker rode a nice wave of good PR and marketing for donating anti-overdose injectors to police departments. One little problem — the drugs were almost expired. And remember that NIH alcohol study where scientists courted the industry for funding? It was yanked after an internal investigation revealed that “so many lines” were crossed that “people were frankly shocked.”

The New York Times: Veterans Owe the D.O.D. Thousands for Survivor Benefits. Why Can’t They Opt Out?

Stat: Sarepta’s Gene Therapy for Duchenne Raises Hopes for ‘Real Change’

Stat: Drug Maker’s Donations of Overdose Antidote Were Close to Expiring

The New York Times: It Was Supposed to Be an Unbiased Study of Drinking. They Wanted to Call It ‘Cheers.’

And, as we head into the weekend, a question you can consider: What would you sacrifice for cheaper premiums?

Cigna To Step Into War Against Opioid Epidemic

The health insurer plans to use predictive analytics to identify customers who are at the highest risk for an opioid overdose and develop partnerships in those areas to help combat the crisis. In other news: the government pulls funding for a pain relief training; a lobbying blitz has been launched on Capitol Hill as lawmakers vote on opioid measures; and more.

Doling Out Pain Pills Post-Surgery: An Ingrown Toenail Not The Same As A Bypass

What’s the right painkiller prescription to send home with a patient after gallbladder surgery or a cesarean section?

That question is front and center as conventional approaches to pain control in the United States have led to what some see as a culture of overprescribing, helping spur the nation’s epidemic of opioid overuse and abuse.

The answer isn’t clear-cut.

Surgeon Marty Makary wondered why and what could be done.

So, Makary, a researcher and a professor of surgery and health policy at Johns Hopkins School of Medicine in Baltimore, took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific procedures.

After all, most doctors usually make this decision based on one-size-fits-all recommendations, or what they learned long ago in med school.

Even Makary admitted that for most of his career he “gave [painkillers] out like candy.”

In December, he gathered a group of surgeons, nurses, patients and other leaders, asking them: What should we be prescribing for operation X?”

The answer was illuminating.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, says Dr. Marty Makary, who’s leading an effort to curb overprescribing by offering procedure-specific guidelines for opioid painkillers. (Courtesy of Johns Hopkins Medicine)

“The head of the hospital’s pain services said, ‘You’re the surgeon, what do you think?’” recalled Makary.

Makary didn’t know. Nor did the resident. And the nurse practitioner, who often is the one who most closely follows up with patients, said it varies.

“Wow,” recalls Makary of that day when they first considered appropriate limits. “We’re the experts, the heads of this and that, and we don’t know.”

After a quick couple of weeks of intense discussion, Makary’s group reached consensus and gave its blessing to guidelines setting maximum numbers of opioid-containing pills for 20 different common surgical situations, from relatively minor procedures to coronary bypass surgery.

“We’re in a crisis,” said Makary, explaining why the group didn’t go a more traditional route and publish its findings in a medical journal first, which could take months.

Sometimes the right number of opioids is zero, concluded the group.

Indeed, it recommends no opioids for patients heading home after uncomplicated labor and delivery, or after cardiac catheterization, a procedure in which a thin, hollow tube is inserted into the heart through a blood vessel to check for blockages.

For certain types of knee surgery, such as arthroscopic meniscectomy, the guidelines recommend no more than 12 pills upon discharge, while a patient going home after an open hysterectomy could require as many as 20.

Optimally, “no one should be given more than five or 10 opioid tablets after a cesarean section,” Makary said.

Oh, and for cardiac bypass surgery? No more than 30 pills.

But What About The Pain?

Tens of thousands of Americans are dependent upon opioid medications. An increasing number are dying from overdoses, both from prescription medication and street drugs.

Knowing that, Makary, as well as other surgeons, hospitals and organizations, are taking steps to change how they practice medicine.

After all, many experts view the use of opioid prescription painkillers after surgery as a gateway to long-term use or dependence. A study published last year in the journal JAMA Surgery found that persistent use of opioids was “one of the most common complications after elective surgery.”

