Emil Girardi moved to San Francisco on New Year’s Eve in 1960. He loved everything about the city: the energy, the people and the hills. And, of course, the bars, where Girardi mixed drinks for most of his adult life.

About 10 years ago, the 83-year-old New York native had a stroke and collapsed on the sidewalk near his Nob Hill home. Everything changed.

“I didn’t want to go out of the house,” Girardi recalled, adding he only felt comfortable “going from the bedroom to the dining room.”

He’d started to fear the city’s streets — and growing older.

An out-of-state friend worried about his isolation and called a San Francisco-based nonprofit called Little Brothers, Friends of the Elderly. The organization works to relieve isolation and loneliness among the city’s seniors by pairing them with volunteers.

Little Brothers matched him with Shipra Narruhn, a computer software trainer who has volunteered with various organizations over the years, and became involved with Little Brothers after her mother’s death. The organization started in France after World War II and now operates in several U.S. cities, including Chicago, Philadelphia and San Francisco.

Cathy Michalec, the executive director of the local nonprofit, said older adults often become less mobile as they age. Cities like San Francisco, because of hills, crowded streets or old housing stock, are difficult for many seniors. That can lead to isolation and loneliness, Michalec said.

“Those 50 stairs you used to be able to go up and down all the time, you can’t go up and down all the time,” she said. “The streets are crowded and sometimes unsafe. … Sometimes, our elders say, it’s easier to stay in the house.”

Across the nation, geriatricians and other health and social service providers are growing increasingly worried about loneliness among seniors like Girardi. Their concerns are fueled by studies showing the emotional isolation is linked to serious health problems. Research shows older adults who feel lonely are at greater risk of memory loss, strokes, heart disease and high blood pressure. The health threat is similar to that of smoking 15 cigarettes a day, according to AARP. Researchers say that loneliness and isolation are linked to physical inactivity and poor sleep, as well as high blood pressure and poor immune functioning.

A 2012 study showed that people who felt lonely – whether or not they lived with others or suffered from depression – were at heightened risk of death. It also showed that 43 percent of people over 60 felt lonely.

“If someone reports feeling lonely, they are more likely to lose their independence and they are at greater risk of dying solely from being lonely,” said Dr. Carla Perissinotto, a geriatrician and researcher at the University of California, San Francisco who authored the study.

There can be many causes of loneliness, Perissinotto said, including illness, hearing loss or life changes such as retirement or the loss of a spouse. “The usual social connections we have in younger life end up changing as we get older,” she said.

Narruhn recalled that she and Girardi would just visit at his apartment, in the beginning. She’d tell him about her travels and her adult daughter. He’d tell her about his adventures in San Francisco. He described what the city was like as a young gay man, and told her about the friends he had lost to AIDS. They talked about music, books and cooking.

“I could tell from talking to him that he had a lot of interests,” she said. “At one time, he was very sociable.”

Gradually, Narruhn started bringing him music from Italy, India and Mexico. Girardi liked the songs he could snap his fingers to. Finally, Shipra convinced him to go out to lunch – and to visit a hidden, tile-covered staircase in San Francisco with her.

“Shipra came to see me, and came to see me and came to see me,” he said. “Finally, she said, ‘You have to get out of the house.'”

Soon, they were going to jazz shows, on walks and to the park. Narruhn said she invited Girardi to do eclectic things with her – chakra cleansings, Reiki healing sessions – and he was always game. Over time, his fear subsided. So did his loneliness.

“After she took me out of the house, then I didn’t want to stop,” Girardi said.

There isn’t much research about the effectiveness of programs such as Little Brothers. But Perissinotto said they can help seniors build new social connections. Other efforts to address loneliness include roommate matching services in various states and, in the United Kingdom, a call-in hotline.

“Maintaining connections, that touchy-feely thing, is actually really important,” Perissinotto said. “It’s hard to measure, it’s hard to quantify, but there is something real. Even though we don’t have the exact research, we have tons of stories where we know it’s [had] an effect in people’s lives.”

AARP Foundation also recently launched a nationwide online network to raise awareness about social isolation and loneliness among older adults. The network, Connect2Affect, allows people to do a self-assessment test and reach out to others feeling disconnected.

AARP, the Gerontological Society of America and other organizations are hoping to help create more understanding of isolation and loneliness and to help lonely seniors build more social connections.

“Loneliness is a huge issue we don’t talk enough about,” said Dr. Charlotte Yeh, chief medical officer of AARP Services. “There is a huge stigma.”

One afternoon in November, Narruhn came by to take Girardi out to one of their favorite restaurants on Polk Street. The waiter greeted them by name. Over Italian food, they planned several more visits together.

Girardi said he doesn’t fear growing older anymore. He’s surrounded by his new family. And by good music, he said, and “snapping fingers.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. You can follow Anna Gorman on Twitter: @annagorman.

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Before the virus overwhelmed Puerto Rico, Zika already lurked in Keishla Mojica’s home in Caguas.

First her partner, John Rodríguez, 23, became infected. His face swelled and a red, itchy rash covered his body. Doctors at the time diagnosed it as an allergy.

Two months later, Mojica, 23, had the same symptoms. Medics administered shots of Benadryl to soothe the rash and inflammation. She didn’t give it much more thought.

A month later she also found out she was pregnant, and that eventually led to a surprising revelation. The rashes hadn’t been caused by allergies, but instead by Zika, a virus known to cause serious birth defects.

Since 2015, the virus, which is spread by mosquitoes and sexual contact, has risen from relative obscurity to a worldwide menace. Puerto Rico marks the epicenter of the outbreak in the United States. As of Dec. 16, the commonwealth’s health department reported 35,648 confirmed cases, including 2,864 pregnant women. Federal health officials have declared a public health emergency, and anticipate 25 percent of the population will have contracted the virus by the end of 2016.

