Helen H. Moore's Blog, page 192

Walking with your doctor could be better than talking

(Credit: Getty/sturti)

Gyms across the country will be packed this week with people vowing to “get moving” to lose weight this year.

Much of the effort will be for naught. And, in fact, some of it could lead to injury and frustration.

Currently, Centers for Disease Control and Prevention exercise guidelines call for all individuals to do 150 to 300 minutes of moderate-intensity exercise per week, or 75 minutes of high-intensity exercise per week. In addition, the CDC recommends two days of strength training, or muscle strengthening, for obese people.

I am a physician assistant and exercise physiologist from the Lifestyle Modification Clinic at UConn Health. Current recommendations seem extremely unrealistic, considering less than 10 percent of all individuals meet these criteria for exercise, even without the resistance exercises.

We’ve lost the focus on using the guidelines only as guidelines, and not individualizing an exercise prescription for our patients. We need to be smarter about prescribing it, and here’s why.

A customized approach

The medical profession has learned a few things in recent years about exercise and the obese and those who have become diabetic as a result. All exercise is not created equal, and neither are its benefits.

For those who want to burn fat, aerobic exercise is important. Fat metabolism is greatest during aerobic exercise which is achieved during moderate intensity exercise.

Type 2 diabetes is due to insulin resistance, so the exercise that is more effective to increase insulin sensitivity is more specific to the duration of the exercise than the intensity.

But overweight and obese people may not be able to do either of these without injuring themselves. The Hippocratic oath, whereby doctors pledge to first “do no harm,” gets lost with the prescription of exercise with most individuals. The risk of injury and noncompliance should be the first two things when discussing an exercise routine.

The risk of injury for all individuals, especially of the lower extremities, such as plantar fasciitis and knee pain, is up to four times greater doing high-intensity exercise, such as jogging compared to moderate intensity, such as walking. Obese individuals are at even greater risk.

The risk of injury drives noncompliance, especially with higher-intensity exercise. Educating patients about the benefits of breaking up prolonged sitting throughout the day has been shown to improve insulin sensitivity for diabetics which will help motivate them to start making little changes to start. This will allow them to make realistic changes and even those will have benefits.

Walking the walk

Understanding the importance of exercise, you would assume that physicians spend a lot of time counseling on exercise.

However, in 2010, fewer than 31 percent of physicians recommended physical activity for overweight and less than 47 percent for obese people during an office visit. This was an increase, however, from fewer than 17 percent for overweight and 35 percent for obese in 2000.

This could be partly due to how health care providers are educated, with less than 20 percent of medical schools in the U.S. even requiring one class in physical activity or exercise. More than half of the physicians trained in the United States in 2013 received no formal education in physical activity and may, therefore, be under prepared to properly advise about exercise.

Exercise has been shown to reduce the risk up to 50 percent for all people from becoming diabetic, and since obese individuals are at greater risk, they would benefit the most. For physicians, the challenge is how to help obese patients understand this and help them become more active.

The first thing is to educate our health care professionals during their medical education on exercise physiology and the medical importance of physical activity which will help them give an appropriate exercise prescription.

It has been shown that the more the physicians focus on exercise, the more likely patients will exercise.

Also, the more we doctors go into our “patient’s lifestyle” and find ways to get them moving more and being respectful of them, the more successful they will be. We need to get outside of our box of guidelines and listen to our patients. An example would be to go for a walk during their visits.

Patients walking with their doctors can help doctors assess patients’ fitness levels. Health care providers can assess whether patients have any limitations such as knee or back pain. They also can explain the difference between aerobic and anaerobic exercise, which is best done by explaining the “talk test”. If you can talk but not sing while exercising, you are maintaining aerobic metabolism, which burns fats and is good for weight loss. If you are unable to say more than a few words without pausing for a breath, you will then be exercising anaerobically and burning sugar.

Brad Biskup, Coordinator of Lifestyle Medicine Clinic, University of Connecticut

New York in the 1960s: John Lindsay, Joe Namath and the rise of “Fun City”

Joe Namath is presented with an award from New York City Mayor John Lindsay on Jan. 22, 1969. (Credit: AP)

The Scottish poet, Thomas Campbell, once wrote, “Coming events cast their shadows before.” For New York in the late 1960s, those shad­ows dated back to 1957. Consider some of the events that unfolded that year, some of which were clearly momentous at the time, some whose impact would not fully be felt until the end of the next decade:

On January 1, 35-year-old lawyer John Lindsay left his post as an assistant to Attorney General Herbert Brownell. During his tenure with Brownell, the two had become close, and Brownell would be Lindsay’s mentor for years. Though he was moving back into the private sector with his old law firm, Lindsay—who helped Brownell draft the legislation that would become the 1957 Civil Rights Act—had gained a taste for public service and was eyeing the congressional seat in his home district, Manhattan’s 17th.

On January 3, Harry Wismer, a broadcaster and 20 percent stockholder in the Washington Redskins, charged the team with racial bias while speaking at an event for black journalists. George Preston Marshall, the team’s owner and president, was blatantly racist, and the Redskins had no black players on the roster. The race issue would be one reason Wismer would split with the Redskins and, two years later, buy into a new football venture known as the American Football League. Wismer’s team, the Titans, would play in New York’s Polo Grounds.

On one evening in April, a man named Hinton X. Johnson (also sometimes referred to as Johnson X. Hinton) witnessed a police officer beating a black citizen in Harlem. When Johnson inter­vened, he, too was beaten. Johnson was a member of the Black Muslims, led by a preacher named Malcolm X. After word of Johnson’s beating spread, hundreds of members of the mosque began demonstrating in front of the Harlem police precinct. Fearing violence, the authorities arranged a meeting with Mal­colm X. Assurances were given that Hinton X. Johnson would be given care in a hospital and those responsible for his injuries would be punished. Satisfied, Malcom X stunned police when he, according to one account, “strode to the head of the angry, impatient mob, and then flicked his hands.” Moments later, as if by magic, the crowd dispersed and the street was empty. “No man should have that much power,” one officer said.

On May 28, the eight owners of National League clubs met in Chicago and voted unanimously to grant permission for the two N.L. teams located in New York—the Giants and Dodgers—to seek new homes. Ebbets Field in Brooklyn and the Polo Grounds in upper Manhattan were growing increas­ingly decrepit, and efforts to have new stadiums built had been long stymied. By the end of the 1957 season, the Dodgers had agreed to move to Los Angeles, and the Giants would head to San Francisco.

On October 22, in Saigon, Vietnam—still a distant and unknown corner of the globe to most Americans—three bombs detonated by Communist terrorists injured 13 American soldiers who were part of a team that had been training South Vietnam’s anti-Communist army. The injuries marked the first casualties the United States suffered in Vietnam.

On December 30, the New York Times reported on the state of New York’s economy. All told, 1957 had been a bad year — 50,000 jobs had been lost in New York, while consumer prices continued to rise, by 2.7 percent. The report noted that the city’s factory employment was hard hit, especially the garment industry, which accounted for 38,000 lost jobs — about 12 per­cent of its total, in just one year. The report also stated that unemployment was expected to rise, and that the average age of an unemployment insurance claimant had gone from 47 to 38 in one year. Good-paying, low-skilled jobs in New York City disappeared at an alarming rate in 1957.

These events were all seeds that would sprout separately but become intertwined in New York City during coming years of dramatic change. New York in the 1960s would be a fast-evolving and nearly ungovern­able city. There would be, concurrently, an overhaul in the sports cul­ture, which had long bound together the heterogeneous citizenry that made up the city. Wismer’s AFL Titans would nearly fold, until new owners stabilized the team and turned them into the Jets. The Dodg­ers and Giants were gone, but an endearingly hapless group of losers, the Mets, replaced them. A couple new sports teams were not going to bring back disappearing manufacturing jobs, end overseas wars or ease racial frustrations. But there could be a time — couldn’t there? — at which the exploits of those teams would help.

The Jets introduced rookie quarterback Joe Namath, the western Penn­sylvania slinger who’d picked up a treacly Southern drawl playing for Bear Bryant at Alabama, to New York in January 1965, giving him an astronomical $400,000. Just four months behind him, Lindsay, the handsome, young liberal Republican hailed in some corners as the next John F. Kennedy, entered his name into the race for mayor of New York, an almost unheard-of act of audacity for a member of the GOP in a city where Democrats had a 3-to-1 advantage. On the day the shaggy-maned Namath was introduced, the Giants retired 38-year-old Y.A. Tittle, who was known as the “Bald Eagle” for his long-bare scalp. And the man Lindsay was seeking to replace was 55-year-old Mayor Robert Wagner, whose three terms in office had left him looking every bit his age. The symbolism was obvious, as was the new-guard optimism that Namath and Lindsay each brought to his field. Lindsay’s campaign slogan, taken from a New York columnist, was, “He is fresh and everyone else is tired.” As it was for Lindsay, so it was for Namath. He was fresh, and everyone else—the New York Giants, the NFL, Mickey Mantle’s Yankees—was tired.

