Well past seven one evening in 1988, after the nurses and the office manager had gone home, as he prepared to see the last of his patients and return some phone calls, Dr. Lou Ortenzio stopped by the cupboard where the drug samples were kept. Ortenzio, a 35-year-old family practitioner in Clarksburg, West Virginia, reached for a box of extra-strength Vicodin. The box contained 20 pills, wrapped in foil. Each pill combined 750 milligrams of acetaminophen, the active ingredient in Tylenol, with 7.5 milligrams of hydrocodone, an opioid painkiller. Ortenzio routinely saw patients long after normal office hours ended. Attempting to keep up with the workload on this day, he had grown weary and was suffering from a tension headache; he needed something to keep him going. He unwrapped a pill, a sample left by a drug-company sales rep, certain that no one would ever know he’d taken it. Ortenzio popped the pill in his mouth. “It was a feeling like I’d never felt before,” he told me recently. “I’m tense and nervous, and that anxiety is crippling.” The pill took the anxiety away. The sense of well-being lasted for four hours, carrying him through the rest of the night’s work. Back then, Ortenzio was one of Clarksburg’s most beloved physicians, the kind of doctor other doctors sent their own families to see. His patients called him “Doc O.” He made time to listen to them as they poured out the details of their lives. “To me, he wasn’t like a doctor; he was more like a big brother, somebody I could talk to when I couldn’t talk to anybody else,” says Phyllis Mills, whose family was among Ortenzio’s first patients. When Mills’s son was born with a viral brain infection and transferred to a hospital in Morgantown, 40 miles away, Ortenzio called often to check on the infant. Mills never forgot that. As a physician in a small community with limited resources, Ortenzio did a bit of everything: He made rounds in a hospital intensive-care unit and made house calls; he provided obstetric and hospice care. Ortenzio loved his work. But it never seemed to end. He started missing dinners with his wife and children. The long hours and high stress taxed his own health. He had trouble sleeping, and gained weight. It took many years, but what began with that one Vicodin eventually grew into a crippling addiction that cost Ortenzio everything he held dear: his family, his practice, his reputation. The United States is in the midst of the deadliest, most widespread drug epidemic in its history. Unlike epidemics of the past, this one did not start with mafias or street dealers. Some people have blamed quack doctors—profiteers running pill mills—but rogue physicians wrote no more than a fraction of the opioid prescriptions in America over the past two decades. In fact, the epidemic began because hundreds of thousands of well-meaning doctors overprescribed narcotic painkillers, thinking they were doing the right thing for suffering patients. They had been influenced by pain specialists who said it was the humane thing to do, encouraged by insurance companies that said it was the most cost-effective thing to do, and cajoled by drug companies that said it was a safe thing to do. Opioid painkillers were promoted as a boon for doctors, a quick fix for a complicated problem. By the end of the 1990s, Ortenzio was one of his region’s leading prescribers of pain pills. It was a sign of the times that he didn’t think there was anything wrong with that. Clarksburg sits atop rolling hills in northern West Virginia, halfway between Pittsburgh and Charleston. Lou Ortenzio came here in 1978, a recently married young resident out of the University of Maryland School of Medicine. “Small-town living seemed so much better than suburban life,” he told me as we drove around town one afternoon. “In Clarksburg, every block had something going. We had mom-and-pop grocery stores in every neighborhood. All these houses were occupied by teachers, downtown business owners, and people who worked in glass factories.” Coal mining was the state’s dominant industry, but in Clarksburg, the glass business boomed. Glass manufacturing had arrived at the turn of the 20th century, drawn by the state’s high-quality river sand and rich fields of natural gas. Pittsburgh Plate Glass opened a factory in Clarksburg in 1915 and for years was one of the world’s leading plate-glass producers. Anchor Hocking employed 800 people making tumblers, bottles, fruit bowls. The city had family-owned factories too: Rolland Glass, Harvey Glass, and others. Unlike simple resource extraction, glassmaking required sustained technological investment to meet new demands from the marketplace. The mass production of plate glass made skyscrapers possible. Picture windows and sliding-glass doors made small homes look bigger and more luxurious. The industry forged a middle class in Clarksburg and even gave the city a cosmopolitan air. The glass factories attracted artisans from France and Belgium; French was commonly heard on the streets for years. Each neighborhood was a self-contained world, with its own churches, grocery stores, and school; many had a swimming pool. High-school sports rivalries were fierce, and football games drew large crowds. When Victory played Roosevelt-Wilson, or Washington Irving went up against Notre Dame, people knew to arrive early to find a seat. By the late 1970s, Clarksburg’s older physicians were retiring. Like many small towns at the time, it had trouble attracting young professionals. Ortenzio was among the few physicians who moved there to fill the void. He and two other young doctors opened a practice in 1982. Almost immediately, Ortenzio was seeing 40 to 50 patients a day. The people who came to see him were mostly older; many had served in World War II. They had the aches and pains to show for a lifetime of hard work in the glass factories or at the gas company, but they had retired with something approaching financial security. They owned homes and cars, had pensions and good health insurance. Ortenzio’s patients suffered from the ailments of the old—arthritis, diabetes, hypertension—and most of them did so stoically. This was partly generational and partly an Appalachian inheritance. One man, Ortenzio remembered, came to him thin and wasted away from cancer. “The disease was advanced, but he put up with it. I said, ‘Why didn’t you come in earlier?’ He said, ‘Well, I wouldn’t want you to think I was complainy.’ That was the Appalachian line—‘I wouldn’t want you to think I was complainy.’ ” Ortenzio grew into his adopted city. In 1992, he established a free clinic where Clarksburg’s uninsured could get medical care. The county chamber of commerce named him Citizen of the Year for that. He had been trained to treat patients holistically. Most of what a doctor needs to know to make a diagnosis, his professors had taught him, could be learned from taking time to listen to the patient. X-rays and lab tests were mostly to confirm what you gleaned from asking questions and paying attention to the answers. He’d also been trained to help his patients help themselves. Part of his job was to teach them how to take care of their bodies. Pills were a last resort. This careful approach endeared him to his patients, but it lengthened his day. “He would have office hours until 11:30 at night,” says Jim Harris, a friend and the director of the free clinic. “People waited until then because he was worth the wait.” Drug salesmen visited him weekly. It was a stodgy profession back then. Ortenzio remembers the reps as older men who had grown up and lived locally and who cultivated long-term relationships with doctors. One of the reps for Eli Lilly was a deacon in a local Catholic church. Once a week, he would visit Ortenzio’s office in a business suit, with information about the drugs Lilly produced. Like many in his profession in those years, he avoided hard-sell tactics. Ortenzio grew to rely on the salesman’s counsel when it came to pharmaceuticals. Once, when the Food and Drug Administration removed a Lilly drug from the market, the rep dropped by Ortenzio’s office, embarrassed and apologetic. Before long, Ortenzio and his wife saw Clarksburg as home. They found a two-story, three-bedroom house in the Stealey neighborhood, southwest of downtown and at the foot of a hill. They set off to the bank for a 30-year loan. To their surprise, they were denied. “The house won’t keep its value that long,” the banker told them. “The best we can give you is a 15-year loan.” The banker was right. It wasn’t yet clear, amid the bustle of Main Street and Friday-night football, but the city’s prospects were fading. Newer glass technologies required large factories, which meant stretches of flat land rare in West Virginia. Mexico and Japan emerged as competition in glass manufacturing, and plastic and aluminum emerged as alternatives to glass. Pittsburgh Plate Glass had closed in 1974. Anchor Hocking left in 1987. Its hulking concrete plant is slated for demolition, but for now it remains, just off Highway 50. By the mid-1980s, the city was in decline. Glasswork was replaced by telemarketing. Downtown, locally owned stores began to disappear. Homeowners yielded to renters, many relying on Section 8 assistance from the government. The city eventually had to destroy dozens of abandoned homes, leaving streets with toothless gaps. The swimming pools, too, slowly closed; resident associations lacked the money to maintain them. Ortenzio drove me by the massive Robert C. Byrd High School, home of the Eagles. It was built in 1995 to consolidate two smaller high schools in Clarksburg, whose population had receded. Replacing neighborhood schools with one centralized school allowed for better course offerings. But Byrd is far from any student’s home. School consolidation extinguished the sports rivalries that had brought people together each week. Without local schools, neighborhoods lost their social centers. Lou Ortenzio began to see people in economic as well as physical pain. Many were depressed, worn out by work or the fruitless search for it. Obesity became a more common problem. Some patients began to ask whether he could get them on workers’ compensation or disability. Others left to seek job opportunities in New York, North Carolina, Florida. “I was always calling people out of state telling them how sick their parents or grandparents were,” he said. When Ortenzio had opened his practice, he’d tended to see young people only for pregnancies or the occasional broken leg. By the mid-1980s, younger people were showing up in larger numbers. They were coming in with ailments that their parents and grandparents had borne in silence—headaches, backaches, the common cold. “The new generation that came in the 1980s, those kids began to have the expectation that life should be pain-free,” Ortenzio said. “If you went to your physician and you didn’t come away with a prescription, you did not have a successful visit.” The shift was not peculiar to Clarksburg. Americans young and old were becoming accustomed to medical miracles that allowed them to avoid the consequences of unhealthy behavior—statins for high cholesterol, beta-blockers and ACE inhibitors for hypertension and heart failure, a variety of new treatments for diabetes. Fewer patients showed up for annual physicals or wanted to hear what they could do to improve their wellness. They wanted to be cured of whatever was ailing them and sent on their way. Usually that involved pills. The medical establishment, to a large degree, abetted this shift. In the 1980s, a new cadre of pain specialists began to argue that narcotic pain pills, derived from the opium poppy, ought to be used more aggressively. Many had watched terminal cancer patients die in agony because doctors feared giving them regular doses of addictive narcotics. To them, it was inhumane not to use opioid painkillers. The specialists began to push the idea that the pills were nonaddictive when used to treat pain. Opioids, they said, could be prescribed in large quantities for long periods—not just to terminal patients, but to almost anyone in pain. This idea had no scientific support. One author of an influential paper later acknowledged that the literature pain advocates relied on to make their case lacked real evidence. “Because the primary goal was to destigmatize, we often left evidence behind,” he said. Nevertheless, an alliance of specialists who saw their medical mission as eradicating pain was soon joined by the pharmaceutical companies that manufactured opioids. Medical institutions—the Department of Veterans Affairs, the Joint Commission on Accreditation of Healthcare Organizations, hospitals and medical schools across the country—bought into this approach as well. By the late 1990s, medical schools, when they taught pain management at all, focused on narcotics. By the early 2000s, doctors were being urged to prescribe the drugs after almost any routine surgery: appendectomy, ACL repair, wisdom-tooth extraction. They also prescribed them for chronic conditions such as arthritis and back pain. Chronic pain had once been treated with a combination of strategies that only sometimes involved narcotics; now it was treated using opioids almost exclusively, as insurance companies cut back on reimbursing patients for long-term pain therapies that did not call on the drugs. The U.S. drug industry, meanwhile, was investing heavily in marketing, hiring legions of young salespeople to convince doctors of their drugs’ various miracles. Nationwide, the number of pharmaceutical sales reps ballooned from 38,000 in 1995 to 100,000 a decade later. The old style of drug rep, grounded in medicine or pharmacy, largely passed from the scene. “It went from a dozen [salesmen] a week to a dozen a day,” Ortenzio remembered. “If you wrote a lot of scrips, you were high on their call list. You would be marketed to several times a day by the same company with different reps.” Most drug companies in America adopted the new sales approach. Among them was Purdue Pharma, which came out with a timed-release opioid painkiller, OxyContin, in 1996. Purdue paid legendary bonuses—up to $100,000 a quarter, eight times what other companies were paying. To improve their sales numbers, drug reps offered doctors mugs, fishing hats, luggage tags, all-expenses-paid junkets at desirable resorts. They brought lunch for doctors’ staff, knowing that with the staff on their side, the doctors were easier to influence. Once they had the doctor’s ear, reps relied on specious and misinterpreted data to sell their product. Purdue salespeople promoted the claim that their pill was effectively nonaddictive because it gradually released an opioid, oxycodone, into the body and thus did not create the extreme highs and lows that led to addiction. [From April 2006: The drug pushers] The reps were selling more than pills. They were selling time-saving solutions for harried doctors who had been told that an epidemic of pain was afoot but who had little time, or training, to address it. For a while, Ortenzio still suggested exercise, a balanced diet, and quitting smoking, all of which can alleviate chronic pain. But his patients, by and large, didn’t want to hear any of this, and he was busy. So he, too, gradually embraced pain pills. Nothing ended an appointment quicker than pulling out a prescription pad. The number of people on pain pills grew from a tiny fraction of Ortenzio’s practice to well over half of his patients by the end of the 1990s. The shift was gradual enough at first that he didn’t recognize what was happening. Patients with medical problems unrelated to pain migrated to other doctors. Still, Ortenzio was working 16-hour days, seeing patients who had been scheduled for the afternoon at 9 p.m. The more drugs Ortenzio prescribed, the more he was sought out by patients. Many would use up a month’s supply before the month was out; in need of more pills, they were insistent, wheedling, aggressive. Many lied. Some would curse and scream when Ortenzio told them that he couldn’t write them a new prescription yet, or that he wanted to lower their dosage. The pills were soon on the streets of Clarksburg as well. They replaced beer and pot at many high-school parties. Phyllis Mills, Ortenzio’s longtime patient, had two daughters who abused the pills. Theirs did not come from Ortenzio, at least not directly, but the supply of pills was exploding, due in large part to doctors like him who were overprescribing them. Ortenzio should have noticed what the pills were doing, to his patients and his community, but he was less and less himself. After his late-night encounter with Vicodin in 1988, he had begun his own slide into addiction. By the late 1990s, he was using 20 to 30 pills a day, depleting even the plentiful supply of free samples from the ubiquitous sales reps. Desperate to get his hands on more pills, he found a friend he could trust, a middle-aged accountant and a patient of his. “I’m in some trouble,” Ortenzio told him. “If I write you this prescription, can I ask you to fill it and bring it back to me?” “Sure thing,” the man said, without asking for an explanation. “If you gotta have it, you gotta have it. You’re the doc.” Soon a dozen or so trusted patients were helping Ortenzio. He