The epidemic raises difficult personal questions for women like Mojica, who live on an island with strong religious traditions and a health care infrastructure bowing under the weight of fiscal debt. They include whether to consider an abortion and how to care for a child that might have devastating disabilities like microcephaly.

In response to the association between congenital defects and the virus, virtually all pregnant women on the island undergo testing for Zika as part of their prenatal care. Dr. Alfonso Serrano, 57, chairman of the obstetrics and gynecology department at HIMA San Pablo Hospital in Caguas and Mojica’s doctor, said the testing has shown that 5 to 8 percent of his patients have contracted Zika.

Even though the threat of Zika frightens women, he said, most of his patients don’t consider abortion. “It’s not something that is talked about every day,” he added.

Abortion is easy to obtain here and relatively inexpensive, but surveys show that an overwhelming majority of residents said they oppose the practice.

For Mojica, abortion was the first thought that crossed her mind when she heard she had been infected. She told no one but her mother and Rodríguez about the diagnosis. She cried and prayed often. Public service announcements on television about the outbreak angered her. But Mojica never actually discussed the possibility of an abortion with anyone.

“I waited until they gave me the results and that they verified everything,” she said. But she quickly put aside any thoughts about abortion. “I said, ‘No, forget it. Everything’s fine. Forget about it.’ That was in the moment.”

The echoes of Roman Catholicism introduced by Spanish colonial rule still reverberate through contemporary Puerto Rican society. Ninety-nine percent of its residents say they believe in God. Children greet their elders by asking for a benediction, to which they reply, “Dios te bendiga” — “May God bless you.”

But the church’s influence is declining. Just over half of the population self-identifies as Catholic, according to a 2014 Pew Research Center survey. In contrast, the number of Protestants has surged, now comprising a third of residents.

Although Zika poses a rare and extraordinary threat to pregnant women, Puerto Ricans and religious leaders remain steadfast in their opposition to abortion. More than 70 percent of Catholics and eight out of 10 Protestants in the archipelago say they morally oppose the procedure, according to Pew.

In February, the Catholic Archbishop of San Juan, Roberto Octavio Gonzalez Nieves, released a statement responding to the health department’s advisory to use condoms as part of preventing Zika transmission. The church’s stance against birth control are “well-known,” he said, encouraging couples to practice “personal discipline,” or abstinence from sex, instead.

The Pentecostal Fraternity of Puerto Rico (FRAPE), a network of Pentecostal churches across the island, also view opposition to abortion as a non-negotiable tenet.

“God is the giver of life,” says FRAPE president Alberto Rodríguez. “And he has absolute control to take it or give it.”

Although rates have declined in recent years, thousands of women in Puerto Rico continue accessing abortion services. Seven of the commonwealth’s eight clinics performed 5,363 abortions in the fiscal year starting July 2013, based on the most recent data available from the commonwealth’s health department. In comparison, Connecticut and Iowa, which have roughly the same population as Puerto Rico, reported nearly 12,000 and 4,700 abortions, respectively, in 2012.

Mojica was a faithful member of a Seventh-Day Adventist congregation that does allow for abortion under extraordinary circumstances, but says she now converses with God on her own.

Recent research suggests that Zika may cause a wider range of congenital problems than previously suspected, with some that may not manifest until well after a child is born. And with a quarter of Puerto Rico’s residents thought to be infected, it is unclear how many babies will have special needs. But finding adequate care for children born with disabilities is difficult in Puerto Rico, where services are fragmented, poorly funded and already oversubscribed. Nearly half the population lives in poverty.

The Division of Children with Special Medical Needs, part of the commonwealth’s health department, runs some programs to assist families with children with disabilities, such as Advancing Together, a service that trains caregivers and helps families set up a development plan for the child. But the program expires when the child turns 3, and responsibility for services is transferred to the Puerto Rican Department of Education, which has consolidated or closed dozens of schools in recent years due to declining enrollment rates and strapped budgets. Thirty percent of students attending public schools on the island in 2013 were enrolled in individualized education programs for children with special needs.

Nonprofit groups also play a role in helping children with special needs, such as Support for Parents of Children with Impediments and the Muscular Dystrophy Association. Yet, therapy services available are extremely limited, says Miguel Valencia, director of the Division of Children with Special Medical Needs.

Although half the island’s residents rely on Medicaid for health insurance, Valencia says, many specialized clinicians no longer accept the plan due to low reimbursement rates.

Puerto Rican residents do not qualify for the Social Security Administration’s supplemental security income program, which provides assistance if a medical condition results in severe disability, chronic illness or death. The service is limited to individuals living in the 50 states, the District of Columbia and the Mariana Islands.

Mojica is waiting to meet her son, who so far she has seen only in pixels of black and shades of orange. The ultrasound image shows the outline of a human face with his eyes closed directly facing the camera. It appears modulated, akin to a half finished piece of pottery. The five stubby fingers of his right hand are pressed against his forehead as if he is lost in contemplation.

The nursery overflows with outfits in anticipation of his arrival shortly after the new year. Black Converse booties and Batman onesies hang in the armoire. Wooden letters spell his name on the wall above the crib.

Although the fetus continues to grow without complications or signs of microcephaly, Mojica’s son, whom she plans to name Jayden Aramick, still faces possible developmental delays from the virus that could develop after he arrives. But at this point, the risk no longer weighs on her conscience. She has given her worries to God.

“What He says is what will come to be,” she said.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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In a disappointment to Alzheimer’s patients and researchers, drugmaker Eli Lilly said in late November that a clinical trial of solanezumab, an experimental medication to treat the degenerative neurological condition, had failed.