The five years that followed Lindsay’s arrival in the city from Wash­ington D.C. and Namath’s arrival from Tuscaloosa were unlike any other period in the county’s history. Racial politics dominated, and as the civil rights movement evolved into the black power and separatist move­ment, the Vietnam War reached its peak and sparked a level of public protest and dissent not seen in the United States before or since. Frus­trated minority city dwellers led violent eruptions in ghettoes across the country, pushing the issue of the fate of American cities to the fore. The violence was not only carried out in mass settings—this was a time during which Dr. Martin Luther King Jr. and Senator Robert F. Kennedy were murdered, within two months of each other. While the political and demographic order was giving way, the underpinnings of the nation’s culture and social norms were shifting, too. Sexual promis­cuity and drug experimentation were becoming more acceptable, and anti-authority symbols gained popularity. Men even had the audacity to grow bushy sideburns.

In New York’s political milieu, Lindsay was a symbol: the White Urban Crusader.

In New York’s social milieu, Namath was a symbol: the Hedonist’s Quarterback.

Ultimately, the validity of Lindsay and Namath as symbols would rest on job performance, and each would have his own troubling dis­appointments, low points, and vocal opponents. Namath would be doused with hot coffee, engage in a verbal war with sportswriters, engage in an actual fistfight with a sports editor, have his cheekbone broken by an antagonistic opponent, and find his bitterest critics in his own locker room. Lindsay would alienate just about every prominent Republican in the country, was called an “ungrateful son of a bitch” by fellow Republican and fierce enemy Governor Nelson Rockefeller, was labeled a “pipsqueak” by a prominent labor leader, was hated by rank-and-file police officers and firemen, had to escape an unruly mob at a Jewish center in Flatbush, contended with major municipal labor strikes in each of his first three years in office, and saw himself burned in effigy from his City Hall office. But both Lindsay and Namath would have incredible highs. Lindsay’s willingness and ability to stride into ghetto communities, even in the severest of crises, earned him the kind of respect from minorities few white politicians ever could claim. There was a moment, however brief, when it looked like Lind­say could solve the urban crisis, when national magazines hailed him as a potential political savior. Namath, too, for all the physical and verbal abuse he endured early in his career (and later, too) had that one magical season, that one year in which he took the Jets to the Super Bowl, shattered myths, and wrote his name forever into American sports lore.

Lindsay and Namath were just the headliners of the era. New York City was a battlefield for Lindsay’s fight to save cities, but it also began to regain its lost status as a cultural leader with a rebirth of theater and filmmaking in the city, became an epicenter for anti-war protest, saw a massive building boom that reshaped the architecture of the city’s financial districts and followed through on a commitment to green spaces that led to the creation of vest-pocket parks and the closing of Central Park to automobile traffic. During late-1960s ascendancy of Lindsay and Namath in New York, the Knicks would win their first NBA championship in twenty-four years, Muhammad Ali would defend his title at the old Madison Square Garden, the new Madi­son Square Garden would open and host a track meet that featured the forerunner of what would become the 1968 Olympic black power salute. And there were the Mets, who doused Lindsay with champagne in the locker room during their incredible run to the 1969 World Series championship and helped him win reelection a month later.

During his first month in office, Lindsay oversaw a crippling tran­sit strike that shutdown the subways in the city for nearly two weeks. He tried to maintain a positive outlook, saying he still thought New York was a “fun city.” Columnist Dick Schaap lampooned his cheery attitude, writing, “He certainly has a wonderful sense of humor. A little while later, Lindsay cheerfully walked four miles from his hotel room to City Hall, a gesture which proved that the fun city had a fun Mayor.” Over the course of his time in office, Lindsay would reclaim the “Fun City” moniker, using it to describe the kind of place where he’d like to be mayor. Others, though, would continue to use it as Schaap had — loaded with irony — so that even the words Fun City were endowed with layers of meaning and symbolism, capable of carrying opposite meanings depending on context.

It remains the best way to think about the positives and negatives of New York in those years. It was a Fun City.

Will uterus transplants change the way we perceive gender?

(Credit: Wellcome Images/Michael Frank, Royal Veterinary College)

This year, the United States passed a medical milestone: the first baby in the nation born through a transplanted uterus. Reports on the specific number of successful births via transplanted uterus vary, but all place the count at fewer than 30 births.

However, the number is expected to rise exponentially in the immediate future.

“We’re hoping that in a decade or so, this will become mainstream,” Dr. Zaraq Khan, a Mayo Clinic reproductive endocrinologist and infertility surgeon, told HuffPost.

The procedure is currently limited to a specific set of patients who fit narrow medical criteria for eligibility.

“As of right now, when uterus transplantation is still in its infancy, it will be limited to patients with absolute uterine factor infertility,” Khan said. This excludes women who, for example, are able to conceive but routinely miscarry.

While bioethical questions remain, some wonder if the technology may one day allow men to eventually carry and birth children.

Dr. Richard Paulson, the outgoing president of the American Society for Reproductive Medicine, believes such procedures are already within the scope of immediate possibility for transgendered women.

“You could do it tomorrow. There would be additional challenges, but I don’t see any obvious problem that would preclude it,” Paulson told the Telegraph. “I personally suspect there are going to be trans women who are going to want to have a uterus and will likely get the transplant.”

But Arthur Caplan, a professor of bioethics and head of the Division of Medical Ethics at New York University’s School of Medicine, told LiveScience that performing such a procedure now would violate ethical standards.

“Surgically, could you put [a uterus] in a man tomorrow? Yeah, but it would be completely irresponsible,” he said, citing unknown medical risks that require further study before performing what would be an experimental operation.

That said, no one is ruling out the possibility that uterine transplants could become a possibility not for just transwomen, but for men as well.

Dr. Saima Aftab, medical director of the Fetal Care Center at Nicklaus Children’s Hospital, explains that such a procedure isn’t medically feasible today, but represents a very real possibility for the future.

As contemporary society renegotiates the most basic understandings of gender, the medical development of uterine transplants may come to represent one of the most profound changes in the way we perceive human bodies.

Chris Sosa is a managing editor at AlterNet. His work also appears in Mic, Salon, Care2, Huffington Post and other publications. Follow him on Twitter @ChrisSosa.

What dating an autistic man is like

A portrait of the author. (Credit: Salon/Flora Thevoux)

When you have an invisible disability, the first challenge is getting other people to believe you — to encourage them to express empathy for someone else. After that, though, you need to learn to listen to how your disability may negatively impact them — that is, to show the very empathy for others that you insist on receiving.

I’ve consistently confronted this dual task when writing about being on the autism spectrum, a task that can be especially sensitive (if rewarding) when discussing dating with autism. Indeed, my first article published at Salon discussed autism and dating. That was more than four years ago. When my writing career began in 2012, I never dreamed that I would open up about being on the autism spectrum, much less delve into the vulnerable details of my personal life. Yet the subject proved popular and was cathartic to discuss, so I periodically returned to it over the years.

Starting on August 28, 2016, a new chapter began. On that day, I entered a long-term relationship with my current girlfriend, Charlotte.

It took me awhile to develop the nerve to ask her about what she has learned while dating an autistic man, with what is colloquially known as Asperger’s Syndrome. Before we started dating, I shared a pair of articles with her that I had written on the subject. In one I reviewed a documentary about dating autistic people, and in the other I interviewed several of my exes. Now it was my turn to ask her: What advice would she give to individuals who were thinking about long-term romantic relationships with people who are on the spectrum?

The main thing she focused on was the difficulties that often arose in communication.

“I can’t dance around or fluff things,” Charlotte explained. “I need to say things that I want directly, otherwise you don’t pick up on nonverbal social cues.”

Such was the case during a recent Christmas party when I casually mentioned that John F. Kennedy might be a tad overrated as a president (although for what it’s worth, I do admire much about him).

“I warned him at Christmas about how my family is conservative and Roman Catholic,” Charlotte said. “Within a few minutes, he tells the family how the Kennedys are overrated. I just looked at him, because my great-grandparents had a shrine to Jesus Christ, Mary and JFK in their home.”

“I just shot you the look of STFU,” she added.

The look didn’t work, however, requiring Charlotte to pull me aside and suggest that I focus more on Grover Cleveland, the subject of my Masters thesis and upcoming Ph.D. dissertation.

Speaking of Cleveland, Charlotte pointed out that she noticed I have a tendency to focus more on the esoteric subjects that happen to be on my mind at any given moment, meaning I’m less likely to pay attention in important situations.

“I need to keep you focused and ask if you’re paying attention most of the time. Luckily I can tell when you are present vs. daydreaming of Grover Cleveland or other things,” she explained.

As a result, one of the chief pieces of advice that Charlotte gave for other people who are dating autistic individuals is that they need to learn how to adapt to being involved with someone who won’t always pick up on nonverbal communication cues and will struggle with other forms of basic socialization.

“I think you need to make sure that future partners communicate and set expectations that are reasonable and not rely on nonverbal communication for cues,” Charlotte told me. “I think patience and a good sense of humor are also key as well.”

There are also times when my struggles with empathy can be difficult for Charlotte.