In that study, University of Michigan researchers found that 6 percent of people who had never taken opioids but received them after surgery were still taking the medications three to six months later.

With about 50 million surgeries that occur in the U.S. each year, “there are millions who may become newly dependent,” said Chad Brummett, the study’s lead author and an associate professor of anesthesiology at the University of Michigan Medical School.

Smokers, and those diagnosed with certain conditions such as depression, anxiety or chronic pain before their operations, were most at risk of long-term use.

Each refill or additional week of use makes for a greater risk of misuse, other studies have shown.

Additional research points to another reason for concern. If patients don’t take all the pills they are prescribed following an operation, those pills can be stolen or diverted to other people, who then run the risk of becoming dependent.

Still, there is debate in medical circles about just how effective recommendations and guidelines will be in stemming the epidemic.

For one thing, some experts worry that if the fight against opioids focuses only on safe prescribing at the expense of seeking alternatives, it may miss the bigger picture.

“Are there better methods than opioids in the first place?” asks Lewis Nelson, chair of emergency medicine at Rutgers New Jersey Medical School. “Could you put a lidocaine patch over the wound or is there a better way to immobilize a joint?”

Studies have shown that sometimes a combination of ibuprofen and acetaminophen can be just as good as or better than opioids.

Alternatives should always be considered first, agreed Makary.

Another concern is that guidelines for prescribing relief — even those aimed at short-duration, acute pain, such as that following surgery — have carryover effects on patients with long-term pain. Advocates say all the attention around prescribing limits have made it difficult for chronic pain patients to get the medications they need.

Some people even apply these concerns to recommendations about the treatment of acute pain.

“It’s important for a physician to have the ability, if they feel there’s a medical necessity, to write a prescription for a longer duration,” said Steven Santos, president of the American Academy of Pain Medicine. “It’s challenging to lump all patients into one basket.”

A Different Focus: Duration

Lawmakers — desperate to address overdose problems that are destroying families and communities — have gone where they usually don’t: setting specific rules for doctors.

Legislatures in more than a dozen states, including New Jersey, Massachusetts and New York, have set restrictions, often on the number of days’ worth of pills prescribed for acute pain.

“States said that since physicians haven’t self-regulated, we’re going to do it for them,” said Nelson at Rutgers.

Congress, too, is getting involved, holding a flurry of hearings this spring, and considering legislation that would, among other things, set limits on prescribing opioids for acute pain. The recently passed federal spending bill includes $3 billion in new funding to help states and local governments with opioid prevention, treatment and law enforcement efforts.

To be sure, the medical profession has also responded to the crisis — with medical societies and other expert groups offering a growing number of standards for prescribing opioids.

Some are fairly generic, recommending the lowest dose for the shortest period of time for acute pain. Some are more prescriptive.

None is meant to address the needs of chronic pain patients or those with cancer.

And state rules vary. New Jersey’s, for example, says patients with acute pain should, initially, get no more than a five-day supply, while Massachusetts sets the cap at seven days for a patient prescribed opiates for the first time.

The Centers for Disease Control and Prevention recommends three days.

Makary and some other experts say that, while well-intentioned, such durational rules are too blunt.

A day’s worth of pills can vary, depending on how often the doctor instructs patients to take them. Under many of the state rules, patients could still head home with more than 50 pills.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, said Makary.

Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management, supports guidelines but wants states to take their rules a step further.

“I don’t think the way the states are going at this makes much sense because the issue with overprescribing was quantity, yet they’re passing laws around duration,” he said.

Instead, the laws should require that “if physicians are going to prescribe more than three days, they have to warn the patients that this is an addictive drug and that taking it every day for as little as five days may cause them to become physiologically dependent,” Kolodny said.

That would create a disincentive to prescribing more than three days’ worth of opioid painkillers, he added, and lead to more informed patients among those who need a longer supply.

Rutgers’ Nelson, who sat on the CDC panel that developed recommendations, said durational rules — like those adopted by the states — can be effective.

“I personally think three days is enough,” said Nelson. “That doesn’t mean pain goes away in three days, but most people get better within three to five days.”