The company has pressed on with tests of solanezumab, despite mixed results in earlier studies. The latest test, involving more than 2,000 patients, found the drug didn’t significantly slow cognitive decline in patients with mild dementia from Alzheimer’s.

The sad refrain is a familiar one, unfortunately.

Solanezumab is just the latest casualty in a decades-long parade of disappointing dementia drug trials. But the frustration brought by this particular failure could signal a shift in Alzheimer’s research — a shift away from targeting accumulations of so-called amyloid protein in the brain, long considered by many in the field to be the crux of Alzheimer’s pathology.

Ever since Dr. George G. Glenner’s 1984 discovery that amyloid is the main component of the plaques that riddle the Alzheimer’s-afflicted brain, it has been assumed that the protein somehow contributes to the disorder — that it jams up cellular machinery, rendering neurons unable to effectively communicate, to form new memories, to remember where the keys are.

Like many other failed medications for symptomatic Alzheimer’s, solanezumab works by attacking amyloid in the brain.

So in light of the new findings, is it finally time to let the amyloid theory go? The answer isn’t clear.

“The low magnitude of effects would lend support to the idea that it might be time to move on from amyloid,” says Weill Cornell Medical College neurologist Dr. Richard Isaacson, who wasn’t involved in the solanezumab study. “Yet though the study failed overall, there were improvements in cognition and function in treated patients.”

He points out that perhaps the tested dose wasn’t high enough or that the patients’ disease was too advanced to respond. By the time symptoms of Alzheimer’s arise, the brain is already speckled with amyloid. Two other ongoing trials should confirm whether solanezumab is more effective in patients at risk for Alzheimer’s, but who have not yet developed symptoms, he says.

Solanezumab, an antibody, works by attacking amyloid floating in cerebrospinal fluid. A different type of investigational medication, so-called BACE inhibitors, prevent amyloid formation in the first place, by neutralizing an enzyme that cuts away amyloid from a larger protein. Biogen’s aducanumab, another experimental drug that’s far along in clinical testing, binds to and clears amyloid that is already ensnared in plaques.

Earlier this year the FDA granted aducanumab fast-track status after results from a small, early-stage study suggested that it reduces amyloid plaques and slows cognitive decline in people with very early stage disease. Those people did have amyloid deposits visible with positron emission tomography imaging. At the Clinical Trials on Alzheimer’s Disease and Dementia meeting in San Diego in early December, follow-up data were presented that confirmed cognitive improvement out to two years of treatment.

“The good news is that there are a number of trials in progress with different anti-amyloid drugs in asymptomatic subjects; and that one failed drug doesn’t mean that another won’t have an effect,” says Dr. James Burke, professor of medicine and psychiatry at Duke University’s Alzheimer’s Disease Research Center. “These trials also suggest that the best chance for a significant effect on cognition is likely to be treating asymptomatic people with amyloid deposits on imaging.”

Yet, Burke adds, if these trials don’t show a significant clinical benefit, the focus on amyloid will likely end.

In any event, Weill’s Isaacson feels that researchers should be looking to other options. “I’ve never been a firm believer in the amyloid hypothesis being the be-all and end-all as to the cause of Alzheimer’s,” says Isaacson. “I think it’s much more complicated and there are probably many roads leading to the disease.”

One such road might be to target the tau protein, which also accumulates in tangles inside the Alzheimer’s-hindered brain. Another involves treating the inflammation that occurs with dementia, as the immune system attempts to clear clustered amyloid. Even simpler are dietary interventions. Mediterranean-like diets high in omega-3 fatty acids show particular promise in slowing cognitive decline.

As in so many other disorders, fully understanding Alzheimer’s disease might ultimately entail figuring out how our bodies interact with the trillions of microbes living in our guts, or our “microbiota.” Research in animals and humans suggest that certain combinations of these organisms may rev up the immune system in ways that contribute to dementia. A study published in July in Scientific Reports found that a long course of antibiotic treatment to alter gut flora in dementia-prone mice reduced the number and size of amyloid plaques in the brain.

Whether it’s antibiotics, probiotics or vaccines, the list of potential Alzheimer’s treatments being considered goes on.

“The bottom line is we need to take more shots on goal,” says Isaacson. “The next frontier is recognizing that there probably isn’t a one-size-fits-all approach, and that using targeted therapies based on a person’s own biology and genetics will bring the most benefit. The future of Alzheimer’s therapeutics is in precision medicine.”

Bret Stetka is a writer based in New York and an editorial director at Medscape. His work has appeared in Wired, Scientific American and on The Atlantic.com. He graduated from University of Virginia School of Medicine in 2005. He’s also on Twitter: @BretStetka.

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People in Columbia, S.C., had their pick of four health insurers last year when they shopped for policies during the Affordable Care Act’s open enrollment.

This time they have just one: Blue Cross Blue Shield of South Carolina, which had the most Obamacare enrollees in Richland County in 2016 due to its low prices.

It’s a change that’s been repeated around the country after big health insurers such as Aetna, Humana and United Healthcare pulled out of dozens of Obamacare marketplaces that they judged unprofitable.

Almost a third of all counties in the United States have just one insurer in the marketplace for people buying individual coverage for 2017. In 2015, just 7 percent had one insurer, according to a Kaiser Family Foundation analysis. Twenty percent of Obamacare consumers will choose 2017 plans in counties served by a single insurer, according to the government.

But there’s a surprising bottom line: Although prices are going up in almost all areas, they’re not significantly higher than they are for people living in areas served by multiple insurers, according to data reviewed by consulting firm Avalere Health.

“A lack of competition is bad for the insurance market in the long term, but in counties that have only one plan it hasn’t proven to be catastrophic for consumers for 2017,” says Caroline Pearson, a senior vice president with Avalere. “We expected to see the biggest price hikes in areas without competition.”