“We were driving on the highway on a rainy and foggy night to an event we could not cancel,” Charlotte told me. “The road was bad and I was nervous . . . and you start going on about how funny it would be if a truck hit us on the way to the event. As you say that, a truck became impatient and cut in front of us, almost damaging my car. You thought it was funny and at that point I said ‘Matt, you need to stop talking right now.'”

Charlotte also made a point of identifying positive aspects of being in a relationship with an autistic man (thankfully).

“There is a lot of fun,” Charlotte pointed out. “You often forget a filter which, although at times can be challenging, there is also a lot of funny things and jokes you tell me that you can get away with.”

She added, “I look beyond your disability and know that you’re a person. And there are things that are not going to be always 100 percent, but it’s important to communicate, which is true in all relationships.”

I think this is a valuable way of looking at things for anyone in a relationship. It’s important to be open to changing one’s own behaviors to be a more communicative and responsive partner, and there is nothing unreasonable about insisting on being believed, or wanting your good intentions to be accepted, when you make an honest mistake. Asking for help you when you’re struggling with a problem, whether or not it’s related to a disability, is also a practice everyone should embrace.

At the same time, it is important for those with invisible disabilities to employ empathy themselves. I did not intend to scare Charlotte with my dark jokes about traffic, or to tune her out when she gave advice about specific social situations, but that doesn’t mean what I did was OK. I owed her more than just an apology; I also owed her a promise that I would learn from my mistakes to the greatest extent reasonably possible. Being disabled also doesn’t absolve one of moral consequences for one’s own mistakes. One of my main criticisms of the popular TV show “Atypical,” for instance, is how the main character would behave in cruel ways toward other people but be given an implicit pass. That is not OK.

I’m not going to say that I have all the solutions. More than five years after I first began writing about life with autism, I still find myself asking more questions than I answer. That said, I can’t imagine that encouraging people to pause and think about how the people around them must feel is ever bad advice.

Fieldwork on an island taught me how to navigate family dinners

(Credit: Getty/Rawpixel Ltd)

I am headed home to Maine for the holidays, and I am beyond thrilled. I haven’t celebrated Christmas with my family since 2012, due to warm-weather fieldwork commitments on Johnston Atoll and the Galápagos Islands for my PhD research.

Even though I am excited to share in the magic of the snow, lights, and cookies, I am also a little bit nervous: I have different political views from my family, particularly my father, and in the past this has resulted in hurt, anger, and major frustration. I’m nervous that we will stumble upon a topic of conversation that is a trigger for me – if I believe something strongly enough, I take on an attitude akin to a verbal fight to the death. For me, these topics tend to be science-related – especially climate change – and that is a sensitive topic where my Dad and I disagree. It’s a horrible irony to be a scientist broadly studying the effects of climate on seabirds while my dad is a climate skeptic.

For scientists and even general science supporters, the holidays can be a tricky time of year. It is that time when we are thrown head first into engaging with people that don’t have the same opinions or political leanings. I get excited to talk about my research but hesitate more with my opinions where the science and policy intersect. With the current political environment, that could become a heated topic quicker than I could finish my eggnog.

There are sharp divisions between Democrats and Republicans in the US, and that divide continues to widen. It also carries over to climate change, more in focus than ever as we are the only country to reject the Paris Climate Accord. Given the alterations to websites for government agencies, like the EPA, regarding climate change, one can understand how climate change may be a sensitive topic for a Democrat to bring up in a Republican household. I also have prior experience to go on: political discussions that escalated during a Thanksgiving dinner in 2008 were less-than-positive (to say the least) for all present.

My strategy in my conversation with my Dad that year had been to try to win my argument by sharing knowledge. My dad grew up on a farm in rural Maine, attended the University of Maine, and is a very smart man. I returned home for Thanksgiving break, recently liberalized from university, thinking I was a smart woman. I was sure that when I presented him with my facts, he would think differently about climate change and come to realize that we humans have a direct role in it.

“Climate change is happening; studies have shown this,” I told him heatedly, offended he thought otherwise. “CO2 has increased in the atmosphere. They expect the temperature to increase more than two degrees Celsius in the next century.” Needless to say, this strategy wasn’t effective. We fought, soured Thanksgiving for everyone, and politics were banned as a topic of conversation in our house.

This year, I return home equipped with some new skills. Through my experiences living and working with diverse groups of researchers on remote islands, I have learned that reiterating my opinions or knowledge about a subject will not help me win a persuasive argument. You can’t get in an argument in that situation and then leave afterwards. If you fight with someone, you still see them for breakfast, lunch, and dinner. You hang out in free time and work time. You are each other’s friends, family, and colleagues. Living and working in these unique field environments required a better way to handle minor disagreements. And I would like to credit all the wonderful human beings I worked with on islands for helping show me what worked – or didn’t work – in difficult or sensitive conversations.

Here are some strategies – hard-earned life wisdom – that, when somebody asks a tough question or isn’t on the same page, you can have at the ready:

Know – really understand – your target audience. Facts and evidence do not seem to always convince people, so we need to understand our audience to try to reframe science in a new, digestible package. This requires you to be an active listener.
Know your own opinions and be confident in them. (Yes, I believe human-caused climate change is happening). But don’t let your own opinions make you deaf to another opinion.
When confronted with someone opposing your view, take a deep breath before responding. Don’t start with negating that person’s view point or feeling (even though it may be tempting). Take another deep breath. Or use the opportunity to take a sip of water and nibble a holiday cookie.
Try using wording that really shows you want to converse with the individual, not lecture them. Try saying, “That is interesting. Why do you feel that way?” “Have you considered that…?” Or, “I hadn’t heard that information before; where did you learn that?”
Do be conscious of your tone and body posture. Using the same wording in two different ways can have completely different outcomes. Keep your tone light, make eye contact, and have a smile to show someone that you are open to conversation and listening. Crossing your arms, I have learned, makes you seem defensive and might inspire the same feelings in that person that you actually, really want to engage in conversation.
Be respectful.
Be ready to accept “rejection.” I try – and it is a process of trying – to remember to engage the curiosity inside another person. Even if I don’t persuade someone to think differently, maybe I still gave them a new nugget to ponder.

I present these ideas with the hope that it gives us all things to consider, and not as a cure-all for differences in opinions between people. For example, my dad will never be the environmentalist that I think he has the potential to become. It drives me nuts that he doesn’t believe in climate change and recycles only because they have to pay per trash bag. And that he keeps buying small, disposable water bottles – the kind that holds maybe half-a-cup of water. But I think that over time, and with the right attitude, we can both learn something from one another.

Fire at psychiatric hospital shows need for more beds

(Credit: AP/Jae C. Hong)

As fire raged in Ventura, Calif., earlier this month, Gracie Hartman made her way to the county fairgrounds to look for her friend, Fernando.

She found him there at the evacuation center, among 69 patients from the Vista del Mar acute psychiatric hospital, one of two such facilities in the county. They had been removed with little time to spare as the hospital was overtaken by flames.

Over the next couple of days, Fernando was transferred to one general hospital as a stopgap, then to another, because, unlike the first, it would accept his insurance.

“He was so upset, that he was throwing up,” said Hartman, who spoke on condition that Fernando be identified only by his first name to protect his privacy. “It was a nightmare.”

Overnight, the private hospital’s shutdown wiped out about two-thirds of the psychiatric hospital capacity in Ventura County, population 850,000. That a fire could so quickly devastate a county’s inpatient psychiatric services only underscores how few beds there are — a phenomenon that holds true across California and nationwide.

“It’s a huge loss,” said Dr. Bryan Wong, chief medical officer of the county-run Ventura County Medical Center, which has a 43-bed psychiatric unit. “It leaves us vulnerable. It was a crisis even before the fires. We were at full capacity consistently. Now, it’s turned into a level beyond that.”

There are about 8,805 acute psychiatric beds in California, according to the Office of Statewide Health Planning and Development — not enough, advocates say, to meet the need. California has about 15 psychiatric beds per 100,000 residents compared with a recommended standard of 50 beds for 100,000 people, according to the Arlington, Va.-based Treatment Advocacy Center, which promotes greater access to mental health treatment.

The country has struggled with a national shortage of psychiatric hospital beds for many years. Last year, the United States had 37,679 state psychiatric beds, down 13 percent from 2010, according to the center.

The closure of public psychiatric hospitals has left many people with nowhere to go for treatment during an acute mental health crisis, according to the Virginia-based center. Without a reliable source of inpatient care, patients languish in overcrowded emergency rooms or, even worse, deteriorate until they’re arrested and jailed, often for minor infractions. Some become homeless.

In addition, many people experience severe psychiatric problems while trying to cope with disasters — and those very disasters can limit their options for care.

In recent years, catastrophes have damaged or threatened psychiatric facilities elsewhere around the country, sending doctors and families scrambling to transfer patients to other facilities, sometimes far away from their community, friends and family.

In 2011, Tropical Storm Irene severely damaged Vermont’s state-run psychiatric hospital, forcing the evacuation of 51 residents. The hospital never reopened, and the state replaced it with a smaller facility several years later. Before Hurricane Katrina struck in 2005, 73 adult, adolescent and child patients at an acute psychiatric facility were evacuated by bus from New Orleans to Memphis, Tenn., on a weekend night — a trip of about 400 miles.