That said, Nelson called the Hopkins’ approach an “excellent idea” and one he has tried to do. “It’s a lot harder than it sounds because of the large number of procedures and the diversity of patient needs,” he said.

To get around overprescribing — or setting one-size-fits-all guidelines — physicians at Dartmouth-Hitchcock Medical Center have a developed their own data-based approach.

Dr. Richard Barth, the chief of general surgery at Dartmouth, and colleagues studied 333 patients discharged from the hospital following six common surgeries that included bariatric procedures; operations on the stomach, liver, colon and pancreas; and hernia repair.

Surveying the patients, they asked how many opioid pills they went home with, how many they actually took, how many went unused and how much pain they experienced.

The data helped them land on a way to recommend a specific number of pills. “If they took none the day before discharge, then over 85 percent of patients did not take any when they went home,” said Barth.

Dartmouth-Hitchcock now uses that data as a recommended starting point for physicians.

Under the guidelines, patients taking no opioid pain pills the day before discharge go home with none. Those who take one to three pills get 15, an amount Barth’s study found satisfied 85 percent of patients, and those who took four or more get 30 pills.

“We came out with a very easy to implement and remember guideline,” said Barth. “We actually called patients and asked them how many [pills] they used. That’s what differentiates us from other places.”

Brummett, at Michigan, says the Opioid Prescribing Engagement Network, a collaboration of hospitals, insurers, physicians and others in his state, has used similar data methods to come up with procedure-specific guidelines.

“We’ve taken a data-driven approach,” he said. “We believe patient-reported outcomes are a better way to guide than expert consensus.”

For his part, Makary admitted it is harder to develop guidelines like those at Hopkins and Dartmouth, but he said the effort is vital.

“It’s mind-boggling to me” that so many opioid-prescribing guidelines do not specify the procedure, said Makary. “An ingrown toenail is not the same as cardiac bypass surgery.”

Researcher Zeroes In On The Pre-Clinical Phase Of Alzheimer’s As Way To Stop Disease From Progressing

Reisa Sperling looks at the ten to fifteen year span before the onset of the disease when patients already have build-up of a protein that is believed to trigger the deterioration of the brain. In other public health news: pancreatic cancer, gout, depression, genetic testing, grandchildren for hire, and more.

Risk Level For Harmful Chemicals In Drinking Water Needs To Be 7-to-10 Times Lower Than EPA Recommended, Study Finds

“This study confirms that the EPA’s guidelines for PFAS levels in drinking water woefully underestimate risks to human health,” said Olga Naidenko, senior science adviser at the Environmental Working Group. Other news on the safety of drinking water comes from New York and Cleveland.

Intimidation, Fear Used To Prevent Potential Whisteblowers From Speaking Out, VA Employees Claim

“If you say anything about patient care and the problems, you’re quickly labeled a troublemaker and attacked by a clique that just promotes itself. Your life becomes hell,” said one longtime employee at the Central Alabama Veterans Health Care System. In other veterans’ health care news: a lawsuit over burn pits, the nomination hearing for the president’s pick to lead the VA, and staffing issues at medical centers.

Uno de cada 5 niños detenidos en la frontera tiene menos de 13 años

La administración Trump ha detenido a 2,322 menores de 13 años en medio de las acciones en la frontera, dijo el miércoles 20 de junio un funcionario del Departamento de Salud y Servicios Humanos (HHS) a Kaiser Health News. Representan casi el 20% de los niños inmigrantes que actualmente están bajo custodia del gobierno de los Estados Unidos, mientras avanza la política de “tolerancia cero”.

Su bienestar está siendo supervisado por una pequeña división del Departamento de Salud y Servicios Humanos, la Oficina de Reasentamiento de Refugiados (ORR), que tiene poca o ninguna experiencia en el cuidado de niños pequeños.

El número de niños bajo custodia se ha disparado en las últimas seis semanas, desde que la administración Trump comenzó a detener a los padres y a sus hijos en la frontera de los Estados Unidos, separándolos y enviándolos a diferentes instalaciones. Un total de 11.786 menores de 18 años están detenidos actualmente, dijo el funcionario.

