Sadé Lewis of Queens, New York, has suffered migraines since she was a kid, and as she started college, they got worse. A recent change in her insurance left the 27-year-old looking for a new neurologist. That’s when she found West 14 Street MedicalArts in New York.

MedicalArts recommended that she get an electroencephalogram (EEG) and an MRI to make sure her brain was functioning properly.

An EEG is a test to measure the electrical activity of the brain. It can find changes in brain activity that can help in diagnosing conditions including epilepsy, sleep disorders, and brain tumors. During the procedure, electrodes consisting of small metal discs with attached wires are pasted onto the scalp using adhesive, or attached to an electrode cap that you wear on your head.

A little over a week before her EEG, Lewis was given instructions that she didn’t remember getting before a previous EEG appointment.

To Lewis’ surprise, patients were told to remove all hair extensions, braids, cornrows, wigs, etc. Also, she was to wash her hair with a mild shampoo the night before the appointment and not use any conditioners, hair creams, sprays, oils, or styling gels.

“The first thing I literally did was text it to my best friend, and I was, like, this is kind of anti-Black,” Lewis said. “I just feel like it creates a bunch of confusion, and it alienates patients who obviously need these procedures done.”

The restrictions could discourage people with thick, curly, and textured hair from going forward with their care. People with more permanent styles like locs — a hairstyle in which hair strands are coiled, braided, twisted, or palm-rolled to create a rope-like appearance — might be barred from getting the test done.

Kinky or curly hair textures are typically more delicate and susceptible to damage. As a result, people with curlier hair textures often wear protective hairstyles, such as weaves, braids, and twists, which help maintain hair length and health by keeping the ends of the hair tucked away and minimizing manipulation.

After receiving the instructions, Lewis scoured the internet and social media channels to see if she could find more information on best practices. But she noticed that for people with thick and textured hair, there were few tips on best hairstyles for an EEG.

Lewis has thick, curly hair and believed that explicitly following the instructions on the preparation worksheet would make it harder, not easier, for the technician to reach her scalp. Lewis decided that her mini-twists — a protective style in which the hair is parted into small sections and twisted — would be the best way for her to show up to the appointment with clean and product-free hair that still allowed for easy access to her scalp.

Lewis felt comfortable with her plan and did not think about it again until she received a reminder email the day before her EEG and MRI appointment that restated the restrictive instructions and added a warning: Failure to comply would result in the appointment being rescheduled and a $50 same-day cancellation fee.

To avoid the penalty, Lewis emailed the facility with her concerns and attached photos.

“I got kind of worried, and I sent them pictures of my hair thinking that it would go well, and they would be, like, ‘Oh yeah, that’s fine. We see what you see,’” said Lewis.

Soon after, she received a call from the facility and was told she would not be able to get the procedure done with her hair in the twists. After the call, Lewis posted a TikTok video detailing the conversation. She expressed her frustration and felt that the person on the phone was “close-minded.”

“As a Black woman, that is so exclusionary for coarse and thick hair. To literally have no product in your hair and show up with it loose, you’re not even reaching my scalp with that,” Lewis said in her video.

The comments section on Lewis’ TikTok video is full of people sharing in her frustration and confusion or recounting similar experiences with EEG scheduling.

West 14 Street MedicalArts declined to comment for this article.

The New York medical center is not the only facility with similar EEG prep instructions. The Neurology Center, which has several locations in the Washington, D.C., area, provides EEG pretest instructions for patients reading, “Please remove any hair extensions or additions. Do not use hair treatment products such as hair spray, conditioners, or hair dressing, nor should you fix your hair in tight braids or corn rows.”

Marc Hanna, the neurophysiology supervisor at the center’s White Oak location in Silver Spring, Maryland, has more than 30 years of experience performing EEGs. He oversees 10-12 EEG technicians at the facility.

Hanna said the hair rules are meant to help a technician get an accurate reading from the test. “The electrodes need to sit flat on the scalp, and they need to be in precise spots on the scalp that are equally apart from each other,” Hanna said.

For people with thick and curly hair, this can be a challenge.

A 2020 article from Science News detailed a study that measured how much coarse, curly hair could interfere with measuring brain signals. A good EEG signal is considered to have less than 50 kilo-Ohms of impedance, but the researchers found unbraided, curly hair with standard electrodes yielded 615 kilo-Ohms.

Researchers are working to better capture brain waves of people with naturally thick and curly hair. Joy Jackson, a biomedical engineering major at the University of Miami, developed a clip-like device that can help electrodes better adhere to the scalp.

Experimentation with different braiding patterns and flexible electrode clips shaped like dragonfly wings, designed to push under the braids, has had promising results. A study, published by bioRxiv, found this method resulted in a reading well within the range for a reliable EEG measurement.

But more research has to be done before products like these are widely used by medical facilities.

Hanna said the facility where he works does not automatically ask patients to remove their protective styles because sometimes the technician can complete the test without them doing so.

“Each one of those cases are an individual case,” Hanna said. “So, at our facility, we don’t ask the patient to take all their braids out. We just ask them to come in. Sometimes, if one of the technicians are available when the patient is scheduling, they’ll just look at the hair and say, ‘OK, we can do it’ or ‘We don’t think we can do it.’ And we even might say, ‘We don’t think we can do it but come in and we’ll try.’”

In practice, Hanna said, it’s not common for hair to be an issue. But for patients whose hairstyle might make the test inaccurate, he said, it becomes a conversation between the doctor and the patient.

When Lewis arrived the following day for her MRI and EEG appointment, she was told her EEG had been canceled.

“It was just kind of baffling a little bit because, literally, as soon as I walk in, I saw about four different Black women who all had either twists, locs, braids, or something,” she said. “And on the call, the woman was saying if you come in and my hair is not loose, we’re going to charge you. And she did recommend to cancel my appointment. But I never approved that.”

After Lewis explained what happened during the phone call, she said, the receptionist was very apologetic and said the information Lewis was given was not true. Lewis said she spoke with one of the EEG technicians at the facility to confirm that her mini-twists would work for the test — and felt a sigh of relief when she saw the technician was also a Black woman.

“The technician, I think overall, they just made me feel safe,” Lewis said. “Because I felt like they could identify with me just from a cultural standpoint, a racial standpoint. So, it did make me feel a little bit more valid in my feelings.”

Lewis later returned to the facility to get the procedure done while still wearing mini-twists. This time, the process was seamless.

Her advice for other patients? “When you feel something, definitely speak out, ask questions.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Opponents of the Affordable Care Act may have stopped trying to overturn the entire law in court, but they have not stopped challenging pieces of it — and they have found an ally in Fort Worth, Texas: U.S. District Judge Reed O’Connor. In 2018, O’Connor held that the entire ACA was unconstitutional — a ruling eventually overturned by the Supreme Court. Now the judge has found that part of the law’s requirement for insurers to cover preventive care without copays violates a federal religious freedom law.

In a boost for the health law, though, North Carolina has become the 40th state to expand the Medicaid program to lower-income people who were previously ineligible. Even though the federal government will pay 90% of the cost of expansion, a broad swath of states — mostly in the South — have resisted widening eligibility for the program.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Sandhya Raman of CQ Roll Call.

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Rachel Cohrs
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Alice Miranda Ollstein
Politico

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Sandhya Raman
CQ Roll Call

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Read Sandhya's stories

Among the takeaways from this week’s episode:

• Thursday’s decision out of Texas affects health plans nationwide and is expected to disrupt the health insurance market, which for years has provided preventive care without cost sharing under the ACA. Even if the decision survives a likely appeal, insurers could continue offering the popular, generally not-so-costly benefits, but they would no longer be required to do so.
• The decision, which found that the U.S. Preventive Services Task Force cannot mandate coverage requirements, hinges on religious freedom objections to plans covering PrEP, the HIV medication, alongside other preventive care.
• Speaking of the ACA, this week North Carolina became the latest state to expand Medicaid coverage under the health law, which will render an estimated 600,000 residents newly eligible for the program. The development comes amid reports about hospitals struggling to cover uncompensated care, particularly in the 10 states that have resisted expanding Medicaid.
• Pushback against Medicaid expansion has contributed over the years to a yawning coverage divide between politically “blue” and “red” states, with liberal-leaning states pushing to cover more services and people, while conservative-leaning states home in on policies that limit coverage, like work requirements.
• On the abortion front, state attorneys general are challenging the FDA’s authority on the abortion pill — not only in Texas, but also in Washington state, where Democratic state officials are fighting the FDA’s existing restrictions on prescribing and dispensing the drug. The Biden administration has adopted a similar argument as it has in the Texas case challenging the agency’s original approval of the abortion pill: Let the FDA do its job and impose restrictions it deems appropriate, the administration says.
• The FDA is poised to make a long-awaited decision on an over-the-counter birth control pill, an option already available in other countries. One key unknown, though, is whether the agency would impose age restrictions on access to it.
• And as of this week, 160 Defense Department promotions have stalled over one Republican senator’s objections to a Pentagon policy regarding federal payments to service members traveling to obtain abortions.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: New York Magazine/The Cut’s “Abortion Wins Elections: The Fight to Make Reproductive Rights the Centerpiece of the Democratic Party’s 2024 Agenda,” by Rebecca Traister.

Alice Miranda Ollstein: Stat’s “How the Drug Industry Uses Fear of Fentanyl to Extract More Profit From Naloxone,” by Lev Facher.

Rachel Cohrs: The Washington Post’s “These Women Survived Combat. Then They Had to Fight for Health Care,” by Hope Hodge Seck.

Sandhya Raman: Capital B’s “What the Covid-19 Pandemic and Mpox Outbreak Taught Us About Reducing Health Disparities,” by Margo Snipe and Kenya Hunter.

Also mentioned in this week’s podcast:

• The New York Times’ “‘We’re Going Away’: A State’s Choice to Forgo Medicaid Funds Is Killing Hospitals,” by Sharon LaFraniere.
• KHN’s “Fresh Produce Is an Increasingly Popular Prescription for Chronically Ill Patients,” by Carly Graf.
• California Healthline’s “Prescription for Housing? California Wants Medicaid to Cover 6 Months of Rent,” by Angela Hart.

click to open the transcript

Transcript: A Judicial Body Blow to the ACA

KHN’s ‘What the Health?’Episode Title: A Judicial Body Blow to the ACAEpisode Number: 291Published: March 30, 2023

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 30, at 11 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Alice Miranda Ollstein of Politico.

Alice Miranda Ollstein: Good morning.

Rovner: Sandhya Raman of CQ Roll Call.

Sandhya Raman: Good morning.

Rovner: And happy birthday to you.

Raman: Thank you.

Rovner: And Rachel Cohrs of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: We’ve got breaking news, so we will get right to it. In Texas, we’ve got a major decision from a federal judge with national implications. No, not the abortion pill case — that is still out there. This time, Judge Reed O’Connor has ruled that the Affordable Care Act can’t require coverage of preventive services recommended by the [U.S.] Preventive Services Task Force because the PSTF, as an independent advisory board, can’t legally mandate anything. This case was specifically — although it was about a lot of things — but it was mostly about employers who didn’t want to cover preexposure prophylaxis [PrEP] for people at high risk of HIV because it violated their religious beliefs. And if the name Reed O’Connor sounds familiar, that’s because he’s the same judge who ruled in 2018 that the entire Affordable Care Act was unconstitutional, a finding that wasn’t formally overturned until it got to the Supreme Court. Alice, you’ve been following this case. What happens now?

Ollstein: I’m expecting the Biden administration to appeal at lightning speed, although that appeal will go to the 5th Circuit, which is very right-leaning. It’s ruled to chip away at the Affordable Care Act in the past. So who really knows what will happen there? But yeah, this is really huge. This is saying that this board that has decided what services insurance companies have to cover for free, with no cost sharing, going all the way back to 2010 is not constitutional, and thus what they say can’t be enforced. And so this throws the insurance market into a bit of chaos.

Rovner: Yeah, although one would think that it wouldn’t affect this year’s policies — I mean, for people who are going to be worried that all of a sudden, you know, oh my God, I scheduled my mammogram and now my insurer might not pay for it. It’s not going to be that immediate, right?

Ollstein: We’re not expecting that. I mean, we’re expecting the Biden administration to ask for courts to stay the impact of the ruling until further arguments and appeals can be made. But we really don’t know at this point. And I will say, you know, I’ve seen some misinformation out there about how the ruling deals with contraception. They do not block the contraception mandate. That is related to this case, but the court did not accept that part of the challengers’ claims.

Rovner: Yeah, we should say there are a bunch of different claims and the judge only accepted a couple of them. It could have been even broader. But, you know, unlike the previous Affordable Care Act cases, this one doesn’t threaten the entire law, but it does threaten one of the law’s most popular pieces, those requirements that plans cover preventive care that’s been shown to be cost-effective. This could be an uncomfortable case for the Supreme Court, assuming it gets there, couldn’t it?

Cohrs: It could be an uncomfortable case for the Supreme Court, but it’s also uncomfortable for insurers, too, who’ve promised this. People have come to expect it. And if it is cost-effective, I mean, certainly there may be plans that, you know, make choices to restrict coverage or impose some cost sharing. If this stands, if this is applied nationwide — again, very big ifs at this point — but if these really are cost-effective, then it’s kind of an open question what insurers will choose to do, because obviously they want people to enroll in their plans as well.