Vista del Mar, an 87-bed acute care facility and the only one that treats children and teens, as well as adults, in Ventura County, didn’t completely burn down, but it lost key buildings. Although its owner, Corona, Calif.-based Signature Healthcare Services, has said it will rebuild, it is unlikely to reopen soon.

Vista del Mar’s closure further burdens the region’s emergency rooms, which often board psychiatric patients for days on end while they wait for a mental health bed to open up, Wong said. These patients are seriously ill, posing a danger to themselves or others, he said.

A nearby addiction treatment center, Evolve Camarillo, has offered “emergency mental health triage” for teens, but the center is not a licensed psychiatric hospital.

A state bill that would have established an online registry to help medical providers find psychiatric beds was supported by the California Psychiatric Association but opposed by the California Hospital Association as unlikely to meet the complex challenge of finding appropriate treatment for patients, and the bill died in committee in late 2016.

In Ventura, Wong said the county-run acute psychiatric facility accepted 20 patients from Vista del Mar the night they were evacuated, hastily revamping a triage area to house them. Other patients, including children and teens, were sent to hospitals as far away as Bakersfield and Los Angeles.

The patients likely would stay for several days, then be referred to outpatient treatment if they were well enough, Wong said.

Fernando, who suffers from a rare bone disease, was being treated for anxiety and depression at Vista del Mar. He eventually was transferred to a Kaiser Permanente psychiatric facility in Los Angeles, Hartman said. (Kaiser Health News is not affiliated with Kaiser Permanente.)

Blair Stam, executive vice president for Vista del Mar’s owner, said his company plans not just to rebuild but to expand the hospital “because the need is so great.”

The hospital has been between 85 and 90 percent full at any given time, he said. He hopes state health officials will fast-track construction plans, he said. But that could take years, given complex hospital building regulations and what’s likely to be intense competition for construction resources in the region.

The vast and deadly Thomas Fire, which has burned an estimated 272,000 acres and destroyed hundreds of buildings, was only about 55 percent contained as of Wednesday, according to firefighters.

In the meantime, “families are scrambling” as their loved ones are on the verge of being discharged from the far-flung hospitals they were sent to after the fires, said David Deutsch, executive director of the National Alliance on Mental Illness-Ventura chapter, an advocacy group. “We’re in pretty dire straits here” Deutsch said. “It’s quite chaotic.”

 

Why are so many of our pets overweight?

(Credit: AP)

When I looked at my appointment book for the day, I thought something must be wrong. Someone who worked in the fitness industry was bringing his cat in to the Tufts Obesity Clinic for Animals. Did he confuse us for a different kind of weight management clinic? Is he looking to get muscle on his cat or maybe kitty protein shakes?

I was utterly surprised when I called for my appointment in the lobby and an athletic man stood up with an almost 20-pound cat! I asked if I could speak bluntly with him. Why does someone who clearly knows a lot about keeping healthy need to bring his cat to a veterinary nutritionist? What would he say if the cat was one of the people he helps to keep fit every day? Our conversation then went something like this…

“Well, I’d tell her, suck it up, buttercup. Do some kitty pushups and no more treats!”

“Well, I have to ask, then, what’s stopping you from doing this with your cat?”

With a worried look of guilt on his face, he replied, “Well, Dr. Linder, I mean… she meows at me…”

This was the moment I realized that I was treating pet obesity all wrong. I needed to focus less on the pet and more on the relationship between people and their pets. That’s what’s literally cutting the lives short of the dogs and cats we love so much.

An obese pet isn’t a happy pet

As with humans, obesity in pets is at epidemic proportions. Over half of the dogs and cats around the globe battle the bulge.

While overweight pets may not face the same social stigma as humans, medical and emotional damage is being done all the same. Obesity in animals can cause complications in almost every system in the body, with conditions ranging from diabetes to osteoarthritis.

Owners often say they don’t care if their pet is “fat” – there’s just more of them to love! It’s my job to then let them know there’s less time to provide that love. A landmark lifespan study showed Labradors who were 10-20 percent overweight – not even obese, which is typically defined as greater than 20 percent – lived a median 1.8 years shorter than their trim ideal weight counterparts.

Another study shows that obesity indeed has emotional consequences for pets. Overweight pets have worse scores in vitality, quality of life, pain and emotional disturbance. However, the good news is those values can improve with weight loss.

Furthermore, humans struggle to succeed even in the best conditions – and so do pets. In one study, dogs on a weight-loss program were only successful 63 percent of the time.

Showing love through food

So where exactly is the problem? Are foods too high in calories? Are pets not getting enough exercise? Is it genetics? Or do we just fall for those puppy dog eyes and overfeed them because they have in fact trained us (not the other way around!)? From my experience at the pet obesity clinic, I can tell you it’s a bit of all of the above.

It seems veterinarians and pet owners may be a little behind the curve compared to our human counterparts. Studies show that it doesn’t really matter what approach to weight loss most humans take – as long as they stick to it. But many in veterinary medicine focus more on traditional diet and exercise plans, and less on adherence or the reason these pets may have become obese to begin with. (This should be easy, right? The dogs aren’t opening the fridge door themselves!)

However, the field is starting to understand that pet obesity is much more about the human-animal bond than the food bowl. In 2014, I worked among a group of fellow pet obesity experts organized by the American Animal Hospital Association to publish new weight management guidelines, recognizing that the human-animal bond needs to be addressed. Is the pet owner ready to make changes and overcome challenges that might slow down their pet’s weight loss?

One interesting editorial review compared parenting styles to pet ownership. As pet owners, we treat our cats and dogs more like family members. There’s a deeper emotional and psychological bond that was not as common when the family dog was just the family dog. If vets can spot an overindulgent pet parent, perhaps we can help them develop strategies to avoid expressing love through food.

A healthier relationship

Managing obesity in pets will require veterinarians, physicians and psychologists to work together.

Many veterinary schools and hospitals now employ social workers who help veterinarians understand the social aspect of the human-animal bond and how it impacts the pet’s care. For example, a dog owner who has lost a spouse and shares an ice cream treat every night with their dog may be trying to replace a tradition they used to cherish with their significant other. A social worker with a psychology background could help prepare a plan that respects the owner’s bond with their pet without negatively impacting the pet’s health.

At our obesity clinic at Tufts, physicians, nutritionists and veterinarians are working together to develop joint pet and pet owner weight-loss programs. We want to put together a healthy physical activity program, so pet owners and their dogs can both improve their health and strengthen their bond. We also created a pet owner education website with additional strategies for weight loss and pet nutrition.

Programs that strengthen and support the human-animal bond without adding calories will be critical to preserve the loving relationship that is the reason why we adopt our pets, but also keep us from literally loving them to death by overfeeding. Hopefully, we can start to chip away at the notion that “food is love” for our pets.

Deborah Linder, Head of Tufts Obesity Clinic for Animals, Tufts University

How hospitals are failing black mothers

(Credit: effe45 via Shutterstock)

When Dacheca Fleurimond decided to give birth at SUNY Downstate Medical Center earlier this year, her sister tried to talk her out of it.

Her sister had recently delivered at a better-rated hospital in Brooklyn’s gentrified Park Slope neighborhood and urged Fleurimond, a 33-year-old home health aide, to do the same.

But Fleurimond had given birth to all five of her other children at the state-run SUNY Downstate and never had a bad experience. She and her family had lived steps away from the hospital in East Flatbush when they emigrated from Haiti years ago. She knew the nurses at SUNY Downstate, she told her sister. She felt comfortable there.

She didn’t know then how much rode on her decision, or how fraught with risk her delivery would turn out to be.

It’s been long-established that black women like Fleurimond fare worse in pregnancy and childbirth, dying at a rate more than triple that of white mothers. And while part of the disparity can be attributed to factors like poverty and inadequate access to health care, there is growing evidence that points to the quality of care at hospitals where a disproportionate number of black women deliver, which are often in neighborhoods disadvantaged by segregation.

Researchers have found that women who deliver at these so-called “black-serving” hospitals are more likely to have serious complications — from infections to birth-related embolisms to emergency hysterectomies — than mothers who deliver at institutions that serve fewer black women.

Still, it’s difficult to tell from studies alone how this pattern plays out in real life. The hospitals are never named. The women behind the numbers are faceless, the specific ways their hospitals may have failed them unknown.

ProPublica did its own analysis, using two years of hospital inpatient discharge data from New York, Illinois and Florida to look in-depth at how well different facilities treat women who experience one particular problem — hemorrhages — while giving birth.

We, too, found the same broad pattern identified in previous studies — that women who hemorrhage at disproportionately black-serving hospitals are far more likely to wind up with severe complications, from hysterectomies, which are more directly related to hemorrhage, to pulmonary embolisms, which can be indirectly related. When we looked at data for only the most healthy women, and for white women at black-serving hospitals, the pattern persisted.

Beyond this bird’s-eye view, our analysis allowed us to identify individual hospitals with higher complication rates, to look at what kinds of protocols they have and to examine what went wrong in specific cases.