El presidente Donald Trump firmó una orden ejecutiva el miércoles 20 de junio para que se detenga a los padres y a sus hijos juntos.  La orden también pasa la supervisión de este proceso del HHS al Departamento de Seguridad Nacional. Pero no está claro cuándo los niños se reunirán con sus padres, y si esta orden cumplirá con los estandares para el tratamiento de niños bajo custodia, conocido como el acuerdo Flores.

Desde 2003, la ORR ha estado a cargo de albergar y encontrar hogares adecuados para “niños extranjeros no acompañados”, generalmente inmigrantes adolescentes que llegan a los Estados Unidos sin un padre o tutor.

Pero sus responsabilidades han cambiado y han aumentado exponencialmente desde abril por las nuevas políticas migratorias, lo que significa que la oficina ahora es responsable de tener bajo custodia no solo a más niños, sino también a niños mucho más pequeños que los que llegaron en el pasado, dijeron expertos.

Más allá de la atención médica especializada, los niños más pequeños tienen diferentes necesidades de alimentos y vivienda, y requieren una atención personalizada.

“Los niños son más chiquitos y estarán allí por un tiempo más prolongado, y están profundamente traumatizados al ser separados de sus padres por la fuerza”, dijo Mark Greenberg, ex funcionario de la Administración para Niños y Familias del HHS, que supervisa la ORR. “Todo eso hace que sea mucho más difícil operar el programa”.

La compleja crisis se magnifica por la inexperiencia de algunos de los responsables políticos que lideran estas acciones, dijeron los críticos, entre ellos ex funcionarios de las administraciones republicana y demócrata de la última década.

Scott Lloyd, director de la ORR, es un abogado cuya carrera se ha centrado en impulsar estrategias contra el aborto. Fue el que dirigió los esfuerzos legales de la administración Trump para prohibir abortos en inmigrantes adolescentes detenidas. La principal experiencia de inmigración de Lloyd antes de liderar la ORR fue la investigación para un informe sobre refugiados realizada para los Knights of Columbus, una organización católica con una postura antiabortista, según una declaración en una demanda presentada por la Unión de Libertades Civiles de los Estados Unidos.

Kenneth Wolfe, el vocero de HHS que proporcionó las cifras de menores detenidos, se negó a contestar preguntas sobre cuántas personas trabajan actualmente en la ORR o si la oficina ha asegurado personal adicional o la experiencia necesaria para hacer frente a la afluencia de niños pequeños. Tampoco dijo cuántos de los 2,322 niños menores de 13 años han sido separados de sus familias.

Antes, la administración se había negado a proporcionar las edades de los niños separados de sus familias, diciendo solamente que alrededor de 2,300 niños han sido separados y detenidos desde que la política entró en vigencia.

Las condiciones de detención, que incluyen a niños retenidos en corrales y tiendas de campaña, han encendido una tormenta política sobre posibles abusos en el tratamiento de niños de tan solo 4 años. Algunos de estos niños, incluidos los más pequeños, están siendo enviados a refugios especiales para niños pequeños, según informes de medios. La atención también es costosa: solo las tiendas le cuestan al HHS $775 por persona por día, según estos reportes.

Los republicanos, incluida la ex primera dama Laura Bush, han pedido a la administración que ponga un freno a estas acciones. El presidente Donald Trump ha culpado al Congreso por las detenciones, pero los principales asesores de la Casa Blanca han promovido activamente las separaciones familiares como un cambio de política.

Los informes de noticias han descrito a los niños de hasta 5 años siendo regañados por jugar, un adolescente enseñando a otros cómo cambiar el pañal de un niño pequeño, y cuidadores a los que no se les permite tocar a los niños. ProPublica informó que más de 100 niños detenidos son menores de 4 años.

La ORR, agregan los expertos, ya está en desventaja.