Rovner: Yeah, I was going to say, I could see insurers sort of deciding as a group that we’re going to keep providing this stuff, as you say, Rachel, because they want, you know, they want to attract customers, because for the most part it’s not that expensive. I mean, obviously, you know, things like colonoscopies can run into the thousands of dollars, but a lot of these things are, if not de minimis, then just not very expensive. And, as I mentioned, they’re very popular. So it’s possible that, even though they may strike down the mandate, there won’t be as much of an impact from this as some people are saying. But, as Alice points out, we don’t really know anything at this point.

Ollstein: And I think some of the concern is the kind of risk-pool sorting we used to see, you know. So the challengers said that their right to purchase insurance that doesn’t cover certain things was being infringed upon. And so if insurers start to create separate plans, some of which cover all kinds of preventive care, including sexual health care, and separate ones that don’t, and people who don’t think they need a lot of stuff, you know, sort themselves into some plans and not others, you can see that reflected in premiums that could lead to some of the major pre-ACA problems we used to see.

Rovner: If the idea that somebody doesn’t like something and therefore can’t buy something without it, you can see that leading to all kinds of problems down the line about people saying, well, “I don’t like that drugstores sell condoms, so therefore I should be able to go to a drugstore that doesn’t sell condoms,” although that’s not a mandate. But you can see that this could stretch very far with people’s religious beliefs. And indeed, the basis of this claim is that this violated the Religious Freedom Restoration Act. That’s one of the things that Judge O’Connor found, and that could be taken to quite the extreme, I imagine.

Ollstein: Right. I mean, they weren’t required to actually purchase PrEP. They weren’t required to use it. They weren’t required to prescribe it. Just the insurance company was required to cover it along with everything else they cover. And the folks said even purchasing insurance that had that as one of the things it could conceivably cover violated their religious rights.

Rovner: Yes. And this goes back to the contraceptive cases, where the religious organization said that, you know, by having birth control in their plans, it made them complicit in something that they thought was a sin. And that’s exactly what’s being stressed here, even among the individual plaintiffs: that having to buy insurance that has these benefits, even if they don’t use them, makes them complicit in, basically, sex outside of marriage. I mean, that’s what’s in the decision. It’s quite a reach. I’ll be interested to see, as this goes up, what people think of it. So, before we got Judge O’Connor’s opinion, what I thought would be the biggest news of the week comes from North Carolina, which on Monday became the 40th state to expand Medicaid under the Affordable Care Act, to cover people with incomes up to 138% of poverty. That’s about $20,000 in 2023. Well, it’s almost there. The newly eligible 600,000 people won’t be able to sign up until the legislature approves a budget, which is likely later this spring. North Carolina expanding the program leaves only a swath of states across the South, including Florida, Georgia, and Texas, and a couple in the Great Plains as still holding out on a 90% federal match. Is anyone else on the horizon or is this going to be it for a while?

Raman: I think one thing to note about how this is happening is that North Carolina was able to do this finally through the legislature after like a yearslong process. And it has been increasingly rare for this to happen through the legislature. The last time was Virginia, in 2018, but every other state that has done it in recent years has all been through ballot initiative and going that route. And the 10 holdouts that we have, you know, we have Republican-controlled legislatures who’ve been pretty against doing this. So I think if any of those states were to be able to do that at this point that haven’t been tempted by, you know, any of the incentives … [unintelligible] … get a higher match rate or anything like that, it would have to be through the ballot, which is already a difficult process, can take years. There have been various roadblocks to push back and even some of the states in the past that have been able to get it through ballot initiative — some of the legislatures afterwards have tried to like push back on it — when we saw with Utah a few years ago, where even if the voters had voted that they wanted to expand, they wanted to kind of pull it back.

Rovner: We thought in Maine, where the governor blocked it until basically he was out of office.

Raman: Yeah.

Ollstein: And in Missouri, where they just refused to fund it.

Raman: Yeah, so I think that’ll be definitely something to watch with how the budget goes in the next few months. But I guess, at least with North Carolina, this was something that was bipartisan. It was spearheaded in the legislature by Republicans, so I think they might not have the same issues there than Missouri, but it’s a tough haul to get the remaining 10 at this point after this many years.

Rovner: Yeah, I feel like North Carolina is much more like Virginia, which is that, finally, after a lot of wearing down, the Republican legislature and the Democratic governor were able to come to some kind of agreement. That’s what happened in Virginia. And that seems to be what’s happened here in North Carolina. Meanwhile, in those 10 states, hospitals which end up providing free care to people who can’t pay aren’t doing so well. In Florida, the state’s hospital association has been all but begging the state government to expand Medicaid pretty much since it was available to them, which is now going on 13 years. According to the American Hospital Association, 74% of rural hospital closures around the country took place in states that have not expanded Medicaid or where expansion had been in place for less than a year. And the New York Times has a story this week about the toll that that lack of insurance is taking — I’m sorry — and the New York Times has a story this week about the toll that lack of insurance for the working poor is taking there, not just on the state’s hospitals, but on the health of the state’s population. Lawmakers in these states are very happy to take federal money for all manner of things. What is it about this Medicaid expansion that’s making them say, “No, no, no”?

Raman: This was something that came up this week in the House. Appropriations’ Labor, HHS, Education Subcommittee had a hearing this week specifically on rural communities and some of the issues they face. And Medicaid expansion obviously did come up with some of the witnesses and some of the lawmakers as something that would be helpful given the number of hospital closures they’ve seen, and there might only be one health care facility for miles or in a county, and just how it would be helping them to kind of relieve paying for the uncompensated care that they’re already dealing with, you know, highlighted a number of the issues there. So it’s something that comes up, but I think one of the pushbacks that we saw was, you know, again, that it is a) tied to the Affordable Care Act, which has been such a partisan back-and-forth since its inception, and then b) just the messaging has always been about the cost. I mean, even if the general consensus is that it does save money over time for taking care of that care, something that came up was why states get more of a reimbursement for expansion than they do for traditional Medicaid. That was brought up a couple times, things like that. And so I think it’s hard to get some of those folks on board just because of how partisan it has become.

Rovner: Yeah, I remember I watched the hearing in Wyoming on this last year. They didn’t want to do it, it seemed, more for ideology. I mean, a lot of states that are doing this, you know, you can levy a tax on hospitals and nursing homes, who are happy to pay the tax because they’re now getting paid for these patients who couldn’t pay. And the state’s really not out-of-pocket, as it were, at all. But and yet, as we point out, these last 10 states, including some of the really big ones, have yet to actually succumb to this. Well, while we are talking about Medicaid, there have been a couple of interesting stories from my KHN colleagues in the past few weeks about so-called social determinants of health, those not strictly medical interventions that have a big impact on how sick or healthy people are. In California, Democratic Gov. Gavin Newsom wants to use Medicaid to pay for six months of rent or temporary housing for homeless people. And in Montana, health professionals can now prescribe vouchers for fruit and vegetables for patients with little access to fresh food. Is this the wave of the future, or will those who want to shrink rather than expand the welfare state and government in general roll programs like these back?

Cohrs: I think there certainly is a trend, a lot of momentum behind the idea of food as medicine and, you know, moving away and exploring some of these non-medication treatments or some of these underlying reasons why people do have health issues. I think certainly support for the Medicaid program is going to be a hot-button issue in D.C. over the next few months, but there is a lot that states can do on their own as well. And I know states have, you know, programs to kind of cover people that fall between the cracks of traditional insurance programs. California has a robust program for that, the local levels as well. So I think there may be ways to get around that, even if we do see some more restrictions. And again, the administration is Democratic at this point, so I think they may be friendlier to some of these innovations than prior ones, and that could change at any time. But this certainly isn’t something that’s going to go away.

Rovner: I wonder if we’re going to end up with blue states having all of these more robust pro — I mean, we already have blue states with more robust programs, but blue states having these more inclusive programs and red states not. Alice, you’re nodding.

Ollstein: Absolutely. And that’s been the trend for a while, but it could even accelerate now, I think, and you’re seeing that on both sides, with blue states looking to cover more and more things; also looking to cover more and more people, including undocumented people. That’s another trend in Medicaid. At the same time, you have red states that have long explored how to cover fewer and fewer, you know, trying to change the income eligibility threshold for expanded Medicaid, trying to do work requirements, trying to do, like, other restrictions. And so I think the patchwork and the divide is only going to continue.

Rovner: Well, moving on to abortion this week, we are still waiting, as I said, for that other decision out of Texas that could impact the future of the abortion pill mifepristone. But Alice, there’s another case at the other end of the country that could have something to say about the Texas case. What’s going on in Washington state?

Ollstein: This one has really flown under the radar. So this is an interesting situation where the same — a lot of the same Democratic attorneys general who were siding with the Biden administration in the Texas case are challenging the Biden administration in a different case in Washington state, basically saying that the remaining federal restrictions on abortion pills — mainly that providers have to get certified in order to prescribe the drugs or dispense them — saying that that should be tossed out, that it’s not supported by medicine and science. And so it’s interesting because you have the Biden administration fighting back against an effort to make the pills more accessible, which is not what a lot of people expect. It goes sort of against their rhetoric in recent months; they’ve talked about wanting to make the pills more accessible and they’re opposing an effort that would do that. But it is somewhat consistent with their position in the Texas case, which is, they’re saying, “Look, this is the FDA’s job. Let the FDA do its job. The FDA has a process, came up with these rules, got rid of some, kept others, and you outside folks don’t have the right to challenge and overturn it.”

Rovner: So what happens if the judges in both of these cases find for the plaintiffs, which would be kind of, but not completely, conflicting?

Ollstein: Yeah, so the Washington state case could just apply to the dozen states that are part of the challenge. And so you could have, again, more of a patchwork in which the abortion pills become even more accessible in those blue states and even less accessible in other states. You could also have these competing rulings that ultimately trigger Supreme Court review.

Rovner: Yeah, it’s not exactly a circuit split because it wouldn’t be opposite decisions on the same case; they’re different cases here. But as you point out, it’s really a case challenging the authority of the FDA to do what the FDA does. So it’s going to be really interesting to watch how this all plays out. While the future of mifepristone remains in doubt, the FDA is going to consider making at least one birth control pill over the counter. We know that morning-after pills, which are high doses of regular birth control pills, are already available without a prescription. So why hasn’t there been an over-the-counter birth control pill until now?

Ollstein: Everything concerning birth control, emergency contraception, abortion, it just — these fights drag on for years and years and years. So finally, we seem to be on the cusp of having a decision on this. It’s expected, from most people I’ve talked to, that they will approve this over-the-counter birth control. There’s a lot of data from around the world. A lot of other countries already have this. And one key unknown is whether the FDA will maintain an age restriction on it. A lot of progressive advocates do not want an age restriction because they think that this is important to help teens prevent unwanted pregnancies. And I think that’s going to be a big piece of the fight that I’m watching.

Rovner: And oh, my goodness, it was that age restriction that held up the over-the-counter morning-after pill for years. That was like a 13-year process to get that over the counter. It went on and on and on, and I covered it. All right. Well, there is abortion-related action on Capitol Hill too this week. We’ve got a potential abortion standoff brewing in the Senate over reproductive health policy at the Department of Defense. Who wants to talk about that one?

Raman: This one has been, I think, really interesting, since we’re all health reporters. And it’s been really something that I think my defense colleagues have been following so closely. But we have Senator Tuberville, who’s been holding up military nominations because the Pentagon has a policy that allows, you know, service members leave for reproductive care and it covers travel to seek an abortion. And so —

Rovner: Although it still doesn’t pay for the abortion.

Raman: It does not pay for the abortions. It’s for the travel. And so I know that my colleagues have looked at this and how this point, like, both sides have been getting a little frustrated, you know, with even some senators saying, “Hey, I agree that I don’t like this policy, but you need to find another way,” because as of earlier this week 160 promotions have been stalled. And so it’s just been kind of ramping up and holding up a lot of folks for kind of an unusual method.

Rovner: Yeah, and the defense secretary saying, I mean, this threatens national security because these are promotions — are important promotions. Flag officers, these are not, you know, just sort of — they’re routine, but they’re, you know, but if they don’t happen, if they get stalled, it’s a problem. In all of my years of seeing anti-abortion senators hold up things, this is not one I have seen before. It’s at least — it’s sort of new and imaginative, and I guess we will see how that plays out. Back in the states, though, it seems that the efforts to restrict reproductive rights are getting very extreme, very fast. Yes, the Oklahoma Supreme Court ruled earlier this month that a pregnant woman does have a right to an abortion when continuing the pregnancy threatens her life. But four of the nine justices there didn’t even want to go that far, suggesting that the legislature has the right to basically require saving the fetus even at the cost of the pregnant person’s life. In Texas, a lawsuit in which the ex-husband is suing the friend of his ex-wife for the wrongful death of his child for helping her get abortion medication is setting the stage for the so-called personhood debate: the idea that a new person with full legal right is created upon fertilization of an egg by sperm. Over the past few decades, several states have rejected personhood ballot measures as a bridge too far. But it feels like all bets are off now. I mean, it’s sort of like a race to see who can be the most extreme state.