She suggests that didn’t happen because insurers had to file their initial 2017 rates to regulators earlier this year, before they knew exactly where competitors were dropping out.

“Those rates could be adjusted, but broadly the pricing was set in the absence of full competitive information,” Pearson says. When open enrollment for 2018 begins next fall, “you could see big price increases in regions without competition.”

Uncertainty surrounds the future of the exchanges after the Trump administration and Republican-led Congress take power. Worries about the future of Obamacare may be spurring a burst in enrollments, which were up by 400,000 to 6.4 million from Nov. 1 to Dec. 19, compared with the same period last year, the government reported.

Even in Richland County, where premium increases exceeded the average rate hike nationwide, individuals and the navigators who help them enroll say they have found good deals — especially for people with lower incomes that make them eligible for subsidies.

Open enrollment for 2017 ends Jan. 31, with a few exceptions.

Richland was one of 74 counties that dropped from at least four insurers in 2016 to just one in 2017, according to a Kaiser Health News analysis of federal data for the 39 states that enroll people through healthcare.gov. In 66 of those counties, the Blue Cross and Blue Shield affiliated plan was the sole survivor.

Blue Cross plans generally dominated the individual insurance market before the 2010 health law was passed, and they have recaptured their place in many cities and counties, says Pearson. That helped them outlast insurers such as UnitedHealthcare and Humana, which lacked that experience when they began selling individual plans under Obamacare in 2014. Even so, Blue Cross plans have withdrawn from Nebraska and Minnesota for 2017, as well as from densely populated counties in Arizona and Tennessee.

“In some ways the individual market looks today much like it did before the ACA, from a competitive standpoint,” Pearson says.

Stephanie Hickman, 29, of West Columbia, S.C., feared the worst when she began shopping for 2017 coverage on the exchange with help from a federally funded navigator at the downtown library. Hickman was uninsured most of the year, and paid $200 a month for her prescription drugs.

After sorting 20 options, the certified nursing assistant was stunned to find a subsidized plan that would cost her $22.30 a month and not more than $700 a year out-of-pocket in co-pays and deductibles. She would pay nothing to see a primary care doctor.

“Wow, it seems almost too good to be true,” says Hickman, who makes about $16,000 a year.

The impact of subsidies makes Hickman’s case “pretty typical,” says Shelli Quenga, director of programs for the nonprofit Palmetto Project, which hires navigators to help enroll people in Obamacare.

More than 80 percent of the nearly 13 million people who enrolled for coverage on the marketplace last year qualified for subsidies, which are pegged to the price of the second-lowest silver premiums. That means that as the cost of the silver plans rise, so do the subsidies.

But that doesn’t help the millions of people with higher incomes who don’t qualify for subsidies and are facing higher premiums. For them, the loss of insurance competition and higher rates has been a double blow, according to insurance agents. “People are getting slammed and having to pay through the nose,” says Jocelyn Boland, an insurance agent in the Columbia, S.C., area who is handling about 500 Obamacare clients this year. “I have a lot of upset people.”

Despite the higher prices and promises by president-elect Donald Trump and GOP leaders to repeal the health law in 2017, most are still signing up, she says.

Seventy miles south of Columbia, Augusta, Ga., is also down to just one Obamacare insurer after having four in 2016. Among those who have signed up for the remaining Blue Cross Blue Shield of Georgia plan, some are thrilled at low rates and others, not so much.

Dorothy Johnson, 57, a caterer who lives in a mobile home with her disabled husband, was disappointed that the lowest Obamacare premium would still cost her $56 a month, even with a subsidy.

Sitting with navigator Monica Baldwin inside a converted storage room just big enough for a desk and two chairs at Christ Community Health Services, Johnson broke down in tears when told that if she did not enroll, she would owe the IRS the higher of $695 or 2 percent of her income under the health law’s individual mandate. She and her husband live on $1,400 a month, mostly from his disability check and her part-time job, Johnson says. She gets around in a 1994 car and after paying the electric bill, trash, food, gas and car insurance, there is little left.

“Well, just go ahead and enroll me because there’s no way I want to pay the government that penalty,” Johnson told Baldwin.

She and her husband had been shopping for life insurance, but they’ve decided they can’t afford it as well as health insurance.

The Augusta area lost Humana, Cigna and Coventry health plans for next year. Humana was the most popular plan because of its price and its inclusion of University Hospital, one of four major area hospitals which Blue Cross Blue Shield of Georgia does not cover.

But so far, Baldwin says, most people are switching to the Blue Cross plans without complaint. Joel Caceres, 27, of Augusta, said he is pleased that his monthly premium for the same subsidized Blue Cross plan that he had in 2016 will drop to $40 from $43 and his annual deductible will stay at $250. The pastry chef says subsidized coverage is vital for him because the insulin and other medications he takes will only cost him $15 a month after insurance. “Having the insurance really helps ends meet,” he says after Baldwin helped him find a plan.

Ron Ellis, 55, another Obamacare customer aided by Baldwin, says he voted for Trump despite his pledge to repeal the law. “I didn’t like Hillary (Clinton),” he says.

His subsidized monthly premium for his Blue Cross policy will be $65 next year, up slightly from the $63.30 he paid this year. Ellis says he went without health insurance for many years before Obamacare. With high blood pressure, arthritis in his knees and a potential need for another hip replacement, he says, “It’s been great for me.”

Elizabeth Lucas contributed to this report. Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation.

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At 44 years old, Dave Adox was facing the end of his two-year battle with ALS, also known as Lou Gehrig’s disease. He needed a ventilator to breathe and couldn’t move any part of his body, except his eyes. Once he started to struggle with his eyes — his only way to communicate — Adox decided it was time to die.