knew he was out of control and needed help—even the amount of acetaminophen he was consuming was toxic—but he feared that seeking treatment for his addiction might cost him his medical license. Around 1999, he found a new way to get his fix. He began writing prescriptions in his children’s names. Ortenzio could plainly see that the claim that these pills were nonaddictive was untrue. He would try to quit and feel the symptoms of withdrawal. “I couldn’t be away from my supply,” he said. His patients, too, were terrified of going without. One, a nurse at a local hospital suffering from chronic pain as well as depression and anxiety, would approach him in his office parking lot, often bearing gifts of quilts or canned goods, insisting that she needed her pills that morning, that she couldn’t wait for her monthly appointment. Ortenzio saw no way to break the cycle the pills had created for the people in his care. He never found a way to get his patients down to lower doses of narcotics. They rebelled when he suggested tapering; just cutting people off made them sick. The area didn’t have enough pain clinics or addiction specialists to refer them to, and insurance companies wouldn’t reimburse for many pain treatments that did not involve pills. Without good alternatives for his patients, he kept on writing prescriptions. Addiction and overwork had estranged Ortenzio from his wife and children. As Clarksburg declined, his wife moved the kids to Pittsburgh to find better schools. In 2004, after more than a decade of living in different cities, they divorced. Raised Catholic but without much feeling for the Church, Ortenzio joined a Protestant congregation. Ultimately, he found Jesus in his exam room. During an appointment one day, he and a patient, a Baptist, talked of his search for redemption. The patient knelt with Ortenzio on the linoleum floor and prayed for the doctor. Ortenzio marks that moment as his new beginning. He had advantages many addicts don’t have: a home and a car, financial resources, generous friends and colleagues, and, later, the support of a second wife. He managed to taper off the drugs. A couple of months later, he was baptized in a deep section of Elk Creek, where baptisms have taken place since the early 1800s. Not long after that, federal agents raided his office. They interrogated his staff and confiscated hundreds of patient records. The investigation dragged on for nearly two years. His children had to testify before a grand jury that they knew nothing about the prescriptions their father had written in their names. In October 2005, prosecutors charged Ortenzio with health-care fraud and fraudulent prescribing. That year, 314 West Virginians died from opioid overdoses, more than double the number of people five years earlier. By 2006, according to the Centers for Disease Control and Prevention, physicians were writing 130 opioid prescriptions for every 100 West Virginians. In March 2006, Ortenzio pleaded guilty. His sentencing occurred shortly after a 2005 Supreme Court decision made federal sentencing guidelines nonmandatory and individual sentences up to judges’ discretion. Despite what he’d done, Ortenzio was still beloved in Clarksburg. More than 100 people wrote to the judge on his behalf. He received five years of supervised release plus 1,000 hours of community service, and was ordered to pay $200,000 in restitution. He would serve no prison time, but he did lose his medical license. At 53, Ortenzio was unemployed. A temp agency offered him a landscaping job at the Stonewall Resort, where, as a doctor, he had taken his family for Sunday brunch. He’d never worked outdoors in his life, but he took the job. It paid $6.50 an hour. He worked at the resort for a couple of months, then as the janitor at a local community center before returning to Stonewall as a full-time groundskeeper. He also found a night job. Tom Dyer is one of northern West Virginia’s leading defense attorneys; Ortenzio had been his client. One night in 2006, Dyer ordered a pizza from Fox’s Pizza Den in Bridgeport, a town near Clarksburg. When the doorbell rang, he opened the door and there stood Lou Ortenzio, holding a pie. It took a minute before Dyer realized: Doc O was now a pizza-delivery guy. “I was just speechless,” Dyer told me. “I made pizza deliveries where I used to make house calls,” Ortenzio said. “I delivered pizzas to people who were former patients. They felt very uncomfortable, felt sorry for me.” But, he said, “it didn’t bother me. I was in a much better place.” Ortenzio eventually left pizza delivery. But the way he told me the story, the job was an important step in his recovery: Every pie he delivered liberated him. He was free of the lies he’d told his colleagues, his family, and himself to hide his addiction. He liked hearing kids screaming “The pizza guy’s here!” when he knocked on the door. “You make people happy,” he said. “That was what I liked about being a doctor.” Today, Ortenzio spends his days trying to atone. He does this through constant work. There are places in and around Clarksburg where addicts can get help, and Ortenzio can be found at most of them. The Mission opened in 1969, in Clarksburg’s Glen Elk neighborhood, at the time a small red-light district with bars and backroom gambling. The shelter started with a few beds, intended for alcoholics and homeless veterans. A neon-blue jesus saves sign outside has remained illuminated for all the years since, as the shelter has expanded. Today, many of its 120 beds are occupied by opioid addicts. One afternoon, I met Ortenzio in a small, windowless office at the Mission. Now 66, he is thin, gray-haired, and bespectacled; he dresses in a hoodie, blue jeans, and sneakers. He does a bit of everything at the Mission, from helping the addicted find treatment to helping them find a coat, or shoes for their children, or a ride to the probation department. He is a volunteer adviser there, too, and at the county’s drug court, where he guides addicts through the criminal-justice system. Ortenzio is also involved with two newer initiatives, which suggest the challenges of repairing the damage done by opioids. A wood-beamed downtown church is home to Celebrate Recovery, a Christian ministry founded in Orange County, California. Celebrate Recovery has grown nationwide due in large part to the opioid epidemic. On the cold Tuesday night I visited, the service featured an electric band singing the kind of fervid new gospel music that is common to nondenominational Christianity: “You are perfect in all of your ways …” Ortenzio is Celebrate Recovery’s lay pastor in Clarksburg, running its weekly services. The flock is about 100 or so strong. One evening, a young mother named Sarah stood before the congregation to give her testimony. Sarah’s story started with parents who married too young and divorced before she was 3. It featured father figures who were coal miners and truck drivers and a stepfather who molested her repeatedly, beginning when she was 8. Then a life of illicit drugs, marriage, divorce, and addiction to prescription pain pills. Clarksburg’s traditional congregations have dwindled along with the city’s population; many rely on support from former residents who commute in from elsewhere on Sundays. The place these churches once held in this community has been taken by new churches proclaiming a gospel of prosperity, insisting that God wants us all to be rich. And by ministries such as Celebrate Recovery. Ortenzio coordinates the training of recovery coaches at the church, people who can help addicts as they try to wean themselves from narcotics. Addiction, however, seems as present as ever in Clarksburg. At the Mission one day, I met a group of recovering young drug users. Several of them had started out on heroin but then turned to meth. In Clarksburg and many other parts of the country, meth is coming on strong, poised to be the fourth stage in an epidemic that began with prescribed pills, then moved to heroin, and then to fentanyl. Meth seems to reduce the symptoms of withdrawal from opioids, or maybe it’s just a way to get high when anything will do. Whatever the case, like the various forms of opioids before it, meth is now in plentiful supply in Clarksburg. A couple of years ago, Ortenzio decided to open a sober-living house downtown, where recovering addicts could spend six months or more stabilizing their lives. He said God had instructed him to undertake the project, and had told him, in fact, where to do it—in a house right around the corner from the duplex where Clarksburg’s first resident overdosed on fentanyl. In 2017, more than two West Virginians a day were being claimed by opioids. Recovering addicts needed places where they could maintain sobriety. “We thought, This is going to be great. They’ll throw a parade for us,” says Ben Randolph, a businessman whom Ortenzio helped recover from pill addiction. Instead, the idea of a sober-living house outraged many in town. The principals of two local schools were concerned that the house was too close to their campuses. Owners of local businesses worried that the house might further tarnish the city’s image. “The property value of the homes around it are going to plummet. You’re going to have both drug dealers and recovering addicts in one area, so they’ll have a captive market,” one resident told The Exponent Telegram. But Ortenzio persisted, and a bank eventually granted him a mortgage. Since July 2017, he has run a six-bed home for men, with daily supervision and no problems—no spike in crime nearby, no complaints of loitering—reported so far. A similar home for women opened last May. Nevertheless, the episode showed where the city, perhaps even the country, was when it came to addiction: afflicted mightily and wanting it to go away, but not knowing how to make that happen. Lou Ortenzio was the first Clarksburg doctor prosecuted for improperly prescribing pain pills. He was the first person most residents I talked with recall as putting a different face on addiction. He was the first to show that this was a new kind of drug plague, and the first to puncture the idea that the supply came from street dealers. He was also the first to publicly work at his own recovery without shame. He was not, however, alone. In 2005, another local doctor, Brad Hall, gathered with members of the West Virginia State Medical Association concerned about addiction among physicians in a state that cannot afford to lose them. They started the Physician Health Program, which has helped some 230 West Virginia doctors with substance-abuse problems get confidential treatment and retain their license to practice. Many are overworked, as Ortenzio had been. Some were self-treating emotional and physical problems. About a quarter abused opioids. Ortenzio managed to escape drugs, but he’s still living with the effects of his addiction. He is working to repair his relationship with his youngest son; Ortenzio didn’t attend his wedding and has yet to meet a young grandson. He leans on his faith to keep him going. Many of his encounters with addicts prompt sudden, public prayers, Ortenzio bowing his head as he clasps the person’s shoulder. His faith has humbled him, relieving him of a sense of hubris that got him into trouble as a doctor: the idea that he could heal an entire community, if he just kept the office open a few hours longer. Doc O will never practice medicine again. Yet his work at the Mission doesn’t seem so different from his routine as a family physician, tending to the needs of one person after another. One morning, he took a resident to a clinic, then talked on the phone with an addicted doctor living in a halfway house. A pastor from the coalfields of southern West Virginia called to ask how to set up a Celebrate Recovery ministry in his large but dying church. A 24-year-old mother of four from a West Virginia mountain town was looking for $225 to pay the utilities for an apartment she was trying to rent. Ortenzio promised to reach out to the Mission’s supporters for a donation. As the morning wore on, a gaunt 26-year-old man from North Carolina, a construction worker addicted to heroin and meth, showed up to report that he’d had five of his teeth pulled. The dentist had prescribed a dozen hydrocodone pills. The construction worker couldn’t fill the scrip without proper ID, which he didn’t possess. Ortenzio sat and listened as the young man, slumped beneath a baseball cap, stared at the floor and insisted on his need for the painkiller. The dentist had probably figured that the fellow had lost a lot of teeth, that a dozen pills weren’t many. If that were the case, it would mark a change. Not that long ago, the dentist might have prescribed 20 to 40 pills. Ortenzio offered the construction worker a prayer. The man clearly still wanted the drugs. Ortenzio, who as a doctor had prescribed pills by the hundreds each day, could only give him packets of ibuprofen. “You want to stay away from hydrocodone,” he said. This article appears in the May 2019 print edition with the headline “The Penance of Doc O.” from https://www.theatlantic.com/magazine/archive/2019/05/opioid-epidemic-west-virginia-doctor/586036/?utm_source=feed
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The first time I tried on a pair of Allbirds sneakers, I was in the brand’s San Francisco boutique, sitting on a gently curved wooden stool designed to tip forward in aid of shoe-changing. The stool was created by the same people who design the start-up’s shoes, and it made me feel the same combination of familiarity and irritation: Do we really need tech to disrupt the established technology of stools and sneakers? My answer, after sitting on the stool and trying the shoes, is a begrudging, contemptuous “sometimes.” The tip forward helped. And the shoes, I silently admitted to myself, were astonishingly comfortable. Allbirds has been selling sneakers made from environmentally friendly materials since 2016. The brand’s most recognizable style is its Runner, which looks a lot like a logo-free, work-appropriate version of Nike’s popular Roshe One. It’s what a running shoe needs to be in order to fly under the radar in an office. In theory, I should be the brand’s ideal customer: I hate uncomfortable shoes, I work in an office with a vaguely casual dress code, and I’ve owned several pairs of Roshe Ones. I’m a member of the digital creative class in which Allbirds has found its most dedicated market, which includes the Silicon Valley tech workers often characterized as the brand’s biggest fans. When I look around at work or in my neighborhood in New York City, I often spot a pair. Instead, for Allbirds’ entire three-year existence, I’ve hated what I believed the company was pushing. I spent a decade covering the fashion industry, and the “noise” the company cut through with its super-simple shoes, I told myself, was actually a vibrant, imaginative world of glow-in-the-dark high tops and snakeskin stilettos. Allbirds seemed like a way for men to intellectualize their way out of personal taste in favor of start-up culture’s efficient sameness. I had, on more than one occasion, referred to the shoes derisively as “Yeezys for software developers.” Press coverage of the company is divided along similar lines: Some writers praise the brand’s style and functionality, others lament its popularity as proof that the algorithms are winning. Much of the fashion industry is firmly in the latter camp. Structurally and philosophically, the fashion industry isn’t great at dealing with change. American life has been casualizing since the 1990s, and nowhere is that clearer than in offices. The trend has left both designers and shoppers confused about what people should be wearing for jobs that were much different (or entirely non-existent) before the advent of the cell phone. Now, Silicon Valley is stepping into the rift it helped create. Start-ups want to help people get dressed—and they might beat fashion at its own game. In another time, developing manufacturing or textile technologies and licensing them to existing brands might have been the whole story of these new companies. But the upheaval in the American wardrobe has let outsiders into fashion’s territory, according to the fashion historian Nancy Deihl. “The idea of ‘careerwear’ is so dispersed and a little less determined,” says Deihl, a professor at New York University. “The career office [at NYU] has these little workshops on what to wear to interviews and things because there isn’t this kind of monolithic style guidance out there.” Not only has the American office gone more casual, but work itself has changed since Dockers started pushing business-casual dressing in 1992. More women than ever before are living full professional lives, and they need shoes that do much more than just look appropriately conservative with a skirt suit. “It isn’t like, ‘Oh, I wear sneakers while I commute and then I put my heels on in the office,’” says Kerry Cooper, the president and chief operating officer of Rothy’s, a start-up that specializes in women’s shoes and rivals Allbirds in newfound prominence. “That’s just sort of a silly, non-modern way of thinking.” Six months ago, I bought a pair of Rothy’s. Nothing about start-up shoes had