“Es muy difícil y costoso crear esa capacidad”, señaló Robert Carey, ex director de la ORR durante la administración Obama. “Todos los aspectos de la atención son dramáticamente diferentes en función de la edad… se necesitan personas capacitadas en el desarrollo o cuidado de la primera infancia”.

Esa es una carga pesada para una oficina que, insisten expertos, nunca fue pensada para servir como un sistema de vivienda a largo plazo.

Carey y otros dijeron que no está claro si la administración tuvo suficiente tiempo o apoyo para adaptarse.

Muchos empleados de la ORR, agregó Carey, son personal de carrera con amplios conocimientos sobre inmigración y bienestar infantil, con quienes él mismo trabajó frecuentemente durante su mandato.

“Los niños están bajo la custodia de la ORR sin los recursos adecuados”, dijo Shadi Houshyar, quien dirige las iniciativas de primera infancia y bienestar infantil en Families USA, un grupo de defensa. “Definitivamente va a dar lugar a que se tomen decisiones potencialmente perjudiciales”. La capacidad, el entrenamiento y la orientación fundamentales, como la comprensión de las necesidades de los niños, no es la orientación que tiene la ORR”.

Mientras la ORR tiene un historial de ubicar a adolescentes que llegan solos con parientes en los Estados Unidos, ese desafío crece por la política de separar a los niños, que son pequeños y pueden entender muy poco sobre esta experiencia, o pueden no ser capaces de identificar a los familiares que podrían acogerlos.

Para complicar más las cosas, cuando las familias están separadas, los padres e hijos son monitoreados por diferentes agencias federales: los padres por el Departamento de Seguridad Nacional y los niños por la ORR. A los niños pequeños se los trata de la misma manera que a los menores que llegaron por su cuenta. Todo esto hace que la reunificación sea más difícil. Y ese es un problema que preocupa a los expertos, incluso si se termina con las separaciones familiares.

“No parece que hayan encontrado una solución a este proceso”, dijo un ex funcionario de HHS, que solicitó el anonimato porque podría enfrentar problemas profesionales por hablar en público. Como resultado, agregó, “el tiempo que el niño permanece en la ORR podría ser significativamente más prolongado”, lo que a su vez aumenta el trauma y causa otros problemas a largo plazo.

La cobertura de KHN de los problemas de salud de los niños es apoyada en parte por la Heising-Simons Foundation.

1 In 5 Immigrant Children Detained During ‘Zero Tolerance’ Border Policy Are Under 13

The Trump administration has detained 2,322 children 12 years old or younger amid its border crackdown, a Department of Health and Human Services official told Kaiser Health News on Wednesday. They represent almost 20 percent of the immigrant children currently held by the U.S. government in the wake of its latest immigrant prosecution policy.

Their welfare is being overseen by a small division of the Department of Health and Human Services — the Office of Refugee Resettlement (ORR) — which has little experience or expertise in handling very young children.

The number of children has exploded in the past six weeks since the Trump administration moved to stop parents and their children at the U.S. border and separate and detain them in different facilities. A total of 11,786 children under age 18 are currently detained, the official said.

Since 2003, ORR has been charged with sheltering and finding suitable homes for “unaccompanied alien children” — generally teenaged immigrants who reach the United States without a parent or guardian.

But its responsibilities have morphed and multiplied since April because the immigration crackdown means that the ORR is now responsible for detaining not only more children, but minors who are far younger than those who had arrived in the past, experts said.

Beyond specialized medical care, younger children have different food and housing needs, and require more personal attention.

“The children are younger and will be there for a longer time and are deeply traumatized by being forcibly separated from their parents,” said Mark Greenberg, a former administration official at HHS’ Administration for Children and Families, which oversees the ORR. “All of that makes it much more difficult to operate the program.”

The complex crisis is magnified by the inexperience of some of the political appointees leading the response, said critics who include former officials from both Republican and Democratic administrations of the past decade.

ORR Director Scott Lloyd is a lawyer whose career has been focused on anti-abortion efforts. He led the Trump administration’s legal efforts to prevent abortions for detained teen immigrants. Lloyd’s main immigration experience before leading ORR was research for a report on refugees for the Knights of Columbus, a Catholic service organization with an anti-abortion stance, according to a deposition he gave in lawsuit filed by the American Civil Liberties Union.