He wanted to donate his organs, to give other people a chance for a longer life. To do this, he’d need to be in a hospital when he went off the ventilator.

“I was always interested in organ donation and had checked the box on my license,” Adox said last spring at his home in South Orange, N.J., through a machine that spoke for him. He laboriously spelled out these words, letter by letter, by focusing his eyes on a tablet. Adox had spent a career with words that now came slowly — he was a freelance reporter, including for public radio, then went on to work in advertising.

“When I got diagnosed with ALS at 42, and the disease paralyzed my entire body in six months, I definitely developed a greater appreciation of the value of the working human body,” he said.

Adox and his husband, Danni Michaeli, made a plan. They would go to University Hospital in Newark, where Adox often had been treated, and have his ventilator disconnected. The doctors there had reassured Adox he could ask to come off the ventilator anytime.

In May his family and friends flew in from around the country, and joined neighbors for a big celebration of Adox’s life. They spent one last weekend with him, planting a tree and painting a big, colorful mural in his honor. Some wore T-shirts printed with Adox’s motto, “Celebrate everything until further notice.”

But their plan suddenly changed when University Hospital’s attorneys intervened.

“At the 11th hour, they emailed us and said their lawyers had stopped the process because they were afraid it looked too much like assisted suicide,” Adox explained. “I was crushed.”

Every day, physicians withdraw life support on behalf of patients in hospitals who choose to refuse care. That’s generally not considered physician-assisted suicide or euthanasia — the key being that the patient is already in the hospital.

But Adox was asking to be admitted to the hospital specifically to end his life. And despite the planning, his request made some people uncomfortable.

Dr. John Bach, a professor of physical medicine rehabilitation and neurology at Rutgers New Jersey Medical School, which is affiliated with University Hospital, was Adox’s primary physician, and understood and approved of his patient’s plan to end his life and share his organs.

“I could have given [him] a prescription for morphine and he could have been taken off the ventilator at home,” Bach says. “But he wanted his organs to be used to save other people’s lives!”

Other physicians at the hospital supported Adox’s plan, too.

“We have an ethics committee that approved it 100 percent,” Bach says. “We have a palliative care committee — they all agreed, 100 percent. But it didn’t make any difference to the lawyers of our hospital.”

University Hospital has declined several requests for comment, but Bach says the hospital’s attorneys were concerned about liability.

“The legal issue is: What is euthanasia?” Bach explains. “Are you killing a patient by taking him off a respirator that’s keeping him alive?”

Adox had an advance directive that stated, “I do not want medical treatment that will keep me alive if I have an incurable and irreversible illness and the burdens of continued life with life-sustaining treatment become greater than the benefits I experience.”

Having an advance directive on file is especially important for ALS patients, Bach says, because they can eventually become “locked in,” unable to express their wishes.

“To be locked in means you cannot move anything at all — not a finger, not a millimeter,” Bach says. “You cannot move your eyes; you cannot move your tongue; you cannot move your facial muscles at all. You cannot even wink to say yes or no.”

In this particular case, the hospital wouldn’t have had to rely on the directive, Bach noted: Adox was still fully capable of expressing his wishes clearly. It deeply troubled the physician that his patient’s wishes could not be met.

“Myself and all the other doctors who took care of him in the hospital were almost as upset about it as he and his husband were,” Bach says.

Dr. Joshua Mezrich, a transplant surgeon at the University of Wisconsin Hospital, has had patients with ALS who, like Adox, wanted to donate organs. He believes hospitals need to create protocols for these situations — even though such cases are rare.

Mezrich acknowledges this could challenge a key principle for physicians: First, do no harm. But that mandate can and should be interpreted broadly, he believes.

“I think it’s fair to say that doing no harm doesn’t always mean making people live as long as possible — keeping them alive no matter what,” Mezrich says. “Sometimes, it means letting them have the death that they want, and it means letting them give this gift, if that’s what they want.”

Still, planning one’s death to allow for organ donation raises some thorny questions, says Arthur Caplan, director of the division of medical ethics at New York University and author of Replacement Parts: The Ethics of Procuring and Replacing Organs in Humans.

Typically a separate team of physicians or an organ procurement team discusses donation with family members after a patient dies, to avoid any tones — whether real or perceived — of coercion or conflict of interest, Caplan points out.

“You’d have to change the culture of critical care and say it’s OK to talk with the person about organ donation as part of their dying,” he explains.

This issue may get bigger, Caplan believes, as states move to legalize physician-assisted death. Although, so far, there has been little public discussion because “it’s too controversial.”

“If we went in the direction of bringing more people who are dying — whether it’s ALS or whatever it is — into settings where we could have them consider organ donation because they’re on the machines, we’d probably have a bigger pool of organ donors,” Caplan says.

But that approach would have a downside, too, he continues. People might perceive doctors as more focused on “getting organs” than caring for dying patients.

There is at least one hospital that has established a policy for patients with ALS who want to be organ donors. Froedtert Hospital and its partner Medical College of Wisconsin, in Milwaukee, approved such a policy in May.

About a year ago there, a patient with ALS wanted to donate her organs, but the hospital wasn’t able to honor her wish. The experience prompted physicians to develop a multistep system that includes evaluation from psychologists, an ethics review and considers technical matters such as transportation or insurance coverage.

“Obviously we’re all sensitive to any perception of assisted expedition of death,” says Dr. William Rilling, vice chair of clinical operations of radiology at Froedtert Hospital. “But, at the end of the day, the patient’s wishes count for a lot.”

After University Hospital declined to admit Adox, he and his husband reached out to six other hospitals through various intermediaries. They waited for days to hear back.