changed, but my job had: When The Atlantic hired me, I left the fashion world and found myself in a realm of indeterminate business-casualness. In spite of years spent writing about how people shop, I had no idea what I was supposed to wear. The harder I looked for an answer, the clearer it became that no one else did, either. Rothy’s is a 3-year-old start-up that makes women’s flats from recycled plastic. The shoes are bright and feminine, which has made them common in the aesthetically pleasing environs of Instagram, where women post about their colorful collections. Instead of the leathers or textiles common in footwear manufacturing, Rothy’s knits its uppers (the part of the shoe that covers the foot) from soft, durable thread made from recycled plastic bottles. Allbirds and Rothy’s have charted remarkably similar paths: Both companies started selling their shoes in 2016, and they say they’ve each pulled in more than $100 million in revenue and sold more than a million pairs of shoes. Both brands emphasize their sustainable materials and manufacturing practices. Although the companies are based on the same street in San Francisco, they do their biggest sales numbers on the East Coast: Allbirds sells better in New York City than anywhere else, while Rothy’s colorful flats are a hit in D.C. In charting a way forward in textiles and manufacturing, both Rothy’s and Allbirds offer something valuable to fashion that the industry itself has repeatedly declined to pursue. For traditional fashion brands, which usually use third-party textiles and factories, designers have to start guessing what shoppers might want as much as a year in advance. Rothy’s says that their three-dimensional knitting process dramatically shrinks both the amount of material waste from manufacturing and the timeline between when the company places an order and when those shoes can be put up for sale. “If there’s something bananas that no one could have predicted, we’d rather not overproduce colors we have to bet on. It’s such a waste,” says Erin Lowenberg, the Rothy’s creative director. Allbirds, for its part, uses wool and eucalyptus textiles for its sneakers, and it worked with a Brazilian chemical company to develop foam soles made from the waste of sugarcane processing. In conventional sneakers, that foam is made with fossil fuels. For any of the existing players in the fashion supply chain, there’s little incentive to invest in new materials or techniques. If a textile company develops a waste-reducing product, there’s no promise that brands will order it or their factories will be able to process it. If no one ever develops or orders new textiles, factories won’t shift to accommodate them. It’s a standoff, and it makes fashion allergic to innovation on a structural level. Manufacturing waste, combined with the overproduction that happens when designers inevitably make a wrong guess about consumers’ future whims, account for a huge portion of the fashion industry’s well-documented harm to the environment. As I tried on sneakers in the San Francisco Allbirds shop, I found myself in the middle of an existential crisis. I looked around for the sense of aesthetic doom that critics assured me the shoes’ popularity promised. Instead of the suffocating sameness or joyless efficiency that critics have ascribed to the shoes, I saw just a small, conventional boutique in which a handful of customers ranging from teen boys to female retirees were trying on sneakers. Tim Brown, Allbirds’ cofounder, seems aware of—and chafed by—the insinuation that his shoes are boring, or only for tech bros. “I actually think there is excitement in the simplicity and calmness, which belies an enormous amount of work,” he says of the design. He also says women have always made up the majority of Allbirds’ customers. I was having trouble remembering what so many fashion people found threatening. Upstairs from the shop, in an impromptu studio, some Allbirds employees were photographing the simple sneakers against an Instagram-friendly peachy background with giant Monstera leaves as props. On the feet of the young women who worked in the office, the shoes were free of the jarring, swagless business-athlesiure aesthetic I’d always associated them with. Like Uggs, Birkenstocks, Crocs, and Tevas before them, it started to feel like fashion’s Allbirds acceptance was both inevitable and, at worst, completely fine. All it takes for any particular shoe to make the crossover is for some already-cool people to decide it should. (Case in point: New Balance sneakers are currently having a moment.) Silicon Valley has done more than enough to earn knee-jerk skepticism. For all the middle-class conveniences its new technologies and platforms have offered us, its tools have also been used for disseminating propaganda, inciting genocide, and destabilizing whatever notions of privacy most Americans might have had in the 1990s. Allbirds found its first audience on the crowdfunding platform Kickstarter, so the associations between the brand and internet behemoths were probably unavoidable, even if improving fashion manufacturing isn’t quite as questionable as anything Facebook might be up to on a given day. The fashion industry has long been selling vaguely harmful cultural influence, too, but it benefits from how much people want to be cool, and how well it has managed to be a gatekeeper to the designation. If you don’t like the idea of wearing the same shoe for all occasions, Allbirds’ Zwillinger says that you can blame a familiar modern villain: your smartphone. “Everyone works on their phones now, and maybe in different chunks of the day and over the weekend,” he says. “It’s a different experience, and you’d expect the wardrobe to evolve so it can float in and out of those activities more fluidly.” For a certain chunk of the population, there isn’t an opportunity to go home and change into a dinner outfit after work, or a clear border between work and not-work at all. If your head’s always in the office, maybe you feel like your feet should be, too. And if that’s the case, the shoe isn’t the problem. On the subway home from work recently, I looked around at my fellow riders’ feet, as I had been for weeks while thinking about this story. I spotted a pair of Allbirds on an unfashionable millennial man in dress pants, sure, but there were also two identical pairs of Gucci loafers on women wearing post-gym mixtures of athleisure and work clothing. Another rider was wearing a pair of Adidas Superstar sneakers exactly like my own. In San Francisco, I had seen plenty of Superstars while I was getting to the bottom of whether or not new start-ups were conspiring to make us all wear the same shoes. I no longer have much of a grasp on what made the ubiquity of my sneakers or those Gucci loafers shoes less troubling than the ubiquity of Allbirds or Rothy’s, which now mostly just seem like a comfortable, useful tool to have in a busy person’s wardrobe, even if they don’t really meet my personal definition of “cool.” It all suddenly feels a bit Chicken Little. Maybe the sky wasn’t really falling. But if there’s one thing the fashion industry loves more than uncomfortable shoes, it’s a bit of drama. from https://www.theatlantic.com/health/archive/2019/04/allbirds-rothys-silicon-valley-shoe-fashion/587428/?utm_source=feed The last two weeks have been frenetic for Bre Hushaw, who is now known to millions of people as the girl in the depression helmet. Hushaw has been hearing from people all around the world who want to try it, or at least to know how it works. Her life as a meme began when she agreed to an on-camera interview with the local-news site AZfamily.com for a story headlined “Helmet Approved by FDA to Treat Depression Available in Arizona.” The feel-good tale of Hushaw’s miraculous recovery from severe depression was tossed into the decontextualizing maw of the internet and distilled down to a screenshot of a young woman looking like a listless stormtrooper. Jokes poured in. Some of the most popular, each with more than 100,000 likes on Twitter, include: “If u see me with this ugly ass helmet mind ur business.” “Friend: hey everything alright? Me, wearing depression helmet: yeah I’m just tired.” “The depression helmet STAYS ON during sex.” Hushaw has been tracking the virality, sometimes cringing and sometimes laughing. She replies to as many serious inquiries as she can, while finishing up her senior year at the University of Northern Arizona before starting a job in marketing. A year ago, she didn’t think she was going to live to graduation. Back when she was 10 years old, her mother died. Her depression symptoms waxed and waned from then on, and they waxed especially when she heard the gunshots on her campus during a shooting at the school in 2015. She tried many medications over the years—14, by her count. “From age 15 until I was 20, I was extremely suicidal, and I was self-harming,” she told me last week. She recounted multiple related hospitalizations, and a gradual loss of faith in the medical system. So last year, when Hushaw learned of a helmet that promised to magnetically rewire her brain, she saw this as an obvious yes. The helmet contains magnets that exert energy on the electrical functioning of the brain, a process known as transcranial magnetic stimulation, or TMS. Hushaw went to a clinic and absorbed electrical impulses for 20 minutes every (business) day for six weeks. [Read: Why a ‘lifesaving’ depression treatment didn't pass clinical trials] Though Hushaw likens the feeling to being “tapped” by a pencil, the chin strap makes it appear as if the helmet is going to blast her with energy. This didn’t help with the jokes. I retweeted the news story with, “After wearing it you feel like a weight has been lifted off you.” That made me feel clever until I actually read the story and saw that Hushaw said almost exactly the same thing—“I felt like there was a huge blanket that was lifted off my shoulders and I felt completely free”—referring to suicidal depression. Hushaw is okay with it. Despite the mockery, she’s overall thrilled by the attention given to the helmet. The image above is a recreation—she went back to the clinic to take the photo, and she sent it to me. I didn’t ask her to do this. But she is passionate: “I just want to make sure that people are getting help,” she said. “I had a friend commit suicide on my campus and I just never want that to happen again.” As she put it multiple times, “It actually, really saved my life.” The attention Hushaw’s story received is testament to how few people know what to make of TMS. Even when I surveyed physician friends about it, several hadn’t heard of it, and no one had seen it used in more than a rare case. It is certainly not woven into typical treatment plans. Researchers at some academic institutions are taking the technology seriously. Yale has a Transcranial Magnetic Stimulation Research Clinic, and the service is offered at Johns Hopkins. There have been numerous studies suggesting promising clinical uses, including one this week in the journal Neurology. But the mechanisms proposed are vague. TMS may be beneficial in treating addiction, according to a 2017 paper in Nature Neuroscience Reviews, by “influencing neural activity ... throughout the brain.” According to the Mayo Clinic: “Though the biology of why TMS works isn’t completely understood, the stimulation appears to impact how the brain is working, which in turn seems to ease depression symptoms and improve mood.” Yes, TMS seems to impact how the brain is working. These statements are not abdications of explanatory burden, but come close to the extent of what is known. Serenity Mental Health Centers, the Arizona clinic that provided Hushaw with the electromagnetic treatment, claim that “people with depression often have areas of their brain with decreased activity, and people with [obsessive-compulsive disorder] often have overactive areas of their brain, so TMS stimulates and resets those regions of the brain.” The notion that the device has dramatic effects on the structure or function of the brain is at odds, though, with the U.S. Food and Drug Administration’s classification. In March, the regulatory agency issued a rule deeming them Class II medical devices, along with electric wheelchairs and pregnancy tests, which means that they are presumed to be safe. Most therapeutic devices that affect human physiology are Class III, which would certainly be the case with anything that “resets the brain.” The FDA argued that a Class II designation would “enhance patients’ access to beneficial innovation, in part by reducing regulatory burdens by placing the device into a lower device class than the automatic Class III assignment.” The first TMS helmet approved by the FDA, Neurostar, was for treatment of major depressive disorder, in 2008. Others have been since, as the market began to boom. On Tuesday, Brainsway, the company that made the helmet used by Hushaw, announced its initial public offering. Brainsway was also approved for obsessive-compulsive disorder in August of 2018, and the publicity efforts around this approval were what eventually led to Hushaw’s news fame, according to the marketing director of the clinic that provides the helmet, Sunrise Mental Health Centers. This marketing director, Candise Miller, has her own miraculous personal story of recovery via TMS. “My life is forever changed. I’m a completely different person,” she told me. She asked me to include a link to the clinic’s home page, which features her testimonial but does not mention that she is director of marketing. Until the FDA’s new classification this year, the agency had reigned in marketing of such health claims by requiring pre-market approval for TMS devices. Manufacturers had to submit evidence that the devices had no immediately obvious adverse effects and at least a small amount effectiveness. For instance, the FDA said it based approval of Brainsway for OCD on a single study of 100 people, which showed improvements in some patients. A control group wore actual TMS helmets that secretly weren’t turned on. Presumably due to placebo effect, this group also saw an 11 percent decrease in symptoms. Like most treatments in psychiatry, there is value in showing up, and in believing you are being treated. These and other mechanisms are mysterious, and the effects are unreliable—attesting to the complexity of mental illness, and the many factors that go into causing and treating it. The basic idea of shocking the system into compliance has deep roots. Since electroconvulsive therapy was introduced almost a century ago, the approach has been shown to unreliably but sometimes dramatically effective for treatment of severe depression. At least partly due to its barbaric connotations and the uncertainty of the outcomes, electroconvulsive therapy remains one of the most controversial treatments in medicine. It isn’t practiced by most psychiatrists. The electrical charges delivered by TMS are meant to be more focused, but still very powerful. Inside the helmet, a series of looped wires are connected to capacitors that pass electrical currents through them in bursts. Pulses generate a secondary electric current that alters the electric fields in the brain, depolarizing neurons and causing them to fire. The scalp and skull do not shield the electrical processes in the brain from such a force any more than a cubicle wall shields your ears from a colleague who is incapable of keeping their phone on silent. Whether or how TMS would cause lasting change in brain function is not entirely clear. The concept was introduced in 1985 at the University of Sheffield, in England, as a diagnostic and mapping tool for the motor cortex. The technology can reliably be used to make a person’s legs jerk, but the ostensible aim of the current treatments is to reach beyond transient cortical activity and fundamentally alter the brain’s circuitry. And unlike the invasive neurological procedure of deep-brain stimulation, which has proven useful in treating OCD as well as Parkinson’s disease and other conditions, the helmet doesn’t require any holes in the skull and electrodes planted in the brain. But TMS’s marketing claims raise questions about how the helmet’s electrical currents could reach the brain’s emotion-driving portions without causing any unwanted cortical activity or serious adverse effects. In electroconvulsive therapy, a person must be anesthetized and made to convulse, and this was always seen as an unfortunate byproduct of the attempt to reset deeper parts of the nervous system. TMS requires no sedation, and only rarely causes seizures. (The sessions are still supposed to be closely monitored by a licensed technician—and the helmet is not supposed to be worn in public, as was implied in most of the jokes that hit the internet last week.) The only people who claim to know precisely how these helmets treat such complex sociocultural-behavioral conditions as depression and anxiety are the ones selling treatment with the machine, or machines themselves. As TeeJay Tripp, the medical director of Arizona’s Sunrise Mental Health Centers who treated Hushaw, understands it, TMS activates the prefrontal cortex, which can lead to downstream effects that