Ollstein: I think the trends are revealing some interesting things. I mean, one, anti-abortion folks are well aware that people are still getting abortions, mainly in one of two ways: either traveling out of state or ordering pills online and taking them at home, both of which are very difficult to enforce and stop. And so there’s just a lot of, like, throwing spaghetti against the wall and seeing what sticks, in terms of, can we actually criminalize either of those things? If so, how is it enforced, or does it even need to be enforced? Or is just the fear and the chilling effect enough? I mean, we definitely see that. We definitely see medical providers holding off on doing even perfectly legal things because of fear and the chilling effect. And so there’s just a lot of experimentation at the state level right now.

Rovner: Yeah, I forgot to mention Idaho, where the legislature introduced a bill that would make it a crime — that creates abortion trafficking as a crime — for someone to take a minor, it’s not really across state lines, because the state can’t do that, so it’s like taking the minor to the border in an effort to cross state lines to get an abortion. There was, for many years in the late 1990s and early 2000s, something called the Child Custody Protection Act in Congress, because they needed that for the interstate part of it, that would make it a crime to take a minor across state lines in violation of the home state’s parental involvement laws. It passed both the House and the Senate at various times. It never became law. It’s been introduced recently, but nobody’s tried to take it up recently. I wouldn’t be surprised to see that come back up, too. But it really does seem that every day there’s another bill in another state legislature that says — after all the claims of the anti-abortion movement for decades, that we don’t want to punish the women, we only want to punish the providers — that’s gone out the window, right?

Raman: I guess I would add that, you know, we’re seeing a lot of this activity now. But something that I keep in mind is that a) it’s gotten a lot harder to know what’s going to, you know, using the spaghetti metaphor that Alice did, like what will stick. So there’s just a lot more flurry of action. And then I feel like I see increasingly, you know, people, since they don’t know that, just like fixating a lot on various things, just because you don’t know. I think, you know, even a few years ago, there were a lot of things that would have one sponsor or two sponsors and have no chance of going anywhere, as most bills introduced anywhere do. But now, a) a lot of these things are moving very, very quickly in the legislature, and b) since we don’t know, it’s hard to know where to kind of focus, even to some of the experts that I’ve talked to, where it’s just, “We’re not sure.” So just be aware of all of these things in various places because of kind of that uncertainty.

Rovner: Yeah, I know I’m generally loath to talk about bills that got introduced either in Congress or in state legislatures, because I think it unnecessarily creates expectations that for the most part don’t happen. But as both of you say, some of these things are happening so fast that, if you mention them one week, they’re law by the next week. So we will see as this continues to move quickly. All right. That’s the news for this week. Now it is time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week?

Cohrs: All right. So my story is from the Washington Post, and the headline is “These Women Survived Combat. Then They Had to Fight for Health Care,” by Hope Hodge Seck. And I thought it was just a really great feature on this very niche issue. And I think veterans’ kind of health care overall just doesn’t get as much coverage as it should, and —

Rovner: Particularly women’s veteran’s health care.

Cohrs: Exactly. Yes. And so these women were essentially going into combat situations to help relations with women in very conservative cultures, and they were exposed to the grenade blasts and a lot of these combat situations. But then their health care coverage upon returning wasn’t covered. And there is kind of a new bill with some momentum behind it that is trying to plug that loophole. So, yeah, I thought it was a very great feature on an issue that’s undercovered.

Rovner: Yeah, this was something I knew nothing about until I read this story. Alice?

Ollstein: I chose a piece by Rachel’s colleague at Stat, Lev Facher, called “How the Drug Industry Uses Fear of Fentanyl to Extract More Profit From Naloxone.” And this is really timely, with the approval this week of over-the-counter opioid-overdose-reverse medication. And basically it’s about how these drug companies are coming up with new forms of the drug, really huge doses, new delivery forms, injectables, and nasal sprays, and stuff that are not really justified by science and are sort of just an opportunity for more profit because the basic form of the drug that works extremely well and is very affordable, they are basically hyping the fear of fentanyl to try to push these stronger products they’re coming up with. And the fear is that municipal governments that have limited resources are going to spend their money on those not really justified new forms and get fewer medication for everyone than just using the basic stuff that we know works.

Rovner: Indeed. Sandhya?

Raman: My extra credit is from Margo Snipe and Kenya Hunter at Capital B, and it’s called “What the Covid-19 Pandemic and Mpox Outbreak Taught Us About Reducing Health Disparities.” And I thought this was an interesting look that they did, highlighting how, you know, there’s been a lot more talk about the various health inequities among, you know, racial and ethnic and sexual minority communities after these two pandemics have started. And they look at how some of the targeted efforts have narrowed some of the gaps in things like vaccines, but just how some of these lessons can be used to address other health disparities, you know, things like community outreach and expanding types of screenings and how many languages public health information is translated into and things like that. So, it’s a good read.

Rovner: Well, my extra credit this week is a long read, a very long read, by Rebecca Traister in New York Magazine, called “Abortion Wins Elections: The Fight to Make Reproductive Rights the Centerpiece of the Democratic Party’s 2024 Agenda.” And while I’m not sure I’m buying everything that she’s selling here, this is an incredibly thorough and interesting look at the past, present, and possibly future of the abortion rights movement at the national, state, and local levels. If you are truly interested in this subject, it’s well worth the half hour or so of your time that it takes to get through the entire thing. It’s a really, really good piece. OK, that is our show for this week. As always, if you enjoyed the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me still. I’m @jrovner. Alice?

Ollstein: @AliceOllstein.

Rovner: Rachel?

Cohrs: @rachelcohrs.

Rovner: Sandhya?

Raman: @SandhyaWrites.

Rovner: We will be back in your feed next week. Until then, be healthy.

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El segundo embarazo de Tamara Etienne estuvo lleno de riesgos y preocupaciones desde el principio, exacerbado porque ya había sufrido un aborto espontáneo.

Como maestra de tercer grado en una escuela pública del condado de Miami-Dade, pasaba todo el día parada. Le pesaban las preocupaciones financieras, incluso teniendo seguro de salud y algo de licencia paga.

Y, como mujer negra, toda una vida de racismo la volvió desconfiada de las reacciones impredecibles en la vida diaria. Estaba agotada por el trato despectivo y desigual en el trabajo. Justamente el tipo de estrés que puede liberar cortisol, que, según estudios, aumenta el riesgo de parto prematuro.

“Lo experimento todo el tiempo, no camino sola, o lo hago con alguien a quien debo proteger. Sí, el nivel de cortisol en mi cuerpo es incontable”, expresó.

A los dos meses de embarazo, las náuseas implacables cesaron de repente. “Empecé a sentir que mis síntomas de embarazo estaban desapareciendo”, dijo. Entonces comenzó un extraño dolor de espalda.

Etienne y su esposo corrieron a la sala de emergencias, donde confirmaron que corría un grave riesgo de aborto espontáneo. Una cascada de intervenciones médicas —inyecciones de progesterona, monitoreo fetal en el hogar y reposo en cama— salvó a la niña, que nació a las 37 semanas.

Las mujeres en Estados Unidos tienen más probabilidades de dar a luz prematuramente que las de la mayoría de los países desarrollados. Esto coincide con tasas más altas de mortalidad materno infantil, miles de millones de gastos en cuidado intensivo y a menudo una vida de discapacidad para los prematuros que sobreviven.

Aproximadamente uno de cada 10 nacimientos vivos en 2021 ocurrió antes de las 37 semanas de gestación, según un informe de March of Dimes publicado en 2022. En comparación, investigaciones recientes citan tasas de nacimientos prematuros del 7,4% en Inglaterra y Gales, del 6% en Francia y del 5,8% en Suecia.

En su informe, March of Dimes encontró que las tasas de nacimientos prematuros aumentaron en casi todos los estados de 2020 a 2021. Vermont, con una tasa del 8%, tuvo la calificación más alta del país: una “A-”. Los resultados más sombríos se concentraron en los estados del sur, que obtuvieron calificaciones equivalentes a una “F”, con tasas de nacimientos prematuros del 11,5% o más.

Mississippi (15 %), Louisiana (13,5 %) y Alabama (13,1 %) fueron los estados con peor desempeño. El informe encontró que, en 2021, el 10,9% de los nacidos vivos en Florida fueron partos prematuros, por lo que obtuvo una “D”.

Desde que la Corte Suprema anulara Roe vs. Wade, muchos especialistas temen que la incidencia de nacimientos prematuros se dispare. El aborto ahora está prohibido en al menos 13 estados y estrictamente restringido en otros 12: los estados que restringen el aborto tienen menos proveedores de atención materna, según un reciente análisis de Commonwealth Fund.

Eso incluye Florida, donde los legisladores republicanos han promulgado leyes contra el aborto, incluida la prohibición de realizarlo después de las 15 semanas de gestación.

Florida es uno de los estados menos generosos cuando se trata de seguro médico público. Aproximadamente una de cada 6 mujeres en edad fértil no tiene seguro, lo que dificulta mantener un embarazo saludable. Las mujeres de Florida tienen el doble de probabilidades de morir por causas relacionadas con el embarazo y el parto que las de California.

“Me quita el sueño”, dijo la doctora Elvire Jacques, especialista en medicina materno-fetal del Memorial Hospital en Miramar, Florida.

Jacques explicó que las causas de los partos prematuros son variadas. Alrededor del 25% se inducen médicamente, por condiciones como la preeclampsia. Pero la investigación sugiere que muchos más tendrían sus raíces en una misteriosa constelación de condiciones fisiológicas.

“Es muy difícil identificar que una paciente tendrá un parto prematuro”, dijo Jacques. “Pero sí puedes identificar los factores estresantes en sus embarazos”.

Los médicos dicen que aproximadamente la mitad de todos los nacimientos prematuros debido a factores sociales, económicos y ambientales, y al acceso inadecuado a la atención médica prenatal, se pueden prevenir.

En el Memorial Hospital en Miramar, parte de un gran sistema de atención médica pública, Jacques recibe embarazos de alto riesgo referidos por otros obstetras del sur de Florida.

En la primera cita les pregunta: ¿Con quién vives? ¿Donde duermes? ¿Tienes adicciones? ¿Dónde trabajas? “Si no supiera que trabajan en una fábrica paradas cómo les podría recomendar que usaran medias de compresión para prevenir coágulos de sangre?”.

Jacques instó al gerente de una tienda a que permitiera a su empleada embarazada trabajar sentada. Persuadió a un imán para que le concediera a una futura mamá con diabetes un aplazamiento del ayuno religioso.

Debido a que la diabetes es un factor de riesgo importante, a menudo habla con los pacientes sobre cómo comer de manera saludable. Les pregunta: “De los alimentos que estamos discutiendo, ¿cuál crees que puedes pagar?”.

El acceso a una atención asequible separa a Florida de estados como California y Massachusetts, que tienen licencia familiar paga y bajas tasas de residentes sin seguro; y a Estados Unidos de otros países, dicen expertos en políticas de salud.

En países con atención médica socializada, “las mujeres no tienen que preocuparse por el costo financiero de la atención”, apuntó la doctora Delisa Skeete-Henry, jefa del departamento de obstetricia y ginecología de Broward Health en Fort Lauderdale. Y tienen licencias por maternidad pagas.

Sin embargo, a medida que aumentan los nacimientos prematuros en Estados Unidos, la riqueza no garantiza mejores resultados.

Nuevas investigaciones revelan que, sorprendentemente, en todos los niveles de ingresos, las mujeres negras y sus bebés experimentan resultados de parto mucho peores que sus contrapartes blancas. En otras palabras, todos los recursos que ofrece la riqueza no protegen a las mujeres negras ni a sus bebés de complicaciones prematuras, según el estudio, publicado por la Oficina Nacional de Investigación Económica.

Jamarah Amani es testigo de esto como directora ejecutiva de Southern Birth Justice Network y defensora de la atención de parteras y doulas en el sur de Florida. A medida que evalúa nuevos pacientes, busca pistas sobre los riesgos de nacimiento en los antecedentes familiares, análisis de laboratorio y ecografías. Y se centra en el estrés relacionado con el trabajo, las relaciones, la comida, la familia y el racismo.

“Las mujeres negras que trabajan en ambientes de alto estrés, incluso si no tienen problemas económicos, pueden enfrentar un parto prematuro”, dijo.

Recientemente, cuando una paciente mostró signos de trabajo de parto prematuro, Amani descubrió que su factura de electricidad estaba vencida, y que la empresa amenazaba con cortar el servicio. Amani encontró una organización que pagó la deuda.

De los seis embarazos de Tamara Etienne, dos terminaron en aborto espontáneo y cuatro fueron de riesgo de parto prematuro. Harta de la avalancha de intervenciones médicas, encontró una doula y una partera locales que la ayudaron en el nacimiento de sus dos hijos más pequeños.

“Pudieron guiarme a través de formas saludables y naturales para mitigar todas esas complicaciones”, dijo.

Sus propias experiencias con el embarazo dejaron un profundo impacto en Etienne. Desde entonces, ella misma se ha convertido en una doula.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Jimmy Carter estaba orgulloso de que Estados Unidos no hubiera iniciado ninguna guerra durante su mandato como presidente.

Pero después de dejar el cargo, lanzó una guerra contra las llamadas enfermedades olvidadas, males de tierras lejanas que la mayoría de los estadounidenses nunca sufrirán y de las que tal vez ni siquiera hayan oído hablar.

Enfermedades como la filariasis linfática, el tracoma, la ceguera del río, la esquistosomiasis… y una particular causada por un bichito desagradable llamado gusano de Guinea.