In the end, LiveOnNY, the organ procurement organization based in New York City, stepped in to help. The organization’s medical director, Dr. Amy Friedman, went to visit Adox at his home to vet his suitability as a donor.

“There was a hospital partner,” Friedman says, “that felt very supportive of this circumstance, understood the challenges that they would be faced with, [and was] prepared to be supportive of what Dave wanted and would be able to provide a bed.”

Finally, on the palliative care floor at Mt. Sinai Hospital on May 18, Adox and Michaeli prepared to say their goodbyes.

“We sat; we listened to ’80s music. I read Dave a poem,” Michaeli recounts, close to tears. “And when they were really sure — and we were all really sure — that he was in a deep state of sedation they disconnected his breathing machine.”

And in the end, Adox’s wishes were met — he was able to donate his liver and kidneys. Michaeli says he felt “an incredible swelling of gratitude” to the hospital team who helped make that happen.

“The person we were trying to do a direct donation for was a match,” Michaeli says. “And he has Dave’s kidney right now.”

This story is part of a reporting partnership with NPR, Side Effects Public Media and Kaiser Health News.

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The Affordable Care Act is on the chopping block, likely to be one of the first casualties when President-elect Donald Trump takes office next month.

“We will repeal the disaster known as ‘Obamacare’ and create new health care — all sorts of reforms that work for you and your family,” Trump promised in Florida last week.

Before that happens, President Obama and his aides want to put a marker down on what they see as the law’s accomplishments over the last six years.

“When I came into office, 44 million people were uninsured,” Obama told reporters during his pre-Christmas news conference at the White House. “Today, we’ve covered more than 20 million of them. For the first time in our history, more than 90 percent of Americans are insured.”

So far, more than 6.4 million people have signed up for insurance coverage in 2017 through the federal exchange. Enrollments are on track to exceed last year’s total, with many coming from states like Florida, Texas, and North Carolina that were carried by Trump.

While expanded insurance coverage is the yardstick most often cited, defenders argue the Affordable Care Act has also helped limit rising health care costs and put more emphasis on the quality of care, not just how much is done.

“While multiple factors are likely playing a role, payment reforms introduced in the [Affordable Care Act] have made substantial, quantifiable contributions to slowing the growth of health care costs in both Medicare and private insurance,” White House economists wrote in a report this month.

The report cites estimates from the Congressional Budget Office that Obamacare has shaved 1.3 percentage points off the annual growth in per-person Medicare spending.

For people who get health coverage through their employer, the slowdown has been even sharper, the report says. The cost of family coverage has grown just over 3 percent per year since the Affordable Care Act was passed in 2010. That’s a 45 percent reduction from the pace of the previous six years. While many workplace insurance plans now include higher deductibles and co-pays, workers’ out-of-pocket costs are still growing more slowly than they were before Obamacare, White House economists say.

The law also encourages payment reforms that reward doctors and hospitals for high-quality care, not simply performing a lot of tests and procedures. More than 30 percent of Medicare payments are now based on these “alternative payment models,” along with about 10 percent of payments for workers covered by private insurance.

To be sure, the Affordable Care Act remains deeply controversial. Americans who dislike the law slightly outnumber those who approve of it. That’s partly a reflection of the law’s partisan history. It was passed without a single Republican vote.

Implementation has also been rocky — especially the disastrous debut of the government’s insurance exchange website in 2013. Nineteen states — most with Republican leadership — declined to take advantage of the Affordable Care Act’s Medicaid expansion.

What’s more, after losing money in past years, many insurance companies have stopped offering policies on the government-run exchanges. According to the Kaiser Family Foundation, about 20 percent of people shopping for coverage on the exchanges this year have just one insurance company to choose from. With less competition, premiums on the exchanges have risen sharply: about 25 percent on average.

Despite these drawbacks, supporters say the Affordable Care Act has been a net-plus, both for individual customers who can no longer be denied access to health insurance and for the federal government which has steadily reduced its forecast of long-term health-care costs.

At the same time, the law has not proven to be the drag on job growth that many Republicans warned of.

“Since I signed Obamacare into law, our businesses have added more than 15 million new jobs,” Obama noted.

The president can point to a number of other positive indicators as he prepares to leave office, including long-awaited wage gains in the last year and a modest decrease in income inequality, stemming, in part, from higher taxes on the wealthy.

The president and his team are trying to document those gains, mindful that the next occupant of the White House wants to reverse much of what Obama has put in place.

“What the president-elect is going to be doing is going to be very different than what I was doing, and I think people will be able to compare and contrast and make judgments about what worked for the American people,” Obama said during his year-end news conference. “I hope that, building off the progress we’ve made, that what the president-elect is proposing works. What I can say with confidence is that what we’ve done works.”

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“This year there’s been one big home run and a lot of scratch singles.” That’s how Red Sox fan and editor-in-chief of the New England Journal of Medicine, Dr. Jeffrey Drazen, sums up the year-that-was in public health.

Zika was the home run of 2016. It got lots of attention. It created a lot of drama. And it had a significant public health impact this year, says Drazen, who is a professor at the Harvard T.H. Chan School of Public Health. The Zika outbreak prompted travel warnings throughout the hemisphere and sparked frantic efforts to develop a vaccine.

And then there are the “scratch singles.” In baseball a “scratch single” is when a hitter barely hits the ball — “scratches” it — but still manages to get to first base. Drazen is talking about the non-glamorous work in public health that wins games over the long haul.

With ongoing efforts to combat mosquitoes and get people to sleep under bed nets, deaths from malaria continue to decline in Africa — down from more than 800,000 a year in 2000 to roughly 400,000 last year.