ultimately impact the amygdala or other deep structures tied to emotion. The lack of understanding about what might be happening in those deep structures is paired with uncertainty about what parts of the cortex should be stimulated in the first place. The common wisdom among TMS practitioners is that depression occurs in the right side of the brain and anxiety on the left. Depending on which you have, the energy needs to be focused on one side. But this two-sided model of the brain is not supported by any neuroscience text I can find. In addition to treatments for depression and anxiety, Sunrise Mental Health Centers also offers to provide TMS for: “ADD/ADHD, addiction, Alzheimer’s disease, anxiety, autism, bipolar disorder, chronic pain, eating disorders, multiple sclerosis, schizophrenia, stroke rehabilitation, and substance abuse.” The FDA has only approved TMS for depression and OCD, but the approach can still legally be used “off-label.” When asked where in the brain electricity should be applied for these various conditions, Tripp says he bases his treatment on a mix of trial and error, along with whatever small studies have been done on any particular condition. Most notably among these uses, he and other practitioners have begun putting the helmets on children with autism. I asked Tripp if he was concerned about potential long-term repercussions, or simply about rewiring the wrong area. He cited the fact that the FDA had approved the helmet 10 years ago (for use in depression), and there has been no research showing long-term harm yet. Miller, Sunrise’s marketing director, believes that TMS’s overhead so far has prevented it from being more widely known and used; she put the ballpark cost of a Brainsway at $200,000. She also contends that uptake has been slow because of “Western medicine’s reliance on pharmaceuticals,” and the insurance companies’ unwillingness to pay for it. Insurance companies are increasingly covering the treatment, though. Direct-to-consumer marketing has increased demand in recent years, practitioners tell me, and many plans will cover the $10,000 to $12,000 treatment for people who haven’t responded to trials of medications and therapy. This is how LeeAnn Tucker afforded six weeks in the helmet. A 47-year-old former elementary school teacher in the Houston Area, she spent two decades “on and off of every antidepressant,” she says. She has been diagnosed with bipolar II, and she also has generalized anxiety disorder, PTSD, and panic attacks. The anxiety has led her to develop agoraphobia. “I don’t leave my house unless I absolutely have to. It’s just bad,” she says. “Sometimes if I’m in the grocery store I will have to leave my cart and just go home.” Tucker has also been suicidal. “The suicidal thoughts were so severe that I never told anyone,” she told me, “not my doctor, not my husband. Because when you tell someone, then they’ll try to save you.” A few years ago, she began seeing a new psychiatrist who had a video commercial for the Neurostar TMS helmet playing on a loop in his waiting room. (Neurostar provides all marketing material for patients. Clinicians buy the machine, and they also pay for each use of it.) She was convinced to try it. She was “tapped,” as they call it, “on the left side for depression, and on the right side for anxiety.” She sent me a video from her phone of her undergoing treatment. Her face is expressionless, and the piercing blasts sound like laser guns. After six weeks of daily treatment, Tucker saw no improvement. “I would love to say it worked, but I felt no different when it was over,” she says. “I’m still depressed as fuck.” One thing that did help, though, was that Tucker made friends with her technician, Allison Rose Zartier, over the course of weeks of treatment. “Having someone like Allison administer TMS was actually the best part for me,” Tucker says. Zartier, who is now the TMS coordinator at a business called Elite Medical Wellness in Lake Charles, Louisiana, says she finds it unbelievable that some practitioners leave people alone during the 20-to-30-minute treatments. Some of the biggest benefits she has seen have come through talking to people while the magnets are firing. She says that a recently retired CEO needed to find a way to have purpose with all of his free time. Another extremely isolated person felt better after Zartier recommended a dog. Advocates of the depression helmet consider the treatment great if it ends up actually helping even a small number (and harming fewer than it helps). For ECT and TMS, and anything that proposes to offer a hard restart to your central nervous system, the health risks cannot be zero—and should be expected to be significant. TMS and other high-tech, high-cost treatments also have the potential to divert focus from social, structural, and preventive support—the basic elements of health that, when ignored, often manifest as depressive symptoms. [Read: The diet that might cure depression] The medical model of depression tends to offer treatments that imply they can fix emotions that may actually be related to a need to feel valued and secure. Addressing these and other basic imperatives—to sleep and eat well, and be physically active and socially connected—is the first priority for treating and preventing most illnesses, mental and otherwise. This emphasis can be lost when an expensive magnetic helmet that promises to make the feelings somehow simply go away is seen as anything other than a last resort. Zartier went through TMS herself, and told me she was able to stop taking antidepressants shortly after. She now runs a Facebook support group for TMS patients, in which Hushaw is also active. Zartier says the shared experience of having gone through this process fosters a sense of community. It’s also a tool for recruiting prospective patients. Zartier says the $12,000 cost can be well worth it. She tells people it’s like “going to the gym, but for your brain.” That community is growing. “It keeps climbing faster, especially in the last four months. The word is finally getting out there,” Zartier says, which she believes is partly because Neurostar is now running television commercials. And she’s seeing ever more parents in the concerned Facebook community bringing in children. “I had a 10th grader who was suicidal, and I saw the pain in her eyes,” she says. “The younger you are, the more the brain can be affected—their brains seem to want to change.” from https://www.theatlantic.com/health/archive/2019/04/depression-helmet/587242/?utm_source=feed Scientists suspect that one element of the obesity epidemic is that the brains of obese people respond differently to images of delicious, calorically dense foods. Obese individuals’ brains seem to light up at the sight of donuts, pizza, and other calorie bombs, even when they’re no longer hungry. Some studies have suggested that this heightened activity might predispose people to overeating. Today, nearly 40 percent of American adults are obese, and obesity is predicted to become the leading cause of cancer among Americans, replacing smoking, within five or 10 years. (Though it’s still not clear yet which comes first—the obesity or the overactive brain activity.) “Part of the reason for the obesity epidemic is that people eat when they’re not hungry,” says Elizabeth Lawson, an associate professor of medicine at Harvard Medical School and a neuroendocrinologist at Massachusetts General Hospital. [Read: How therapy can cure overeating] A remedy for this over-activation in the brain might come from an unexpected source: oxytocin, the brain chemical often associated with love and social relationships. Oxytocin is sometimes called the “cuddle hormone” because it’s released during sex, childbirth, and breastfeeding. People who are in the early stages of falling in love have higher levels of oxytocin than normal. The drug ecstasy also increases concentrations of the hormone in the blood. Oxytocin has a variety of other surprising functions. A form of the chemical, Pitocin, induces labor, and another form might help treat stomach pain. Early studies have suggested the hormone might boost social skills among kids with autism. Now, Lawson and other researchers are investigating whether oxytocin might also prevent overeating. Lawson and her colleagues recently showed images of high-calorie foods to 10 overweight and obese men. She found that the regions of the brain involved in eating for pleasure lit up when the men viewed the images. A dose of oxytocin, compared to a placebo, weakened the activity in those regions, and it also reduced the activity between them. Meanwhile, oxytocin didn’t have that effect when the men viewed images of low-calorie foods or household items. Lawson’s colleagues presented the research, which has not yet been published in a peer-reviewed journal, last month at Endo 2019, the Endocrine Society’s annual meeting. “One of the key ways oxytocin works in limiting the amount of food that we eat is that it speeds up the satiety process, or reaching fullness,” says Pawel Olszewski, an associate professor of physiology at the University of Waikato in New Zealand who was not involved with Lawson’s study. “Then, oxytocin works through brain areas that are associated with the pleasure of eating, and it decreases our eating for pleasure.” [Read: Why comfort food comforts ] That’s just one of the ways oxytocin shows potential as an obesity treatment. Previously, Lawson and her colleagues found that the hormone improves insulin sensitivity and encourages the body to use of fat as a fuel for the body. Lawson’s other studies have shown that oxytocin reduces activation in the hypothalamus, an area of the brain that controls hunger, and increases activation in areas of the brain associated with impulse control. To Lawson, the results together suggest that the hormone creates less of a need to eat, reduces the compulsion to eat for fun, and improves impulse control when it comes to actually reaching for that second slice of cake. Oxytocin, in other words, appears to make food seem less rewarding. Other researchers have found that oxytocin might weaken alcoholics’ dependence on alcohol, drawing parallels to the hormone’s effects on how some obese people’s brains perceive food. A study published in the journal PLoS this month showed that oxytocin cut the desire to drink among alcohol-dependent rats. It’s not clear what this anti-drinking element of oxytocin has to do with its love-hormone properties, if anything. So why can’t we just pick up bottles of oxytocin at CVS? For one thing, most of these studies have been very small; 10 is a minuscule sample size. They’ve been largely conducted on men, so future research would need to be expanded to women. The entire mechanism behind oxytocin’s effects on eating behavior and metabolism needs to be firmed up, and the safety of using the hormone over the long term needs to be established. The way Lawson’s and many other studies have been conducted is by putting oxytocin in a nasal spray and attempting to shoot it directly toward the brain. But it’s not clear how much of the drug the person is actually getting through this kind of application, and researchers are still working on making it more precise. To answer some of these questions, Lawson is currently conducting an NIH-funded randomized, controlled trial that will administer oxytocin to obese men and women for eight weeks. Finally, even if all of these studies are successful, it’s important to remember that there are myriad reasons—social, economic, biological, cultural—that people become obese, addicted to food, or addicted to other substances. An oxytocin treatment might only work for some of them, and even if it did, not all obese people desire to lose weight. “Its effectiveness may depend on the reason for why the obese individual is obese,” Olszewski says. Still, a drug that helped even a fraction of America’s 93 million obese people would be a major breakthrough. If all of this research bears results, many years from now, there may be another reason to love the love hormone. from https://www.theatlantic.com/health/archive/2019/04/oxytocin-obesity-treatment/587533/?utm_source=feed In the early 2000s Terry Mitchell’s dentist retired. For a while, Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient 10-minute walk from Mitchell’s home, in San Jose, California. Lund’s practice was situated in a one-story building with clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows, round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars. To hear more feature stories, see our full list or get the Audm iPhone app. Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell’s insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and cost of the treatments did not trouble him. He had no idea that it was unusual to undergo so many root canals—he thought they were just as common as fillings. The payments were spread out over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he might as well get them before things grew worse. Meanwhile, another of Lund’s patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s, had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly healthy, although she’d had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and telling her she needed root canals and crowns. Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a doctor’s daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent, so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the work cost her about $70,000. In early 2012, Lund retired. Brendon Zeidler, a young dentist looking to expand his business, bought Lund’s practice and assumed responsibility for his patients. Within a few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly successful, but Zeidler was making only 10 to 25 percent of Lund’s reported earnings each month. As Zeidler met more of Lund’s former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work—a much larger proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn’t need any additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he checked thoroughly? In the summer, Zeidler decided to take a closer look at Lund’s career. He gathered years’ worth of dental records and bills for Lund’s patients and began to scrutinize them, one by one. The process took him months to complete. What he uncovered was appalling. We have a fraught relationship with dentists as authority figures. In casual conversation we often dismiss them as “not real doctors,” regarding them more as mechanics for the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are so anxious that they avoid the dentist almost entirely, and a smaller percentage have a genuine phobia requiring psychiatric intervention. When you’re in the dentist’s chair, the power imbalance between practitioner and patient becomes palpable. A masked figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like a personal failure. When a dentist declares that there is a problem, that something must be done before it’s too late, who has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what’s true? In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist’s office—perhaps because we both dread dental procedures and belittle their medical significance—the impulse is to comply without much consideration, to get the whole thing over with as quickly as possible. The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. “We are isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of the equation,” says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the American Dental Association’s Center for Evidence-Based Dentistry, which was established in 2007. “We’re kind of behind the times, but increasingly we are trying to move the needle forward.” Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such a young age, that we’ve internalized it as truth. But this supposed commandment of oral health has no scientific grounding. Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months. Many standard dental treatments—to say nothing of all the recent innovations and cosmetic extravagances—are likewise not well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available are not always reassuring. The Cochrane organization, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure. For example, dental sealants—liquid plastics painted onto the pits and grooves of teeth like nail polish—reduce tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another. Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but there is only “weak, very unreliable” evidence that it combats plaque. As for common but invasive dental procedures, an increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don’t clearly indicate whether it’s better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards. “The body of evidence for dentistry is disappointing,” says Derek Richards, the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland. “Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don’t test them properly in a good-quality trial.” The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients. Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she would probably not find much to help her. When we submit to a dentist’s examination, we are putting a great deal of trust in that dentist’s experience and intuition—and, of course, integrity. When Zeidler purchased Lund’s practice, in February 2012, he inherited a massive collection of patients’ dental histories and bills, a mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain the alarmingly abundant dental work in the mouths of Lund’s patients, he would find it in those records. He spent every weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical analyses. The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates. Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly, and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it. Dental crowns were one of Lund’s most frequent treatments. A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so its new shell will fit. Crowns typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace them every five years—the minimum interval of time before insurance companies will cover the procedure again. More than 50 of Lund’s patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has 32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that a root canal is a “quick, comfortable procedure” that is “very similar to a routine filling.” In truth, a root canal is a much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple trips to a dentist or specialist. It’s also much more costly. [Read: Americans are going to Juarez for cheap dental care] Root canals are typically used to treat infections of the pulp—the soft living core of a tooth. A dentist drills a hole through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery. Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage, known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections, which occur in a minority of cases. Yet they were extremely common in Lund’s practice. In 2009, for example, Lund billed his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would almost certainly have been a memorable experience. In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical complications, and further operations, Lund had apparently billed patients for treatments he had never administered. Zeidler was alarmed and distressed. “We go into this profession to care for patients,” he told me. “That is why we become doctors. To find, I felt, someone was doing the exact opposite of that—it was very hard, very hard to accept that someone was willing to do that.” Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell them that the man to whom they had entrusted their care—some of them for two decades—had apparently deceived them for his own profit.