Los gusanos de Guinea se propagan a través del agua potable contaminada y al comer pescado poco cocido. Los gusanos hembra, que pueden medir hasta 3 pies de largo una vez que maduran, causan ampollas abiertas increíblemente dolorosas, en general en la parte inferior de las piernas y los pies de la persona infectada, a través de las cuales emergen los gusanos.

Puede permanecer en el cuerpo durante semanas o meses, y a veces de forma permanente, dejando a algunas personas incapaces de trabajar y mantener a sus familias.

Si alguien con gusano de Guinea tiene contacto con el agua, tal vez para aliviar el dolor ardiente causado por la aparición de un gusano, el gusano puede liberar decenas de miles de gusanos bebés, contaminando todo el curso de agua.

El esfuerzo por acabar con esta enfermedad no se basó en métodos de alta tecnología. “La enfermedad del gusano de Guinea no tiene cura, no hay vacunación, básicamente todo el esfuerzo de erradicación se basa en el cambio de comportamiento”, dijo Kelly Callahan, trabajadora de salud pública que pasó años luchando contra la enfermedad del gusano de Guinea en el sur de Sudán con el Centro Carter, la organización benéfica que el ex presidente y su esposa crearon junto con la Universidad Emory.

Eso ha significado enseñar a las personas en áreas vulnerables a filtrar el agua y brindarles las herramientas de bajo costo para hacerlo.

Otras estrategias incluyen brindar acceso a suministros de agua potable, una mejor detección de casos humanos y animales, limpiar y vendar heridas, evitar que las personas y los animales infectados entren al agua y usar larvicidas para matar a los gusanos.

Gracias a Carter, el mundo ha estado increíblemente cerca de acabar con el gusano de Guinea.

“Me gustaría ver al gusano de Guinea completamente erradicado antes de morir”, dijo Carter en una conferencia de prensa en 2015. “Me gustaría que el último gusano de Guinea muera antes que yo. Creo que ahora mismo tenemos 11 casos. Empezamos con 3,6 millones”.

Parecía que el último gusano de Guinea iba a morir antes que el presidente número 39 de los Estados Unidos. Luego, hace unos años, científicos descubrieron que el parásito se estaba propagando entre los perros callejeros en Chad, y que los babuinos en Etiopía también portaban el parásito.

Este reservorio de gusanos que se pasó por alto durante mucho tiempo fue un revés para el programa de erradicación global y demostró que matar al último gusano de Guinea sería más difícil de lo que se pensaba.

Además, a medida que el número de casos ha disminuido, han surgido nuevos desafíos. En 2018, se detectó la enfermedad del gusano de Guinea en Angola, un país en donde no se habían registrado casos en el pasado.

Como resultado, en 2019, la Organización Mundial de la Salud (OMS) retrasó su fecha prevista de erradicación de la enfermedad una década completa, de 2020 a 2030.

Los investigadores ahora están buscando un tratamiento para los perros infectados, y los trabajadores de salud pública han recurrido a nuevas intervenciones, como pagar a las personas para que informen sobre los animales infectados. No obstante, la campaña de Carter ha tenido un éxito notable.

En una entrevista con NPR en 2015, Carter recordó los orígenes de su cruzada. El ex zar antidrogas de Carter, Peter Borne, estaba trabajando en una iniciativa de las Naciones Unidas (ONU) llamada “Década del agua dulce”. Borne fue al Centro Carter para hablar sobre enfermedades olvidadas que se propagan por “beber agua en mal estado”. Una de ellas fue el gusano de Guinea.

“La razón principal por la que [Borne] vino al Centro Carter fue porque no podía conseguir que nadie más abordara este problema”, recordó Carter. “Es una enfermedad despreciable. Y se presentaba en pueblos tan remotos que nadie quería asumir la tarea. Entonces, decidimos asumirla”. Eso fue en 1986.

El doctor Paul Farmer, fundador de Partners in Health y defensor de causas mundiales de salud que murió el año pasado, habló con NPR en 2019 sobre los esfuerzos de Carter. Farmer dijo que el ex presidente merece gran parte del crédito por llevar al gusano de Guinea al borde de la extinción.

La viruela, dijo Farmer, es “la única enfermedad humana [que ha] sido erradicada. Y si… el gusano de Guinea está justo detrás, será gracias a Carter. Quiero decir, hubo millones de casos en los que se involucró… después de su presidencia a mediados de los años 80. Y ahora tenemos menos de 100 el año pasado”.

El Centro Carter informó que en 2022, solo hubo 13 casos humanos registrados de la enfermedad, un número provisional que se confirmará oficialmente, probablemente este mes.

“Cuando te enfrentas a un problema como este, como el gusano de Guinea, tienes que hablar con persuasión a los funcionarios del ministerio, las figuras políticas, las enfermeras, los médicos, los activistas comunitarios, los agricultores, las personas que están… en mayor riesgo. Carter ha tenido que hablar con persuasión a todas esas personas. Y eso es algo que ha sido muy inspirador para muchos de nosotros”, dijo Farmer.

Christopher Plowe, profesor adjunto de medicina en la Facultad de Medicina de la Universidad de Maryland, está de acuerdo en que la defensa de Carter ha ayudado a los gobiernos y las agencias de salud pública de todo el mundo a mantenerse enfocados en erradicar la enfermedad del gusano de Guinea. El Centro Carter también ha contribuido, invirtiendo alrededor de $500 millones desde 1986.

“Creo que deberíamos ser optimistas de que es algo factible”, dijo Plowe. “Creo que no deberíamos ser demasiado optimistas sobre lo rápido que ocurrirá”.

El gusano de Guinea fue solo uno de los objetivos de la guerra de Carter. La oncocercosis, también conocida ceguera del río, ha sido eliminada de la mayor parte de las Américas y reducida drásticamente en África gracias al trabajo de Carter y el Centro Carter. También se han hecho avances importantes contra otras enfermedades desatendidas, como la filariasis linfática, que provoca una horrible inflamación de las piernas y los genitales.

Aquellos que conocen bien a Carter dijeron que fue su educación en una zona empobrecida del sur lo que lo hizo tener un fuerte sentido de autosuficiencia y sacrificio, y el deber de ayudar a los demás.

Nacido en Plains, Georgia, en 1924, se mantuvo cerca de sus raíces y regresó a casa después de su carrera en la Marina para administrar la granja de maní de la familia. La iglesia fue una parte central de su vida en Plains —enseñó en la escuela dominical hasta los 90 años— y sus amigos dijeron que su fe cristiana lo impulsaba.

“Hizo lo que hizo por amor a la humanidad”, dijo Linda Fuller Degelmann, cofundadora de Habitat for Humanity, que ha contado a Jimmy y Rosalynn Carter entre sus muchos voluntarios, clavando clavos durante el día y durmiendo en literas durante la noche. Los Carter trabajaron en proyectos de Hábitat en 14 países.

En febrero, Carter ingresó a cuidados paliativos, renunciando a un tratamiento médico adicional para prolongar su vida. Pero su muerte no significará el fin de su obra. En un comunicado, el Centro Carter se comprometió a continuar la lucha para erradicar al gusano de Guinea.

Cuando la enfermedad llegue a su fin, se convertirá en uno de los logros característicos de Carter, un logro extraordinario que refleja un principio simple pero profundo de su filosofía personal: “tratar de ayudarse unos a otros en lugar de estar dispuestos a ir a la guerra uno contra otro”.

Este artículo fue producido como parte de una alianza entre KHN y NPR.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Researchers at the Texas Biomedical Research Institute are developing a vaccine candidate against HIV. The vaccine is intended to block HIV entry into the body and is administered to the mucosal lining of the rectum and vagina to achieve this. The formulation then stimulates antibodies against HIV in precisely the areas where the virus first enters the body’s cells. Cleverly, the researchers designed the vaccine to target the basal cells of the epithelium, which then give rise to a constant supply of epithelial cells to replace cells that are routinely sloughed off. This may lead to long-term protection against HIV with this vaccine. In tests with primates, the vaccine has shown significant efficacy in reducing viral transmission, and when vaccinated animals did become infected, they were able to control the infection much better and showed no disease symptoms.

HIV has evaded our best attempts to create an effective vaccine for decades. Although anti-retroviral therapy can allow people with HIV infection to live normal lives and avoid progression to AIDS, it still requires that someone takes these treatments for the rest of their lives. Moreover, these treatments may not be widely available for everyone, and lack of access can be an issue in low-resource areas. A vaccine that prevents people from getting infected with HIV in the first place, and allows them to control the infection if it does occur, would be very useful.

Part of the issue is that HIV spreads through the body relatively quickly. In response, these researchers had the idea of developing a vaccine that acts specifically on the areas of the body where the virus typically enters – the mucosal lining of the vagina or rectum. The concept is to give the virus a hard time before it even gets a chance to get a foothold in the body. “I had this idea as a postdoc,” said Marie-Claire Gauduin, a researcher involved in the study. “I thought it had to be naïve because nobody was talking about it. It was so obvious and simple to me; I thought someone would have already done it.”

The vaccine is a live attenuated vaccine, meaning that the viral particles within contain the full genetic code, albeit with some alterations to prevent the virus from replicating. The researchers describe the resulting particles as “single-cycle” vaccine virus. These modified viral particles can enter cells in the mucosa, but cannot proliferate and leave the cells again. The immune system can recognize that these cells are ‘infected’ and so generates antibodies against the virus, which will give any real virus attempting to enter the mucosa a hard time.

Cleverly, the vaccine targets cells in the mucosa that give rise to new cells, helping to keep the vaccine effective for as long as possible. “The idea is that as long as the vaccine is in the mother cells, it will be passed on and be present in all new epithelial cells in these regions,” said Gauduin. “I did not think it would work so well, but it did!”

In tests in non-human primates, the vaccine candidate helped animals to avoid infection in the first place, and once infected they showed a better ability to control the virus and showed no disease symptoms. It’s too early to know if the vaccine will work in humans, but the researchers have recently received some funding to develop it further.

Via: Texas Biomedical Research Institute

Researchers at the Garvan Institute of Medical Research in Australia have developed a new generation of antibodies to treat COVID-19. So far, the antibodies have been shown to neutralize several of the viral variants behind COVID-19, and the researchers hope that they will form an effective treatment for at-risk patients. Previously developed antibody treatments for COVID-19 have been rendered largely useless as the virus has mutated. Such antibodies have focused on binding to the most obvious site on the viral spike protein, the ACE2 receptor binding site, but their efficacy in destroying the virus has waned with new viral variants. However, these new antibodies bind to a different site on the spike protein that is partially hidden, and appear to essentially rip the spike protein apart, prompting the researchers to surmise that the virus will find it hard to develop resistance.

SARS-CoV-2 continues to proliferate around the world. While vaccines have provided many of us with protection against severe disease, they do not offer the same level of protection for everyone. For instance, severely immunocompromised patients may not receive much benefit from current COVID-19 vaccines, and will likely require additional treatment if they contract the disease.    

Developing new treatments for COVID-19 will greatly benefit such patients, but SARS-CoV-2 is a formidable adversary, with new variants popping up around the world. Unfortunately, previous iterations of antibody treatments for COVID-19 have been rendered largely ineffective by these mutations.   

“Almost all commercially available antibodies for COVID-19 don’t work well anymore,” said Jake Henry, a researcher involved in the study. “Most are class 1 or 2, which refers to the fact that they bind to the most obvious spot on the spike protein – the ACE2 receptor binding site. They have downsides, including failure against new variants as they evolve. We’re delighted our research could lead to new antiviral therapy providing reliable ‘passive immunity’ to at-risk individuals.”

The new ‘class 6’ antibodies bind to a different part of the spike protein and can lead to its destruction. “This is a new mechanism of action we’re seeing with these class 6 antibodies,” said Daniel Christ, another researcher involved in the study. “Our hypothesis is that they’re so effective because the area we’re targeting is close to the center of the spike’s structure. When the antibody attaches there, it distorts the spike and rips it apart. It would be very difficult for the virus to adapt to that.”

Study in journal Nature Communications: Broadly neutralizing SARS-CoV-2 antibodies through epitope-based selection from convalescent patients

Via: Garvan Institute of Medical Research

The Host

Julie Rovner
KHN

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Both Republicans and Democrats in Congress reacted with compassion to the news that Sen. John Fetterman (D-Pa.) has checked himself into Walter Reed National Military Medical Center for treatment of clinical depression. The reaction is a far cry from what it would have been 20 or even 10 years ago, as more politicians from both parties are willing to admit they are humans with human frailties.

Meanwhile, former South Carolina governor and GOP presidential candidate Nikki Haley is pushing “competency” tests for politicians over age 75. She has not specified, however, who would determine what the test should include and who would decide if politicians pass or fail.

This week’s panelists are Julie Rovner of KHN, Sarah Karlin-Smith of the Pink Sheet, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Roubein of The Washington Post.