We found, for example, that SUNY Downstate, where 90 percent of the women who give birth are black, has one of the highest complication rates for hemorrhage across all three states. On average, 34 percent of women who hemorrhage while giving birth at New York hospitals experience significant complications. At SUNY Downstate, it’s 62 percent.

SUNY Downstate officials defended the hospital’s handling of obstetric hemorrhages, saying it has extensive protocols for responding to them and gets exemplary results despite handling deliveries involving mothers with higher-than-average numbers of health problems like diabetes, obesity and high blood pressure. They would not comment on Fleurimond’s case, citing patient privacy.

Fleurimond was admitted to Downstate on Aug. 9.

Pregnant with twins, her doctor noticed she was in preterm labor at her 34-week checkup and prepped her for an unplanned cesarean section. When they cut into her womb to deliver the babies, Fleurimond’s uterus didn’t fully contract as it should have. She began to bleed. By the time the doctors controlled the hemorrhage, she had lost more than a liter of blood, requiring two transfusions.

At first, it seemed she’d be fine. She awoke the following morning thinking the worst was over, eager to see her new sons.

She wouldn’t survive the day.

Every year in the United States, between 700 and 900 women die from causes related to pregnancy and childbirth. For every woman that dies, dozens more experience severe complications, which affect more than 50,000 women annually.

The U.S. rate of maternal mortality is substantially higher than those of other affluent nations and has risen over the past decade. Outcomes for black women have led the way, intensifying efforts by medical experts and academics to understand what’s driving the racial disparity.

A complicating factor in understanding how hospital care figures in is that hospitals take on different proportions of tough cases — patients who have less access to consistent, quality prenatal care or have chronic health issues, like diabetes or heart disease, that make pregnancy and childbirth riskier.

Some prominent researchers are using a methodology for analyzing birth outcomes that attempts to even the playing field.

The California Maternal Quality Care Collaborative, which studies maternal deaths and develops techniques to prevent them, looks at how well hospitals respond to obstetric hemorrhage, typically defined as losing more than 500 milliliters of blood during a vaginal birth or a liter of blood during a cesarean section. Why hemorrhages? Because women of all races experience them at roughly the same rates and their likelihood is less affected by factors like race or economic status, said CMQCC medical director Dr. Elliott Main.

CMQCC evaluates hospitals by calculating what percent of women who hemorrhage during birth wind up with major complications. Researchers count both the complications more directly related to hemorrhages, like hysterectomies and blood transfusions, and those that could be indirectly related, including embolisms, blood clots, heart attacks, kidney failure, respiratory distress, aneurysms, brain bleeds, sepsis and shock. Ultimately, this approach measures how often doctors prevent complications when a hemorrhage occurs, and when looked at over time, can show if a hospital has been able to improve.

ProPublica used the metric to analyze inpatient hospital discharge data collected by New York, Illinois and Florida for 2014 and 2015, examining all obstetric cases that were coded as involving hemorrhages — about 67,000 cases in all.

We also put each hospital into a category based on the concentration of black mothers who gave birth there, defining facilities as low, medium or high black-serving. We crafted our analysis so that it reflected the racial distribution of mothers delivering in each state. In New York, if black mothers represented roughly a third or more of the deliveries at a hospital, we considered the hospital high black-serving. In Florida, we considered a hospital high black-serving if about 40 percent of the mothers were black. In Illinois, we considered a hospital high black-serving if at least half of its mothers were black.

In New York, we defined a hospital as low black-serving if less than eight percent of the women delivering there were black. In Illinois, the cutoff was 14 percent. In Florida, it was 18 percent.

Across the three states, about one in 10 hospitals in our analysis was high black-serving — in some cases, extremely high. Ninety-nine percent of the mothers who gave birth at Jackson Park Hospital and Medical Center in Chicago were black.

While a handful of low black-serving hospitals had high complication rates, our analysis found that, on average, outcomes at hospitals that served a high number of black patients were far worse.

In New York, on average, high black-serving hospitals had complication rates 21 percent higher than low black-serving hospitals. In Illinois and Florida, high black-serving hospitals had complication rates 11 percent higher.

When we limited our patient pool to only mothers of average birthing age — between 25 and 32 — who did not have any chronic conditions like heart disease or diabetes, the pattern remained largely the same. This bolstered the notion that differences in care, along with patient characteristics, affected outcomes.

Deeper analysis of the data for each state underlined this finding. At low black-serving hospitals in New York, just under a third of the women who hemorrhaged had complications. At high black-serving hospitals, that rate climbed to about half.

Dr. Elizabeth Howell, a professor of obstetrics and gynecology at the Icahn School of Medicine at Mount Sinai Hospital, has taken a more refined look at racial disparities among New York City’s hospitals. She found black mothers were twice as likely to suffer harm when delivering babies than white mothers, even after adjusting for patients’ differing characteristics, suggesting that some of the racial disparity may be due to hospital quality. In a separate study, she estimated that the rate of harm for black women would fall by nearly 50 percent if they gave birth at the same hospitals as white women.

She’s also considered the same dynamic nationally. Because three quarters of black mothers deliver in about a quarter of the country’s hospitals, Howell believes that racial disparities could be reduced if hospitals that disproportionately serve black women improved their care.

There is clear evidence hospitals can make such improvements.

In California, complications related to obstetric hemorrhage decreased by about 20 percent in hospitals that adopted protocols promoted by Main’s group, which include keeping carts stocked with supplies to stave off massive bleeding and holding drills to simulate severe hemorrhage events. “It creates improvement in the team, increases communication and improves your response to all emergencies,” Main said.

Still, Main’s protocols haven’t been universally adopted in California, let alone elsewhere in the U.S., and many hospitals go their own way.

The spokesperson for SUNY Downstate — where more than 14 percent of women hemorrhage during birth, an average of one mother every other day — said the hospital “has already developed their own ‘best practice’ protocols for hemorrhage that other hospitals should be following.” These include a special “Code Mom” that details steps doctors and nurses need to take when responding to a hemorrhage. And women with placental problems are monitored by ultrasound, so that doctors can anticipate the most complex cases before beginning cesarean surgeries.

According to public documents posted in an online repository of the hospital’s policies, the obstetric and gynecology department’s emergency response policy on hemorrhage does not explicitly follow some of Main’s recommendations, such as having pre-fab kits to respond to hemorrhages and doing staff drills to prepare for them. SUNY Downstate did not respond to questions about these differences.

Dr. Ovadia Abulafia, the chair of the hospital’s department of obstetrics and gynecology, noted that SUNY Downstate serves a particularly “underserved” and “high-risk” population. More than 80 percent of women who deliver there are obese, a spokesperson said, and the hospital sees a higher incidence of diabetes, blood pressure disorders and placental separation problems compared to the rest of the nation.

But Dr. Allison Bryant Mantha, a high-risk obstetrician and health care disparities researcher at Massachusetts General Hospital, said hospitals shouldn’t use demographics or patient characteristics to excuse poor outcomes. Instead, they should hone their practices to deliver the care their patients need.

“Hospitals have to own the conditions that women walk in with,” Bryant said. “You have to give patients what they need to get to a quality level of care. We are doing a good job of equal care, but not adjusting for needs.”

Fleurimond awoke in good spirits in the labor and delivery unit on Aug. 10, the day after her delivery. Her biggest concern that afternoon was what she was going to eat. “What is Jell-O going to do for me?” she complained to her sister Merline Lamy, who responded, “This is your two-day diet, baby girl.” Fleurimond rolled her eyes.

She might not have felt it at the moment, but Fleurimond was still at risk of serious complications related to her hemorrhage, including pulmonary embolism, typically caused when a blood clot travels from a patient’s leg to a lung artery, blocking blood flow to the lungs.

Her blood was already predisposed to clotting, a biological mechanism that likely evolved in pregnant women to prevent hemorrhage during birth. Carrying twins can put extra pressure on the vessels around the uterus, further constricting blood flow. The cesarean surgery, like all surgeries, substantially increased her risk, as did the transfusions.

On top of that, Fleurimond weighed 260 pounds and was being treated for high blood pressure.

To prevent clotting, nurses had put compression boots on her legs. Just after 3 p.m., according to family members who were visiting Fleurimond, a nurse unfastened the boots, helped Fleurimond into a wheelchair and took her to visit the twins, Jayden and Kayden, in the neonatal intensive care unit. She’d held them only briefly in the operating room and craved another look. They had her round cheeks, which shone like polished apples.

Experts say compression boots lose their deterrent effect about 15 minutes after they are removed. Fleurimond spent about 90 minutes in the NICU with her aunt, who recalled her sitting in her wheelchair the whole time, her legs hanging down. Shortly after her aunt left, she complained that she felt unwell, but three hospital employees who spoke to ProPublica on the condition of anonymity say that she waited at least 40 minutes for a transport aide to wheel her back to her room. There is no evidence in her medical record that anyone came to assess her when she returned.

Doctors also did not prescribe heparin, a blood-thinning medicine being used at other hospitals to prevent pulmonary embolism in mothers with high risk factors, for whom compression boots are unlikely to be enough.