The idea of the dentist as potential charlatan has a long and rich history. In medieval Europe, barbers didn’t just trim hair and shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of enemas, and tooth extraction. Barber surgeons, and the more specialized “tooth drawers,” would wrench, smash, and knock teeth out of people’s mouths with an intimidating metal instrument called a dental key: Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s, Thomas Berdmore, King George III’s “Operator for the Teeth,” described one woman who lost “a piece of jawbone as big as a walnut and three neighbouring molars” at the hands of a local barber. Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies as a trade akin to blacksmithing (Paul Revere was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic, nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen—who genuinely believed in the therapeutic power of bloodsucking worms—were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged them extra to stuff their pitted molars with homemade gunk of dubious benefit. In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From 1839 to 1840, Horace Hayden and Chapin Harris established dentistry’s first college, scientific journal, and national association. Some historical accounts claim that Hayden and Harris approached the University of Maryland’s School of Medicine about adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry was of little consequence. But no definitive proof of this encounter has ever surfaced. Whatever happened, from that point on, “the professions of dentistry and medicine would develop along separate paths,” writes Mary Otto, a health journalist, in her recent book, Teeth. Becoming a practicing physician requires four years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When physicians complete their residency, they typically work for a hospital, university, or large health-care organization with substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the nation’s 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically don’t have the same level of oversight. [Read: Why dentistry is separate from medicine] Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral health is somehow divorced from one’s overall well-being is absurd; the two are inextricably linked. Oral bacteria and the toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation. Dentistry’s academic and professional isolation has been especially detrimental to its own scientific inquiry. Most major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the phrase evidence-based medicine was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based medicine, but only a handful devoted to evidence-based dentistry. In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that curate useful resources. But its adoption “has been a relatively slow process,” as a 2016 commentary in the Contemporary Clinical Dentistry journal put it. Part of the problem is funding: Because dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and industry to tackle these issues. “At a recent conference, very few practitioners were even aware of the existence of evidence-based clinical guidelines,” says Elliot Abt, a professor of oral medicine at the University of Illinois. “You can publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change.” Among other problems, dentistry’s struggle to embrace scientific inquiry has left dentists with considerable latitude to advise unnecessary procedures—whether intentionally or not. The standard euphemism for this proclivity is overtreatment. Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for “microcavities”—incipient lesions that do not require immediate treatment—and superfluous restorations and replacements, such as swapping old metal fillings for modern resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and misguided treatment, dentistry is lagging behind. It remains “largely focused upon surgical procedures to treat the symptoms of disease,” Mary Otto writes. “America’s dental care system continues to reward those surgical procedures far more than it does prevention.” “Excessive diagnosis and treatment are endemic,” says Jeffrey H. Camm, a dentist of more than 35 years who wryly described his peers’ penchant for “creative diagnosis” in a 2013 commentary published by the American Dental Association. “I don’t want to be damning. I think the majority of dentists are pretty good.” But many have “this attitude of ‘Oh, here’s a spot, I’ve got to do something.’ I’ve been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or 12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the procedure.” Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband in Texas, recalls many troubling cases: “We would see patients seeking a second opinion, and they had treatment plans telling them they need eight fillings in virgin teeth. We would look at X-rays and say, ‘You’ve got to be kidding me.’ It was blatantly overtreatment—drilling into teeth that did not need it whatsoever.” Studies that explicitly focus on overtreatment in dentistry are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180 dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists singled out 13 different teeth for drilling; each advised one to six fillings. Similarly, in an investigation for Reader’s Digest, the writer William Ecenbarger visited 50 dentists in 28 states in the U.S. and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about $500 and going up to nearly $30,000. A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in dentistry. In addition to dentistry’s seclusion from the greater medical community, its traditional emphasis on procedure rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than $200,000. And then there’s the expense of finding an office, buying new equipment, and hiring staff to set up a private practice. A dentist’s income is entirely dependent on the number and type of procedures he or she performs; a routine cleaning and examination earns only a baseline fee of about $200. In parallel with the rising cost of dental school, the amount of tooth decay in many countries’ populations has declined dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the 1950s and ’60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts, and veneers. It’s easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and proactive treatments—a small filling here, a new crown there—even when waiting and watching would be better. It’s equally easy to imagine how that behavior might escalate. “If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward this attitude of ‘I’ve got tools so I’ve got to fix something’ much too often,” says Jeffrey Camm. “Maybe it’s greed, or paying off debt, or maybe it’s someone’s training. It’s easy to lose sight of the fact that even something that seems minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad.” In the summer of 2013, Zeidler asked several other dentists to review Lund’s records. They all agreed with his conclusions. The likelihood that Lund’s patients genuinely needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund’s decisions or to explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I asked Zeidler how those meetings went, he offered a single sentence—“I decided shortly thereafter to take legal action”—and declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither responded.) One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund’s care, explaining what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his diagnoses and treatments were meant to keep them healthy. Isn’t that what doctors do? “It makes you feel like you have been violated,” Terry Mitchell says—“somebody performing stuff on your body that doesn’t need to be done.” Joyce Cordi recalls a “moment of absolute fury” when she first learned of Lund’s deceit. On top of all the needless operations, “there were all kinds of drains and things that I paid for and the insurance company paid for that never happened,” she says. “But you can’t read the dentalese.” “A lot of them felt, How can I be so stupid? Or Why didn’t I go elsewhere?” Zeidler says. “But this is not about intellect. It’s about betrayal of trust.” In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit, Zeidler and his lawyers argued that Lund’s reported practice income of $729,000 to $988,000 a year was “a result of fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never performed.” The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund’s former patients, including Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They collectively reached a nearly $3 million settlement, paid out by Lund’s insurance company. (Lund did not admit to any wrongdoing.) Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney’s office is prosecuting a criminal case against him based on 26 counts of insurance fraud. At the time of his arraignment, he said he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund’s license, which is currently inactive. Many of Lund’s former patients worry about their future health. A root canal is not a permanent fix. It requires maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell’s root canals has already failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a crown were fixed in place. “I don’t know how much these root canals are going to cost me down the line,” Mitchell says. “Six thousand dollars a pop for an implant—it adds up pretty quick.” Joyce Cordi’s new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday chewing. “It hurts like hell,” she says. She has to wear a mouth guard every night. What some of Lund’s former patients regret most are the psychological repercussions of his alleged duplicity: the erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. “You lose your trust,” Mitchell says. “You become cynical. I have become more that way, and I don’t like it.” “He damaged the trust I need to have in the people who take care of me,” Cordi says. “He damaged my trust in mankind. That’s an unforgivable crime.” This article appears in the May 2019 print edition with the headline “The Trouble With Dentistry.” from https://www.theatlantic.com/magazine/archive/2019/05/the-trouble-with-dentistry/586039/?utm_source=feed At Texas Tech University’s medical school, just 4 percent of students are black; 13 percent are Hispanic. And those numbers may soon shrink. Research has shown that’s what happens when schools no longer consider race in admissions, and that’s what the school plans to do. In late February, Texas Tech University reached an agreement with the U.S. Department of Education to end its use of race in admissions to its medical school. The resolution, first reported by the Wall Street Journal, brought to an end a 14-year federal investigation into the school’s affirmative-action practices. The complaint had been filed following the Supreme Court decisions in the Michigan affirmative action cases, Grutter vs. Bollinger and Gratz vs. Bollinger, where the court decided race could be used in admissions but only in a “narrowly tailored” way. Texas Tech had stopped using race in admissions at its pharmacy school in 2008, and for its undergraduate college in 2013, but not at its medical school. There, the school argued, it needed to use race as a factor to ensure a diverse class of future doctors, and there was no other way around it. The law, as interpreted by the Supreme Court in affirmative action cases over the last 40 years, requires schools to show that they have exhausted all other, race-neutral options to achieve a diverse student body before using race as an admissions criteria. Most schools are able to show that the way they are using race in admissions is in the narrowly-tailored way that the Supreme Court has said, time and again, is legal. But Texas Tech was not periodically reviewing those race-neutral alternatives; or, at least, could not show that it was. That’s why it’s hard to read too much into what this means for the future of affirmative action, Scott Schneider, a higher-education attorney with Husch Blackwell, told me, because the details of the case were specific to Texas Tech. [Read: The movement to diversify medical schools.] In a letter to the Department of Education’s Office for Civil Rights, Eric Bentley, the general counsel for the Texas Tech University system, said that the school could prove that it was using race in an constitutionally-accepted way, but that Texas Tech would voluntarily agree to drop the practice anyway. Still, he wrote, the medical “strongly believes that diversity in academic medicine is not only a necessity at the [School of Medicine], but is a necessity nationally as well; therefore, we continuously strive to enhance the diversity of our student body.” But diversity in medical schools, broadly, has been difficult to achieve—especially without the use of race in admissions. Many minority groups—particularly blacks, Hispanics, and Native Americans—are significantly underrepresented at medical schools, Liliana Garces, an associate professor at the University of Texas who has studied the effects that affirmative-action bans have had on student representation, told me. And according to a recent report from the Association of American Medical Colleges, positive increases in racial diversity are few. For example, the number of black matriculants to medical school rose by 4.6 percent last year to 1,856, and the number of American Indian or Alaska Native matriculants rose by 6.3 percent to 218. These numbers could yet get smaller. Research shows that banning affirmative action—eliminating the use of race in admissions—leads to a decline in the enrollment of those underrepresented students. This is just as true at medical schools as it is at undergraduate institutions. For example, the number of black and Chicano students enrolled at University of California medical schools between 1996 and 1997 declined by 38 percent and 29 percent, respectively, following the state’s affirmative action ban. The lack of diversity isn’t merely a problem for young black college graduates hoping to become doctors some day, but for many of their would-be patients. Research has shown that health outcomes are improved when black patients have black doctors; they’re more likely to go to them for treatment, and to be more satisfied with the care they receive. Those facts make the continuing lack of diversity in medical schools even more acute; and the potential for a decline in enrollments more threatening. “For health care and medical schools in particular to be in a situation where we might be likely to have fewer black doctors creates real implications for the type of care and treatment that