New HIV infections and fatalities have stabilized globally, although that still means that the virus spread to about 2 million more people in 2016 and killed another million. This flat-lining on HIV/AIDS is seen by some as a worrisome indication that progress against the epidemic has stalled. The more optimistic voices in the HIV world, however, point out that given the rapidly expanding population in Africa, where the bulk of new infections occur, the fact that numbers aren’t rising illustrates a heroic effort to keep this epidemic from getting far worse through prevention, education and HIV treatment programs.

Middle Eastern Respiratory Syndrome or MERS refuses to die but appears to be slouching toward extinction. MERS has primarily been a Saudi Arabia problem thus far. Since the virus was first discovered in 2012, 1482 of the 1841 cases reported to the World Health Organization have been in Saudi Arabia. One significant exception came in 2015, when a MERS outbreak in Korea caused panic in Seoul, temporarily shutting down schools, hospitals and factories. The outbreak in Korea was sparked by a businessman who’d recently returned from the Middle East. And although transmission of the virus continues at only a low level in Saudi Arabia, there’s no reason that a traveler couldn’t trigger another outbreak like the Korean one somewhere else in the world.

But in baseball terms, MERS in 2016 was the slugger at the bottom of the batting order, still getting up to the plate, still a threat but not causing much concern.

On the good news front, there have been lots of little advances — promising stars emerging from the ranks of the minor leagues. “There’s a new herpes vaccine for shingles that’s 90 percent effective,” Drazen says enthusiastically about a Glaxo Smith Kline vaccine that just wrapped up clinical trials. The GSK vaccine is far more effective than the roughly 50 percent offered by the only commercial shingles vaccine currently on the market.

“And guinea worm, we are almost close to eradicating that,” Drazen adds. Guinea worm is a nasty tropical parasite that’s spread by contaminated water. The worms pop out of people’s legs like long, burning strands of spaghetti. The Carter Center, which has been one of the lead agencies in the effort to stamp out guinea worm, says there were fewer than two dozen cases in the first 10 months of 2016.

Rob Henry, a senior public health adviser with USAID’s Neglected Tropical Disease (NTD) program, shares Drazen’s outlook: “I think 2016 was an excellent year,” he says.

“This year, for example, Guatemala was declared free of onchocerciasis — river blindness. That’s a big one.”

River blindness is a parasitic infection, spread by black flies, that causes excruciating itching and in severe cases blindness. The declaration that Guatemala is now free of the disease means that river blindness has been eliminated from everywhere in the Americas except one remote area in the Amazon along the border between Brazil and Venezuela.

River blindness is one of the seven neglected tropical diseases that USAID’s NTD program focuses on. Lymphatic filariasis is another. Also known as elephantiasis, it can cause horrific swelling of the legs and scrotum.

“Cambodia this year got acknowledgement from WHO as having eliminated lymphatic filariasis as a public health problem,” Henry says. “That’s a big moment for Cambodia.”

Henry says eliminating diseases like elephantiasis can’t compete in the headlines with the fight against fatal conditions. But he too is a big believer in the power of small hits: “It’s one thing to say you’re out there saving lives but it’s another thing to talk about how do you improve lives. How do you improve things to enable people to be able to make a living for themselves, for kids to be able to go to school, for people to be able to take care of their farms.”

Mass de-worming programs supported by USAID can break the transmission cycle of the parasite that causes lymphatic filariasis. And Henry notes that significant progress is being made against this disease not just in Cambodia but across the tropics.

“In Africa, Togo is just about ready to be able to declare the elimination of lymphatic filariasis,” he says. In the year 2000 in some parts of Togo up to 22 percent of residents were infected with the parasites that cause the debilitating swelling.

The other disease eradication effort that is tantalizingly close to victory but can never quite hit it out of the park is the campaign to end polio. And 2016 was a complicated year for the virus. On the one hand only 34 cases had been detected in 2016 as of this week. Unfortunately four of them were in Nigeria, which had previously been declared “polio-free” along with the rest of the African continent.

The new cases in Africa were found in areas recently liberated from Boko Haram. The insurgents barred health workers, destroyed health clinics and made routine immunization campaigns impossible.

Jeff Drazen says polio eradication is no longer a medical problem.

“We have the medical capacity to do this but it’s become a political problem,” he says. “It’s not as much a medical challenge as it is a political challenge.”

Or as the great baseball player Yogi Berra once said, “It ain’t over ’til it’s over.”

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Chelsea Arnold was getting into debt over tiny pieces of plastic: diabetic test strips. When Arnold was first diagnosed with diabetes she needed to test her blood sugar 10 times a day. She went to Wal-Mart and found that one box, which contained only a five-day supply of test strips, was $80. Arnold called her parents and told them she didn’t know what to do. She didn’t have the money.

Arnold then did what a lot of people do when they need help: She searched on Google. She typed in the words “cheap test strips,” and Craigslist came up. She bought eight boxes for less than $100. At Wal-Mart, she would have paid $640. Arnold said, “it was like having a life sentence and then realizing that there’s a cure.”

With this Google search, Arnold stumbled into an underground economy for diabetic supplies. It’s a market that offers a lower-cost option for test strips, though it is hard for customers to know where the boxes come from. Some boxes may be repackaged and unsafe to use, and some boxes are sold by diabetics who are desperate for cash. But many of them come from people who have health insurance and have accumulated extra test strips.

Trey falls into this category. (He asked us not to use his last name, because he fears retribution from his insurance company, even though he feels he hasn’t broken any laws.) He moved from one type of blood sugar monitoring system to another type of monitoring system and ended up with 20 extra test strip boxes.

At that point, Trey began researching. He said, “Obviously No. 1: Is it legal to be able to sell test strips?” Trey realized that it is legal, with a caveat. “It’s kind of a gray market as long as you don’t get them from Medicare and Medicaid,” he said. Trey then found a local buyer on Craigslist.