In the United Kingdom, protocols that advocate more aggressive use of blood thinners, particularly after C-sections, helped reduce embolism deaths by more than half within three years.

In the United States, a chorus of medical trade groups and maternal safety organizations have begun to promote more widespread use of blood thinners during pregnancy and childbirth, but not all hospitals have made it their practice.

“There are some experts who feel that it’s not worth the time, trouble and cost to avoid relatively rare events,” said Dr. Alexander Friedman, an assistant professor of obstetrics and gynecology at Columbia University Medical Center.

Friedman’s hospital on the edge of Harlem typically administers the drug to high-risk mothers, but Fleurimond wouldn’t have had to travel that far. Three miles away from Downstate, at a Brooklyn hospital that has a smaller concentration of black patients and a lower complication rate related to hemorrhages, Maimonides Medical Center gives blood thinners to nearly all of mothers who undergo cesarean sections or have other risk factors.

Friedman, who reviewed Fleurimond’s medical records at ProPublica’s request, said she should’ve received the drug.

Dr. Douglas Montgomery, an obstetrician-gynecologist and director of the Maternal Fetal Medicine Department at California’s Kaiser Permanente Riverside Medical Center, said he would prescribe the drug to any patient who had Fleurimond’s risk factors.

At around 6 p.m., Fleurimond called the father of her twins. She sounded short of breath. She said she was in pain and asked him to come to the hospital, then hung up and waited, alone.

At about 6:25 p.m., Fleurimond screamed, medical records show. A doctor and nurse entered her room and found her gasping for air. More responders came. They couldn’t find a pulse. After more than an hour of resuscitation attempts, she was pronounced dead at 7:45 p.m.

Because Fleurimond died “during diagnostic or therapeutic procedures or from complications of such procedures,” as Downstate’s website puts it, she was referred to the New York City medical examiner’s office for an autopsy. Her cause of death, according to the autopsy report: pulmonary embolism, also known as “venous thromboembolism,” a condition that almost always has a chance of being prevented.

In an emailed statement, Abulafia said SUNY Downstate “follows the proven [American College of Obstetricians and Gynecologists] protocols for obstetric hemorrhage, severe hypertension and venous thromboembolism.” SUNY Downstate has not had a maternal death related to hemorrhage in the past 15 years, a spokesperson said.

Such assurances provide little solace to Fleurimond’s relatives, who have sought an attorney to represent them.

“Dacheca Fleurimond was clearly at high risk to have a blood clot and there weren’t adequate preventative measures,” said the attorney, Eleni Coffinas. “The obesity, the hypertension, and the fact that she hemorrhaged after her C-section were all high-risk factors and she needed to be monitored for that.”

New York City occupies a unique place in the discussion of racial disparities in maternal mortality as both a hub of groundbreaking research on the subject and one of the nation’s starkest examples of such gaps.

In addition to the work by Howell, the New York City Department of Health and Mental Hygiene has published a couple of reports, including one documenting how, as the mortality rate of expectant and new mothers overall across the city has dropped, the disparity between black and white mothers has grown.

Even when accounting for risk factors like low educational attainment, obesity and neighborhood poverty level, the city’s black mothers still face significantly higher rates of harm, the agency found. Of note, black mothers who are college-educated fare worse than women of all other races who never finished high school. Obese women of all races do better than black women who are of normal weight. And black women in the wealthiest neighborhoods do worse than white, Hispanic and Asian mothers in the poorest ones.

The health department has even mapped where the most maternal harm occurs, dividing the city into community districts. The highest rates of complications are concentrated in a swath of land in Central Brooklyn, in an area largely untouched by the wave of gentrification that has swept other parts of the borough. Here, mothers face up to four times the complication rates of neighborhoods just a few subway stops away. Fleurimond lived in one such danger zone, in a public housing development in eastern Crown Heights.

At three medical centers in this area that deliver babies — Brookdale University Hospital Medical Center, Kings County Hospital and SUNY Downstate — more than half of mothers who hemorrhaged during delivery experienced complications, ProPublica’s data analysis shows. More than three quarters of the women who give birth at Brookdale are black, as are nearly 90 percent of the women who deliver at Kings County Hospital.

Officials at Brookdale, a private nonprofit hospital, would not respond to questions from ProPublica. The New York City Health + Hospitals Corporation, the public benefit organization that operates Kings County Hospital, gave a detailed response laying out its protocols for obstetric hemorrhages, including some recommended by Main’s group. Robert de Luna, a spokesperson for the city’s hospital operator, said in an email that while hemorrhage is a good proxy indicator for maternal harm, “some of our patients come from all over the world (self-referred), a good number coming to us too late to benefit from our prenatal care services.” (Read the full response here.)

Some of the women who deliver at these hospitals are well aware of their reputations.

Brookdale, for example, was recently rated an ‘F’ by Leapfrog, the health care quality and safety nonprofit, one of only 15 hospitals in the country to receive a failing grade.

But proximity sometimes takes precedence over choice. That was the case for Merowe Nubyahn, a 37-year-old hospice aide.

In March 2013, when Nubyahn was 24 weeks pregnant, she was overcome with intense nausea and vomiting, and unexpectedly, her water broke. When emergency medical technicians arrived at her East New York apartment, she begged them to take her anywhere but Brookdale. She hadn’t liked what she had heard about the hospital and had been getting her prenatal care elsewhere. The ambulance took her to Brookdale anyway because it was closest.

At the hospital, she was rushed in for a cesarean section. Her daughter, delivered at what’s considered the edge of viability, barely clung to life in the hospital’s NICU. When Nubyahn awoke in the recovery room, layers of gauze covered her belly and her throat felt like sandpaper. Disoriented, she said she asked a nurse what had happened, but the words felt garbled leaving her mouth. Two of her teeth had been knocked out when she was intubated for anesthesia, according to her medical records. Nubyahn recalled that when she asked the doctor about them, he gave her an incredulous look and asked, “Are you sure you had teeth when you came in here?”

A bigger threat to her health emerged the morning after she was discharged from the hospital. As she sat in bed, she says she felt sharp cramping pains and a warm, viscous feeling. She looked down at her belly and saw dark, clotted blood — “plums and prunes” — bursting out of her cesarean incision.

Her wound had become infected — a common complication — and had begun to come apart. Still wearing her hospital bracelet, she was shuttled back to Brookdale and told she’d also developed a hematoma, a mass of blood, around her incision site.

While Nubyahn was being treated in one part of the hospital for her various complications, her baby died in another. Overcome with grief and stung by her treatment, Nubyahn checked herself out and vowed to never return. “All the horror stories that I have heard about Brookdale … I totally have my own now,” she said.

Khari Edwards, the vice president of external affairs at Brookdale, said the hospital would not comment on Nubyahn’s case due to privacy laws.

Recognizing that hospitals in Central Brooklyn have some of the highest maternal complication rates in the city, the health department has begun to target the area with services in recent years. It supports the By My Side initiative that pairs up women with doulas who can advocate for them during birth. The department also supports prenatal programs in the area based on a model of assessment, education and support, also known as CenteringPregnancy.

“We are data driven and we look to where the outcomes are the worst,” said Dr. Deborah Kaplan, the assistant commissioner for maternal, infant and reproductive health at the department.

This month, the city convened a new committee to review deaths and severe complications related to pregnancy and childbirth. One of its priorities will be to figure out why — despite years of research and attention — the city’s racial disparities have persisted and even grown.

“We used to say we are not sure why we are seeing these racial disparities. Now we say unequivocally that racism causes these problems,” said Kaplan. She emphasized that this encompassed not only health care but all aspects of life in the city, from housing to schools. “If we provide equally to everyone, we could widen the inequity. We have to prioritize putting resources in neighborhoods with the highest rates of severe maternal morbidity and the least access.”

Just three months after Fleurimond died at SUNY Downstate, another black woman died there, hours after giving birth.

Tanesia Walker, a 31-year-old flight attendant, had originally planned to deliver at New York-Presbyterian Brooklyn Methodist Hospital in Park Slope, where she had her first son. But a week before her scheduled cesarean, her doctor changed her delivery to Downstate, where he also had privileges.

Walker grew nervous after reading negative reviews of the hospital online, family members said. They tried to calm her down. Hers was not a high-risk pregnancy, they reminded her. She wasn’t overweight and her blood pressure was fine.

Walker seemed okay after a C-section at SUNY Downstate on Nov. 27, holding her newborn son Tyre close to her chest as her family spent the afternoon with her. Then, at 2 a.m., she sent a text message to her fiancé saying she had a pain in her side, he told ProPublica.

A few hours later, she was dead.

As family members trickled into the hospital that morning, shocked and confused, doctors couldn’t say why she died, said her father Junior Walker. They mentioned the possibility of blood clots in her lungs, he added.

The family has requested her medical records from the hospital. As with Fleurimond, the city medical examiner’s office has done an autopsy, but has not yet released its report.

Walker’s death haunts her younger brother Dwayne, who kept in touch with her nonstop as she traveled. He can’t stop thinking, why her? She was educated, had a criminal justice degree from John Jay College. She was healthy, didn’t drink or smoke, ran track in high school. She was financially stable, quit a management job at Chase Bank to see the world aboard American Airlines.