Panelists

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories

Among the takeaways from this week’s episode:

• Acknowledging a mental health disorder could spell doom for a politician’s career in the past, but rather than raising questions about his fitness to serve, Sen. John Fetterman’s decision to make his depression diagnosis and treatment public raises the possibility that personal experiences with the health system could make lawmakers better representatives.
• In Medicare news, Sen. Rick Scott (R-Fla.) dropped Medicare and Social Security from his proposal to require that every federal program be specifically renewed every five years. Scott’s plan has been hammered by Democrats after President Joe Biden criticized it this month in his State of the Union address.
• Medicare is not politically “untouchable,” though. Two Biden administration proposals seek to rein in the high cost of the popular Medicare Advantage program. Those are already proving controversial as well, particularly among Medicare beneficiaries who like the additional benefits that often come with the private-sector plans.
• New studies on the effectiveness of ivermectin and mask use are drawing attention to pandemic preparedness. The study of ivermectin revealed that the drug is not effective against the covid-19 virus even in higher doses, raising the question about how far researchers must go to convince skeptics fed misinformation about using the drug to treat covid. Also, a new analysis of studies on mask use leaned on pre-pandemic studies, potentially undermining mask recommendations for future health crises.
• On the abortion front, abortion rights supporters in Ohio are pushing for a ballot measure enshrining access to the procedure in its state constitution, while a lawyer in Florida is making an unusual “personhood” argument to advocate for a pregnant woman to be released from jail.

Plus for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Stat’s “Current Treatments for Cramps Aren’t Cutting It. Why Aren’t There Better Options?” by Calli McMurray

Joanne Kenen: The Atlantic’s “Eagles Are Falling, Bears Are Going Blind,” by Katherine J. Wu

Rachel Roubein: The Washington Post’s “Her Baby Has a Deadly Diagnosis. Her Florida Doctors Refused an Abortion,” by Frances Stead Sellers

Sarah Karlin-Smith: DCist’s “Locals Who Don’t Speak English Need Medical Translators, but Some Say They Don’t Always Get the Service,” by Amanda Michelle Gomez and Hector Alejandro Arzate

Also mentioned in this week’s podcast:

• The Hill’s “Nikki Haley: Bernie Sanders Is ‘Exactly the Reason’ Mental Competency Tests Are Needed,” by Niall Stanage
• USA Today’s “Idaho Bill Would Criminalize Giving mRNA Vaccines — The Tech Used in Popular COVID Vaccines,” by Thao Nguyen
• The Washington Post’s “Twenty Governors Are Forming a New Coalition to Support Abortion Rights,” by Rachel Roubein with McKenzie Beard
• The Washington Post’s “Fla. Lawyer Argues Pregnant Inmate’s Fetus Is Being Illegally Detained,” by Kyle Melnick

click to open the transcript

Transcript: Senators Have Mental Health Crises, Too

KHN’s ‘What the Health?’Episode Title: Senators Have Mental Crises, TooEpisode Number: 286Published: Feb. 23, 2023

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Feb. 23, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Rachel Roubein of The Washington Post.

Rachel Roubein: Hi. Thanks for having me.

Rovner: Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Rovner: So, no interview this week, but lots of interesting news, even with Congress in recess and the president out of the country. So we will get right to it. We’re going to start this week with mental health. No, not the mental health of the population, although that remains a very large problem, but specifically the mental health of politicians. I am old enough to remember when a politician admitting to having been treated for any mental health problem basically disqualified them from holding higher office. You young people go Google Tom Eagleton. Now we have Sen. John Fetterman [D-Pa.], who made headlines while campaigning during his stroke recovery, checking himself into Walter Reed for major depression treatment. And the reaction from his colleagues on both sides of the aisle has been unusually compassionate for political Washington. Have we turned a corner here on admitting to having problems not meaning incapable of serving or working?

Karlin-Smith: It’s obviously getting better, but I think as we saw with Fetterman’s coverage during the campaign, it was far from perfect. And I think there was some dissatisfaction that his coverage was in many … sometimes unfair in how his stroke and his stroke recovery and his needs for accommodations were presented in the media. But I do think we are shifting at least somewhat from thinking about, Does this situation make a person fit to serve? to thinking about, OK, what does this person’s experience navigating the health care system perhaps provide that might actually make them a better representative, or understand their constituents’ needs in navigating the health care system, which is a big part of our political agenda?

Kenen: There are very few times when Congress makes nice. I think on rare occasions mental health has done it. I can think of the fight for mental parity. It was a bipartisan pair: Sen. Pete Domenici [R-N.M.] had a daughter with schizophrenia, and Sen. Paul Wellstone [D-Minn.] had … what, was it … a brother?

Rovner: I think it was a sibling, yeah.

Kenen: … with a severe mental illness. I no longer remember whether it was schizophrenia or another severe mental illness. And they teamed up to get mental health parity, which they didn’t get all the way. And there are still gaps, but they got the first, and it took years.

Rovner: And they were a very unlike pair, Domenici was …

Kenen: They were a very unlikely couple.

Rovner: a very conservative Republican. Wellstone was a very liberal Democrat.

Kenen: And their personalities were completely like, you know, one was a kind but grumpy person and one was the teddy bear. And they were a very odd couple in every possible way. And it didn’t make lawmakers talk about themselves at that point, but they did get more open about their family. About 10 or 15 years later, there was a senator’s son died by suicide and he was very open about it. It was really one of the most remarkable moments I’ve ever seen on the Hill, because other people started getting up and talking about loved ones who had died by suicide, including [Sen.] Don Nickles [R-Okla.], who was very conservative, who had never spoken about it before. And it was Sen. Gordon Smith [R-Ore.] whose son had died at the time. And he tried to put it to use and got mental health legislation for college. So these were like, you know, 10 or 15 years apart. But Congress, they don’t treat each other very well. It’s not just politics. They’re often quite nasty across party lines. So this was sort of like the third moment I’ve seen where a little bit of compassion and identification came out. Is it a kumbaya turnaround? No, but it’s good to see kindness, not “he should resign this moment.” I mean, the response was pretty human and humane.

Rovner: And we also had the unique moment with Patrick Kennedy, who was then in the House, son of Sen. Ted Kennedy, who was still in the Senate. And Patrick Kennedy, of course, had had substance abuse issues in addition to his mental health issues. And he actually championed through what turned into the final realization of the mental health parity that Domenici and Wellstone had started. So, I mean, to Sarah’s point, I think, sometimes if the person experiences it themselves, they may be even more able to navigate through to help other people, so …

Kenen: You’re not immune from mental illness if you’re a lawmaker and neither is your family. And there are a number of very sad stories and there are other lawmakers who have lost relatives to suicide. So there’s this additional connection between stroke and depression that I think got a little bit of attention here, because that’s also a thing.

Rovner: Well, all right, then again, it is not all sunshine and roses on the political mental health front. Former South Carolina Republican Gov. Nikki Haley, who’s now running for president, is proposing a mental competency test for politicians over the age of 75. That would, of course, include both Donald Trump and Joe Biden. But this week, Haley extended her proposed mental competency test to the Senate, where there are dozens of members over the age of 75. She specifically called out 81-year-old Bernie Sanders after he called her proposal ageism. Now, it’s pretty clear that Haley is using this to keep herself in the news, and it’s working. But could we actually see mental competency tests rolled out at some point? And who would decide what constitutes competency in someone who’s getting older?

Kenen: Or younger.

Rovner: Or younger, yeah.

Karlin-Smith: Wait, has Joanne solved the aging [mystery]? I think … what Julie said, in terms of who would decide, I think that’s where it gets really dicey. I think, first of all, if you’re going to deal with this, there seems no way you can make it based on age, right? Because competency is not necessarily tied with age. But I think, ethically, I’m not sure our society has any fair way to really determine … and it would just become such a political football that I don’t think anybody wants to deal with figuring out how to do that. Obviously, you don’t want somebody, probably, in office who is not capable of doing the job to a point where they really can’t be productive. But again, as we’ve seen with these other health issues, you also don’t want to exclude people because they are not perfectly in some sort of heightened state of being that, you know, all people are not perfect in capacity at every single moment and deal with struggles. So there’s this fine line, I think, that would be too difficult to sort of figure out how to do that.

Kenen: And you could be fine one day and not fine the next. If you have a disease [of] cognitive decline that’s gradual, you know, when do you pick it up? When do you define it? And then you can have something very sudden like a car crash, a stroke and any number of things that can cause cognitive damage immediately.

Rovner: Now, we didn’t know then, but we know now that Ronald Reagan had the first stages of dementia towards the end of his second term. Sorry, Rachel, you wanted to say something?

Roubein: We’ve seen careful reporting around — I think, about like the San Francisco Chronicle story last year — about [Sen.] Dianne Feinstein [D-Calif.], which essentially looked at this. There were some questions around [Sen.] Thad Cochran [R-Miss.], as well. And it’s something journalists have looked at pretty carefully by talking to other senators and those who know the lawmakers well to see how they are essentially.

Kenen: And Strom Thurmond, who was, to a layperson, like all the reporters covering the Hill, it was clear that … he served until he was, what, 98 or something? You know, it was very clear that half the time he was having struggles.

Rovner: And I remember so many times that there would be the very old senators on the floor who would basically be napping on the floor of the Senate.

Kenen: That might be a sign of mental health.

Rovner: Yeah, that’s true. But napping because they couldn’t stay awake, not just curling up for a nap. But, I mean, it’s an interesting discussion. You know, as I say, I’m pretty sure that Nikki Haley is doing it to try and poke at both Biden and Trump and keep herself in the news. And, as I say, it’s working.

Kenen: But I think there’s a question of fitness that I think has come up over and over again. I mean, Paul Tsongas was running for president, what, the Nineties and said he was over his lymphoma or luekemia.

Rovner: I think he had lymphoma. Yeah.

Kenen: He said he was fine, and it turns out he wasn’t. And he actually died quite young, quite soon after not getting the nomination. So there are legitimate issues of fitness, mental and physical, for the presidency. I would think that there’s a different standard for senators just because you’re one out of 100 instead of one out of one. I think there is a tradition, which Trump didn’t really follow. There is a tradition of disclosure, but it’s not foolproof. And Trump certainly just had — remember, he had that letter from his doctor who also didn’t live much longer after that, saying he was the most fit president in history, Like, just don’t get me started, but basically said he was a greek god. So there are legitimate concerns about fitness, but it’s hard to figure out. I mean, it was really hard to figure out in Congress how to do that.

Rovner: Yeah, I think the “who decides” what will be the most difficult part of that, which is probably why they haven’t done it yet. All right. Well, turning to policy, two weeks ago, we talked about the coming Medicare wars with President Biden taking aim at Republicans in his State of the Union speech, and particularly, although he didn’t name him, with Florida Sen. Rick Scott, who last year as head of the Republican Senate Campaign Committee, released a plan that would have sunset every federal program, including Medicare and Social Security, every five years. And they would cease to be unless Congress re-approved them. We know how much trouble Congress has doing anything. This horrified a whole lot of Republicans, who not only have been on the wrong end politically of threatening Medicare — and paid a price for it at the ballot box — but who themselves have used it as a weapon on Democrats. See my column from last week, which I will put in the show notes. So now, kind of predictably, Sen. Scott has succumbed and proposed a new plan that would sunset every federal program except Medicare and Social Security. But I imagine that’s not going to end this particular political fight, right? The Democrats seem to have become a dog with a bone on this.

Roubein: Yeah. And it’s known as “Mediscare” for a reason, right? It’s something both political parties use and try and weaponize. I mean, I think one of the really big questions for me when I kept on hearing this, like what? Cuts to Medicare, what does that actually mean in practice? Some experts said that it might simply mean slowing the rate of growth in the program compared to what it would have been, which doesn’t necessarily impact people’s benefits. It can; it depends how it’s done. But I mean, we’ve seen this political fight before. It happened during the Affordable Care Act and afterwards, the effect of cutting Medicare Advantage plan payments, etc., didn’t really make plans less generous. They continued to be more generous. So it’s something that we’ll continue to see Biden talk about because the administration thinks that it plays well among seniors.

Rovner: But even as Bernie Sanders pointed out this week, we’re going to have to deal with Medicare and Social Security eventually. They can’t continue on their current path because they will both run out of money at some point unless something gets changed. But right now, it seems that both sides are much happier to use it as a cudgel than to actually sit down and figure out how to fix it.

Kenen: But one thing that’s interesting is that it wasn’t a big issue in the November elections. The Democrats late in the game tried to draw attention to the Rick Scott proposal. I almost wrote a piece how there was no discussion of Medicare for the first time in years. And just as I was starting to write it, they began talking about it a little bit. So I didn’t write it. But it never stuck. It wasn’t a major issue. And the one race where it really could have been would have been Wisconsin, because that was a tight Senate race — the Democrats really wanted to defeat Ron Johnson, who is to the right of Rick Scott on phasing out Medicare. He’s the only one who endorsed Scott and actually wanted to go further, and it didn’t even really stick there. So it’s sort of interesting that it’s now bubbling up. I mean, yes, we’re into 2024, but we’re not into 2024 the way we’re going to be into 2024. It’s sort of interesting to see that the Democrats are hitting this so far.

Rovner: No, I think that’s because of the debt ceiling.

Kenen: Right. But it’s supposedly off the table for the debt ceiling, which doesn’t mean, as Rachel just said, there are legitimate fiscal issues that Democrats and Republicans both acknowledge. They’re, crudely speaking, Democrats want to raise more money for them, and Republicans want to slow spending. That’s a that’s an oversimplification. But the rhetoric is always throwing Grandma off the cliff. Never Grandpa, always Grandma.

Rovner: Always Grandma.

Kenen: You know, actually, you can do things over a 20-year period. That’s what we did with Social Security. We did raise the age in a bipartisan fashion on Social Security 20 years … took like 20 years to phase it.