It starts to look a little seedy here. He put the 20 boxes in a brown paper lunch bag. “When I went to sell the test strips we met in a McDonald’s parking lot,” Trey said. “I came out with the bag full of test strips, and he had his wallet full of money and it was like we were doing a geriatric drug deal in the McDonald’s parking lot to get rid of some test trips.”

Trey made $300 off the geriatric drug deal. He jokingly calls the cash he made “blood money.” He used his “blood money” to buy Christmas presents for his kids.

As far as we can tell, his test strips went on to the next stop: a gray market middleman, something like a wholesaler, someone like Christa Kral. Along with her cousin, Kral purchases diabetic test strips from people like Trey. Their website is called sellusdiabeticteststrips.com.

To advertise, Kral used to post fliers near the train station in her town. Now her ads are online. She thinks the company’s unusual tagline has also brought in customers: “Two moms will buy your test strips.”

Kral operates her business out of her dining room. She has a cardboard box with about 20 boxes of test strips inside. She might pay $50 a box. It depends on the brand, the condition of the box, and the expiration date for the test strips.

Then she sells them at a markup to the next part of this chain: retailers. Arnold, the woman who bought test strips off Craigslist because they were too expensive at Wal-Mart, is now a retailer. That time when she couldn’t afford her test strips and keep her blood sugar in check — it scared her, and it made her decide to change her career path.

Arnold had been planning to go to medical school. But “that’s what really made me think I shouldn’t be a doctor and that I should go and help people try to afford the test strips,” she said.

Arnold started a website, glucomart.com. It’s a place where people can buy affordable test strips. She turned her garage into a kind of pharmacy. Her floor is epoxied, and she has pharmacy shelves.

Arnold realizes that if manufacturers or insurance companies lowered the price of test strips, she could be put out of business. She’s actually OK with that, because, she said, “the business exists to help people afford the test strips they need.”

Arnold would be happy to go back to her original plan and trade in her pharmacy shelves for a doctor’s coat.

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Each Wednesday at St. Francis Episcopal Church on the north side of San Antonio, dozens of refugees from all over the world come for free care at the Refugee Health Clinic.

Students and faculty at the University of Texas Health Science Center in San Antonio have teamed up to operate one of the only student-run refugee clinics in the country.

In the past six years, more refugees have resettled in Texas than in any other state. That was before the state of Texas pulled out of the refugee resettlement program in September, citing concerns over terrorism.

The refugees who come seeking care are from the Middle East, southern Africa and Asia. They have fled violence and persecution. An estimated 5,000 refugees live within 3 miles of San Antonio’s medical center.

Most who have resettled here receive temporary federal government health benefits that run out after six months or so.

“We really fill that gap before they can kind of get on their feet after they’ve lost their government benefits,” says Michael Tcheyan, a medical student who volunteers at the clinic. “We feel like it’s our duty, and it’s their right to get medical care and to be connected with services that are going to make their life better.”

Medical students from the Student Faculty Collaborative Practice of UT Health San Antonio help provide care along with students from the School of Nursing, the School of Dentistry and the School of Allied Health Professions, which includes physician assistants, physical therapy and respiratory care.

Layla Mohsin, 52, came to the clinic for dental care. She’s a teacher from Iraq who came to the U.S. with her family of seven to escape the violence.

“We left Iraq and came to the United States because there is safety here. There, there is no safety,” Mohsin says as her son, Karrar Al Gburi, interprets for her. “The main concern? The lethal explosive cars. You can get caught by an explosive car at any place, any time.”

Laxmi Adhikari, a 65-year-old old man who fled Bhutan to a refugee camp in Nepal, is being treated for an itchy stubborn rash. He sports a T-shirt with a local high school team logo, a gift from one of the many people in San Antonio who he says have welcomed him.

“It’s far better than the refugee camp,” Adhikari says through Nepalese interpreter Dal Gajmer. “I trust and believe all of the nurses and doctors. They treat me very well.”

Dental student Eduardo Vela is originally from another country, too. He understands his patients’ challenges. “If you don’t know the language, there are a lot of cultural differences. I myself grew up in Mexico, so I know a little bit of the feeling of being an outsider and then trying to fit in,” Vela says.

The refugee population has many unmet medical needs, says clinic medical director Browning Wayman. “They are in search of people to manage their high blood pressure, their diabetes, their high cholesterol, thyroid disease, mental health issues,” Wayman explains. “For a lot of us that went into medicine, we went into it to help people. This is a population that needs help, and so it’s really a joy.”

Funding for the Refugee Health Clinic is provided through the Kronkosky Charitable Foundation and St. Luke’s Lutheran Health Ministries Inc., as well as the operations budget of the Center for Medical Humanities and Ethics, part of the School of Medicine of the University of Texas Health Science Center at San Antonio. Endowment funds, individual donors and the university pitch in to cover other costs.

Texas will continue to be home to new refugees. But instead of giving financial assistance to the state, the federal Office of Refugee Resettlement will be giving that money directly to nonprofits.

The refugees don’t use the free clinic forever. The staff helps them find more permanent care. If patients need a referral to a specialist, they may have to find a way to pay for that visit.

The students and faculty also work to connect patients to whatever health coverage they might be eligible for, such as CareLink, a financial assistance program for health care services through University Health System. It’s available for Bexar County residents who do not have public or private health insurance. The cost is based on family size and income.

Navigating the health care system can be difficult even for Americans, says one of the clinic’s founders, Dr. Andrew Muck, an associate professor of emergency medicine at UT Health Science Center, so he says it is hard to imagine the difficulty for these refugees.

“You don’t speak the language, may not have a job,” Muck says. “And even though you’re in the midst of this robust health system, you can’t get in the door, can’t get over those hurdles.”

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