“I just want to know why she died,” he said, eyes wet with tears. He keeps sending her text messages, even now that she is gone. “She was a healthy woman who shouldn’t have died from a cesarean section.”

Fleurimond’s family is doing its best to survive without her.

Her sister, Merline Lamy, took in Fleurimond’s six youngest children, blending them into her own household, but that meant squeezing 12 people into a three-bedroom apartment. The landlord threatened to evict them.

Fleurimond’s brother and his wife have tried to collect money for the children on GoFundMe, but so far have only raised about $250. (ProPublica reporter Nina Martin, who was not involved in the reporting or preparation of this story, donated $100 three months ago.)

Fleurimond’s 58-year-old mother has become the principal surrogate parent — changing diapers, cooking dinners and breaking up sibling spats. She sleeps no more than a couple of hours each night, her eyes permanently rimmed with dark shadows.

The kids, too, are struggling to settle into their new life.

On a recent evening, Joshua, 9, tried to tune out the noise in Lamy’s packed apartment and concentrate on his math homework. Berlynda, 10, comforted a twin in each arm. Aiden, 2, climbed on the couch with a runny nose.

Like all toddlers, his mood teeters between buoyancy and despair. But when he calls for “mama,” his siblings have to remind him she will not come.

ProPublica Illinois reporters Duaa Eldeib and Jerrel Floyd contributed to this report.

 

Best essays of 2017: Timothy McVeigh, my dad and me

The author's father, Randall Coyne, visiting Timothy McVeigh at the Denver courthouse during the trial. (Credit: Courtesy of the author)

It was a sunny afternoon in 1995, a week after the Oklahoma City bombing, during the brief period that Dad knew Timothy McVeigh only as America’s most hated man, and nothing more.

A baby had been found buried in the rubble of the Alfred P. Murrah Federal Building after seven days, the media reported. Her last name was Coyne, like mine, and she was soiled in blood and soot and shit. She was 14 months old, five months my junior. Our mothers, who never met, both worked at courthouses in downtown Oklahoma City. I attended day care in Norman, the nearby college town where Dad taught at the law school. She was in the Murrah building’s nursery across the street from her mom’s office when McVeigh’s bomb went off. Any connection I shared with the dead little girl was, by all accounts, an unremarkable coincidence.

When Dad realized why the reporter simpering lukewarm condolences had called our house, he yanked our answering machine straight from the wall. The bastard had probably found our number in the white pages and mistaken our family for the little girl’s, Dad guessed. Or perhaps he’d simply called every Coyne in the book, for good measure. How callous, how cruel, turning tragedy into pity porn. Dad considered, for a moment, giving the reporter the sound bite he deserved, but as he thought of his own daughter, safe in the next room, a sick sadness overcame him. It didn’t matter anyway; the message cut off before the reporter gave his contact information.

One of Dad’s former law students from his capital punishment class, Jim Hankins, called three weeks after Dad reinstalled our answering machine. Now a bona fide member of the bar, Jim worked for a firm called Jones & Wyatt in Enid, Oklahoma. It was no secret the firm had a notorious new client, and the government wanted him dead. Dad, Oklahoma’s premier capital punishment scholar, could really help out, Jim said.

That’s how Dad became one of Timothy McVeigh’s lawyers. And that’s when Timothy McVeigh — the scrawny kid with blood vengeance and a buzz cut, the man who murdered Jaci Coyne — became Tim.

*  *  *

In total, Tim killed 169 people. Nineteen of them were children. The Oklahoma City bombing remains the deadliest act of domestic terrorism to this day. It surprises me how many people my age don’t know that. I guess I can’t blame my peers; I don’t remember the bombing either.

My generation was the first to grow up under the threat of modern terror, taught to hide in bathroom stalls and crouch atop toilets so school shooters wouldn’t spy our sneakers. Our growth spurts and awkward phases have been documented in Transportation Security Administration-mandated full-body renderings.

The Oklahoma City bombing eludes me, though. I was 19 months old when the Alfred P. Murrah building exploded, 2 and a half years old when Tim’s trial began, 7 years old when he withdrew his appeal and accepted his death sentence, and nearly 8 years old when he died with his eyes wide open. By then I had grown into someone who could grapple with death. How could I miss that?

There’s a scene in “The Princess Bride” where Inigo Montoya, the Spanish swordsman; Fezzik, the gentle giant; and Westley, the farm boy turned pirate, crouch behind a balcony, overlooking the swarm of men guarding Prince Humperdinck’s castle. Westley, who spent the day mostly dead, has just regained consciousness. “Who are you? Are we enemies? Why am I on this wall? Where is Buttercup?” he asks with feverish confusion.

“Let me explain,” Inigo says, then pauses. “No, there’s too much. Let me sum up: Buttercup is to marry Humperdinck in a little less than half an hour. So all we have to do is get in, break up the wedding, steal the princess and make our escape . . . after I kill Count Rugen.”

“That doesn’t leave much time for dillydallying,” Westley says.

Like Westley, I must rely on others to fill me in on what I have missed. My parents’ stories are at once plentiful and sparse, overwhelming and inadequate. I lose myself in questions. I succumb to nightmarish imagination. I haven’t figured out how to mourn what I can’t remember.

After I was born, Dad designed a set of personalized trading cards. A lifelong Red Sox fan, he distributed the novelty to family and friends, noting the potential value of a Marley Coyne original, collector’s edition.

On the front of the card sits me, in the mushroom cloud of my diaper, hoisting a yellow building block like a World Series trophy. The back of the card read:

Marley B. Coyne: Peripatetic Prodigy. Ms. Coyne is an accomplished literary critic who enthusiastically recommends Pat the Bunny, Goodnight Moon and The Itsy Bitsy Spider. She speaks fluent Duck and delights in toppling tall stacks of building blocks. Her favorite pastimes: prattling and perambulation.

Dad gave a copy of the card to Tim when he first met him, six weeks after the bombing. Tim stared at the picture of my chubby face, then flipped it. “Oh, you meant business card!” Dad said. If Tim betrayed any emotion, it was placid bemusement. Dad took back my card and reached in his breast pocket for the business card Tim wanted. “Just a joke,” he added.

*  *  *

“He wasn’t very old. I don’t think he’d had much sex,” Dad told me over FaceTime. “He was shy and goofy and tall and awkward and disillusioned and immature and angry. He was all those things.”

I was a senior in college, writing about how the Oklahoma City bombing affected my family for my thesis. As it happened, the piece was due on April 19, 2016, the tragedy’s 21st anniversary. It felt right, necessary even, to end my formal education learning this story and telling it in my own way. I have never worked harder than I did on this project.

My parents answered my questions with caution, but they did answer them. Together we stifled the obvious horror of it all — the blood, so much blood, children’s blood — and looked inward. Dad told me the case “fucked things up pretty good” for him. He apologized, too often, for a hell I don’t remember. I failed to convince him of my forgiveness. Mom warned me to not get lost in the depths that nearly swallowed him. I couldn’t resist.

Dad shared photographs and anecdotes as if Tim were a troubled friend he had lost touch with after adolescence. He told me how Tim once sent me an episode of “Barney & Friends” on VHS. Tim knew Dad hated the singing, dancing dinosaur so much he banned the show from our house. It was just Tim’s little joke — using me to needle Dad.

Dad discarded the video, but he gave me a birthday card Tim wrote — official prison mail, resealed and government stamped — behind Mom’s back. “To honor Tim’s good gesture,” he said. That was the kind of rapport they had.

*  *  *

If Dad remembers correctly, I spoke to Tim just once. I was maybe 6. I answered his collect call from the Terre Haute United States Penitentiary on Christmas morning. We talked about Santa Claus.

“How did he deal with that? Talking to a child when he killed so many?” I asked.

“I don’t think he ever did,” Dad said. “Whenever we talked about the 19 children in the day care center, a wall just went up. I don’t think he could allow himself to even think about it because it would have crushed him — the horror of what he’d done.”

I scanned the pixelated image: Dad sitting on the couch in a room I once knew; his mutt, whose fleas we used to pick, wagging her tail in and out of the frame.

“I think it was really a boost for him.” Dad said finally. “Just to hear a little kid’s voice talking about the wonder of Christmas.”

I have never experienced a strangeness comparable to knowing that I once brought a mass murderer something close to happiness. I made Timothy McVeigh’s Christmas.

*  *  *

I won’t linger on the trial — the scandals and incompetence, the devastating run-ins with the victims’ families, the friendship Dad built with the man who had annihilated their loved ones, the animosity he and Tim harbored towards the case’s lead attorney. Dad left the case officially, after Tim was sentenced to death, but he agreed to help Tim pro bono get his will and other affairs in order. He remained his ally and confidant until the end.

I should mention: I have always been frantically protective of my father, though I have often felt powerless to defend him. Once at a gathering of colleagues and friends, and after what I’m sure was more than a couple of beers, Dad and one of his buddies decided to wrestle on the living room floor for the amusement of the crowd. I was a toddler curious about the source of excitement. To my dismay, I saw a man pinning my dad, who in turn was trying to grip his attacker in a headlock. I ran forward, shaking my inchworm of an index finger at the villainous stranger and cried, “Don’t hurt my Daddy!” The crowd laughed hysterically. I was quite serious.