black patients are likely to receive,” Adia Harvey Wingfield, a professor of sociology at Washington University in St. Louis, told me. Wingfield’s new book, Flatlining: Race, Work, and Health Care in the New Economy, explores how changes in work affect black medical professionals. Black doctors, she finds, end up doing an extra level of work—the attentiveness to black patients; the added attention to caregiving—that are a part of why black patients have better health outcomes with doctors who look like them. With fewer black doctors, those who are already doing more work would be stretched more thin. “If we're talking about practitioners who are going to be servicing communities that are only going to become a larger and larger part of our society,” the goal, Wingfield says, should be to boost the ranks of those underrepresented minorities in medical professions. from https://www.theatlantic.com/education/archive/2019/04/affirmative-action-medical-school-diversity/587290/?utm_source=feed Where do our minds go at night? For more than a century, discussions of dreams have tended to revolve around the interpretation of our dreams’ contents. Do they reflect our unconscious anxieties? Are they an attempt to simulate threats, training us to cope with future challenges? Or are they simply the result of our mental housekeeping, as the sleeping brain reactivates our memories and processes them for long-term storage? In each case, the focus has been on the more immersive, surreal flights of fancy that occupy the sleeping brain. Yet our most puzzling dreams may not have contents at all. Have you ever woken up with the certainty that had just been dreaming, yet you were unable to recall even a single detail of the scene your mind was playing out? Various sleep studies have found that approximately 30 percent of the time, participants wake up with the sensation that they have been dreaming about something, yet when they are asked to describe the experience, they draw a complete blank. This is a distinct experience from waking up and have no sense of having been dreaming at all, which occurs around 20 percent of the time, or the rich narratives found in the other 50 percent. Sleep researchers refer to that first vague sensation as a “white dream”—and its true nature is a scientific mystery. It’s known that white dreams can occur at any part of the sleep cycle, though they are more likely to occur during non-rapid eye movement, earlier in the night. Sometimes, they are explained as a case of simply forgetting what was being dreamed. But some researchers now believe that something much stranger is going on. Rather than reflecting a memory deficit, white dreams might represent a boundary between sleep states, consisting of a basic form of consciousness without detailed sensual content. If so, for a large part of the night, we really are dreaming of nothing. And probing that fundamental state of being might help us understand the foundations of all other conscious experiences. The idea that white dreams are due to some kind of lack of memory dates to at least the time of Sigmund Freud, in the late 19th and early 20th centuries. In The Interpretation of Dreams, the father of psychoanalysis argued that dreams express our subconscious desires and anxieties, as the brain’s repressive instincts are relaxed. On awakening, however, this “psychic censorship” could come into full force again by blotting out any fantasies that would be too shocking for the conscious mind to handle. Contentless dreams—now known as white dreams—were the result of this repression, Freud said, but he believed they could be recovered through analysis. [Read: The trippy state between wakefulness and sleep] Freud’s theories of psychic censorship might have fallen out of fashion, but modern neuroscientists have hypothesized that white dreams are rich mental simulations that were indeed simply forgotten, perhaps because the neural activity at night was not sufficient to encode the experience for later recall. In a 2017 study, Francesca Siclari at the Lausanne University Hospital and colleagues at the University of Wisconsin at Madison invited 32 participants to spend a night in the lab, while EEG electrodes on the scalp recorded their brain activity as they slept. The team woke the participants and asked them to record whether or not they had been dreaming in the moments beforehand—and if so, what they had been dreaming about. When the participants reported white dreams, Siclari and her colleagues found that the front and center of the brain—normally implicated in memory encoding—lacked the characteristic high-frequency activity that was found with remembered dreams. The brain, in other words, didn’t appear to be running the machinery to create memories in the first place. So why would humans evolve to have these vivid nighttime experiences if so many of them are forgotten? “Maybe forgetting is a natural part of the function of dreaming,” says Tore Nielsen at the University of Montreal, who wasn’t involved in the study. It’s possible that dreaming might play some important role—such as processing the day’s emotions—but the contents are then forgotten to avoid clogging up our memories with fictitious events. Memory problems alone, however, do not appear to be the whole story. In a new paper for Sleep Medicine Reviews, Peter Fazekas, of the University of Antwerp, and colleagues instead suggest that white dreams are better understood as a diminished form of consciousness. According to this hypothesis, white dreaming is a bit like watching a badly tuned TV, with the volume muted: The sleeper really is dreaming, but the signal is too weak to establish any definite details beyond the vaguest impressions. Fazekas’s previous research focused on the variations in waking consciousness, such as the vividness of a sensory experience. In so-called masking experiments, for example, researchers quickly flash one image, “the target,” before the participants’ eyes, followed by another picture, “the mask.” Sometimes the participants have a clear impression of the target—a cat, say—while other times its presentation is too quick for conscious perception; they only see the mask. [Read: A new theory explains how consciousness evolved] In between those extremes, however, many participants report a vague sense of having seen something, without being able to give the details of what that is. This sense of vividness—or lack of it—usually correlates with activity in the posterior regions at the back of the brain. The greater the high-frequency activity in this area, the richer and more detailed the experience, while muted activity corresponds to the weaker impressions. Perhaps, Fazekas hypothesized, white dreams are similar to those minimal forms of conscious awareness. Working with Georgina Nemeth at Eotvos University in Hungary and Morten Overgaard at Aarhus University, he took another look at Siclari’s data to see if this were true. They noticed that Siclari’s statistical analysis had unintentionally obscured some potentially important differences in the posterior brain activity between white dreams, remembered dreams, and the sensation of having not dreamed at all. Sure enough, a reanalysis of the raw data suggested that white dreams do indeed reflect a striking reduction in that posterior brain activity, compared to remembered dreams, but still greater activity than when participants report no dreaming experience at all. The reduced frontal and central activity that Siclari observed would naturally follow from this, Fazekas believes, since those regions would have little information to encode into a memory. “For those areas to ‘turn on,’ so to speak, you need an intense experience, which you don’t have in the white dream,” Fazekas says. Siclari agrees that Fazekas offers a feasible interpretation of her data, though she believes that the reduced recall is still the primary distinguishing feature of white dreams. When prompted to dig deep into their memories, she says, some participants were later able to draw details from those apparently content-less experiences, which suggests that in at least some cases, it is purely a failure of recall. Other researchers have responded warmly to Fazekas’s new paper. “I was thrilled to see white dreams, which are an often-neglected topic, get so much attention,” says Jennifer Windt at Monash University in Melbourne, Australia. One very real possibility—supported by both Siclari and Fazekas—is that white dreams may in fact comprise a whole spectrum of experiences, the nuances of which may have been lost as the scientists averaged the data across participants. Some white dreams may be vivid, cinematic visions that are simply forgotten, as Siclari suggests, while others may be the kind of vague, gist-like experiences proposed by Fazekas. At the extreme, some white dreams may be completely content-less, containing only “the experience of the passage of time, of an indeterminate duration,” according to Windt. Studying those particular cases could give us a view of the “the simplest forms of subjective experience that exist,” Windt says—something that is “perched on the border between unconscious sleep and more complex and dreamful experiences.” She points out that experienced meditators regularly report a “‘pure,’ non-conceptual awareness” in sleep in which they are conscious of being asleep, but lacking any specific thoughts or images. Further research, she hopes, might help to verify those descriptions and compare the neural activity with other participants’ white dreams to see if there is any overlap with this mysterious state. The concept of “pure consciousness” can sound like a New-Age buzzword, but philosophers and neuroscientists are coming to view it as an important concept. You could think of consciousness like a Fabergé egg, and once you peel away the outer layers you are left with the most fundamental state of conscious existence—the core of our mental world. Finding ways to strip down our mental activity to this has been incredibly difficult, but this latest research suggests that white dreams could offer one important entry point to explore that state and to understand the starting point of all thought and feeling. White dreams may appear meaningless, but for scientists probing the mysteries of sleep and consciousness, they are rich with possibility. from https://www.theatlantic.com/health/archive/2019/04/white-dreams-pure-consciousness/587293/?utm_source=feed SAN FRANCISCO—The thought I had when the $100 chicken nugget hit my expectant tongue was the one cartoon villains have when they entrap a foreign critter and roast him over a spit: It tastes like chicken. That’s because it was chicken—albeit chicken that had never laid an egg, sprouted a feather, or been swept through an electrified-water bath for slaughter. This chicken began life as a primordial mush in a bioreactor whose dimensions and brand I’m not allowed to describe to you, for intellectual-property reasons. Before that, it was a collection of cells swirling calmly in a red-hued, nutrient-rich “media,” with a glass flask for an eggshell. The chicken is definitely real, and technically animal flesh, but it left the world as it entered it—a mass of meat, ready for human consumption, with no brain or wings or feet. This meat was what most of the world calls “lab grown,” but what Just, the company that makes the nugget, and other Silicon Valley start-ups want me to call “cultured meat” or “cell-based” meat, or better yet, “clean meat.” The argument is that almost all the food we eat, at some point, crosses a laboratory, whether in the course of researching flavors or perfecting packaging. So it is not fair to single out this particular product as being associated with freaky science. (Yes, I raised the point that all meat is technically cell-based, too, and no, this did not persuade anyone at the start-ups.) “Every big brewery has a little room in the back which is clean, and has people in white lab coats, and they’re not ‘lab-grown’ beer,” argues Michael Selden, the co-founder of a cell-based-fish start-up, Finless Foods. “But we’re for some reason lab-grown fish, even though it really is the exact same thing.” Regardless of what you call it, Just and others say it’s coming. Just, which was called Hampton Creek until last year, started out making vegan “eggs” and mayonnaise, then revealed in 2017 that it had also been working on cultured meat. The nugget was served to me to demonstrate that Just isn’t vaporware, in Silicon Valley parlance, or in this case, vapor-poultry. There’s a there there, and it’s edible. Just has been mired in turmoil in recent years, as board members resigned and former employees complained of shoddy science. (CEO Josh Tetrick calls the claims “blatantly wrong.”) Because of what the company said are regulatory hurdles, Just missed its goal of making a commercial sale of the chicken nuggets by the end of 2018. The Atlantic ran a somewhat unflattering profile of Tetrick in 2017, implying that the company is more style than substance. Tetrick seemed eager to prove this magazine wrong. He told me he tries not to get too down about bad press. A couple of years ago, “we were pretty much just selling mayonnaise,” he said. But now the plant-based Just Egg, which was practically a prototype when the Atlantic article came out, is in grocery stores, and as of this week, you can order it at Bareburger and the mid-Atlantic chain Silver Diner. Cultured chicken is, too, now on the horizon—that is, if people are willing to eat it. And if Just can ever make enough of it to feed them. Tetrick is hawklike and southern, which, when combined with his conservational tendencies, lends him young–Al Gore energy. He’s nostalgic for chicken wings even though he’s vegan and does not eat them. When I visited Just a few weeks ago, he showed me a photo of wads of meat and fat in a bowl. They are chunks of Japanese beef that the company hopes to grow into a cultured version by scraping off samples within 24 hours of the animal’s demise. This product wasn’t ready for me to taste yet, but it’s important, in Tetrick’s view, to be a little bit aspirational. “If my team cannot see where we want to go, they’re never gonna go there,” he said. “There” is a world in which cultured meat is inexpensive and everyone eats it, even if those same people have never heard of tempeh. Living, breathing, belching livestock is responsible for 15 percent of global greenhouse-gas emissions, about on par with cars. But Tetrick thinks that for many Americans, flavor and price rule the shopping cart, not environmentalism. “I was born in Birmingham, Alabama, so imagine one of my friends who doesn’t care about any of the shit that I’m doing now,” he said, while perched on a bar stool in front of Just’s test kitchen. This hypothetical friend goes to a Piggly Wiggly to buy burgers. Except—oh wait!—next to the animal-based patties wrapped in clear plastic, he sees a Just burger patty for less money. “That, to me, is what it’s gonna take in order to break the dam of a habit,” Tetrick said. Animal meat is a habit that many young Americans are ready to abandon. A quarter of 25-to-34-year-old Americans now say they are vegans or vegetarians, prompting The Economist to proclaim 2019 “the year of the vegan.” Burger King this month introduced a Whopper made with a plant-based Impossible patty. True, chicken grown in a bioreactor like Just’s is still animal, not vegetable; but without the factory-farming component, some vegetarians and vegans might be inclined to love their chickens and eat them too. I am the ideal customer for this, because I enjoy meat-like flavors but don’t appreciate the more carnal elements of meat. I’m sure the Wrangler-clad Texan Council will revoke my Texanship for saying this, but I have never had a rare steak. I’ve never eaten something and thought, I wish this would make more of a murdery mess on my plate. And yet, I have no interest in passing up barbecue or Tex-Mex when I visit home or in telling my first-generation immigrant parents that I no longer eat meat. I would like a protein-rich substance that reminds me of my childhood and injects a robust, savory essence into my salad. I do not, however, care if that substance was ever technically alive. Because frankly, life for many mass-bred animals is no life at all. In her book Big Chicken, Maryn McKenna describes seeing 30,000 birds crammed into a hot shed, some with bellies rubbed raw and legs twisted underneath them. Or, behold this description of the chicken-slaughtering process in a 2017 New Yorker story about Case Farms in Canton, Ohio:
(In response to the New Yorker story, Case Farms issued a statement that read, in part, “Our employees and growers share a committed responsibility to ensure the well-being and humane handling of all animals in our care.”) Just’s process, meanwhile, is much more clinical. The company takes live cells from biopsies that don’t require the death of the chicken. It then isolates the cells that are most likely to grow, and gently nurtures them in tank-like bioreactors in a soup of proteins, sugar, and vitamins. Across the bay from Just, in Emeryville, California, Finless Foods is attempting to perform this same procedure on fish. It’s not as far along as Just: Finless Foods has only 11 employees, to Just’s 120. Its office looks even less like a traditional workplace, with mismatched desks that early employees picked up from a used-furniture store. Its largest bioreactor only holds a liter of fish meat, while Just expects that in the “near term,” it will be able to produce hundreds to thousands of liters of meat. Finless Foods’ Michael Selden rattled off an assortment of environmental and social injustices that motivate the need for cultured meat, from microplastics in our oceans, to greenhouse gases from shipping, to what he calls “environmental imperialism”: “The way that we get our food is very much just sort of like, we take what we want,” he told me. “If you live in San Francisco and you eat bluefin tuna, that bluefin tuna almost definitely comes from the Philippines. And we basically have fishing fleets in the Philippines that are, like, destroying local ecosystems to feed us.” Whether Americans are sufficiently distraught over the state of Filipino ecosystems to replace a dinnertime staple remains to be seen. But for now, these companies have bigger challenges to getting to market. For Finless Foods, a major hurdle is texture. It aims to make cultured bluefin tuna, which in animal form glistens like raspberry jam and springs back like a wet sponge. “I will not say we’ve fully solved that problem, because I’d be totally lying,” Selden said. The few journalists who have tasted the product were served a carp croquette that one reporter described as having “a pleasant aftertaste of the sea, though not fish as such.” Selden is looking into 3-D printing as a potential path to creating a sashimi-like simulacrum. Similarly, when I asked Tetrick when his nuggets would actually be on sale, he glanced at Andrew Noyes, Just’s PR guy. “I know Andrew loves when I give timelines,” he said coyly. “I drive him crazy. It’s more likely than not … between now and the end of the year that we’re selling outside of the United States.” Before that happens, the bioreactors needs to get larger, and there have to be many, many more of them, without sacrificing quality. Tetrick estimated that there would need to be 25 to 100 culturing facilities just to fulfill America’s demand for meat. These companies are also searching for a way to reduce the cost of the “media”—the vitamin slush the cells incubate in—potentially by reusing it. Finally, the Just employees told me, they need the U.S. government to figure out a way to regulate the product, so people can rest assured that it’s not going to make them ill. Al Almanza, the former acting deputy undersecretary for food safety at the U.S. Department of Agriculture, agrees that there aren’t enough data yet for food inspectors to know what’s normal or abnormal—and thus potentially unsafe—in a cultured-chicken plant. But he also says that regulators would probably expedite approval for Just if the company reached a scale at which it could sell its cultured meat, which it hasn’t yet. (The USDA did not return a request for comment.) And while Just argues that its process is better, from a food-safety standpoint, than animal slaughter, we only have the company’s word to go on at this point. “Unless you have a perfectly sterile facility, with a cleanroom, and the bioreactors are being operated by robots, you’re at risk of some kind of contamination,” says Ben Wurgaft, a writer and historian who’s writing a book about laboratory-grown meat. The U.S. Cattlemen’s Association has argued that only beef that’s been raised and slaughtered should be labeled “beef.” Just fervently hopes that when labeling rules do come down, it will be allowed to call its product “meat,” rather than “lab-grown meat,” for the good of public relations, if not fairness. “Back in Alabama, where all my old friends drive pickup trucks, imagine if Tesla put out a really fast, really affordable pickup truck, but Tesla couldn’t call it a pickup truck,” Tetrick said. “On the back, they had to say, like, ‘Electric mobility transport wheeler,’ or some godforsaken name. My friends do not want to drive that, because it fucks with their identity, unfortunately.” On my visit to Just’s office, I asked Josh Hyman, the company’s chief of staff for research and development, whether the concept of cultured meat ever weirds anyone out. “Yeah! I think it does,” he said as he prepared to fry up my $100 nugget from its frozen state. “Till you explain it.” This is what Tetrick calls the “cultural component,” or letting “the consumer know this is a positive thing and they should eat it for dinner.” As I chewed my nugget, I realized that though its taste asymptotically approached chicken, it was not, alas, chicken. It was crunchy, thanks to the fried, breaded coating; it was flavorful, thanks to the salt and spices inside; and its innards were creamy, which frankly is an improvement on the graininess of most processed nuggets. But it lacked the gamey animal kick that screams “chicken.” We like meat to taste a certain way, but I realized that if I had never before had chicken, I might prefer this. Why is gaminess a virtue, anyway? Some people relish traditions such as hunting and fishing and the more visceral experiences with meat they provide. But if Just and similar companies are successful, future generations might only know chicken to be a pleasant, meat-esque paste, with no bones and skins to speak of. In fact, our entire notion of animal products might become unhinged from animals. The idea that human gustatory pleasure necessarily involves the inhumane farming of other creatures might come to be seen as outdated and gauche. A “real” chicken sandwich might be viewed, in some quarters, as barbarous as poaching. That is, if the bioreactor thing gets worked out. Several Just employees have culinary backgrounds, and Hyman presided in front of the tasting table like a proud chef. There was heating up and cooling down of a pot of oil to reach the perfect temperature for my nugget. Noyes, who lived in D.C. before moving out West, shifted warily and remarked a few times that we were running “behind schedule.” After serving me the nugget, Hyman scrambled up a custard-colored mung-bean egg substitute—the Just Egg, which comes in a squeeze bottle. It was fine; I don’t love scrambled eggs. Then he fed me a dairy-free rum-raisin ice cream that was one of the best desserts I’ve ever had. Finally, he served up a breakfast sandwich made with a firm, plant-based “egg” patty. The patty had a pleasing earthiness, offset perfectly by a glop of spicy, stringy pimento cheese. Even at 3 p.m., after a full lunch, it was objectively tasty. If I had been hungover, it would have been heaven. “Is this real cheese?” I asked. “No,” Hyman said. “What is it?” I asked. He smiled. “We’re not allowed to say.” from https://www.theatlantic.com/health/archive/2019/04/just-finless-foods-lab-grown-meat/587227/?utm_source=feed The letters went out to governors on March 14, 2017. Seema Verma had recently been appointed by President Donald Trump as the administrator of the Centers for Medicare and Medicaid Services, the agency within the Department of Health and Human Services that oversees health-care programs for more than 130 million Americans. Verma and then–HHS Secretary Tom Price, also a Trump appointee, wanted to alert state leaders across the nation that a new era was dawning: Some people would be required to work in exchange for Medicaid benefits. Ushering in this new regime was, in some ways, what Verma had spent her entire career seeking to accomplish. In 2001, five years after earning a master’s degree in public health at Johns Hopkins University, Verma founded a consulting company called SVC. The company, which exists now as HMA Medicaid Market Solutions, helps states adjust how Medicaid programs are operated and delivered. (Verma sold the company shortly after becoming CMS administrator.) In 2010, SVC took center stage in state-level Medicaid reform when the Patient Protection and Affordable Care Act—Obamacare—gave states the option of expanding Medicaid, with a hefty federal subsidy, to people making up to 138 percent of the poverty line. (The current poverty line is $12,490 per year for individuals and $25,750 per year for a family of four.) In Indiana, Verma partnered with Mike Pence, who at the time was the state’s governor, to implement an expansion program called the Healthy Indiana Plan 2.0. Among other things, the program instituted a system of premiums, ranging from $1 to $27 per month, for the new Medicaid-expansion population. Policy makers on the right applauded the move. But there was a consequence. Medicaid expansion in Indiana did give approximately 240,000 new people coverage, but in the years since it was implemented, portions of those eligible for benefits have been unable to pay their premiums. From 2015 to 2017, about 25,000 people in Indiana lost access to Medicaid. In 2017, in her new position as CMS administrator, Verma gained the power to influence how every state administered its Medicaid programs. In January 2018, for the first time since Medicaid’s creation, in 1965, Verma’s CMS gave permission to a state government to require certain citizens to work in order to keep benefits. The state was Kentucky, which planned to launch a work-requirement program this year. Details about who exactly would be subject to the requirement are still being ironed out. But according to Kentucky state officials’ estimates, at least 95,000 people would lose Medicaid coverage over a five-year period. Then, in March, Arkansas received permission to introduce a work requirement—and Arkansas was faster out of the starting gate, inaugurating its effort in phases. Beginning last June, people on Medicaid in Arkansas ages 30 to 49 who earned at or below the poverty line had to find work or participate in activities such as volunteering or job training to continue receiving Medicaid benefits. Certain people were exempt, such as those who were medically frail or who had a dependent child. From June to December, more than 18,000 people lost coverage in Arkansas as a result of the new policy, according to the Arkansas Department of Human Services. Medicaid advocates have not been quiet. Both HHS and CMS, along with Verma and Alex Azar II—who took over as HHS secretary after Price resigned following a scandal involving his use of chartered jets and military aircraft—were immediately the target of lawsuits seeking to overturn the work requirements. They were filed in the U.S. District Court for the District of Columbia on behalf of people in Arkansas and Kentucky, as well as those in New Hampshire, whose work-requirement mandate has just gone into effect. The plaintiffs allege that work requirements contradict one of the two chief stated objectives of Medicaid, as laid out in the 1965 Social Security Act Amendments: to “furnish medical assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services.” For its part, the Trump administration argues that work requirements further the second objective of Medicaid: to provide “rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care.” Verma and others maintain, in effect, that employment should be considered a form of rehabilitation that leads to financial independence. A judge examining this rehabilitation interpretation has found that it stretches the statutory language considerably: In the first round of rulings on the lawsuits, earlier this year, Kentucky and Arkansas were told to go back to the drawing board. Still, other states have followed their lead undeterred. In January 2019, Indiana began implementation of its work-requirement program. Programs in Arizona, Michigan, Wisconsin, Ohio, and Utah have been approved by HHS but have not yet started. Alabama, Mississippi, Oklahoma, South Dakota, Tennessee, and Virginia have submitted plans and are awaiting the green light. [Read: The trouble with Medicaid work requirements] This push for work requirements isn’t new. Politicians and policy experts on the right have been promoting them for decades, and have successfully implemented them in other programs, such as Temporary Assistance for Needy Families (TANF) and the Supplemental Nutrition Assistance Program (SNAP). The stated rationale is that work requirements will discourage dependence on welfare. In 1984, Charles Murray—who later wrote the controversial work The Bell Curve—published a book called Losing Ground, in which he claimed that welfare programs deter poor people from working, because welfare recipients know they can rely on government help instead. The book was the subject of heated criticism and debate. As an era of work requirements potentially looms for Medicaid, it’s possible to look beyond conjecture at the likely impact. By now a significant number of studies have considered what work requirements for social programs do and don’t accomplish. Are the new policies a good-faith effort to help people help themselves? Are they simply a way of using supposedly good intentions to clamp down on entitlements? Are they a tool for whittling away the ACA? Are they all those things? This battle is going to be fought for years to come. Medicaid covers more than 65 million people (not including those covered under the Children’s Health Insurance Program, or CHIP), at an annual cost of about $560 billion, which is borne by both the federal government and the states. All told, 36 states and the District of Columbia have opted to expand Medicaid under the ACA. The way Verma has characterized it, the ACA moved millions of working-age, nondisabled adults onto Medicaid. She contends that CMS must give people more than a health service: “We owe our fellow citizens more than just giving them a Medicaid card. We owe a card with care, and more importantly a card with hope,” she said in a November 2017 speech to the National Association of Medicaid Directors. “Hope that they can break the chains of generational poverty and no longer need public assistance.” In this view, Medicaid—or, more precisely, the threat of losing it—is a tool to encourage people to provide for themselves. This is where work requirements come in. Section 1115 of the Social Security Act lets states propose experimental projects that promote the twin objectives of Medicaid: providing medical care as well as services designed to guide people toward independence. Verma maintained in the 2017 speech that the Barack Obama administration’s refusal to approve work requirements for Medicaid on the grounds that they don’t satisfy the program’s objectives is an example of “the soft bigotry of low expectations,” a phrase coined by Michael Gerson, a speechwriter for President George W. Bush. (The phrase appears in Bush’s defense of the 2001 No Child Left Behind Act, which attempted to make additional federal aid contingent on better test-score results.) In other words, those who do not believe that low-income people can hold down a job and engage with their communities are making assumptions that have a way of proving self-fulfilling. The argument over the statutory objectives of Medicaid is central when it comes to the actual conduct of government. Dustin Pugel, a policy analyst at the Kentucky Center for Economic Policy, believes that Verma’s case for the meaning of Medicaid’s second objective is inadequate. “The context of that part is really specific to physical rehabilitation,” he says. “It talks about folks who have some sort of ailment that is preventing them from a full, independent life, and Medicaid is meant to fill in the gaps so that people can get back on their feet.” In this light, the second objective is simply about achieving physical independence through medical care. It is not about withdrawing benefits to influence people’s behavior. In January 2018, CMS announced in a letter to state Medicaid directors, written by Brian Neale, then the director of the Center for Medicaid and CHIP Services, that it would begin approving proposals that promote participation in community-engagement activities—working, volunteering, going to school, receiving job training—in return for Medicaid benefits. Neale cited research showing that higher earnings are positively correlated with a longer life span, that unemployment is generally harmful to people’s health, and that activities such as volunteering are associated with improved health and can lead to paid employment. In Arkansas, the first state to implement work requirements, nearly 280,000 people are on Medicaid. About 69,000 are subject to the new requirements. Unless exempted, a person must log 80 hours of work or community activities a month and report those hours online or by phone. If, over a period of three successive months, a person fails to show that he or she has met the monthly threshold, Medicaid benefits will cease until the next calendar year. The 18,000 Arkansas residents who lost their coverage last year failed to meet these work requirements for many reasons. Some people lost coverage for reasons beyond their control. Many simply didn’t know about the change or were confused by it. Others couldn’t navigate the website. A significant number didn’t have computers or reliable cellphone or internet access. As of February, just 11 percent of the 18,000 had reapplied for and regained coverage. Last