Rovner: And I would point out that the only person who really reacted to Rick Scott’s plan when it came out last February was, I think, a year ago this week, was Mitch McConnell.

Kenen: Yeah, he blew a gasket.

Rovner: But he immediately disavowed it. So Mitch McConnell knew what a problem it could turn into and kind of has now. So we have kind of the reverse sides in Medicare Advantage of the fight. That’s the private alternative to traditional Medicare. It’s the darling of Republicans, who touched off the current popularity of the program when they dramatically increased payments for it in 2003, which led to increased benefits and increased profits for insurance companies. They split those — that extra money between themselves and the beneficiaries. And, not surprisingly, increased popularity to the point where a majority of beneficiaries right now are in Medicare Advantage plans rather than traditional Medicare. On the other hand, these plans, which were originally supposed to cut overall Medicare costs, are instead proving more expensive than traditional Medicare. And Democrats would like to claw some of those profits back. But that looks about as likely as Republicans sunsetting Medicare, right? There’s just too many people who are too happy with their extra benefits.

Roubein: I guess we’ve seen two proposals from the administration this year which would change Medicare benefits. Then Republicans are trying to paint this as a cut but are saying it wouldn’t change benefits. But to change Medicare Advantage, one way …

Rovner: To change payments for Medicare Advantage.

Roubein: Yes, exactly. One which essentially would increase the government’s ability to audit plans and recover past overpayments and one which is the annual rate proposal. And there’s some aspects in there that Medicare Advantage plans are on a full-court lobbying press to say these are cuts which the administration is pushing back on really, really hard. So this is another microcosm of this Medicare scare tactics.

Rovner: And they’re all over TV already, commercials that probably don’t mean much to anybody if you’re not completely up on this fight of, like, “Congress is thinking about cutting Medicare Advantage.” No, really? I do laugh every time I see that ad.

Kenen: But, you know, Julie, you’re right that this began as a Republican cause, I mean, they had a similar program in the late ’90s that flopped and they revived it as Medicare Advantage. But it didn’t stay a Republican pet project for long. I mean, Democrats, starting with those in states with a lot of retirees — I’m thinking in Florida, who had Democratic senators at the time. I mean, they jumped on board, too, because people like … there are people who want to stay in traditional Medicare and there are people who jumped on to Medicare Advantage, which has certain advantages. It is less partisan than it began. It has always been more expensive than it was touted to be. And it’s now, we’re heading into 20 years since the legislation was passed, and nothing has really been done to change that trajectory, nothing significant. And I don’t think you’re going to see a major overhaul of it. There may be things that you can do [on] a bipartisan basis that nip. But if you’re nipping at that many billions of dollars, a nip as can be a lot of money.

Rovner: Yeah, that’s the thing about Medicare. Although I would point out also that the reason it flopped in the late 1990s is because Congress whacked the payments for it as part of the Balanced Budget Act. And as they gave the money back, it got more popular again because, lo and behold, extra money means extra benefits and people liked it. So its popularity has been definitely tied to how much the payments are that Congress has been willing to provide for it.

Kenen: And how they market and who they market to.

Rovner: Absolutely, which is a whole ’nother issue. But I want to do a covid check-in this week because it’s been a while. First, we have a study from Duke University published in this week’s Journal of the American Medical Association showing that using the deworming drug ivermectin, even at a higher dose and for a longer time, still doesn’t work against covid. This was a decent-sized, double-blind, randomized, controlled trial over nine months. Why is this such a persistent desire of so many people and even doctors to use this drug that clearly doesn’t work?

Karlin-Smith: You know, there’s been a lot of misinformation out there, particularly spread by the right and people that have not just, in general, trusted the government during covid and felt like this drug worked. And for whatever reason, they were being convinced that there was a government effort to kind of repress that. What’s interesting to point out, you know, you mentioned the trial being run at Duke. This was actually a part of a big NIH [National Institutes of Health] study to study various drugs for covid. So even NIH has been willing to actually do the research and to prove whether the drug does or doesn’t work. One of the issues this raises is this was one of many studies at this point that has shown the drug doesn’t work. In this one they even were willing to test, OK, a lower dose didn’t work. Let’s test a higher dose. Again, it fails. And the question becomes is, is there any amount of data or trials that can convince people who have, again, gone through this process where they’ve been convinced by this misinformation to believe it works and that the government is lying to them? Is there any way to convince them, with this type of evidence, it doesn’t work? And then what are the ethics of doing this research on people? Because you’re wasting government resources. You’re wasting resources in general. You’re wasting time, money. You’re giving people a drug in the trial when they could be getting another drug and that might actually work. So it’s really complicated because, again, I’m not sure you can convince the true ivermectin fans. I’m not sure there’s any amount of this type of scientific evidence that’s going to convince them that it doesn’t work for covid.

Rovner: But while we are talking about scientific studies about covid, a controversial meta-analysis from the esteemed Cochrane Review found basically no evidence that masks have done anything to prevent the spread of covid. But this is another study that seems to have been wildly misinterpreted. It didn’t find … what it looked like was not necessarily what we think. A lot of it turned out to be studies that were seeing whether flu, whether masks prevented against flu, rather than against covid. I mean, have we ended the whole idea of mask wearing and maybe not correctly?

Kenen: This was a meta-analysis for Cochrane, which is really basically … I mean, I think Sarah probably knows more about Cochrane than the rest of us, but their reviews are meaningful and taken seriously and they’re usually well done. The studies that they use in this meta-analysis didn’t ask the question that the headlines said it asked. And also, I mean, I don’t totally understand why they did it, because a) as Julie just pointed out, there was something like 78 studies, 76 of which were done before covid. So, you know, a) that’s a problem. And b), it didn’t actually measure who was wearing a mask. It was like, OK, you’re told to wear a mask or maybe you’re required to wear a mask if you’re working in a hospital while you’re in the hospital. But then you go out to a bar that night and you’re not wearing … I mean, it didn’t really look at the totality of whether people were actually wearing masks properly, consistently. And therefore, why use this flu data to answer questions about masking? And secondly, I also think it always is worth reminding people that, you know, no one ever said masks were the be-all and end-all. It was a component — you know, masking, handwashing, vaccination, distancing, testing, all the things that we didn’t do right. Ventilation … I mean, all that. There’s a long list of things we didn’t do right; masking was one of many. This is not going to help if we ever need masks for any disease again in the future. It did not advance this public health strategy — they call it, like, they like to talk about Swiss cheese, that any one step has holes in it. So you use a whole lot of steps and you don’t have any more holes in your Swiss cheese. It’s going to make it harder if we ever need them.

Rovner: Yeah. Well, notwithstanding scientific evidence now, we have two Republican state lawmakers in Idaho who have introduced a bill that would make any mRNA vaccines illegal to administer in the state, not just to people, but to, quote, “any mammal” with violators subject to jail time. And if I may read the subhead of the story about this … at the science website Ars Technica, quote, “It’s not clear if the two lawmakers know what messenger RNA is exactly.” In a normal world, I would say this is just silly and it couldn’t pass. But we’re not in a normal world anymore, right? I mean, we could actually see Idaho ban mRNA technology, which is used, going to be used for a lot more than covid.

Karlin-Smith: So I think the thing that really interests me about reading about this, and I’d be interested to hear what legal scholars think about this, but I was wondering if there’s a parallel here between this and what’s going on with the abortion pill in Republican states and what the courts may do with that, because it seems to me like there’s probably should be some kind of federal preemption that would kick in here, which is that vaccines are regulated, approved by this technology, by the federal government. Yes, there’s some practice of medicine where states have control from the federal government. But this seems like a case where, and in the past, when states have tried to get into banning FDA-approved products in this way, courts … have pushed back and said, you can’t do this. And I would say, I don’t think this Idaho law would hold up if it gets passed. But now we have this issue going on with the abortion pill, and it seems like there could be this major challenge by the courts to FDA’s authority. So you do sort of wonder, is this another example of what could happen if this authority gets challenged by the states? And, like you said, we are in this different world where maybe three years ago I would say, well, you know, even if Idaho can pass this, of course, this isn’t going to come to practice. But I do wonder, as we’re watching some of these other legal challenges to FDA-approved technologies, what it could mean down the line.

Kenen: I mean, remember, it also … with ivermectin, there are state legislatures that have actually protected patients’ rights to get ivermectin.

Rovner: And doctors’ rights to provide it.

Kenen: Right. And I know more than half the states had legislation. I don’t know how many actually passed it. I don’t remember. But I mean, it was a significant number of states. So these are … all these things that we’re talking about are related — you know, who gets to decide based on what evidence or lack thereof.

Rovner: So if there’s a reason that I brought these three things up, because after all this, a federal judge in California has temporarily blocked enforcement of a new state law that would allow the state medical board to sanction doctors who spread false or misleading information about covid vaccines and treatments. One of the plaintiffs told The New York Times that the law is too vague, quote “Today’s quote-unquote, ‘misinformation’ is tomorrow’s standard of care, he said.” Which is absolutely true. So how should we go about combating medical misinformation? I mean, you know, sometimes people who sound wacky end up having the answer. You know, you don’t want to stop them, but you also don’t want people peddling stuff that clearly doesn’t work.

Kenen: In addition to state boards, there are large medical societies that are — I don’t know how far they’ve gone, but they have said that they will take action. I’m sure that any action they take either will or has already ended up in court. So there are multiple ways of getting at misinformation. But, you know, like Sarah said it really well, there are people who’ve made up their mind and nothing you do is going to stop them from believing that. And some of them have died because they believe the wrong people. So I don’t think we’re going to solve the misinformation problem on this podcast. Or even off — I don’t think the four of us …

Rovner: If only we could.

Kenen: Even if we were off the podcast! But it’s very complicated. I — a lot of my work right now is centered on that. The idea that courts and states are coming down on the wrong side, in terms of where the science stands right now, understanding that science can change and does change. I mean, whether another version of that law could get through the California courts, I mean, there are apparently some broad drafting problems with that law.

Rovner: It hasn’t been struck down yet. It’s just been temporarily blocked while the court process continues. We’ll see. All right. Well, let’s move on to abortion since we’ve been kind of nibbling around the edges. Rachel, you wrote about a group of abortion rights-supporting Democratic governors organizing to coordinate state responses to anti-abortion efforts. What could that do?

Roubein: Yeah, so it’s news this week. It’s called the Reproductive Freedom Alliance. And essentially the idea is so governors can have a forum to more rapidly collaborate, compare notes on things like executive orders that are aimed at expanding and protecting abortion bills, moving through the legislature, budgetary techniques. And as we’re talking about lawsuits, I mean, talk to some governors and you know that the Texas lawsuit from conservative groups seeking to revoke the FDA’s approval of a key abortion pill is top of mind in this new alliance. Kind of the idea is to be able to rapidly come together and have some sort of response if the outcome of that case doesn’t go their way or other major looming decisions. I think it’s interesting. They are billing themselves as nonpartisan. But, you know, only Democratic governors have signed up here.

Rovner: Well, we could have had Larry Hogan and the few moderate Republicans that are left.

Roubein: Yes, Charlie Baker.

Rovner: If they were still … Charlie Baker.

Roubein: Sununu.

Rovner: If they were still there, which they’re not.

Roubein: I mean, I think the other interesting thing about this is if … you looked at 2024, and if a Republican’s in the White House in 2025, they might try and roll back actions Biden has done. So I could foresee a Democratic governors alliance trying to attempt to counteract that in a way that states can.

Rovner: Well, also, on the abortion rights front, supporters in Ohio are trying to get a measure on the ballot that would write abortion rights into the state constitution. This has worked in other red and purple states like Kansas and Michigan. But Ohio? A state that’s been trending redder and redder. It was the home of the first introduced six-week abortion ban five or six years ago. How big a message would that send if Ohio actually voted to protect abortion rights in its constitution? And does anybody think there’s any chance that they would?

Roubein: I think it’s interesting when you look at Kentucky and Kansas, which their ballot measures were different. It was for the state constitution to say that there was no right to an abortion, but abortion rights …

Rovner: There was a negative they defeated saying there was no right.

Roubein: Yeah. I mean, abortion groups really think the public is on their side here. And anti-abortion leaders do think that ballot measures aren’t … like, fighting ballot measures isn’t their best position either. So I think it’ll be interesting to see. Something that caught my eye with this is that the groups are trying to get it on the 2023 general election ballot. And right now what some Republican lawmakers are trying to do to counteract not just abortion ballot measures, but more progressive ballot measures, which is to try and increase the threshold of passage for a ballot measure. And there’s a bill in the Ohio legislature that would increase passage for enshrining anything into the state constitution to 60% support. But that would have to go to the people, too. So essentially, the timing here could counteract to that. So.

Rovner: Yeah, and as we saw in Kansas, if you have this question at a normally … off time for a big turnout, you can turn out your own people. So I assume they’re doing that very much on purpose. They don’t want it to be on the 2024 ballot with the president and Senate race in Ohio and everything else. All right. Well, one more on the abortion issue. Moving to the other side. A Florida lawyer is petitioning to have a pregnant woman who’s been accused, although not convicted, of second-degree murder released from jail because her fetus is being held illegally. Now, it’s not entirely clear if the lawyer is actually in favor of so-called personhood or it’s just trying to get his client, the pregnant woman, out of jail. But these kinds of cases can eventually have pretty significant ramifications, right? If a judge were to say, I’m going to release this woman because the fetus hasn’t done anything wrong.