Kenneth Wolfe, the HHS spokesman who provided the figures, declined to address how many people are currently working at ORR or whether ORR had secured additional staff or expertise to cope with the influx of young children. He also would not say how many of the 2,322 children 12 and younger have been separated from their families.

The administration had previously refused to provide the ages of the children separated from their families — saying only that about 2,300 children have been separated and detained since the policy took effect.

The detention conditions, which include children being held in chain-link holding pens and “tent cities,” have ignited a political firestorm over possible abuse in the treatment of children as young as 4. Some of these younger children — including toddlers — are being sent to “tender age” shelters, according to media reports. The care is also costly: Tents alone cost HHS $775 per person per day, according to media reports.

Republicans, including former first lady Laura Bush, have called on the administration to stop the policy. President Donald Trump has blamed Congress for the detentions, but top White House advisers were actively promoting family separations as a policy shift.

News reports have described children as young as 5 being scolded for playing, one teenager teaching others how to change a small child’s diaper, and caretakers not being permitted to touch children. ProPublica reported that more than 100 children detained are younger than 4.

ORR, experts add, is already at a disadvantage.

“It’s significantly challenging to create that capacity, and quite expensive,” noted Robert Carey, a former ORR director from the Obama administration. “All the aspects of care are dramatically different based on age. … You need people who are trained in early childhood development or care.”

That’s a heavy lift for an office that, experts stress, was never built to serve as a long-term housing system.

It’s not clear, Carey and others said, that the administration has had sufficient time or support to adapt.

Many ORR employees, Carey added, are career staffers with deep knowledge about immigration and child welfare, with whom he frequently worked while in office.

“The kids are going into the custody of ORR without adequate resources,” said Shadi Houshyar, who directs early childhood and child welfare initiatives at Families USA, an advocacy group. “It’s definitely going to result in some potentially damaging decisions being made. The capacity, training and fundamental orientation — while understanding the needs of children — is not the orientation that ORR has.”

While ORR has a history of placing teenagers who arrive on their own with relatives of families in the U.S., that challenge is heightened by the policy of separating children, who are young and may understand little of the experience or be able to identify relatives who could take them in.

Making matters more complicated, when families are separated, parents and children are tracked by different federal agencies — the parents by the U.S. Department of Homeland Security, and the children by ORR. Children are also tracked and treated the same as minors who arrived on their own. Together, that makes reunification more difficult. And that’s a problem experts worry will persist, even if family separations cease.

“It does not look like they’ve figured out this process,” said a former HHS official, who requested anonymity because she could face professional ramifications for speaking publicly. As a result, she added, “the time the child stays in ORR could be significantly longer” — which in turn adds to trauma and causes other long-term problems.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Parents Worried Pharma Company’s Plans For Cannabis Drug Will Interfere With Access To Medical Marijuana

Families that rely on states’ medical marijuana laws are more cautious than celebratory as one company’s actions to make sure its product can be legally prescribed and sold by pharmacies threaten to curtail programs that have been in effect for years. Marijuana news comes out of New York, Florida and Virginia, as well.

Parents Worried Pharma Company’s Plans For Cannabis Drug Will Interfere With Access To Medical Marijuana

Families that rely on states’ medical marijuana laws are more cautious than celebratory as one company’s actions to make sure its product can be legally prescribed and sold by pharmacies threaten to curtail programs that have been in effect for years. Marijuana news comes out of New York, Florida and Virginia, as well.

When Others Have Given Up On Patients, This Neurologist Steps In

Dr. Alice Flaherty likes to tinker with machines until she fixes what’s broken. And her current interest involves patients who others say aren’t really sick or lack motivation to get better. “I got interested in that whole thing, like if you want to get better then you’re sick, if you don’t want to get better, then it’s a vice,” she says. “What was it that made us attribute willfulness to people who were obviously miserable?” In other public health news: smoking, video game addiction, autism, diets, ticks, alternative medicines, and more.