month, Secretary Azar testified during a Senate Finance Committee hearing that this small proportion of reapplications “seems a fairly strong indication that the individuals who left the program were doing so because they got a job [in] this booming economy.” But the Center on Budget and Policy Priorities, a liberal think tank, analyzed new Arkansas state data and found that, of the 18,000 beneficiaries who lost coverage, only 1,981 “had matches in the state’s New Hire Database, indicating they found work.” The analysis uncovered no evidence that the remaining 16,019 have found new jobs. (An HHS spokeswoman told Politico that Azar’s comments were not intended to be definitive.) Arkansas’ second phase of work-requirement implementation began in January of this year and targeted two groups: 30-to-49-year-olds who earn from 101 to 138 percent above the poverty level, and 19-to-29-year-olds who make up to 138 percent above the poverty level. By March, “7,066 enrollees had one month of non-compliance with the requirements, and 6,472 enrollees had two months of non-compliance in the new calendar year,” according to a March 2019 report from the Kaiser Family Foundation. If it weren’t for the recent string of lawsuits, Kentucky would have rolled out its own work-requirements plan by now. Kentucky’s January 2018 case involved 15 residents—represented by the National Health Law Program, the Southern Poverty Law Center, and the Kentucky Equal Justice Center—who sued HHS and CMS, naming Verma, Azar, and two other top officials. The group argued that the Kentucky plan does not fulfill the objectives of Medicaid and would put them and others “in danger of losing” their health insurance altogether. [Reihan Salam: “Medicare for all” is a fantasy] In June 2018, the 15 residents won their case. Judge James Boasberg ruled that Kentucky had ignored Medicaid’s first objective—providing medical assistance, pure and simple—by disregarding the state’s own estimates that work requirements would kick at least 95,000 people off the Medicaid rolls. Kentucky had focused primarily on its broad interpretation of Medicaid’s second objective—furnishing rehabilitation and other services that lead to independence or self-care. Judge Boasberg vacated the approval of Kentucky’s plan and “remanded the matter to HHS for further review.” In November, HHS approved Kentucky’s revised program. The state had made some changes, but what it resubmitted was largely identical to the first application. The consequences would be exactly the same: At least 95,000 people would still lose Medicaid coverage. The same plaintiffs, plus one new resident, sued Kentucky again. And in March of this year, they won for a second time. Kentucky’s governor, Matthew Bevin, had already warned of what could happen next. In January 2018, he had directed officials within the Cabinet for Health and Family Services to essentially un-expand Medicaid as soon as legally possible if any part of Kentucky’s Section 1115 waiver, which asked for work requirements, was prevented from being implemented. Also in March of this year, and in the same court, the state of Arkansas lost a similar lawsuit brought against its existing work-requirement effort. On April 10, Justice Department attorneys appealed the decisions dealing with Arkansas and Kentucky on behalf of Verma and Azar—and HHS continues to push ahead. The New Hampshire case is still in its initial phase. When asked to respond to the court rulings, CMS offered a statement that Seema Verma had made in March: “We will continue to defend our efforts to give states greater flexibility to help low income Americans rise out of poverty. We believe, as have numerous past Administrations, that states are the laboratories of democracy and we will vigorously support their innovative, state-driven efforts to develop and test reforms that will advance the objectives of the Medicaid program.” As politicians and policy analysts on the right have claimed for decades, work requirements are intended to address work disincentives. If people know they can receive food, health care, and housing from the government, more or less for free, then why would they work? Recent data, however, suggest that only a small proportion of people who receive Medicaid benefits might avoid work simply because they don’t want to and don’t have to. In January 2018, the Kaiser Family Foundation published its analysis of 2016 data on the 25 million Medicaid recipients aged 19 to 64, as reported in the March 2017 Current Population Survey, which interviews people in person and via phone to gather results. It found that 42 percent of those people worked full-time, and that 18 percent worked part-time. Of the 10 million remaining people who reported not working, 36 percent said it was because they were disabled, 30 percent said it was because they were taking care of their home or family, and 15 percent said it was because they were going to school. Six percent said they couldn’t find work, and 9 percent said they were retired; 3 percent reported “other” reasons. Based on these data, only about 2 million to 5 million people of the 25 million nonelderly people on Medicaid could even work in the first place, depending on families’ abilities to find other caretakers, come out of retirement, and so forth. Over a two-year period, researchers at the Brookings Institution’s Hamilton Project collected data on the work status of people on Medicaid over a period of two years. They found that the way data had been gathered for a 2018 report by the White House’s Council of Economic Advisers—taking a nationwide snapshot in a single month—masked the fact that low-income Americans were continually entering and leaving the labor force, and doing so for many reasons, often temporary. A person might work nine months out of the year, but if he or she doesn’t work for three consecutive months, this person would still lose health care in Arkansas. Although work requirements have been built into two major programs, TANF and SNAP, studies show that those requirements have not been wildly successful. When Bill Clinton ran for president in 1992, he promised to “end welfare as we have come to know it.” Four years later, he signed the Personal Responsibility and Work Opportunity Reconciliation Act—generally referred to simply as “Clinton’s welfare reform”—which ended a program known as Aid to Families With Dependent Children and replaced it with TANF. The new program introduced a limit on how long families could receive benefits as well as a requirement to work, and states could determine which adults would be subject to it. In its 2017 study of TANF, the Kaiser Family Foundation looked at two groups of aid recipients: those who were and were not required to work. It found that people who had not been required to work were just as likely to be working five years later as those who had been subject to a work requirement—and sometimes were even more likely to be working. Later that same year, the Urban Institute released a report that looked at the first decade of TANF. It found that employment gains had been modest and had declined over time. Moreover, the requirements did not increase stable employment. Intriguingly, there is evidence that what the Trump administration aims to accomplish by instituting work requirements is already happening without them. Medicaid expansion has had “positive or neutral effects on employment and the labor market,” according to another 2018 Kaiser Family Foundation report. It has not led to droves of people halting job searches in order to live off the government’s largesse. Instead, more people find work. Or volunteer. Or go back to school. [Read: Medicaid expansion’s troubled future] More than 80 percent of people on Medicaid in Ohio, for example, say that “coverage made it easier to work,” and 60 percent say that “coverage made their job search easier,” according to state data. The reason, the Kaiser Family Foundation report found, is that many Medicaid adults who are not working are not working because of an illness or a disability that prevents them from doing the physically demanding tasks that most entry-level or low-income jobs require. Health care helps many of them manage those health issues well enough to participate in the labor force. In the agency’s statement to The Atlantic, CMS did not address requests for comment on these studies. Medicaid work requirements might not encourage more people to seek employment, but they do remove large numbers of people from health-care coverage. The result is especially severe for African Americans. The pattern is familiar: The Urban Institute found in its 2017 report that work requirements for TANF had a disparate impact on African Americans. States with higher concentrations of African Americans tended to have more severe sanctions for initial incidents of noncompliance, and African Americans were more likely to be sanctioned than their white counterparts, even when the form of noncompliance was the same. Last May, Nicholas Bagley and Eli Savit, who teach law at the University of Michigan, argued in The New York Times that Michigan’s proposed work requirements for Medicaid discriminated against African Americans by exempting people living in high-unemployment rural counties, which are predominantly white. Michigan’s minority population tends to live in cities, such as Flint and Detroit, which have high unemployment but are embedded in low-unemployment counties. In terms of access to health care, the ACA, including Medicaid expansion, has had the effect of narrowing disparities in coverage between people of color and other Americans for the first time in years. If work requirements for Medicaid accomplish nothing else, they will widen these disparities once again. from https://www.theatlantic.com/health/archive/2019/04/medicaid-work-requirements-seema-verma-cms/587026/?utm_source=feed In the debate over whether human beings should set off to other worlds beyond Earth, one of the most compelling cons is this: Our bodies don’t like it. Few people know this better than Scott Kelly, the NASA astronaut who spent nearly a year on the International Space Station between 2015 and 2016. Like other astronauts, Kelly served as a test subject in the study of space travel’s effects on the human body. Unlike other astronauts, Kelly has an identical twin, Mark, an astronaut himself. This gave researchers an uncommon opportunity to monitor the two brothers as they lived in two very different environments—one on Earth and the other 250 miles above it. According to their results, published Thursday in Science, Scott experienced a number of changes that Mark did not. Most of those changes went away after Scott returned to Earth. The long stint in space, the researchers say, produced some unexpected changes—but did not lead to any clinically significant health differences. The body, sensing and reacting to weightlessness, bristles at life in space. Fluids float freely and clog the sinuses, giving faces a puffy appearance. Bones, relieved of the job of bearing weight, thin. Muscles, faced with the same, atrophy. Parts of the eyeball, for reasons scientists are still trying to pin down, become squished or swollen. And from head to toe, the cells, exposed to unearthly levels of radiation, become more at risk for cancer. Only brain seems to love it; after all, it’s the one that fervently processes the beautiful views of the gleaming planet below, delights in the somersaults made natural by microgravity, and comprehends—or at least, attempts to—the wonder of being there, in outer space. [Read: ]What’s different about astronaut DNA? Scientists had expected some of the changes observed in Scott, based on earlier research of astronauts. Some of the effects were no more dramatic than stress-related changes studied on Earth—and space travel is certainly stressful. The others, like the eyeball squishing, can clearly be attributed to Scott’s unique experience in space. But that’s where the explanations end. With all the variables involved, isolating a single cause is nearly impossible. Researchers can’t know whether the changes were caused by microgravity, increased exposure to radiation, lack of air circulation, sleep disruption, a diet of freeze-dried food, or the stress of living in a cramped metal tube with the same people, day in and day out. Some of the most intriguing changes occurred at the chromosomal level, in the protective bits at the ends of chromosomes that make sure they replicate properly when cells divide. These caps, known as telomeres, are known to shorten as a result of stress. Researchers expected to see this change in Scott. Instead, the astronaut’s telomeres lengthened instead. “You might at first think, ‘Oh, this is great. He’s going to live longer,’” Susan Bailey, the Colorado State University professor who led the telomere research, once told me. “But the opposite side of that coin is always that it also increases cancer risk, because one of the very first things cancers do is turn telomerase on to maintain telomere length so they can essentially be immortal.” Most of the telomeres bounced back after Scott returned to Earth, but he now has more short telomeres than he did before his mission. In general, this puts someone at a greater risk for quicker aging, Bailey says. Researchers found some surprises in Scott’s gene expression. On Earth, changes in gene behavior occur in response to shifts in routine activities, like sleep and diet, and Mark’s gene expression changed as well. But the changes to Scott’s gene expression were distinct, and scientists were stunned at the number of changes they recorded, especially in mitochondrial genes, which help the body produce energy, and in genes related to the immune system. More than 90 percent of these genes returned to normal when Scott came back. (This doesn’t mean, researchers are careful to note, that the rest are somehow “mutated,” as some news reports erroneously suggested last year.) Researchers also detected changes in the mechanism cells use to control gene expression, but they were too tiny to matter by the time Scott came back. “We don’t know yet if these changes are good or bad,” explains Christopher Mason, a geneticist at Weill Cornell Medicine in New York, who led this part of the research. “This could just be how the body responds, but the genes are perturbed, so we want to see why and track them to see for how long.” [Read: ]How did astronaut DNA become “fake news”? That seems to be the theme of most of the findings: something changed, probably because Scott was in space, but it’s not clear whether that’s a good or bad thing. Like other astronauts, Scott’s retinal nerve thickened, but it’s unclear whether his long-term vision will be affected. One category of bacteria in Scott’s gut increased, while another decreased; the ratio returned to normal after the mission, and the shift remains a mystery. Scott’s cognitive abilities, which improved during his mission, sharply declined after he came back, and though they rebounded, they never returned to pre-flight levels. Scientists suspect the sudden return to gravity played a role, but so could the sudden return to interacting with more than six people he saw constantly. Part of it could even have been the fault of people like me—the deluge of journalists who wanted to talk to Scott after he landed. “Post-mission schedules—science and media events—are often very hectic and could have contributed to the decline,” says Mathias Basner, a psychiatry professor at the University of Pennsylvania School of Medicine who designed the cognitive-performance tests. From the outset, researchers expected to find uncertainty in these results. The research, funded by NASA, is a case study of a single patient, Scott. Any detectable changes could be the result of space travel—or of differences in experiences, or of random chance. The findings cannot be extrapolated to the wider astronaut population, let alone the general population. Nor are they very useful for predicting what might happen to humans if they venture beyond the orbit of the International Space Station, where the protective properties of Earth’s magnetic field are still felt. Here, astronauts receive 10 times the usual amount of radiation, high-speed particles from the sun or other sources in the cosmos. Out there, the exposure would be far worse. Scott Kelly retired from NASA in 2016, about a month after he returned to Earth and his body began to adjust. For some time, his legs felt jiggly, his joints ached, and his skin burned, unused to the touch of fabric, hugged close to him by gravity. Space, he said back then, had been disorienting. “Even after I’ve been here nearly a year, you don’t feel perfectly normal,” he said. “There’s always a lingering something you feel. It’s not necessarily uncomfortable, but it is a harsh environment.” The study of the twins doesn’t have to be over. There’s another important mission coming up: the 2020 election. Mark Kelly, also retired, is running for a Senate seat in Arizona. Maybe some researchers would like to see how astronauts do in a different kind of stressful situation. from https://www.theatlantic.com/science/archive/2019/04/what-happens-human-body-space/586966/?utm_source=feed |