Kenen: Well, there’s going to be an amendment to the personhood amendment saying, except when we don’t like the mother, right? I mean, she’s already almost at her due date. So it probably is going to be moot. There’s an underlying question in this case about whether she’s been getting good prenatal care, and that’s a separate issue than personhood. I mean, if the allegations are correct and she has not gotten the necessary prenatal care, then she certainly should be getting the necessary prenatal care. I don’t think this is going to be ruled on in time — I think she’s already in her final month of pregnancy. So I don’t think we’re going to see a ruling that’s going to create personhood for fetal inmates.

Rovner: She’ll have the baby before she gets let out of jail.

Kenen: I think other lawyers might try this. I mean, I think it’s legal chutzpah, I guess. If one lawyer came up with it, I don’t see why other lawyers won’t try it for other incarcerated pregnant women.

Rovner: Yeah. And you could see it feeding into the whole personhood issue of, you know, [does] the fetus have its own set of individual rights, you know, apart from the pregnant woman who’s carrying it? And it’s obviously something that’s that we’re going to continue to grapple with, I think, as this debate continues. All right. That is the news for this week. Now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it; we will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Sarah, why don’t you go first this week?

Karlin-Smith: I took a look at a story in the DCist. It’s called “Locals Who Don’t Speak English Need Medical Translators, but Some Say They Don’t Always Get the Service.” It was by Amanda Michelle Gomez and Hector Alejandro Arzate, and it basically takes a look at a lack of medical translators who can help patients who don’t speak English in the D.C. area and the harm that can be caused when patients don’t have that support, whether they’re in the hospital or at medical appointment, focusing on a woman who basically said she wasn’t getting food for three days and actually left the hospital to provide her food and she was undergoing … cancer treatment and in there for an emergency situation. It also highlights a federally funded facility in D.C. that is trying to support patients in the area with translators, but some of the health policy challenges they face, such as, you know, there’s reimbursement for basically accompanying a patient to an appointment, but there’s out-of-appointment care that patients need. Like if you’re sent home with instructions in English and there’s difficulty funding that care. And I mean, I just think the issue is important and fascinating because people who cover health policy, I think, tend to realize sometimes, even if you have an M.D. and a Ph.D. in various aspects of this system, it can be very hard to navigate your care in the U.S., even if you are best positioned. So to add in not speaking a language and, in this case, having had experience trying to help somebody who spoke a language much less more commonly spoken in the U.S. You know, I was thinking, well, she spoke Spanish, you know, how bad could it be? A lot of people in the U.S. often are bilingual and Spanish is a common language that you might expect lots of people in a medical facility to know. So I think, you know, again, it just shows the complexities here of even when you’re best positioned to succeed, you often have trouble succeeding as a patient. And when you add in other factors, we really set people up for pretty difficult situations.

Rovner: Yeah, it was kind of eye-opening. Rachel.

Roubein: My extra credit is titled “Her Baby Has a Deadly Diagnosis. Her Florida Doctors Refused an Abortion,” and it’s by Frances Stead Sellers from The Washington Post. I chose the story because it gives this rare window into how an abortion ban can play on the ground when a fetus is diagnosed with a fatal abnormality. So Frances basically chronicles how one woman in Florida, Deborah Dorbert, and her husband, Lee, were told by a specialist when she was roughly 24 weeks pregnant that the fetus had a condition incompatible with life, and the couple decided to terminate the pregnancy. But they say they were ultimately told by doctors that they couldn’t due to a law passed last year in Florida that banned most abortions after 15 weeks. And so that new law does have exceptions, including allowing later termination if two physicians certify in writing that the fetus has a fatal fetal abnormality. So it’s not clear exactly how or why the Dorberts’ doctors said that they couldn’t or how they applied the law in this situation.

Rovner: Yeah, I feel like this is maybe the 10th one of these that I’ve read of women who have wanted pregnancies and wanted babies and something goes wrong with the pregnancy, and an abortion ban has prevented them from actually getting the care that they need. And I just wonder if the anti-abortion forces have really thought this through, because if they want to encourage women to get pregnant, I know a lot of women who want babies, who want to get pregnant, want to have a baby, but they’re worried that if something goes wrong, that they won’t be able to get care. You know, this question of how close to death does the pregnant woman have to be for the abortion to, quote-unquote, “save her life”? We keep seeing it now in different states and in different iterations. Sorry, it’s my little two cents. Joanne.

Kenen: My extra credit is from The Atlantic’s Katherine J. Wu. And the headline is “Eagles Are Falling, Bears Are Going Blind.” It’s about bird flu or avian flu. It does not say it couldn’t jump to humans. It does say it’s not likely to jump to humans, but that we have to be better prepared, and we have to watch it. But it really made the interesting point that it is much more pervasive among not just birds, but other animals than prior, what we and laypeople call “bird flu.” And it’s going to have — 60, something like 60 million U.S. birds have died. It is affecting Peruvian sea lions, grizzly bears, bald eagles, all sorts of other species, mostly birds, but some mammals. And it’s going to have a huge impact on wildlife for many years to come. And, you know, the ecological environment, our wildlife enviornments. And it’s a really interesting piece. I hadn’t seen that aspect of it described. And if you think — and eggs are going to stay expensive.

Karlin-Smith: I was going to say this morning, I actually saw that in Cambodia reported one of the first deaths in this recent wave, of a person with this bird flu. So the question, I guess, is in the past, it hasn’t easily spread from person to person. And so that would be like the big concern where you’d worry about really large outbreaks.

Rovner: Yeah, because we don’t have enough to worry about right now.

Kenen: We should be watching this one. I mean, this is a different manifestation of it. But we do know there have been isolated cases like the one Sarah just described where, you know, people have gotten it and a few people have died, but it has not easily adapted. And of course, if it does adapt, that’s a different story. And then … in what form does it adapt? Is it more like the flu we know, or, I mean, there are all sorts of unanswered questions. Yes, we need to watch it. But this story was actually just so interesting because it was about what it’s doing to animals.

Rovner: Yeah, it is. The ecosystem is more than just us. Well, my story is from Stat News by Calli McMurray, and it’s highly relevant for our podcast. It’s called “Current Treatments for Cramps Aren’t Cutting It. Why Aren’t There Better Options?” And yes, it’s about menstrual cramps, which affect as many as 91% of all women of reproductive age. Nearly a third of them severely. Yet there’s very little research on the actual cause of cramps and current treatments, mostly nonsteroidal anti-inflammatory drugs or birth control pills, don’t work for a lot of people. As someone who spent at least a day a month of her 20s and 30s in bed with a heating pad, I can’t tell you how angry it makes me that this is still a thing with all the other things that we have managed to cure in medicine.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Joanne?

Kenen: @JoanneKenen

Rovner: Rachel.

Roubein: @rachel_roubein

Rovner: Sarah.

Karlin-Smith: @SarahKarlin

Rovner: We will be back in your feed next week. Until then, be healthy.

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Estados Unidos se estancó en las regulaciones químicas después de la década de 1970, según Bhavna Shamasunder, profesora asociada de política urbana y ambiental en el Occidental College. Y eso ha dejado un vacío regulatorio, ya que la blanda supervisión federal permite que productos potencialmente tóxicos que estarían prohibidos en Europa se vendan en las tiendas estadounidenses.

“Muchos productos en el mercado no son seguros”, dijo Shamasunder. “Es por eso que los estados están ayudando a generar una solución”.

La posible exposición a sustancias tóxicas en los cosméticos es especialmente preocupante para las mujeres de color, porque estudios muestran que las mujeres negras usan más productos para el cabello que otros grupos raciales, y que las hispanas y asiáticas han informado que usan más cosméticos en general que las mujeres negras y blancas no hispanas.

La legislación del estado de Washington es un segundo intento de aprobar la Ley de Cosméticos Libres de Tóxicos, luego que, en 2022, los legisladores aprobaran un proyecto de ley que eliminó la prohibición de ingredientes tóxicos en los cosméticos.

Este año, los legisladores tienen un contexto adicional después que un informe encargado por la Legislatura, y publicado en enero por el Departamento de Ecología del estado, encontró múltiples productos con niveles preocupantes de químicos peligrosos, incluyendo plomo y arsénico en la base CoverGirl Clean Fresh Pressed Powder de tinte oscuro.

El lápiz labial de color continuo CoverGirl y la base de maquillaje Black Radiance Pressed Powder de Markwins Beauty Brands se encuentran entre otros productos de varias marcas que contienen plomo, según el informe.

Los equipos de investigación preguntaron a mujeres hispanas, negras no hispanas y multirraciales qué productos de belleza usaban. Luego, probaron 50 cosméticos comprados en Walmart, Target y Dollar Tree, entre otras tiendas.

“Las empresas están agregando conservantes como el formaldehído a los productos cosméticos”, dijo Iris Deng, investigadora de tóxicos del Departamento de Ecología estatal. “El plomo y el arsénico son historias diferentes. Se detectan como contaminantes”.

Markwins Beauty Brands no respondió a las solicitudes de comentarios.

“Las trazas nominales de ciertos elementos a veces pueden estar presentes en las formulaciones de productos como consecuencia del origen mineral natural, según lo permitido por la ley que aplica”, dijo Miriam Mahlow, vocera de la empresa matriz de CoverGirl, Coty Inc., en un correo electrónico.

Los autores del informe de Washington dijeron que los países de la Unión Europea prohíben productos como la base CoverGirl de tinte oscuro. Esto se debe a que el arsénico y el plomo se han relacionado con el cáncer, y daño cerebral y del sistema nervioso. “No se conoce un nivel seguro de exposición al plomo”, dijo Marissa Smith, toxicóloga reguladora sénior del estado de Washington. Y el formaldehído también es carcinógeno.

“Cuando encontramos estos químicos en productos aplicados directamente a nuestros cuerpos, sabemos que las personas están expuestas”, agregó Smith. “Por lo tanto, podemos suponer que estas exposiciones están contribuyendo a los impactos en la salud”.

Aunque la mayoría del contenido de plomo de los productos era bajo, dijo Smith, las personas a menudo están expuestas durante años, lo que aumenta considerablemente el peligro.

Los hallazgos del departamento de ecología de Washington no fueron sorprendentes: otros organismos han detectado conservantes como formaldehído o, más a menudo, agentes liberadores de formaldehído como quaternium-15, DMDM hidantoína, imidazolidinil urea y diazolidinil urea en productos para alisar el cabello comercializados especialmente para las mujeres negras.

El formaldehído es uno de los productos químicos utilizados para embalsamar los cadáveres antes de los funerales.

Además de Washington, al menos 12 estados —Hawaii, Illinois, Massachusetts, Michigan, Nevada, Nueva Jersey, Nueva York, Carolina del Norte, Oregon, Rhode Island, Texas y Vermont— están considerando leyes para restringir o exigir la divulgación de sustancias químicas tóxicas en cosméticos y otros productos de cuidado personal.

Los estados están actuando porque el gobierno federal tiene una autoridad limitada, dijo Melanie Benesh, vicepresidenta de asuntos gubernamentales del Environmental Working Group, una organización sin fines de lucro que investiga qué hay en los productos para el hogar y para el consumidor.

“La FDA ha tenido recursos limitados para intentar la prohibición de ingredientes”, agregó Benesh.

El Congreso no ha otorgado a la Agencia de Protección Ambiental (EPA) una amplia autoridad para regular estos productos, a pesar de que los contaminantes y conservantes de los cosméticos terminan en el suministro de agua.

En 2021, un hombre de California solicitó a la EPA que prohibiera los químicos tóxicos en los cosméticos bajo la Ley de Control de Sustancias Tóxicas, pero la petición fue denegada, porque los cosméticos están fuera del alcance de la jurisdicción de la ley, dijo Lynn Bergeson, abogada en Washington, D.C.

Bergeson dijo que la regulación de los productos químicos está sujeta a la Ley Federal de Alimentos, Medicamentos y Cosméticos, pero la Administración de Medicamentos y Alimentos (FDA) regula solo los aditivos de color y los productos químicos en los protectores solares porque sostienen que disminuyen el riesgo de cáncer de piel.

Minnesota, por ejemplo, llena los vacíos regulatorios al realizar pruebas de mercurio, hidroquinona y esteroides en productos para aclarar la piel. También aprobó una ley en 2013 que prohíbe el formaldehído en productos para niños, como lociones y baños de burbujas.

California ha aprobado varias leyes que regulan los ingredientes y el etiquetado de los cosméticos, incluida la Ley de Cosméticos Seguros de California, en 2005. Una ley adoptada en 2022 prohíbe las sustancias de perfluoroalquilo y polifluoroalquilo agregadas intencionalmente, conocidas como PFAS, en cosméticos y prendas de vestir a partir de 2025.

El año pasado, Colorado también aprobó una prohibición de PFAS en maquillaje y otros productos.

Pero expertos en seguridad del consumidor dijeron que los estados no deberían tener que llenar el vacío dejado por las regulaciones federales, y que un enfoque más inteligente implicaría que el gobierno federal sometiera los ingredientes de los cosméticos a un proceso de aprobación.

Mientras tanto, los estados están librando una batalla cuesta arriba, porque miles de productos químicos están disponibles para los fabricantes. Como resultado, existe una brecha entre lo que los consumidores necesitan como protección y la capacidad de acción de los reguladores, dijo Laurie Valeriano, directora ejecutiva de Toxic-Free Future, una organización sin fines de lucro que investiga y defiende la salud ambiental.