After months of living in Denver and flying back on the occasional weekend, Dad returned to Mom and me and a life in Norman. He brought Tim home with him, too.

Dad balanced chores, like picking me up from day care, with errands, like mailing porn and books on anarchy to Tim. He took Tim’s sister out for Thai with Mom and me, “the girls.” He promised to smuggle Tim’s ashes into Giza and spread them at the base of the pyramids. He sent love letters and presents on Tim’s behalf. He handled all the minutiae that accompanies a death sentence.

Eventually Dad cracked.

The thing about the Oklahoma City bombing is that it follows you. At least, it follows Dad. A week after he returned home from the trial in Denver, he wrote in his trial journal, “Readjustment is incredibly painful for everyone. I hate myself for the damage I have done to my girls.”

As I said, I don’t remember much. But one memory sticks while the rest wither in oblivion. I was in the music room, surrounded by wall-to-wall bookshelves, packed with thick legal tomes. Tim smiled down at me from a framed photo atop the Yamaha piano that was Dad’s homecoming present. I was wearing a black velvet dress with silver stripes and an Empire waist bow. Dad swears he was sober that day; I remember he reeked of skunk and stale bread.

Dad wanted to take me with him to the Laundromat, and Grandma, who was helping Mom care for me, said no. He screamed at her. She screamed back. I felt oddly aware of my stature, my childishness. I watched the vitriol soar above my head. At some point, Dad pulled me to his side of the room and, in his fury, ripped the bow off my favorite dress. Quiet fell. The angry faces I didn’t recognize became familiar again. Dad — my daddy — asked me what I wanted.

In the car, I shuffled through the glove compartment and checked under the seats for spare quarters to feed the machines. Of course, I chose to go with him.

*  *  *

One night in the spring of 1998 while sitting on our front porch, head in her hands, wondering how she was going to shield me from her husband’s self-destruction, Mom swore she saw God. It felt as if someone were holding her in a blanket of sunshine in the middle of a cold night. I vividly remember her telling me this because I’ve carried that image with me every day since.

Dad had stopped showing up to teach his death penalty classes. He picked fights with the dean of the law school. He forgot to pay bills. He beat his drums so hard he nearly rendered himself arthritic. He screamed and thrust his finger in Mom’s face. He drank and drank and wrote letters to Tim.

On that night, Mom had discovered Dad was hiding a gun in his music studio. When either divine intervention or exhausted delusion returned her to the ground, she decided to divorce him.

* * *

Today, Dad is more or less retired. He focuses full-time on drumming, his first passion. (Before going to law school, he had taught high school band.) Pummeling his Yamaha kit at Chinese restaurants and Lutheran churches across Oklahoma helps him abate the nightmares filled with autopsied corpses rising from rigor mortis. He hasn’t had a drink in 18 years, and I’m so proud of him.

Dad also lives his life like he is on death row. He doesn’t go to the doctor as often as he should. His friends tend to die gruesome, premature deaths. On his iPhone, he keeps a playlist of songs to play at his funeral.

At least once a year, he reminds me to sell everything he owns after he dies. “I have Tim’s old Army fatigues, all his medals. . . . There are some crazies out there who would pay a good deal of money for that kind of thing. Just don’t throw it all out,” he says.

I dread the day I’ll have to sort through boxes of Tim’s fatigues and other remnants of Dad’s life to divide into keep, sell and toss piles. This is my inheritance, to pass on to the highest bidder. I want to feel liberated when I finally discard the man who has haunted us for 22 years. I want to find comfort knowing what remains of him will rot in the back of someone else’s closet. I want it to be that simple, but it’s not. I’m afraid the day my father dies, Tim will come to collect him. I’m afraid he will one day steal my daddy for good.

How does the flu actually kill people?

(Credit: Getty/Koldunova_Anna)

One Sunday in November 20-year-old Alani Murrieta of Phoenix began to feel sick and left work early. She had no preexisting medical conditions but her health declined at a frighteningly rapid pace, as detailed by her family and friends in local media and on BuzzFeed News. The next day she went to an urgent care clinic, where she was diagnosed with the flu and prescribed the antiviral medication Tamiflu. But by Tuesday morning she was having trouble breathing and was spitting up blood. Her family took her to the hospital, where x-rays revealed pneumonia: inflammation in the lungs that can be caused by a viral or bacterial infection, or both. Doctors gave Murrieta intravenous antibiotics and were transferring her to the intensive care unit when her heart stopped; they resuscitated her but her heart stopped again. At 3:25 P.M. on Tuesday, November 28 — one day after being diagnosed with the flu — Murrieta was declared dead.

Worldwide, the flu results in three million to five million cases of severe illness and 291,000 to 646,000 deaths annually, according to the World Health Organization and the U.S. Centers for Disease Control and Prevention; the totals vary greatly from one year to the next. The CDC estimates that between 1976 and 2005 the annual number of flu-related deaths in the U.S. ranged from a low of 3,000 to a high of 49,000. Between 2010 and 2016 yearly flu-related deaths in the U.S. ranged from 12,000 to 56,000.

But what exactly is a “flu-related death”? How does the flu kill? The short and morbid answer is that in most cases the body kills itself by trying to heal itself. “Dying from the flu is not like dying from a bullet or a black widow spider bite,” says Amesh Adalja, an infectious disease physician at the Johns Hopkins University Center for Health Security. “The presence of the virus itself isn’t going to be what kills you. An infectious disease always has a complex interaction with its host.”

After entering someone’s body — usually via the eyes, nose or mouth — the influenza virus begins hijacking human cells in the nose and throat to make copies of itself. The overwhelming viral hoard triggers a strong response from the immune system, which sends battalions of white blood cells, antibodies and inflammatory molecules to eliminate the threat. T cells attack and destroy tissue harboring the virus, particularly in the respiratory tract and lungs where the virus tends to take hold. In most healthy adults this process works, and they recover within days or weeks. But sometimes the immune system’s reaction is too strong, destroying so much tissue in the lungs that they can no longer deliver enough oxygen to the blood, resulting in hypoxia and death.

In other cases it is not the flu virus itself that triggers an overwhelming and potentially fatal immune response but rather a secondary infection that takes advantage of a taxed immune system. Typically, bacteria — often a species of Streptococcus or Staphylococcus — infect the lungs. A bacterial infection in the respiratory tract can potentially spread to other parts of the body and the blood, even leading to septic shock: a life-threatening, body-wide, aggressive inflammatory response that damages multiple organs. Based on autopsy studies, Kathleen Sullivan, chief of the Division of Allergy and Immunology at The Children’s Hospital of Philadelphia, estimates about one third of people who die from flu-related causes expire because the virus overwhelms the immune system; another third die from the immune response to secondary bacterial infections, usually in the lungs; and the remaining third perish due to the failure of one or more other organs.

Apart from a bacterial pneumonia, the secondary complications of the flu are numerous and range from the relatively mild, such as sinus and ear infections, to the much more severe, such as inflammation of the heart (myocarditis), brain (encephalitis) or muscles (myositis and rhabdomyolysis). They can also include Reye’s syndrome, a mysterious brain illness that usually begins after a viral infection, and Guillain-Barré syndrome, another virus-triggered ailment in which the immune system attacks the peripheral nervous system. Sometimes Guillain-Barré leads to a period of partial or near-total paralysis, which in turn requires mechanical ventilation to keep a sufferer breathing. These complications are less common, but can be fatal.

The number of people who die from an immune response to the initial viral infection versus a secondary bacterial infection depends, in part, on the viral strain and the cleanliness of the spaces in which the sick are housed. Some studies suggest that during the infamous 1918 global flu pandemic, most people died from subsequent bacterial infections. But more virulent strains such as those that cause avian flu are more likely to overwhelm the immune system on their own. “The hypothesis is that virulent strains trigger a stronger inflammatory response,” Adalja says. “It also depends on the age group getting attacked. During the H1N1 2009 pandemic, the age group mostly affected was young adults, and we saw a lot of primary viral pneumonia.”

In a typical season most flu-related deaths occur among children and the elderly, both of whom are uniquely vulnerable. The immune system is an adaptive network of organs that learns how best to recognize and respond to threats over time. Because the immune systems of children are relatively naive, they may not respond optimally. In contrast the immune systems of the elderly are often weakened by a combination of age and underlying illness. Both the very young and very old may also be less able to tolerate and recover from the immune system’s self-attack. Apart from children between six and 59 months and individuals older than 65 years, those at the greatest risk of developing potentially fatal complications are pregnant women, health care workers and people with certain chronic medical conditions, such as HIV/AIDS, asthma, and heart or lung diseases, according to the World Health Organization.

So far this flu season more than 6,000 people in the U.S. have tested positive for influenza and 856 have been hospitalized for laboratory-confirmed flu-associated reasons, according to the CDC. The most effective way to prevent the flu and its many potentially lethal complications is to get vaccinated.