“Los sistemas federales son inadecuados porque no requieren el uso de productos químicos más seguros”, dijo Valeriano. “En cambio, permiten productos químicos peligrosos en productos para el cuidado personal, como PFAS, ftalatos o incluso formaldehído”.

Además, el sistema de evaluación de riesgos del gobierno federal tiene fallas, dijo, “porque intenta determinar cuánto riesgo de exposiciones tóxicas es aceptable”. Por el contrario, el enfoque que el estado de Washington espera legislar evaluaría los peligros y preguntaría si los productos químicos son necesarios o si existen alternativas más seguras, es decir, evitar los ingredientes tóxicos en los cosméticos en primer lugar.

Es muy parecido al enfoque adoptado por la Unión Europea (UE).

“Ponemos límites y restricciones a estos productos químicos”, dijo Mike Rasenberg, director de evaluación de peligros de la Agencia Europea de Productos Químicos en Helsinki, Finlandia.

Rasenberg dijo que debido a que la investigación muestra que el formaldehído causa cáncer nasal, la UE lo ha prohibido en productos de belleza, además del plomo y el arsénico. Los 27 países de la UE también trabajan juntos para probar la seguridad de los productos.

En Alemania se examinan anualmente más de 10,000 productos cosméticos, dijo Florian Kuhlmey, vocero de la Oficina Federal de Protección al Consumidor y Seguridad Alimentaria de ese país. Y no termina ahí. Este año, Alemania examinará alrededor de 200 muestras de dentífrico para niños en busca de metales pesados y otros elementos prohibidos en la UE para cosméticos, agregó Kuhlmey.

La legislación en Washington se acercaría a la estrategia europea para la regulación de productos químicos. Si se aprueba, daría a los minoristas que venden productos con ingredientes prohibidos hasta 2026 para vender los productos existentes.

Mientras tanto, los clientes pueden protegerse buscando productos de belleza naturales, dijo la dermatóloga del área de Atlanta, Chynna Steele Johnson.

“Muchos productos tienen agentes liberadores de formaldehído”, dijo Steele Johnson. “Pero no es algo que los clientes puedan encontrar en una etiqueta. Mi sugerencia, y esto también se aplica a los alimentos, sería, cuanto menos ingredientes, mejor”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Las aflicciones del barrio se remontan a principios de los años 70, cuando la industria desapareció y el tráfico de drogas se afianzó. Con cada nueva oleada de drogas, la situación se agrava. Ahora está peor que nunca. Ahora, con la llegada de la xilacina, un tranquilizante de uso veterinario, nuevas complicaciones están sobrecargando un sistema ya desbordado.

“Hay que poner manos a la obra”, dijo Dave Malloy, un veterano trabajador social de Philadelphia que trabaja en Kensington y otros lugares de la ciudad.

Los traficantes utilizan xilacina, un sedante barato no autorizado, para cortar el fentanilo, un opioide sintético 50 veces más potente que la heroína. El nombre callejero de la xilacina es “tranq”, y el fentanilo cortado con xilacina se llama “tranq dope”.

La xilacina lleva una década diseminándose por el país, según la Agencia Antidroga (DEA). Su aparición ha seguido la ruta del fentanilo: empezando en los mercados de heroína en polvo blanco del noreste y desplazándose después hacia el sur y el oeste.

Además, ha demostrado ser fácil de fabricar, vender y transportar en grandes cantidades para los narcotraficantes extranjeros, que acaban introduciéndola en Estados Unidos, donde circula a menudo en paquetes de correo exprés.

La xilacina se detectó por primera vez en Philadelphia en 2006. En 2021 se encontró en el 90% de las muestras de opioides callejeros. En ese año, el 44% de todas las muertes por sobredosis no intencionales relacionadas con el fentanilo incluyeron xilacina, según estadísticas de la ciudad. Dado que los procedimientos de análisis durante las autopsias varían mucho de un estado a otro, no hay datos exhaustivos sobre las muertes por sobredosis con xilacina a nivel nacional, según la DEA.

Aquí en Kensington, los resultados están a la vista. Usuarios demacrados caminan por las calles con heridas necróticas en piernas, brazos y manos, que a veces llegan al hueso.

La vasoconstricción que provoca la xilacina y las condiciones antihigiénicas dificultan la cicatrización de cualquier herida, y mucho más de las úlceras graves provocadas por la xilacina, explicó Silvana Mazzella, directora ejecutiva de Prevention Point Philadelphia, un grupo que ofrece servicios conocidos como “reducción del daño”.  

Stephanie Klipp, enfermera que se dedica al cuidado de heridas y a la reducción de daños en Kensington, dijo que ha visto a personas “viviendo literalmente con lo que les queda de sus extremidades, con lo que obviamente debería ser amputado”.

El papel que desempeña la xilacina en las sobredosis mortales pone de relieve uno de sus atributos más complicados. Al ser un depresor del sistema nervioso central, la naloxona no funciona cuando se trata de un sedante.

Aunque la naloxona puede revertir el opioide de una sobredosis de “tranq dope”, alguien debe iniciar la respiración artificial hasta que lleguen los servicios de emergencia o la persona consiga llegar a un hospital, cosa que a menudo no ocurre. “Tenemos que mantener a las personas con vida el tiempo suficiente para tratarlas, y eso aquí es diferente cada día”, explicó Klipp.

Si un paciente llega al hospital, el siguiente paso es tratar el síndrome de abstinencia agudo de “tranq dope”, que es algo delicado. Apenas existen estudios sobre cómo actúa la xilacina en humanos.

Melanie Beddis vivió con su adicción dentro y fuera de las calles de Kensington durante unos cinco años. Recuerda el ciclo de desintoxicación de la heroína. Fue horrible, pero después de unos tres días de dolores, escalofríos y vómitos, podía “retener la comida y posiblemente dormir”. Con la “tranq dope” fue peor. Cuando intentó dejar esa mezcla en la cárcel, no pudo comer ni dormir durante unas tres semanas.

Las personas que se desintoxican de la “tranq dope” necesitan más medicamentos, explicó Beddis, ahora en recuperación, quien ahora es directora de programas de Savage Sisters Recovery, que ofrece alojamiento, asistencia y reducción de daños en Kensington.

“Necesitamos una receta que sea eficaz”, señaló Jeanmarie Perrone, médica y directora fundadora del Centro de Medicina de Adicciones de Penn Medicine.

Perrone dijo que primero trata la abstinencia de opioides, y luego, si un paciente sigue experimentando malestar, a menudo utiliza clonidina, un medicamento para la presión arterial que también funciona para la ansiedad. Otros médicos han probado distintos fármacos, como la gabapentina, un medicamento anticonvulsivo, o la metadona.

“Es necesario que haya más diálogo sobre lo que funciona y lo que no, y que se ajuste en tiempo real”, afirmó Malloy.

Philadelphia ha anunciado recientemente que va a poner en marcha un servicio móvil de atención de heridas como parte de su plan de gastos de los fondos del acuerdo sobre opioides, con la esperanza de que esto ayude al problema de la xilacina.

Lo mejor que pueden hacer los especialistas en las calles es limpiar y vendar las úlceras, proporcionar suministros, aconsejar a la gente que no se inyecte en las heridas y recomendar tratamiento en centros médicos, explicó Klipp, que no cree que un hospital pueda ofrecer a sus pacientes un tratamiento adecuado contra el dolor. Muchas personas no pueden quebrar el ciclo de la adicción y no hacen seguimiento.

Mientras que la heroína solía dar un margen de 6-8 horas antes de necesitar otra dosis, la “tranq dope” solo da 3-4 horas, estimó Malloy. “Es la principal causa de que la gente no reciba la atención médica adecuada”, añadió. “No pueden estar el tiempo suficiente en urgencias”.

Además, aunque las úlceras resultantes suelen ser muy dolorosas, los médicos son reacios a dar a los usuarios analgésicos fuertes. “Muchos médicos ven eso como que buscan medicación en lugar de lo que está pasando la gente”, dijo Beddis.

Por su parte, Jerry Daley, director ejecutivo de la sección local de un programa de subvenciones gestionado por la Oficina de Política Nacional de Control de Drogas (ONDCP), dijo que los funcionarios de salud y las fuerzas del orden deben comenzar a tomar medidas enérgicas contra la cadena de suministro de xilacina y transmitir el mensaje de que las empresas deshonestas que la fabrican están “literalmente beneficiándose de la vida y las extremidades de las personas”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The neighborhood’s afflictions date to the early 1970s, when industry left and the drug trade took hold. With each new wave of drugs, the situation grows grimmer. Now, with the arrival of xylazine, a veterinary tranquilizer, new complications are burdening an already overtaxed system.

“It’s all hands on deck,” said Dave Malloy, a longtime Philadelphia social worker who does mobile outreach in Kensington and around the city.

Dealers are using xylazine, which is uncontrolled by the federal government and cheap, to cut fentanyl, a synthetic opioid up to 50 times stronger than heroin. The street name for xylazine is “tranq,” and fentanyl cut with xylazine is “tranq dope.” Mixed with the narcotic, xylazine amplifies and extends the high of fentanyl or heroin.

But it also has dire health effects: It leaves users with unhealing necrotic ulcers, because xylazine restricts blood flow through skin tissue. Also, since xylazine is a sedative rather than a narcotic, overdoses of tranq dope do not respond as well to the usual antidote — naloxone — which reverses the effects of only the latter.

Xylazine has been spreading across the country for at least a decade, according to the Drug Enforcement Administration, starting in the Northeast and then moving south and west. Plus, it has proven to be easy for offshore bad actors to manufacture, sell, and ship in large quantities, eventually getting it into the U.S., where it often circulates by express delivery.

First detected in Philadelphia in 2006, xylazine was found in 90% of street opioid samples in the city by 2021. That year, 44% of all unintentional fentanyl-related overdose deaths involved xylazine, city statistics show. Since testing procedures during postmortems vary widely from state to state, no comprehensive data for xylazine-positive overdose deaths nationally exists, according to the DEA.

Here in Kensington, the results are on display. Emaciated users walk the streets with necrotic wounds on their legs, arms, and hands, sometimes reaching the bone.

Efforts to treat these ulcers are complicated by the narrowing of blood vessels that xylazine causes as well as dehydration and the unhygienic living conditions that many users experience while living homeless, said Silvana Mazzella, associate executive officer of the public health nonprofit Prevention Point Philadelphia, a group that provides services known as harm reduction.

Stephanie Klipp, a nurse who does wound care and is active in harm reduction efforts in Kensington, said she has seen people “literally living with what’s left of their limbs — with what obviously should be amputated.”

Fatal overdoses are rising because of xylazine’s resistance to naloxone. When breathing is suppressed by a sedative, the treatment is CPR and transfer to a hospital to be put on a ventilator. “We have to keep people alive long enough to treat them, and that looks different every day here,” Klipp said.

If a patient reaches the hospital, the focus becomes managing acute withdrawal from tranq dope, which is dicey. Little to no research exists on how xylazine acts in humans.

Melanie Beddis lived with her addiction on and off the streets in Kensington for about five years. She remembers the cycle of detoxing from heroin cold turkey. It was awful, but usually, after about three days of aches, chills, and vomiting, she could “hold down food and possibly sleep.” Tranq dope upped that ante, said Beddis, now director of programs for Savage Sisters Recovery, which offers housing, outreach, and harm reduction in Kensington.

She recalled that when she tried to kick this mix in jail, she couldn’t eat or sleep for about three weeks.

There is no clear formula for what works to aid detoxing from opiates mixed with xylazine.

“We do need a recipe that’s effective,” said Dr. Jeanmarie Perrone, founding director of the Penn Medicine Center for Addiction Medicine and Policy.

Perrone said she treats opioid withdrawal first, and then, if a patient is still uncomfortable, she often uses clonidine, a blood pressure medication that also lessens anxiety. Other doctors have tried gabapentin, an anticonvulsant medication sometimes used for anxiety.

Methadone, a medication for opioid use disorder, which blunts the effects of opioids and can be used for pain management, seems to help people in tranq dope withdrawal, too.

In the hospital, after stabilizing a patient, caring for xylazine wounds may take priority. This can range from cleaning, or debridement, to antibiotic treatment — sometimes intravenously for periods as long as weeks — to amputation.

Philadelphia recently announced it is launching mobile wound care as part of its spending plan for opioid settlement funds, hopeful that this will help the xylazine problem.

The best wound care that specialists on the street can do is clean and bandage ulcers, provide supplies, advise people not to inject into wounds, and recommend treatment in medical settings, said Klipp. But many people are lost in the cycle of addiction and don’t follow through.

While heroin has a six- to eight-hour window before the user needs another hit, tranq dope wanes in just three or four, Malloy estimated. “It’s the main driver why people don’t get the proper medical care,” he said. “They can’t sit long enough in the ER.”

Also, while the resulting ulcers are typically severely painful, doctors are reluctant to give users strong pain meds. “A lot of docs see that as med-seeking rather than what people are going through,” Beddis said.

In the meantime, Jerry Daley, executive director of the local chapter of a grant program run by the Office of National Drug Control Policy, said health officials and law enforcement need to start cracking down on the xylazine supply chain and driving home the message that rogue companies that make xylazine are “literally profiting off of people’s life and limb.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).